Removal of Impacted Supernumerary Teeth Using a Dynamic Surgical Navigation System: A Case Report.

Removal of impacted supernumerary teeth can present a unique set of challenges to the dentoalveolar surgeon. Complications associated with these challenges have been well documented in the literature. The use of dynamically guided surgical navigation technology for the removal of impacted supernumerary teeth has the potential to mitigate these challenges and improve clinical outcomes. Although not a currently Food and Drug Administration-approved indication, the use of dynamic surgical navigation systems for the removal of impacted supernumerary teeth will be elucidated in this case report.

A Review of In-Office Dynamic Image Navigation for Extraction of Complex Mandibular Third Molars.

PURPOSE: We performed a retrospective review of in-office removal of complex mandibular third molars with a dynamic image navigation system (DINS). MATERIALS AND METHODS: A retrospective review was conducted of cases completed from 2010 to 2014 by a single oral and maxillofacial surgeon. The average age of the patients was 47 years (range, 27 to 72 years). Extraction complexity was classified with Juodzbalys and Daugela's classification system. The included study cases had complexity scores of 9 or greater. Each patient received custom intraoral splints to secure the tracking array and underwent cone beam computed tomography image acquisition. All surgical procedures were performed with a precalibrated tracking straight handpiece under dynamic navigation. RESULTS: All 25 cases were treated successfully with the use of the DINS. Twelve of these cases were associated with pathologic lesions. Three patients were noted to have inferior alveolar nerve paresthesia. One patient sustained a pathologic fracture at week 2. Postoperative infections were noted in 7 cases, 2 of which had a pre-existing infection. One patient reported temporary limitation of mouth opening. A coronectomy was performed in 1 case. CONCLUSIONS: We present results using a new technology, the DINS, for removal of complex mandibular third molars. Potential advantages are 1) improved visualization and localization of anatomic structures such as the inferior alveolar nerve, lingual cortical plate, and adjacent roots; 2) improved control during osteotomy; 3) decreased surgical access requirements and reduction in overall bone removal; 4) ability to perform complex procedures successfully in an in-office setting; 5) decreased surgical time resulting from improved visualization; and 6) potential use as a teaching tool. Possible limitations of the use of an in-office DINS include increased cost, increased time attributed to presurgical planning, initial learning curve, and optical array interference by the surgeon or assistants during surgery.

Implant Placement Is More Accurate Using Dynamic Navigation.

PURPOSE: The purpose of this prospective study was to measure and compare the accuracy and precision of dynamic navigation with freehand (FH) implant fixture placement. The authors hypothesized that the evaluated dynamic navigation system would have high accuracy and precision and would be superior to FH methods. MATERIALS AND METHODS: The authors designed and implemented a prospective cohort study and enrolled patients who had implants placed from December 2014 through December 2016. The predictor variable was implant placement technique comparing fully guided (FG) and partially guided (PG) dynamic navigation with FH placement. The outcome variables were accuracy measured as deviation from the virtual plan, and precision was represented as the standard deviation of the measurements. Analysis of variance (ANOVA) was used to compare measurements. Virtual implant placement was compared with post-implant placement using mesh analysis. Deviations from the virtual plan were recorded for each implant for each surgeon. FH implant placement was evaluated by comparing a virtual plan with postoperative scans for patients who did not have the navigation system used for their implant placement. One-way ANOVA was performed to determine within-group and between-groups differences to determine whether there were meaningful differences among surgeons and methods (FG, PG, and FH) of placement. RESULTS: Prospective data from 478 patients involving 714 implants were evaluated. There were no demographic differences among surgeons. The sample size differed by the number of implants placed by each surgeon. Within each method group, the only difference among surgeons was angular deviation. All surgeons' data were combined. For FG navigation, the mean angular deviation was 2.97 ± 2.09°, the mean global platform position deviation was 1.16 ± 0.59 mm, and the mean global apical position deviation was 1.29 ± 0.65 mm. For PG navigation, the mean angular deviation was 3.43 ± 2.33°, the mean global platform position deviation was 1.31 ± 0.68 mm, and the mean global apical position deviation was 1.52 ± 0.78 mm. For FH placement, the mean angular deviation was 6.50 ± 4.21°, the mean global platform position deviation was 1.78 ± 0.77 mm, and the mean global apical position deviation was 2.27 ± 1.02 mm. Differences in measurements comparing FG and PG navigation with FH indicated significantly less deviation from the virtual plan (P < .05) using navigation. CONCLUSIONS: Accuracy and precision for implant placement were achieved using dynamic navigation. The use of this type of method results in smaller deviations from the planned placement compared with FH approaches.

