A pseudo-outbreak of Rhinocladiella similis in a bronchoscopy unit of a tertiary care teaching hospital in London, United Kingdom.

Outbreaks of fungal infections due to emerging and rare species are increasingly reported in healthcare settings. We investigated a pseudo-outbreak of Rhinocladiella similis in a bronchoscopy unit of a tertiary care teaching hospital in London, UK. We aimed to determine route of healthcare-associated transmission and prevent additional infections. From July 2018 through February 2019, we detected a pseudo-outbreak of R. similis isolated from bronchoalveolar lavage (BAL) fluid samples collected from nine patients who had undergone bronchoscopy in a multispecialty teaching hospital, during a period of 8 months. Isolates were identified by MALDI-TOF mass spectrometry. Antifungal susceptibility testing was performed by EUCAST broth microdilution. To determine genetic relatedness among R. similis isolates, we undertook amplified fragment length polymorphism analysis. To determine the potential source of contamination, an epidemiological investigation was carried out. We reviewed patient records retrospectively and audited steps taken during bronchoscopy as well as the subsequent cleaning and decontamination procedures. Fungal cultures were performed on samples collected from bronchoscopes and automated endoscope washer-disinfector systems. No patient was found to have an infection due to R. similis either before or after bronchoscopy. One bronchoscope was identified to be used among all affected patients with positive fungal cultures. Physical damage was found in the index bronchoscope; however, no fungus was recovered after sampling of the affected scope or the rinse water of automated endoscope washer-disinfectors. Use of the scope was halted, and, during the following 12-month period, Rhinocladiella species were not isolated from any BAL specimen. All pseudo-outbreak isolates were identified as R. similis with high genetic relatedness (>90% similarity) on ALFP analysis. The study emphasises the emergence of a rare and uncommon black yeast R. similis, with reduced susceptibility to echinocandins, in a bronchoscope-related pseudo-outbreak with a potential water-related reservoir. Our findings highlight the importance of prolonged fungal culture and species-level identification of melanised yeasts isolated from bronchoscopy samples. Possibility of healthcare-associated transmission should be considered when R. similis is involved in clinical microbiology samples.

Symmetry of palatal shape during the first year of life in healthy infants.

OBJECTIVES: The purpose of this study was to quantify the symmetry of the alveolar process of the maxilla and palate during the first year of life in healthy infants with the help of a semiautomatic segmentation technique. MATERIALS AND METHODS: Maxillary plaster models of seventy healthy babies at 0, 3, 6, 9, and 12 months were collected and digitized. A semiautomatic segmentation tool was used to extract the alveolus and palate. The resulting model was aligned within a reference frame and mirrored on its medial plane. Distance maps were created and analyzed to compare and quantify the differences between the two hemispheres. Additional hemispherical width and area measurements were performed. An ANOVA test with additional post hoc tests was performed to check if the symmetry changed during development. Finally, the results were tested on intra- and interobserver variability. RESULTS: The absolute mean inter-surface distance between the original and mirrored models in each age group ranged between 0.23 and 0.30 mm. Width and area analysis showed a small but significant larger left palatal hemisphere. ANOVA and post hoc tests showed no significant difference in symmetry between groups. Reliability analysis showed no significant differences between observers. CONCLUSIONS: This study showed that in this infant population, only a small degree of palatal asymmetry was present, which can be considered as normal and clinically irrelevant. CLINICAL RELEVANCE: The data from this study can be used in future comparative studies as reference data. Furthermore, modeling of these data can help in predicting the growth pattern, which may lead to improved treatment protocols for children with craniofacial anomalies.

Three dimensional maxillary growth modeling in newborns.

