Safety and Efficacy of Arterial Closure Devices in an Office-Based Angiosuite.

INTRODUCTION: We aimed to compare the safety and efficacy of 5 arterial closure devices in an outpatient endovascular surgery center. METHODS: We retrospectively reviewed all cases using femoral arterial access performed between January 2012 and December 2013. Five different arterial closure devices (AngioSeal, Perclose, StarClose, ExoSeal, and Mynx) were used by 7 endovascular surgeons. All femoral arteries were accessed with 6F sheaths under ultrasound guidance. All patients received systemic anticoagulation with sodium heparin (70 IU/kg). Sheath-shot angiograms of all arterial punctures were taken before deploying closure devices. Device failure was defined as any partial or complete failure requiring additional closure assistance. Minor complication was defined as any event that occurred because of incomplete hemostasis but did not result in hospitalization, including hematoma, hypotension, bleeding, arterial dissection, or extended recovery. Major complication was defined as any event that occurred because of incomplete hemostasis requiring inpatient management. Any device failure was identified per device and per surgeon. Device safety, efficacy, and relationships between other variables were analyzed using a binomial logistic regression. Results with P values < 0.05 were considered to be statistically significant. RESULTS: During the study period, there were a total of 3142 endovascular procedures, including 1976 arterial cases (62.9%). Out of 1898 femoral artery punctures, closure devices were used in 1810 (95.4%), which forms the basis of this report. Device failure occurred in 151 cases (8.34%), and minor complications occurred in 53 cases (2.93%). There were 11 hospitalizations (0.61%). AngioSeal had both the lowest device failure rate (3.5%) and minor complication rate (1.3%). Our data showed a significant difference between the respective arterial closure devices for device failure rate (P = 0.007) and minor complication rate (P = 0.049), but not for major complication rate (P = 0.199). No significant difference was observed between surgeons for device failure (P = 0.798), minor complication (P = 0.218), or major complication rate (P = 0.899). CONCLUSIONS: With the lowest device failure and minor complication rate, AngioSeal is a consistently well-performing arterial closure device in the office surgical suite setting.

Accuracy of computer-guided surgery: A comparison of operator experience.

STATEMENT OF PROBLEM: Even though high-precision technologies have been used in computer-guided implant surgery, studies have shown that linear and angular deviations between the planned and placed implants can be expected. PURPOSE: The purpose of this study was to evaluate the effect of operator experience on the accuracy of implant placement with a computer-guided surgery protocol. MATERIAL AND METHODS: Ten surgically experienced and 10 surgically inexperienced operators participated in this study. Each operator placed 1 dental implant (Replace Select) on the partially edentulous mandibular model that had been planned with software by following a computer-guided surgery (NobelGuide) protocol. Three-dimensional information of the planned and placed implants were then superimposed. The horizontal and vertical linear deviations at both the apex and platform levels and the angular deviation were measured and compared between the experienced and inexperienced groups with the independent t test with Bonferroni adjustment (α=.01). The magnitude and direction of the horizontal deviations were also measured and recorded. RESULTS: No significant differences were found in the angular and linear deviations between the 2 groups (P>.01). Although not statistically significant (P>.01), the amount of vertical deviation in the coronal direction of the implants placed by the inexperienced operators was about twice that placed by the experienced operators. Overall, buccal apical deviations were most frequent and of the highest magnitude. CONCLUSIONS: When a computer-guided protocol was used, the accuracy of the vertical dimension (depth of implant placement) was most influenced by the operator's level of experience.

The effect of changes in primary attending doctor coverage frequency on orthodontic treatment time and results.