Validation of an External Support for Coronary Artery Saphenous Vein Grafts without Fibrin Sealant.

BACKGROUND: The aim of the study is to report on a new technique for applying the eSVS Mesh (Kips Bay Medical, Minneapolis, Minnesota, United States), an external saphenous vein support system, without the use of fibrin sealant. METHODS: The mesh covers the entire body of the graft with the exception of both anastomoses. Fibrin sealant was not used to fix the mesh. Two patients underwent surgery using this preparation. EVALUATION: At 4 weeks, computed tomographic angiography revealed no signs of mesh compression at either anastomotic area. The proximal anastomosis inflow diameter was greater than the diameter of the mesh-supported body of the graft. CONCLUSION: This technique successfully eliminates the need for the use of sealant and supports favorable anastomotic geometry.

Static or Dynamic Navigation for Implant Placement-Choosing the Method of Guidance.

The purpose of the present report is to contrast and compare 2 methods of dental implant placement. One method uses computed tomography data for computer-aided design and computer-aided manufacturing to generate static guides for implant placement. The second method is a dynamic navigation system that uses a stereo vision computer triangulation setup to guide implant placement. A review of the published data was performed to provide evidence-based material to compare each method. Finally, the indications for each type of method are discussed.

Long-term follow up of patients undergoing reoperative surgery with aortic or mitral valve replacement using a St. Jude Medical prosthesis.

BACKGROUND AND AIM OF THE STUDY: Between June 1978 and September 2002, a total of 440 reoperative open-heart patients (mean age 62 +/- 14 years; range: 18-91 years), following various primary cardiac operations, underwent single-valve replacement with the St. Jude Medical (SJM) heart valve. Of 241 patients having aortic replacement (AVR) and 199 mitral valve replacement (MVR), 86 (35%) and 42 (21%), respectively, underwent concomitant coronary artery bypass grafting. The study aim was to document patient survival and valve-related events in an experience extending up to 24 years after reoperative open-heart surgery with a single model cardiac valve prosthesis. METHODS: The Cardiac Surgical Associates Research Foundation (CSARF) has maintained an independent database of those patients with the SJM prosthesis since the world's first implant in October 1977. Patients were contacted by questionnaire and/or telephone between November 2002 and June 2003. The hospital course and valve-related events were verified by patient chart review and/or physician contact. RESULTS: Follow up was 94% complete, for a total of 3,114 patient-years (1,671 pt-yr after AVR; 1,443 pt-yr after MVR). The average follow up was 7 +/- 6 years (range: 0.1-24.3 years). The operative mortality was 9% (10% AVR, 8% MVR). Five deaths (13%) were valve-related. Freedom from all late mortality at 10 and 20 years, respectively, was 57% and 35% for AVR and 52% and 22% for MVR, and for valve-related mortality was 89% and 77% for AVR and 84% and 22% for MVR. Freedom from thromboembolic events at 10 and 20 years, respectively, was 93% and 93% after AVR and 92% and 81% after MVR; from anticoagulant-related hemorrhage it was 78% and 76% after AVR and 81% and 67% after MVR; and from reoperation it was 94% and 94% after AVR and 95% and 89% after MVR. CONCLUSION: Reoperative valve replacement carries a significant operative morbidity and mortality. Long-term results with the SJM valve demonstrated a durable prosthetic valve, excellent long-term patient survival, and freedom from valve-related events followed reoperative open-heart valve replacement surgery. However, the early postoperative period carried an increased risk for valve-related events.

Mobile Application for Communication Increases the Efficiency of Organ Procurement and Transplantation.