OBJECTIVES: The aim of this study was to develop an accurate and intuitive semi-automatic segmentation technique to calculate an average maxillary arch and palatal growth profile for healthy newborns in their first year of life. MATERIALS AND METHODS: Seventy babies born between 1985 and 1988 were included in this study. Each child had five impressions made in the first year after birth that were digitalized. A semi-automatic segmentation tool was developed and used to assess the maxillary dimensions. Finally, random effect models were built to describe the growth and build a simulation population of 10,000 newborns. The segmentation was tested for inter- and intra-observer variability. RESULTS: The Pearson correlation coefficient for each of the variables was between 0.94 and 1.00, indicating high inter-observer agreement. The paired sample t test showed that, except for the tuberosity distance, there were small, but significant differences in the landmark placements between observers. Intra-observer repeatability was high, with Pearson correlation coefficients ranging from 0.87 to 1.00 for all measurements, and the mean differences were not significant. A third or second degree growth curve could be successfully made for each parameter. CONCLUSIONS: These findings indicated this method could be used for objective clinical evaluation of maxillary growth. CLINICAL RELEVANCE: The resulting growth models can be used for growth studies in healthy newborns and for growth and treatment outcome studies in children with cleft lip and palate or other craniofacial anomalies.

Postoperative socket irrigation with drinking tap water reduces the risk of inflammatory complications following surgical removal of third molars: a multicenter randomized trial.

OBJECTIVES: The primary aim of the present study was to evaluate the effectiveness of postoperative irrigation of the socket with drinking tap water on inflammatory complications following lower third molar removal. MATERIAL AND METHODS: A multicenter randomized controlled trial was carried out from June 2013 to June 2014. In one arm of the study, patients were instructed to irrigate the tooth socket and surgical site with a Monoject® Curved 412 Tip Syringe (Tyco/healthcare-Kendall, Mansfield, MA, USA) with tap water. In a second arm of the study, the standard postoperative instructions did not include irrigation instructions. The incidences of alveolar osteitis and wound infection were recorded for each group and analyzed by the Fisher's exact test. RESULTS: A total of 280 patients with 333 mandibular third molars were analyzed. According to the intention-to-treat (ITT) analysis, inflammatory complications occurred in 18 cases in the Monoject® group (11.4 %) compared to 34 cases (19.1 %) in the control group (p = 0.04). These complications were associated with significant worse outcomes regarding quality of life, pain, and trismus and caused significantly more missed days of work or study. Female gender, age >26, bone removal, deep impacted third molars, less experienced surgeons, and a high amount of debris at the surgical site were also identified as risk factors for developing inflammatory complications following lower third molar removal. CONCLUSION: Irrigation of the surgical site with drinking tap water using a curved syringe following removal of third molars is effective in reducing the risk of inflammatory complications. CLINICAL RELEVANCE: Water is a very accessible, cost-effective irrigant without side effects and the results from this study have proven that it can be used to reduce the risk of inflammatory complications and associated morbidity following lower third molar removal.

Subcutaneous Phaeohyphomycosis Cyst Associated with Medicopsis romeroi in an Immunocompromised Host.

An 88-year-old man, receiving prednisolone for sarcoidosis, presented with a discrete keratotic lesion on the dorsum of his right hand following the placement of an intravenous cannula a month prior to its appearance. Medicopsis romeroi was isolated from the tissue and identified by sequencing the internal transcribed spacer region ITS-1 and the D1-2 fragment of the 28S rDNA gene. Histopathological examination showed fungal hyphae in the internal inflammatory cells layer and within the histocyte-macrophage layer, highly suggestive of deep mycosis. The patient was successfully treated with surgical excision of the cyst. M. romeroi exhibited high MIC values for echinocandin drugs in vitro, but appeared susceptible to newer triazole agents, amphotericin B and terbinafine. This is the first report of a subcutaneous phaeohyphomycotic cyst occurring following the placement of an intravenous cannula. This report highlights the potential role of M. romeroi as an emerging cause of deep, non-mycetomatous infection in immunocompromised patients.

Three-dimensional facial analysis in acromegaly: a novel tool to quantify craniofacial characteristics after long-term remission.