OBJECTIVE: To determine whether changes in primary attending (PA) doctor coverage frequency caused an increase in orthodontic treatment time or a decrease in the quality of treatment results in a postgraduate orthodontic clinic. The effect of T1 Peer Assessment Rating (PAR) scores on PA doctor coverage frequency, treatment times, and results was also evaluated. MATERIALS AND METHODS: A sample of 191 postorthodontic subjects was divided into three groups based on PA doctor coverage (high, medium, or low). Treatment times, treatment results, and other variables were compared between the three PA coverage groups. Additionally, the sample was divided into three groups based on T1 PAR scores. Attending coverage frequency, treatment times, and results were compared between the T1 PAR groups. RESULTS: No statistically significant differences were found in treatment time (P  =  .128) or results (P  =  .052). There were no statistically significant differences in the mean scores for T1 PAR (P  =  .056), T2 PAR (P  =  .602), patient age at T1 (P  =  .747), total appointments (P  =  .128), missed appointments (P  =  .177), or cancelled appointments (P  =  .183). Statistically significant differences were found between the low T1 PAR group and the medium and high T1 PAR groups (attending coverage, P  =  .008; results, P < .001; treatment time, P  =  .001). CONCLUSIONS: Under the conditions of this study, variations in PA doctor coverage frequency did not lengthen orthodontic treatment or reduce the quality of treatment results. Low T1 PAR scores were associated with less PA coverage, less change in PAR, and shorter treatment times.

Periodontal health of anterior teeth with two types of fixed retainers.

OBJECTIVE: To compare the periodontal health of maxillary and mandibular anterior teeth retained with two types of fixed retainers. MATERIALS AND METHODS: A fixed straight retainer (SR) group had 39 subjects, and a fixed wave retainer (WR) group had 35 subjects. Subjects were between the ages of 13 and 22 years and had been in fixed retention for 2 to 4 years. Pocket probing depths, bleeding on probing, plaque index, calculus index, recession, and gingival crevicular fluid volume were compared between the two retainer groups. A four-question oral hygiene survey was given to each subject. The Mann-Whitney U-test and Fisher exact test was used to analyze the data. RESULTS: There was no clinically significant difference between the retainer groups regarding plaque index, gingival crevicular fluid volume, calculus index, recession, bleeding on probing, and pocket probing depths. A statistically significant increase in the reported frequency of flossing (P  =  .006) and ease of flossing (P < .001) was associated with the WR group. There was no significant difference between the groups in reported frequency of brushing and comfort of the retainer. CONCLUSIONS: Under the conditions of this study, no clinical difference was found in the periodontal health of anterior teeth retained with a SR or WR for a period of 2 to 4 years. Subjects in the WR group reported an increase in frequency and ease of flossing.

Horizontal and vertical dimensional changes of peri-implant facial bone following immediate placement and provisionalization of maxillary anterior single implants: a 1-year cone beam computed tomography study.

PURPOSE: This cone beam computed tomography study (CBCT) evaluated horizontal and vertical dimensional changes to the facial bone following maxillary anterior single immediate implant placement and provisionalization. MATERIALS AND METHODS: CBCT scans taken immediately after (T1) and 1 year after surgery (T2) were evaluated. The midsagittal cut of each implant was identified, and measurements were made at predetermined levels. Horizontal facial bone thickness (HFBT) was measured at 0, 1, 2, 4, 6, 9, and 12 mm apical to the implant platform. Vertical facial bone level (VFBL) was the perpendicular distance from the implant platform (0) to the most coronal point of the facial bone. Measurements were recorded and changes between T1 and T2 were calculated. The data were analyzed statistically at a significance level of α = 0.05. RESULTS: CBCT scans of 21 patients were analyzed. At T2, the mean HFBT changes ranged from -1.23 to -0.08 mm at the seven different levels evaluated. The mean VFBL change was -0.82 mm. The HFBT changes at the 1- to 9-mm levels were not significantly different from one another, but they were significantly smaller than the change at the 0-mm level and significantly greater than the change at the 12-mm level. Significant positive correlations were observed only between horizontal and vertical changes and between horizontal change and initial VFBL at the implant platform. While the VFBL of eight implants (38%) was apical to the implant platform at T2, none was noted at T1. CONCLUSIONS: Dimensional changes to the peri-implant facial bone following maxillary anterior single immediate implant placement and provisionalization should be expected. The greatest HFBT change was noted at the implant platform level, in part because HFBT change is correlated to the initial VFBL and the change in VFBL at that level.

