Assessment of landmark detection in cephalometric radiographs with different conditions of brightness and contrast using the an artificial intelligence software.

OBJECTIVES: To evaluate the reliability and reproducibility of an artificial intelligence (AI) software in identifying cephalometric points on lateral cephalometric radiographs considering four settings of brightness and contrast. METHODS AND MATERIALS: Brightness and contrast of 30 lateral cephalometric radiographs were adjusted into four different settings. Then, the control examiner (ECont), the calibrated examiner (ECal), and the CEFBOT AI software (AIs) each marked 19 cephalometric points on all radiographs. Reliability was assessed with a second analysis of the radiographs 15 days after the first one. Statistical significance was set at p < 0.05. RESULTS: Reliability of landmark identification was excellent for the human examiners and the AIs regardless of the type of brightness and contrast setting (mean intraclass correlation coefficient >0.89). When ECont and ECal were compared for reproducibility, there were more cephalometric points with significant differences on the x-axis of the image with the highest contrast and the lowest brightness, namely N(p = 0.033), S(p = 0.030), Po(p < 0.001), and Pog'(p = 0.012). Between ECont and AIs, there were more cephalometric points with significant differences on the image with the highest contrast and the lowest brightness, namely N(p = 0.034), Or(p = 0.048), Po(p < 0.001), A(p = 0.042), Pog'(p = 0.004), Ll(p = 0.005), Ul(p < 0.001), and Sn(p = 0.001). CONCLUSIONS: While the reliability of the AIs for cephalometric landmark identification was rated as excellent, low brightness and high contrast seemed to affect its reproducibility. The experienced human examiner, on the other hand, did not show such faulty reproducibility; therefore, the AIs used in this study is an excellent auxiliary tool for cephalometric analysis, but still depends on human supervision to be clinically reliable.

Thresholds of Identification and Aesthetic Perception of Simulated Alar Base Widening Among Oral and Maxillofacial Surgeons: an Online Questionnaire-Based International Study / Limiares de Identificação e Percepção Estética do Alargamento Simulado da Base Alar Entre Cirurgiões Buco-Maxilo-Faciais: um Levantamento Internacional

This study aimed to compare the thresholds of identification and aesthetic perception of simulated alar base widening among oral and maxillofacial (OMF) surgeons from Brazil and other countries through an online data collection form. Photographs of one male and one female model were digitally manipulated to obtain aesthetically acceptable, symmetrical faces and to gradually widen the alar base to produce six different images from each original photograph. The online questionnaire was sent to OMF surgeons of different nationalities. The results mshowed that the majority of Brazilian (88%) and international (89%) evaluators considered the female faces with 0 to 2 mm of alar base widening as being more pleasant. In turn, Brazilian (93%) and international (94%) respondents agreed that faces with the greatest widening (8 and 10 mm) were less pleasant. As for the male model, Brazilian (93%) and international (85%) OMF surgeons agreed that faces with none or small widening (0 and 2 mm) were more pleasant. The male face with the greatest widening (10 mm) was considered the least attractive by the respondents (93% in both groups). The findings of this study suggest that alar base widening up to the limit of 2 mm did not alter the perception of facial attractiveness. Thus, faces without alar base widening were considered the most attractive, while those with significant alterations were considered less attractive. Most importantly, despite the limitations of this study design, it seems that different cultural and professional contexts have minor influence on aesthetics analysis performed by OMF surgeons. (AU)

Este estudo teve como objetivo comparar os limiares de identificação e percepção estética do alargamento simulado da base alar entre cirurgiões bucomaxilofaciais (BMF) do Brasil e de outros países por meio de um formulário de coleta de dados online. Fotografias de um modelo masculino e de uma modelo feminina foram manipuladas digitalmente para obter faces esteticamente aceitáveis e simétricas e para ampliar gradualmente a base alar produzindo seis imagens diferentes de cada fotografia original. O questionário online foi enviado aos cirurgiões BMF de diferentes nacionalidades. Os resultados mostraram que a maioria dos avaliadores brasileiros (88%) e internacionais (89%) consideraram as faces femininas com 0 a 2 mm de alargamento da base alar como mais agradáveis. Por sua vez, os entrevistados brasileiros (93%) e internacionais (94%) concordaram que os rostos com maior alargamento (8 e 10 mm) foram os menos agradáveis. Quanto ao modelo masculino, os cirurgiões brasileiros (93%) e internacionais (85%) da OMF concordaram que faces com nenhum ou pequeno alargamento (0 e 2 mm) eram mais agradáveis. A face masculina com maior alargamento (10 mm) foi considerada a menos atraente pelos entrevistados (93% em ambos os grupos). Nossos achados sugerem que o alargamento da base alar até o limite de 2 mm não alterou a percepção da atratividade facial. Assim, rostos sem alargamento da base alar foram considerados os mais atraentes, enquanto aqueles com alterações significativas foram considerados menos atraentes. Mais importante ainda, apesar das limitações, parece que diferentes contextos culturais e profissionais têm pouca influência na análise estética realizada pelos cirurgiões da OMF. (AU)

Artificial intelligence-based cephalometric landmark annotation and measurements according to Arnett's analysis: can we trust a bot to do that?