PURPOSE: The exact quantification of craniofacial characteristics in patients with acromegaly is important because it provides insight in the pathophysiology of the disease and offers a tool to evaluate the effects of treatment on tissue specific endpoints. However, until recently this was not feasible due to limitations of available cephalometric methods. The new technique of three-dimensional (3D) cephalometry enables the accurate quantification of facial anatomical characteristics of both soft tissue and bone. This is the first study that uses 3D cephalometry to analyze craniofacial disproportions in patients in long-term remission of acromegaly. METHODS: Sixteen patients in remission of acromegaly for over 24 months (50% male, mean age 56.0 ± 10.7 years, mean body mass index 29.3 ± 5.5 kg/m(2)) were compared to 16 matched control subjects. A 3D cone beam computed tomography scan and 3D stereophotograph of each individual were acquired and analyzed using 3D cephalometry. RESULTS: In addition to an accurate quantification of the classical craniofacial characteristics, 3D cephalometry, shows that many typical soft tissue deformities persist, even after long-term remission. Furthermore, we found that, compared to controls, the patients in remission of acromegaly have a wider face at the level of the zygoma and longer maxilla (p < 0.05). CONCLUSIONS: 3D cephalometry is an attractive novel imaging modality to accurately investigate craniofacial disproportions of both soft tissue and bony parts of the face in patients with acromegaly, which makes it a promising technique for future research purposes and clinical practice.

[Implant placement in the aesthetic zone: the socket-shield-technique]. / Implanteren in de esthetische zone: de socket-shieldtechniek.

Following the extraction of an incisor in the maxilla, resorption of the -alveolar bone always occurs, especially on the buccal side. This often indicates that in the buccocervical area, insufficient bone is present to cover the dental implant. One treatment option is to carry out a bone transplant on the buccal side prior to or during the placement of the implant. An alternative way of supporting the buccocervical gingival is to leave the buccal part of the radixin situ, the so-called socket-shield technique. The results of this treatment for 16 consecutive patients were evaluated and revealed that the socket-shield technique produces good treatment results.

Does facial asymmetry vary between subjects of different age groups? A 3D stereophotogrammetry analysis.

This study was aimed to assess whether facial asymmetry increases with age and to examine potential gender differences using 3D stereophotogrammetry. A prospective cross-sectional study was performed. 3D photographs were acquired from 600 control subjects, 300 male, 300 female, and were stratified into 15 different age groups ranging from 0 to 70+. The 3D photographs were postprocessed and mirrored. The original and mirrored faces were surface-based matched using an iterative closest point algorithm. The primary outcome variable, facial asymmetry, was evaluated by calculating the absolute mean distance between the original and mirrored images. The primary predictor was age. Pearson's correlation was used to assess the correlation between facial asymmetry and age. The average overall facial asymmetry was 0.72 mm (SD 0.72 mm; range 0.25 - 3.04 mm). Mean facial asymmetry increased significantly with age, from 0.45 mm in the age group of 0-4 years to 0.98 mm in the age group of 70+ (p<0.001). Facial asymmetry was positively correlated with age (Pearson's r = 0.55; p<0.001). Male subjects were significantly more asymmetric compared to females, 0.77 mm and 0.67 mm, respectively (p<0.001). This study indicates that facial asymmetry significantly increases with age and is significantly larger in males than in females.

Detecting Mandible Fractures in CBCT Scans Using a 3-Stage Neural Network.