Recombinant human bone morphogenetic protein 2 combined with an osteoconductive bulking agent for mandibular continuity defects in nonhuman primates.

PURPOSE: Recombinant human bone morphogenetic protein 2 (rhBMP-2) is an option for reconstructing mandibular continuity defects. A challenge of this technique is the need to maintain sufficient space to avoid compression of the defect. A compression-resistant matrix (CRM) provides a bulking agent that provides support during the bone formation phase. MATERIALS AND METHODS: Thirteen Rhesus Macaque monkeys were used to evaluate different forms of an osteoconductive bulking agent compared with an absorbable collagen alone placed into a critical-sized mandibular defect. A total of 5 groups (26 defects) were evaluated: group A, rhBMP-2/absorbable collagen sponge (ACS) (1.5 mg/mL); group B, rhBMP-2/ACS with ceramic granules (15% hydroxyapatite/85% ß-tricalcium phosphate) at 1.5 mg/mL; group C, rhBMP-2 (2.0 mg/mL) with a CRM; group D, rhBMP-2 (0.75 mg/mL) with a CRM; and group E, a CRM alone. RESULTS: Histology and micro computed tomography were used to evaluate and compare new bone formation in the defects. The reconstructed bone was evaluated with regard to the new bone formation, residual voids, and density. Animals treated with the CRM and rhBMP-2 at 2.0 mg/mL (group C) showed significantly higher amounts of new bone formation, bone density, and reduced voids when compared with rhBMP-2 and ACS (1.5 mg/mL) (P < .05). CONCLUSION: The carrier system CRM combined with rhBMP-2 and a reconstruction plate results in significantly higher bone density and better space maintenance than rhBMP-2 combined with ACS in a nonhuman primate mandibular bone repair model.

A comparison of cone-beam computed tomography and direct measurement in the examination of the mandibular canal and adjacent structures.

INTRODUCTION: The purpose of this investigation was to assess the ability of cone-beam computed tomography (CBCT) scanning to measure distances from the apices of selected posterior teeth to the mandibular canal. Measurements were taken from the apices of all posterior teeth that were superior to the mandibular canal. METHODS: A pilot study was performed to determine the scanning parameters that produced the most diagnostic image and the best dissection technique. Twelve human hemimandibles with posterior teeth were scanned at .20 voxels on an I-CAT Classic CBCT device (Imaging Sciences International, Hatfield, PA), and the scans were exported in Digital Imaging and Communications in Medicine (DICOM) format. The scans were examined in InVivo Dental software (Anatomage, San Jose, CA), and measurements were taken from the apex of each root along its long axis to the upper portion of the mandibular canal. The specimens were dissected under a dental operating microscope, and analogous direct measurements were taken with a Boley gauge. All measurements were taken in triplicate at least 1 week apart by one individual (TSK). The results were averaged and the data separated into matching pairs for statistical analysis. RESULTS: There was no statistical difference (alpha = .05) between the methods of measurement according to the Wilcoxon matched pairs test (p = 0.676). For the anatomic measurements, the intra-rater correlation coefficient (ICC) was .980 and for the CBCT it was .949, indicating that both methods were highly reproducible. Both measurement methods were highly predictive of and highly correlated to each other according to regression and correlation analysis, respectively. CONCLUSIONS: Based on the results of this study, the I-CAT Classic can be used to measure distances from the apices of the posterior teeth to the mandibular canal as accurately as direct anatomic dissection.

Temporary anchorage and segmental distraction osteogenesis devices: surgical and orthodontic rationales.

In recent orthodontic literature, the term "temporary anchorage devices (TADs)" has been used interchangeably with mini-implants for orthodontic anchorage. This article describes the use of TADs in conjunction with a tooth-borne segmental distraction osteogenesis device to treat mandibular anterior crowding with skeletal Class II and molar Class I relationships. The use of TADs prevents the rotation of the distracted segment, whereas the maxillary occlusal splint protects the distracted segment from anterior occlusal prematurities. The surgical and orthodontic rationales are also discussed.