BACKGROUND: Donor organ recovery is a complex process involving organ procurement organizations and multiple surgical teams from various transplant centers. Nearly 30% of discarded organs are wasted due to reasons related to improper coordination and communication. PROBLEM STATEMENT: Lack of real-time communication results in many hours of preventable delay between procurement and transplant teams resulting in the high volume of organ waste, clinical frustration, and critical delays. METHODS: A Plan-Do-Study-Act performance improvement methodology was utilized to design and implement a dedicated mobile communication application (app). Critical time points in the organ offer, procurement, and transplant processes were analyzed from the Report of Organ Offers, and relation coordination metrics were measured. PROCESSES ADDRESSED: Members of procurement and transplant teams in Iowa were interviewed and a dedicated smartphone application was implemented to replace phone calls, e-mails, faxes, and text messages during upcoming kidney offers from July 31, 2017 to July 31, 2018. OUTCOMES: Teams reported a substantial increase in clinical productivity and case progress awareness, including a noteworthy reduction in phone calls. The relational coordination data indicated substantially higher relationship and communication quality with the app. The Report of Organ Offer data revealed a 35% increase in organs transplanted and a 50% reduction in time from initial organ offer to transplant with the use of the mobile application. IMPLICATIONS FOR PRACTICE: The use of a dedicated communication application reduces clinical frustration and delays during the coordination of organ offer, procurement, and transplant. Technologies that improve communication have the potential to improve organ utilization.

Efficacy and safety of pyridoxal 5'-phosphate (MC-1) in high-risk patients undergoing coronary artery bypass graft surgery: the MEND-CABG II randomized clinical trial.

CONTEXT: Coronary artery bypass graft (CABG) surgery is frequently performed and effective; however, perioperative complications related to ischemia-reperfusion injury, including myocardial infarction (MI), remain common and result in significant morbidity and mortality. MC-1, a naturally occurring pyridoxine metabolite and purinergic receptor antagonist, prevents cellular calcium overload and may reduce ischemia-reperfusion injury. Phase 2 trial data suggest that MC-1 may reduce death or MI in high-risk patients undergoing CABG surgery. OBJECTIVE: To assess the efficacy and safety of MC-1 administered immediately before and for 30 days after surgery in patients undergoing CABG surgery. DESIGN, SETTING, AND PARTICIPANTS: The MC-1 to Eliminate Necrosis and Damage in Coronary Artery Bypass Graft Surgery II Trial, a phase 3, multicenter, randomized, double-blind, placebo-controlled trial, with 3023 intermediate- to high-risk patients undergoing CABG surgery with cardiopulmonary bypass enrolled between October 2006 and September 2007 at 130 sites in Canada, the United States, and Germany. INTERVENTIONS: Patients received either MC-1, 250 mg/d (n = 1519), or matching placebo (n = 1504) immediately before and for 30 days after CABG surgery. MAIN OUTCOME MEASURES: The primary efficacy outcome was cardiovascular death or nonfatal MI, defined as a creatine kinase (CK) MB fraction of at least 100 ng/mL or new Q waves through postoperative day 30. RESULTS: The primary efficacy outcome occurred in 140 of 1510 patients (9.3%) in the MC-1 group and 133 of 1486 patients (9.0%) in the placebo group (risk ratio, 1.04; 95% confidence interval, 0.83-1.30; P = .76). All-cause mortality was higher among patients assigned to MC-1 than placebo at 4 days (1.0% vs 0.3%; P = .03) but was similar at 30 days (1.9% vs 1.5%; P = .44). There was no difference in the 8- to 24-hour CK-MB area under the curve between the MC-1 and placebo groups (median, 270 [interquartile range, 175-492] vs 268 [interquartile range, 170-456] hours x ng/mL; P = .11). CONCLUSION: In this population of intermediate- to high-risk patients undergoing CABG surgery, MC-1 did not reduce the composite of cardiovascular death or nonfatal MI. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00402506

The St. Jude Medical cardiac valve prosthesis: long-term follow up of patients having double valve replacement.