After nasal bone fractures, fractures of the mandible are the most frequently encountered injuries of the facial skeleton. Accurate identification of fracture locations is critical for effectively managing these injuries. To address this need, JawFracNet, an innovative artificial intelligence method, has been developed to enable automated detection of mandibular fractures in cone-beam computed tomography (CBCT) scans. JawFracNet employs a 3-stage neural network model that processes 3-dimensional patches from a CBCT scan. Stage 1 predicts a segmentation mask of the mandible in a patch, which is subsequently used in stage 2 to predict a segmentation of the fractures and in stage 3 to classify whether the patch contains any fracture. The final output of JawFracNet is the fracture segmentation of the entire scan, obtained by aggregating and unifying voxel-level and patch-level predictions. A total of 164 CBCT scans without mandibular fractures and 171 CBCT scans with mandibular fractures were included in this study. Evaluation of JawFracNet demonstrated a precision of 0.978 and a sensitivity of 0.956 in detecting mandibular fractures. The current study proposes the first benchmark for mandibular fracture detection in CBCT scans. Straightforward replication is promoted by publicly sharing the code and providing access to JawFracNet on grand-challenge.org.

Predictive value of ridge dimensions on autologous bone graft resorption in staged maxillary sinus augmentation surgery using Cone-Beam CT.

INTRODUCTION: No studies are available that provide predictive parameters regarding the expected amount of resorption after maxillary sinus augmentation surgery using autologous bone grafts. Therefore, the aim of this study was to determine parameters influencing the outcome of the bone graft resorption process. MATERIAL AND METHODS: In 20 patients, three-dimensional analysis of alveolar ridge dimensions and bone graft volume change in the atrophic posterior maxilla was performed by Cone-Beam Computerized Tomography imaging. Ridge dimensions were assessed before maxillary sinus augmentation surgery. Bone graft volumes were compared after maxillary sinus floor augmentation surgery and a graft healing interval of several months. To analyze the relation between bone volume changes with the independent variables, patients' gender, age, alveolar crest height and width, and graft healing time interval, a multi-level extension of linear regression was applied. RESULTS: A residual bone height of 6.0 mm (SD = 3.6 mm) and 6.2 mm (SD = 3.6 mm) was found at the left and right sides, respectively. Moreover, alveolar bone widths of 6.5 mm (SD = 2.2 mm) and 7.0 mm (SD = 2.3 mm) at the premolars, and 8.8 mm (SD = 2.2 mm) and 8.9 mm (SD = 2.5 mm) at the molars regions were found at the left and right site, respectively. Bone graft volume decreased by 25.0% (SD = 21.0%) after 4.7 months (SD = 2.7, median = 4.0 months) of healing time. The variables "age" (P = 0.009) and mean alveolar crest "bone height" (P = 0.043), showed a significant influence on bone graft resorption. A decrease of 1.0% (SE = 0.3%) of bone graft resorption was found for each year the patient grew older, and an increase in bone graft resorption of 1.8% (SE = 0.8%) was found for each mm of original bone height before sinus floor augmentation. CONCLUSIONS: Graft resorption occurs when using autologous bone grafts for maxillary sinus augmentation. Alveolar crest bone height and patient age have a significant effect on graft resorption, with increased resorption for higher alveolar crest bone height and decreased resorption for older patients. Consequently, patient characteristics that affect the process of bone graft resorption should be given full consideration, when performing sinus augmentation surgery.

[Sclerosis of lymfangiomas in the head and neck area: evaluation with the use of stereophotogrammetry]. / Sclerosering van lymfangiomen in her hoofd-halsgebied: evaluatie door middel van stereofotogrammetrie.

Lymangiomas are congenital malformations of the lymphatic system. They can appear at any age and in any part of the body. In the head and neck area lymangiomas can give rise to functional as well as esthetic problems. Therapy consist of sclerosis, possibly followed by surgical excision. Stereophotogrammetry is a relatively new technique which, by means of superimposition of pre- and postoperative images, provides the possibility to quantify treatment results. In this paper 3 patients who underwent treatment of a lymphatic malformation and in whom treatment results were measured with stereophotogrammetry are discussed. The conclusion can be drawn that stereophotogrammetry is a promising technique for evaluation of treatment results of superficially localised lymphatic malformations that displace the skin in the head and neck area.