Skeletal effects to the maxilla after rapid maxillary expansion assessed with cone-beam computed tomography.

INTRODUCTION: The purpose of this study was to use cone-beam computed tomography to quantitatively evaluate skeletal expansion and alveolar tipping of the maxilla at the maxillary canine (C1), first premolar (P1), second premolar (P2), and first molar (M1) after rapid maxillary expansion (RME). The transverse effects to the maxillary suture, nasal width, and maxillary sinus were also assessed. METHODS: Thirty consecutive patients (17 boys, 13 girls; mean age, 13.8 +/- 1.7 years) who required RME with Hyrax appliances as part of their comprehensive orthodontic treatment were studied. Measurements before and after RME of palatal and buccal maxillary widths, palatal alveolar angle, nasal width, nasal floor width, and maxillary sinus width at C1, P1, P2, and M1 were compared by using Wilcoxon signed rank, Kruskal-Wallis, and Wilcoxon rank sum tests. Pearson correlation analyses were also performed (* = .05). RESULTS AND CONCLUSIONS: Skeletal expansion of the maxilla had a triangular pattern with a wider base in the anterior region, accounting for 55% of total expansion at P1, 45% at P2, and 38% at M1. Alveolar bending or tipping accounted for 6% of total expansion at P1, 9% at P2, and 13% at M1. The remaining orthodontic (dental tipping) portions of total expansion were 39% at P1, 46% at P2, and 49% at M1. RME produces a statistically significant increase in nasal width and a decrease in maxillary sinus width (P <0.0001). Retention time showed a significant negative correlation to the change in palatal maxillary width at C1, P2, and M1 (P <0.05), the rate of appliance expansion had a significant correlation with palatal maxillary expansion at P1 and P2 (P <0.05), and age had no statistically significant association with any parameter (P >0.05).

Factors affecting buccal bone changes of maxillary posterior teeth after rapid maxillary expansion.

INTRODUCTION: The purpose of this study was to use cone-beam computed tomography (CBCT) images to determine the factors that might affect buccal bone changes of maxillary posterior teeth after rapid maxillary expansion (RME). METHODS: Thirty consecutive patients (17 boys, 13 girls; mean age, 13.8 +/- 1.7 years) who required RME as part of their orthodontic treatment and had the pre-RME (T1) and post-RME (T2) CBCT images available were included in the study. The T1 and T2 measurements of interdental distance, interdental angle (IA), buccal bone thickness (BBT), and buccal marginal bone levels (BMBL) of the first premolar (P1), the second premolar (P2), and the first molar (M1) were compared with the Friedman and the Wilcoxon signed rank tests. To determine which variables were associated with the changes in IA, BBT, and BMBL, the Spearman rank correlation analysis was performed (alpha = .05). RESULTS AND CONCLUSIONS: The results suggest that buccal crown tipping, and reduction of BBT and BMBL of the maxillary posterior teeth are the expected immediate effects of RME. There were no significant differences in dental expansion among P1, P2, and M1 (P >.05). P2 had clinically more buccal crown tipping (P = .116) but statistically less reduction in BBT and BMBL (P <.0001 and P = .001) than P1 and M1. Buccal bone changes and dental tipping on P2 were not affected by any other variables. Factors that showed significant correlation to buccal bone changes and dental tipping on P1 and M1 were age, appliance expansion, initial buccal bone thickness, and differential expansion (P <.05), but rate of expansion and retention time had no significant association (P >.05).

A comparison of synovial fluid pressure after immediate versus gradual mandibular advancement in the miniature pig.