BACKGROUND AND AIM OF THE STUDY: Between October 1977 and February 2002, a total of 343 patients (mean age 62 +/- 13 years; range: 19-91 years) underwent double valve replacement (DVR) with the St. Jude Medical (SJM) heart valve. Among the replacements, 337 (98%) were aortic and mitral in nature. Concomitant coronary artery bypass was performed in 73 patients (21%). METHODS: Cardiac Surgical Associates has maintained an independent database of patients undergoing valve replacement with the SJM prosthesis since the valve's first implantation in October 1977. Patients were contacted by questionnaire and/or telephone (94% complete) between November 2002 and June 2003. The patients' hospital course and valve-related events were verified by patient chart review and/or physician contact. RESULTS: Operative mortality was 8% (n = 29); mortality was valve-related in two cases. The mean follow up was 6.5 +/- 6.0 years (range: 1 month to 24 years); total follow up was 2,226 patient-years. Over 25 years, patient freedom from late mortality was 62%, and from valve-related mortality 78%. Freedom from thromboembolic events was 82% (93% from permanent defect), from bleeding events 76%, from endocarditis 98%, from valve thrombosis 99.9%, and from reoperation 98%. Six reoperations were carried out in five patients (2%), valve repair or replacement in five (2%), and suture closure of paravalvular leak in one patient (0.3%). There were no valve structural failures reported. CONCLUSION: The SJM valve has proven to be an effective and durable heart valve prosthesis. Over the long-term, the event rate is low and there is excellent freedom from reoperation in the double valve configuration.

Bisphosphonate-related osteonecrosis of the jaws: a report of three cases demonstrating variability in outcomes and morbidity.

BACKGROUND: Bisphosphonates are used widely to manage skeletal disorders resulting from malignancies that destroy bone and from some metabolic bone diseases. A strong association between bisphosphonate treatment and the appearance of painful exposed nonvital bone in the mandible and maxilla after oral surgery has been reported in the last decade. Extensive reviews have appeared in the dental literature regarding bisphosphonate-related osteonecrosis of the jaws (BRONJ), including protocols for diagnosis, management and diagnostic imaging for early detection; feature definition; and determination of extent of the disease. CASE DESCRIPTION: The authors provide three case reports to show the contrast in treatment outcomes and morbidity in patients with BRONJ. The cases involved diagnostic imaging modalities commonly used in the practice of dentistry: panoramic radiography and cone-beam volumetric computed tomography. CLINICAL IMPLICATIONS: These case reports demonstrate the usefulness of dental diagnostic imaging in the detection and management of BRONJ, corroborate the increasing number of reports regarding high levels of morbidity associated with various BRONJ treatments, and underscore the danger of performing invasive dental procedures for patients receiving bisphosphonate therapy.

Implant Placement Accuracy Using Dynamic Navigation.

PURPOSE: The aim of this prospective study was to determine platform and angle accuracy for dental implants using dynamic navigation, a form of computer-assisted surgery. Three hypotheses were considered: (1) the overall accuracy for implant placement relative to the virtual plan is similar to that of static tooth-borne computerized tomography (CT)-generated guides; (2) the dynamic system is more accurate than freehand methods; and (3) there is a learning curve associated with this method. MATERIALS AND METHODS: This study involved three surgeons placing implants in the mandible and maxilla of patients using a dynamic navigation system (X-Guide, X-Nav Technologies). Virtual implants were placed into planned sites using the navigation system computer. Post-implant placement cone beam CT scans were taken on all patients. For each patient, this scan was mesh overlayed with the virtual plan and used to determine platform and angular deviations to the virtual plan. The primary outcome variables were platform and angular deviations, comparing the actual placement to the virtual plan. Secondary analyses included determination of accuracy related to case experience and freehand placement of implants. Comparisons to published accuracy studies were made for implant placement using static guides. RESULTS: Accuracy deviations from the virtual plan were similar to those reported for static tooth-based guides using literature references as the comparison. The accuracy of dynamic navigation was superior compared to freehand implant placement. The three surgeons had similar accuracies after their learning curve was achieved. Proficiency based on case series was achieved by the 20th surgical procedure. CONCLUSION: Dynamic navigation can achieve accuracy of implant placement similar to static guides and is an improvement over freehand implant placement. In addition, there was a learning curve to achieve proficiency.

Accuracy of Dynamic Navigation for Dental Implant Placement-Model-Based Evaluation.