Surgical accuracy in 3D planned bimaxillary osteotomies: intraoral scans and plaster casts as digital dentition models.

The aim of this study was to assess whether the use of intraoral scans (IOS) is an eligible alternative to conventional plaster casts in terms of surgical accuracy of three-dimensionally planned bimaxillary osteotomies. This retrospective cohort study included patients who underwent bimaxillary surgery between 2016 and 2020 in the Department of Oral and Maxillofacial Surgery at Radboud University Medical Center, Nijmegen. Three-dimensional virtual planning was performed with the use of plaster casts in one group and IOS in the other group. Cone beam computed tomography scans were acquired preoperatively and at 1 week following surgery. By using voxel-based matching, the maxillary movements were quantified in six degrees of freedom. The primary outcome variable, surgical accuracy, was defined as the difference between the planned maxillary movements and those achieved. Of 152 patients, 113 were documented with plaster casts and 39 with IOS. The surgical accuracy was comparable in terms of maxillary vertical, sagittal, and transverse translations, as well as roll and yaw. Maxillary pitch (difference 0.55 ± 0.26°; P = 0.001) was in favour of the IOS group. This study demonstrated that IOS can be used as an alternative to conventional plaster casts in the three-dimensional planning of bimaxillary osteotomies.

Different effects of warming treatments in forests versus hedgerows on the understorey plant Geum urbanum.

The effectiveness of hedgerows as functional corridors in the face of climate warming has been little researched. Here we investigated the effects of warming temperatures on plant performance and population growth of Geum urbanum in forests versus hedgerows in two European temperate regions. Adult individuals were transplanted in three forest-hedgerow pairs in each of two different latitudes, and an experimental warming treatment using open-top chambers was used in a full factorial design. Plant performance was analysed using mixed models and population performance was analysed using Integral Projection Models and elasticity analyses. Temperature increases due to open-top chamber installation were higher in forests than in hedgerows. In forests, the warming treatment had a significant negative effect on the population growth rate of G. urbanum. In contrast, no significant effect of the warming treatment on population dynamics was detected in hedgerows. Overall, the highest population growth rates were found in the forest control sites, which was driven by a higher fecundity rather than a higher survival probability. Effects of warming treatments on G. urbanum population growth rates differed between forests and hedgerows. In forests, warming treatments negatively affected population growth, but not in hedgerows. This could be a consequence of the overall lower warming achieved in hedgerows. We conclude that maintenance of cooler forest microclimates coul, at least temporarily, moderate the species response to climate warming.

Nasolabial shape and aesthetics in unilateral cleft lip and palate: an analysis of nasolabial shape using a mean 3D facial template.

The aim of this study was to determine the amount of deviation in nasolabial shape in patients with a cleft compared with an average non-cleft face, and to assess whether this difference is related to nasolabial aesthetics. Three-dimensional stereophotogrammetric images of 60 patients with a unilateral cleft were used. To quantify shape differences, four average non-cleft faces were constructed from stereophotogrammetric images of 141 girls and 60 boys. Three-dimensional shape differences were calculated between superimposed cleft faces and the average non-cleft face for the same sex and age group. Nasolabial aesthetics were rated with the modified Asher-McDade Aesthetic Index using a visual analogue scale (VAS). Mean VAS scores ranged from 51.44 to 60.21 for clefts, with lower aesthetic ratings associated with increasing cleft severity. Shape differences were found between cleft faces and the average non-cleft face. No relationship was found for the VAS, age, and sex, except that a lower VAS was related to a higher nose and lip distance between the superimposed cleft and average non-cleft faces for nasal profile (P= 0.02), but the explained variance was low (R2=0.066). In conclusion, except for nasal profile, nasolabial aesthetics were not influenced by the extent of shape differences from the average non-cleft face.

Diagnostic accuracy of transabdominal ultrasound in detecting prenatal cleft lip and palate: a systematic review.