PURPOSE: Mandibular advancement is a commonly performed surgical procedure for the treatment of mandibular hypoplasia. With the increased use of rigid fixation, there has been a decrease in the amount of relapse but an increase in the amount of force transmitted to the condyles. Gradual advancement of the mandible by distraction osteogenesis slowly overcomes the soft-tissue envelope and may decrease the amount of force exerted on the condyles. The purpose of this study was to develop an animal model to measure the magnitude of pressure associated with immediate versus gradual mandibular advancement. MATERIALS AND METHODS: A 2.0-mm pressure transducer was placed in the superior joint space in 2 miniature pigs. In the first animal, immediate advancement of the mandible with rigid fixation was performed. The synovial fluid hydrostatic pressures were measured prior to surgery and postoperatively. A second animal underwent gradual advancement with distraction osteogenesis. The synovial fluid hydrostatic pressures were measured prior to and after each activation of the distraction device. The condyles were examined radiographically and microscopically. RESULTS: The superior joint space fluid pressures increased and remained elevated over a 5-week period after immediate advancement. In the gradually advanced mandible, the pressures were elevated but returned to near baseline prior to the activation the following day. CONCLUSION: This animal model is useful to directly measure the pressure that is exerted on the condyle. This will allow further studies to compare methods for mandibular advancement. It is likely that gradual advancement of the mandible by distraction osteogenesis produces less force and causes less condylar resorption than large mandibular advancement stabilized with rigid fixation.

Implants as absolute anchorage.

Anchorage control is essential for successful orthodontic treatment. Each tooth has its own anchorage potential as well as propensity to move when force is applied. When teeth are used as anchorage, the untoward movements of the anchoring units may result in the prolonged treatment time, and unpredictable or less-than-ideal outcome. To maximize tooth-related anchorage, techniques such as differential torque, placing roots into the cortex of the bone, the use of various intraoral devices and/or extraoral appliances have been implemented. Implants, as they are in direct contact with bone, do not possess a periodontal ligament. As a result, they do not move when orthodontic/orthopedic force is applied, and therefore can be used as "absolute anchorage." This article describes different types of implants that have been used as orthodontic anchorage. Their clinical applications and limitations are also discussed.

Newtom QR-DVT 9000 imaging used to confirm a clinical diagnosis of iatrogenic mandibular nerve paresthesia.

This article describes conventional orthodontic treatment of an adult patient leading to lower lip paresthesia. The paresthesia subsided when the cross elastics to correct the patient's single molar crossbite were removed. It was determined with Digital Volumetric Tomography that the inferior alveolar nerve was located lingual to the lower second molar root and was impinged upon with the tipping force of the cross elastic. Treatment to resolve the crossbite without further paresthesia is discussed.

Factors in intestinal lymph after shock increase neutrophil adhesion molecule expression and pulmonary leukosequestration.

BACKGROUND: Because the ischemic gut may produce factors that initiate systemic inflammation, we tested the hypothesis that factors released from the gut into the mesenteric lymphatics increase neutrophil (PMN) adhesion molecule expression after trauma and shock. METHODS: At 1 and 4 hours after hemorrhagic shock (30 mm Hg x 90 minutes) plus trauma (laparotomy) (T/HS) or sham-shock (T/SS), with or without mesenteric lymph duct ligation, PMN CD11b and CD18 expression was assessed in male rats. In additional rats, mesenteric lymph samples were tested for their ability to increase PMN CD11b expression in vitro. Lastly, at 4 hours after T/SS or T/HS with or without lymph duct ligation, pulmonary PMN sequestration was measured. RESULTS: Compared with T/SS rats, T/HS was associated with up-regulation of PMN CD11b and CD18 expression, which was largely prevented by ligation of the mesenteric lymph duct (p < 0.01). Lymph duct ligation also prevented T/HS-induced pulmonary leukocyte sequestration (p < 0.01). In addition, mesenteric lymph from rats subjected to T/HS but not T/SS increased CD11b expression (p < 0.01). CONCLUSION: Factors produced or released by the postischemic intestine and carried in the mesenteric lymph appear responsible for PMN activation and pulmonary PMN sequestration after an episode of T/HS.

Gut injury and gut-induced lung injury after trauma hemorrhagic shock is gender and estrus cycle specific in the rat.