The purpose of this model-based study was to determine the accuracy of placing dental implants using a new dynamic navigation system. This investigation focuses on measurements of overall accuracy for implant placement relative to the virtual plan in both dentate and edentulous models, and provides a comparison with a meta-analysis of values reported in the literature for comparable static guidance, dynamic guidance, and freehand placement studies. This study involves 1 surgeon experienced with dynamic navigation placing implants in models under clinical simulation using a dynamic navigation system (X-Guide, X-Nav Technologies, LLC, Lansdale, Pa) based on optical triangulation tracking. Virtual implants were placed into planned sites using the navigation system computer. Post-implant placement cone-beam scans were taken. These scans were mesh overlaid with the virtual plan and used to determine deviations from the virtual plan. The primary outcome variables were platform and angular deviations comparing the actual placement to the virtual plan. The angular accuracy of implants delivered using the tested device was 0.89° ± 0.35° for dentate case types and 1.26° ± 0.66° for edentulous case types, measured relative to the preoperative implant plan. Three-dimensional positional accuracy was 0.38 ± 0.21 mm for dentate and 0.56 ± 0.17 mm for edentulous, measured from the implant apex.

The Case for a Conservative Approach to Blood Transfusion Management in Cardiac Surgery.

Limiting blood transfusion in cardiac operations is a well-meaning goal of perioperative care. Potential benefits include decreasing morbidity and limiting procedural costs. It is difficult to identify transfusion as the cause of adverse outcomes. The need for transfusion may identify a sicker patient population at greater risk for a worse outcome that may or may not be related to the transfusion. We reviewed the indications for and adverse effects of blood transfusion in patients undergoing cardiac procedures to provide a balanced approach to management of blood resources in this population. We reviewed current literature, including systematic reviews and practice guidelines, to synthesize a practice management plan in patients having cardiac operations. Several prospective randomized studies and large population cohort studies compared a postoperative restrictive transfusion policy to a more liberal policy and found very little difference in outcomes but decreased costs with a restrictive policy. Evidence-based practice guidelines and implementation standards provide robust intervention plans that can limit harmful effects of transfusion and provide safe and effective procedure outcomes. A restrictive transfusion policy seems to be safe and effective but does not necessarily provide better outcome in most patient cohorts. The implications of these findings suggest that many discretionary transfusions could be avoided. A subset of high-risk patients could undoubtedly benefit from a more liberal transfusion policy, but the definition of high risk is ill defined.

Clinical, angiographic, and interventional follow-up of patients with aortic-saphenous vein graft connectors.

BACKGROUND: The use of aortic connectors for proximal saphenous vein bypass graft anastomoses eliminates the need for aortic clamping during coronary artery bypass grafting (CABG) and may reduce the incidence of stroke in the elderly and in patients with severe aortic atherosclerosis. METHODS AND RESULTS: We studied 74 consecutive patients who received the Symmetry Bypass System aortic connector at the time of CABG. A total of 131 of 144 proximal vein graft anastomoses were performed with this device. The left internal mammary artery was used in 62 patients, and 61 patients had "off-pump" coronary revascularization. A total of 11 patients were readmitted with chest pain consistent with unstable angina 173+/-39 days after CABG. Five of the 11 patients had previous in-stent restenosis before CABG. At angiography, 20 saphenous vein bypass grafts containing 19 connectors were found to have severe stenosis (n=12) or occlusion (n=6) and were treated with angioplasty and stenting or medical therapy. Seven of 11 patients were readmitted 76+/-11 days later with recurrent chest pain and were found to have severe stenosis at the previously stented connector site. Six patients underwent angioplasty followed by brachytherapy. Three of these patients redeveloped chest pain and were readmitted 151+/-71 days later. Two patients were started on oral Rapamune, and one patient underwent redo-CABG. CONCLUSIONS: Eleven of 74 patients who received aortic connectors at the time of CABG developed symptomatically significant stenosis or occlusion at the connector site shortly after CABG, requiring multiple repeat interventions, including brachytherapy.

Initial report of off-pump coronary artery bypass surgery as sole therapy for moderate ischemic mitral regurgitation: operative and intermediate-term outcome.