OBJECTIVES: To systematically review the diagnostic accuracy of second-trimester transabdominal ultrasound in detecting orofacial clefts in low- and high-risk populations and to compare two-dimensional (2D) with three-dimensional (3D) ultrasound techniques. METHODS: MEDLINE and EMBASE were searched for articles published in English, Dutch, French or German using the keywords 'cleft' and 'ultrasound' or 'screening' or 'sonogram' and 'prenatal' or 'antenatal' or 'fetus' to identify cohort studies and randomized trials in order to assess the detection rate by prenatal ultrasound of cleft lip and palate in high-risk and low-risk pregnant women. RESULTS: Of 451 citations identified, 27 met the criteria for the systematic review, 21 involving unselected low-risk populations and six involving high-risk populations. In the selected studies there was diversity in the gestational age at which the ultrasound examination was performed and there was considerable variety in the diagnostic accuracy of 2D ultrasound in the low-risk women, with prenatal detection rates ranging from 9% to 100% for cleft lip with or without cleft palate, 0% to 22% for cleft palate only and 0% to 73% for all types of cleft. 3D ultrasound in high-risk women resulted in a detection rate of 100% for cleft lip, 86% to 90% for cleft lip with palate and 0% to 89% for cleft palate only. CONCLUSIONS: 2D ultrasound screening for cleft lip and palate in a low-risk population has a relatively low detection rate but is associated with few false-positive results. 3D ultrasound can achieve a reliable diagnosis, but not of cleft palate only.

Prenatal ultrasound diagnosis in 51 cases of holoprosencephaly: craniofacial anatomy, associated malformations, and genetics.

OBJECTIVE: To analyze the prenatal ultrasound findings of the craniofacial and extracephalic anatomy, the postnatal pathological findings, and the genetic anomalies in 51 cases of holoprosencephaly (HPE). MATERIALS AND METHODS: Between 1990 and 2005, a collective of 51 fetuses with tentative ultrasound diagnosis of HPE was recruited at two tertiary referral centers for prenatal ultrasound diagnostics via the Pia Fetal Database (GEMedical Systems, Webling, Germany). Cephalic as well as extracephalic anomalies were investigated, and all cases were subdivided into the subgroups lobar, a lobar, and semilobar HPE. In addition to the ultrasound investigation, 45 fetuses were analyzed for genetic anomalies and 21 fetuses underwent an autopsy. RESULTS: The average age at diagnosis was 21.9 weeks of gestation. There was a greater number of female fetuses, with an overall ratio of 2.67:1. In 61% of all cases, there was a reduction of growth in comparison with healthy fetuses of the same age. Within the second trimenon, the cephalic anomalies became evident when investigating the diameter of the fetal head (second trimenon: 71%below the fifth percentile; third trimenon: 92% below the fifth percentile). In 82%of the cases, extracephalic anomalies were diagnosed additionally. In 63%, the diagnosis of holoprosencephaly led to a termination of pregnancy. Ten percent of the fetuses were born alive. In 81% of the cases, the diagnosis of HPE was confirmed postnatally. The remaining 19% showed other severe cephalic and extracephalic anomalies. Chromosomal anomalies were detected in 79% of the fetuses, most frequently trisomy 13 (59%). DISCUSSION: Because of recent advances in the development and improvement of high-resolution ultrasound, early diagnosis of congenital anomalies such as HPE is now possible. In this study, which represents the largest collection of prenatally diagnosed HPE reported in the literature to date, the average age at diagnosis was earlier than in other studies. The ultrasound devices of today provide excellent images of the fetus that allow an exact diagnosis of craniomaxillofacial anomalies as well as extracephalic anomalies. Apart from a very few cases, the diagnosis of HPE is incompatible with life.

Prenatal diagnosis of craniomaxillofacial malformations: a characterization of phenotypes in trisomies 13, 18, and 21 by ultrasound and pathology.