BACKGROUND: The purpose of this study was to test the hypothesis that trauma-hemorrhagic shock (T/HS)-induced gut and lung injury is modulated by gender and the stage of the estrus cycle at the time of injury. METHODS: We compared the incidence and magnitude of gut and lung injury in male and female rats subjected to a laparotomy (trauma) followed by 90 minutes of shock (mean arterial pressure, 30 mm Hg) (T/HS) or sham shock. RESULTS: Lung injury and pulmonary neutrophil sequestration as well as gut injury were increased after T/HS in the diestrus female and the male rats, but not in the estrus or proestrus female rats. Although T/HS caused gut and lung injury in the male and the female diestrus rats, the magnitude of injury was less in the female diestrus than in the male rats (p < 0.05). A strong correlation was found between intestinal villous injury and lung injury as well as between gut injury and pulmonary leukosequestration in the female rats subjected to T/HS (p < 0.0001). Plasma nitric oxide levels were approximately two- to threefold higher in the male and the diestrus female rats subjected to T/HS than in other groups (p < 0.05), and a high degree of correlation (r2 = 0.68, p < 0.0001) was found between villous injury and plasma nitric oxide levels. Ileal constitutive nitric oxide synthase (NOS) and inducible NOS (iNOS) activity was measured. Ileal constitutive NOS activity was similar between the groups, but iNOS activity was three- to fourfold higher in the T/HS male rats than in the sham shock or the T/HS proestrus groups (p < 0.01). CONCLUSION: Gender and estrus cycle stage influence susceptibility to T/HS-induced gut and lung injury. This difference in susceptibility to organ injury was associated with increased plasma nitric oxide levels and increased ileal iNOS activity.

A cephalometric study of the Class II correction effects of the Eureka Spring.

The effect of the Eureka Spring (ES) appliance was investigated on 37 consecutively treated, noncompliant patients with bilateral Class II malocclusions. Lateral cephalographs were taken at the start of orthodontic treatment (T1), at insertion of the ES (T2), and at removal of the ES (T3). The average treatment interval between T2 and T3 was four months. The Class II correction occurred almost entirely by dentoalveolar movement and was almost equally distributed between the maxillary and mandibular dentitions. The rate of molar correction was 0.7 mm/mo. There was no change in anterior face height, mandibular plane angle, palatal plane angle, or gonial angle with treatment. There was a 2 degrees change in the occlusal plane resulting from intrusion of the maxillary molar and the mandibular incisor. Based on the results in this sample, the ES appliance was very effective in correcting Class II malocclusions in noncompliant patients without increasing the vertical dimension.

Trauma/hemorrhagic shock mesenteric lymph upregulates adhesion molecule expression and IL-6 production in human umbilical vein endothelial cells.

Trauma/hemorrhagic shock (T/HS) is associated with significant lung injury, which is mainly due to an inflammatory process, resulting from the local activation and subsequent interaction of endothelial cells and leukocytes. Adhesion molecules expressed by both cell types play a crucial role in the process of neutrophil-mediated endothelial cell injury. We have previously shown that mesenteric lymph duct ligation prevents T/HS-induced lung leukocyte infiltration and endothelial injury, suggesting that inflammatory factors originating from the gut and carried in the lymph are responsible for the lung injury observed following T/HS. Based on these observations, we hypothesized that inflammatory substances in T/HS lymph trigger lung injury by a mechanism involving the upregulation of adhesion molecules. To test this hypothesis, we examined whether T/HS mesenteric lymph induces the expression of E-selectin, P-selectin, and intracellular adhesion molecule-1 (ICAM-1) in human umbilical vein endothelial cells (HUVECs). Furthermore, because the cytokine IL-6 is an important component of the endothelial inflammatory process, we investigated how T/HS lymph affects the production of IL-6 by HUVECs. Mesenteric lymph from T/HS rats increased both E- and P-selectin, as well as ICAM-1 expression on HUVECS, as compared to trauma/sham shock (T/SS) lymph or medium only groups. However, T/HS lymph failed to induce the shedding of E-selectin. In HUVECs treated with T/HS lymph, IL-6 concentrations were higher than HUVECs treated with T/SS lymph. These findings suggest that mesenteric lymph produced after hemorrhagic shock potentiates lung injury by the upregulation of endothelial cell adhesion molecule expression and IL-6 production.