BACKGROUND: Patients undergoing on-pump coronary artery bypass surgery (CAB) with coexistent moderate ischemic mitral regurgitation (IMR) have a significant mortality rate compared to patients without MR. The mortality rate is elevated both perioperatively (0%-12% mortality), as well as over a 1- and 2-year postoperative period (15%-25%). It is thought that some patients are best served by off-pump CAB (OPCAB); however, outcomes have not been reported for such patients with coexistent moderate IMR. METHODS: We reviewed the independent database of patients undergoing OPCAB between 1995 and 2002 to find 989 patients, 17 (1.7%) of whom had moderate or moderately severe MR. Patients were contacted and clinical and echocardiographic data were obtained. RESULTS: The patient group consisted of 11 men and 6 women (age, 65 +/- 15 years). The study group had a PA pressure of 52 +/- 14, creatinine of 1.6 +/- 0.7, and left ventricular ejection fraction of 43 +/- 18. Nine patients (53%) had advanced New York Heart Association (class III-IV) heart failure. Mortality rates perioperatively and at 1, 2, and 3 years were 0%, 6.25% (1/16), 12.5% (2/16), and 38% (4/8), respectively. At the time of this report, no patient had returned for a reparative procedure. CONCLUSION: In patients felt to be best served by OPCAB with ischemic MR, operative and intermediate mortality rates are remarkably similar to those previously reported for on-pump series. These data underscore the continued need to understand which patients undergoing CAB require mitral valve problems to be addressed at the time of surgery.

Multicentric t-cell lymphoma in a dromedary camel (Camelus dromedarius).

A 7-yr-old female dromedary camel (Camelus dromedarius) was evaluated for inappetence, weight loss, polyuria, and polydipsia. The animal did not respond to antibiotic and supportive therapy, became recumbent, and died. Gross examination revealed nodules in the liver, mesenteric and perirenal lymph nodes, and both kidneys, with segmental thickening of the small intestine. Histopathologic examination revealed multifocal lymphoma with moderate mitotic activity. Immunohistochemical staining of neoplastic cells was uniformly CD3-positive, indicating a T-cell lymphoma.

Implantation of the eSVS Mesh: modification of recommended technique.

The eSVS Mesh is a knitted wire lattice manufactured in cylindrical sheaths of various diameters, designed to be placed around the outer surface of a saphenous vein graft before use in coronary surgery. The goal is to improve long-term vein graft patency by preventing expansive endothelial injury obviating neointimal hyperplasia and subsequent graft atherosclerosis. Since the First-In-Man feasibility trial of the eSVS Mesh, postmarket studies in Europe and a feasibility trial in the United States are ongoing. Consensus from the principal investigators indicated the trials had confounding variables that may impact results other than evaluation of the eSVS Mesh alone. With input from these investigators, the recommended operative technique has been modified for future trials by removing the mesh from proximal and distal anastomoses and eliminating the use of fibrin sealant. These changes allow for use of an implant technique closer to standard vein bypass grafting and a more focused evaluation of the eSVS Mesh.

Clinical evaluation of the eSVS Mesh: First-in-Man trial outcomes.

In coronary artery bypass graft surgery, saphenous vein graft (SVG) patency is much lower than that of the internal mammary artery (IMA). To address this problem, an external support device, the eSVS Mesh was developed. A prospective randomized First-in-Man feasibility trial was conducted in 90 patients after institutional ethics committee approval at seven international centers. The left IMA was used to bypass the anterior descending artery. A mesh-supported (treated) saphenous vein was randomized to either the right or the circumflex coronary system, and an unsupported (control) vein was grafted to the opposing territory. Device diameters available for use were 3.0, 3.5, 4.0, and 4.5 mm. Primary end-points were 30 day adverse cardiac and cerebral events and angiographic patency at 9-12 months. Eighty-five of 90 patients returned for 30 day clinical follow-up (94%). Five patients refused to return, but by telephone contacts were asymptomatic. There was one late noncardiac death and 73 patients returned for angiography (82%), thus 12 additional patients were lost to follow-up at 1 year. Overall patency rate was 49% for the treated versus 81% for controls (p < 0.001). Subset analysis revealed significantly lower patency at one center and with use of the 3.0 mm device (p < 0.05). Removing these data, patency was 72% vs. 81% (p = NS). Sternal wound infection was higher than expected at 5.0%, but this was center specific. The eSVS Mesh is safe, but at up to 1 year, patency is equivalent to untreated vein grafts after removal of outlying data. This study provides insight into operative events and parameters that may optimize outcomes and point to potential improvements in the external SVG support device. Furthermore, longer term studies are pending.