OBJECTIVE: To determine the relationship between trisomies 13, 18, and 21 and craniofacial malformations detected by prenatal sonography. DESIGN: During a 29-year period (1976 through 2004), prenatal sonographic findings of 69 fetuses with trisomy 13; 171 fetuses with trisomy 18; 302 fetuses with trisomy 21; and 17 fetuses with other trisomies were evaluated retrospectively, after fetal karyotype identification. Sonographic findings were compared with autopsy results in 209 patients (trisomy 13, n=39; trisomy 18, n=64; and trisomy 21, n=106). RESULTS: For trisomy 13, cleft deformities were detected prenatally in 65.2%, and of the 39 cases with pathological information, 76.9% were found to have a cleft deformity. Ocular and orbital abnormalities were found in 28%. Malformations of the jaws and abnormal profiles were more frequently diagnosed postnatally than prenatally. For trisomy 18, abnormal profiles (41.5%) and ear abnormalities (5.3%) were the most noticeable ultrasound markers, next to abnormalities of the neurocranium (36.8%) and cranial bone configuration (21.6%). Dysmorphisms of the eye, ear, or nose were detected more frequently in autopsy cases. For trisomy 21, ultrasound showed an aberrant shape of the skull in 14.2% of fetuses. In general, the ocular-orbital and nasal abnormalities in fetuses with trisomy 18 or 21 were more evident in pathological examination than in prenatal ultrasound imaging. CONCLUSIONS: Facial anomalies are common in the major trisomies, and their prenatal sonographic identification should be improved. The above-mentioned facial anomalies provide sufficient reason to consider performing cytogenic evaluation.

[Treatment of macroglossia due to acromegaly]. / Behandeling van macroglossie ten gevolge van acromegalie.

A 61-years-old woman had macroglossia due to acromegaly with complaints of dyspneu at a lying sleeping position and complaints of speech and dysphagia. At the age of 55 years she was diagnosed with acromegaly induced by a adenoma of the pituitary gland, which had been removed surgically. The treatment of macroglossia included tongue reduction, removal of the remaining mandibular teeth with severe periodontal attachment loss, huge reduction of the residual alveolar ridge, immediate implant insertion, fabrication of implant-supported overdentures, and logopedic treatment. The speech improved significantly and the patient could sleep again in a lying position. Clinically, acromegaly is diagnosed on clinical signs, such as the morphology and the protrusion of the tongue. Often, macroglossia is a secondary symptom of a systemic disease, needing causal treatment. If surgical reduction of the tongue is indicated, also enlargement of the oral cavity should be considered.

[Bifid and trifid mandibular canal. A coincidental finding]. / Canalis mandibulae bifidus en trifidus. Een toevalsbevinding.

A 26-year-old man was suffering from pericoronitis of his mandibular third molars. To determine the position of the mandibular canal in relation to the roots of the third molars, a panoramic radiograph was made. The radiograph revealed at the right side a bifid mandibular canal and the upper part of the canal seemed to be related to the third molar. Additionally, a cone beam CT was made, which revealed a bifid mandibular canal at the left side and a trifid mandibular canal at the right side. Anatomical anomalies of the mandibular canal may have clinical implications, such as an increased risk of injury to the inferior alveolar nerve in case of removing a mandibular third molar and inadequate local anesthetics.

[Unilateral surgically assisted rapid maxillary expansion using a transpalatal distractor]. / Unilaterale chirurgisch ondersteunde expansie van de bovenkaak door transpalatinale distractor.

A 46-year-old woman was referred for orthodontic surgery consultation because ofa retrognathic maxilla, unilateral cross bite and functional, aesthetic and speech problems. The maxilla was widened unilaterally by unilateral surgically assisted rapid maxillary expansion with a bone-borne transpalatal distractor. During post-operative orthodontic treatment, a temporary anchorage device was administered. With the help of composite veneers, crowns and a removable partial denture, a functionally and aesthetically satisfying result was achieved.