OBJECTIVE: To assess the reliability of CEFBOT, an artificial intelligence (AI)-based cephalometry software, for cephalometric landmark annotation and linear and angular measurements according to Arnett's analysis. METHODS: Thirty lateral cephalometric radiographs acquired with a Carestream CS 9000 3D unit (Carestream Health Inc., Rochester/NY) were used in this study. The 66 landmarks and the 10 selected linear and angular measurements of Arnett's analysis were identified on each radiograph by a trained human examiner (control) and by CEFBOT (RadioMemory Ltd., Belo Horizonte, Brazil). For both methods, landmark annotations and measurements were duplicated with an interval of 15 days between measurements and the intraclass correlation coefficient (ICC) was calculated to determine reliability. The numerical values obtained with the two methods were compared by a t-test for independent variables. RESULTS: CEFBOT was able to perform all but one of the 10 measurements. ICC values > 0.94 were found for the remaining eight measurements, while the Frankfurt horizontal plane - true horizontal line (THL) angular measurement showed the lowest reproducibility (human, ICC = 0.876; CEFBOT, ICC = 0.768). Measurements performed by the human examiner and by CEFBOT were not statistically different. CONCLUSION: Within the limitations of our methodology, we concluded that the AI contained in the CEFBOT software can be considered a promising tool for enhancing the capacities of human radiologists.

Immunolocalization of podoplanin/E11/gp38, CD44, and endomucin in the odontoblastic cell layer of murine tooth germs.

In this study, we attempted to localize the immunoreactivities of podoplanin/E11/gp38 and CD44, a counterpart possessing a high affinity to podoplanin/E11/gp38, as well as endomucin-immunoreactive blood vessels in the regions of odontoblast layers and the underlying sub-odontoblastic layers in murine tooth germs. Endomucin-reactive small blood vessels were scattered throughout the dental papillae of the tooth germs at postnatal day 1 but came to be localized close to the odontoblast/sub-odontoblastic layers until day 3. After postnatal day 5, small blood vessels were seen in odontoblast cell layers, while blood vessels with relatively larger diameters were seen forming in sub-odontoblastic layers. Immunoreactivities of podoplanin/E11/gp38 and CD44 were not detectable in the cells of dental papillae facing the inner enamel epithelium at postnatal day 1. However, at around postnatal days 3-5, podoplanin/E11/gp38 was localized in the odontoblast layer but not in the sub-odontoblastic layer, whereas CD44 was observed in the sub-odontoblastic layer but not in the odontoblast layer. The exclusive immunolocalization of podoplanin/E11/gp38 and CD44 in the odontoblast layers and sub-odontoblastic layers was seen after postnatal day 3 of the tooth germs, when the mesenchymal cells of dental papillae have already differentiated into mature odontoblasts at the cusp tip. Taken together, it seems likely that endomucin-reactive small blood vessels extended to the podoplanin/E11/gp38-positive odontoblast layers, whereas endomucin-reactive large blood vessels were already present in CD44-immmunopositive sub-odontoblastic layer, indicating the cellular regulation on the vascularization of endomucin-reactive endothelial cells during odontogenesis of the tooth germs.

Chronological immunolocalization of sclerostin and FGF23 in the mouse metaphyseal trabecular and cortical bone.

To assess the chronological participation of sclerostin and FGF23 in bone metabolism, this study tracked the immunolocalization of sclerostin and FGF23 in the metaphyses of murine long bones from embryonic day 18 (E18) through 1 day after birth, 1 week, 2 weeks, 4 weeks, 8 weeks, and 20 weeks of age. We have selected two regions in the metaphyseal trabeculae for assessing sclerostin and FGF23 localization: close to the chondro-osseous junction, i.e., bone modeling site even in the adult animals, and the trabecular region distant from the growth plate, where bone remodeling takes place. As a consequence, sclerostin-immunopositive osteocytes could not be observed in both close and distant trabecular regions early at the embryonic and young adult stages. However, osteocytes gradually started to express sclerostin in the distant region earlier than in the close region of the trabeculae. Immunoreactivity for FGF23 was observed mainly in osteoblasts in the early stages, but detectable in osteocytes in the later stages of growth in trabecular and cortical bones. Fgf23 was weakly expressed in the embryonic and neonatal stages, while the receptors, Fgfr1c and αKlotho were strongly expressed in femora. At the adult stages, Fgf23 expression became more intense while Fgfr1c and aKlotho were weakly expressed. These findings suggest that sclerostin is secreted by osteocytes in mature bone undergoing remodeling while FGF23 is synthesized by osteoblasts and osteocytes depending on the developmental/growth stage. In addition, it appears that FGF23 acts in an autocrine and paracrine fashion in fetal and neonatal bones.

Reduction mandibuloplasty for facial aesthetic enhancement in western women - a case report / Mandibuloplastia de redução para melhoria estética facial na mulher ocidental - relato de caso

This paper reports on the case of a Western female patient with square jaw and low mandibular angle deformity who sought treatment for aesthetic facial enhancement. While face-narrowing surgical procedures are especially popular among Asian women, there seems to be a general, cross-cultural agreement that a beautiful female face should be oval and slender. Under general anesthesia, intra-oral incisions were performed bilaterally to approach the mandibular angles. After periosteal elevation, bilateral corticectomies of the mandibular rami and "V" ostectomies of the mandibular base were executed. Postoperative recovery was uneventful. Six months after surgery, the patient's face was not only rounder and gentler in the frontal view, but also showed an evident increase of the gonial angles in the profile and three-quarter views.

Este trabalho relata o caso de uma paciente ocidental do sexo feminino com "face quadrada" e ângulo mandibular baixo que procurou tratamento para o aprimoramento estético facial. Embora procedimentos cirúrgicos que produzem um rosto mais estreito sejam especialmente populares entre mulheres asiáticas, parece haver um consenso geral e transcultural com relação às características de um rosto feminino bonito, que tende a ser oval e afilado. Sob anestesia geral, realizou-se incisões intra-orais para abordagem dos ângulos mandibulares. Após a elevação do periósteo, executou-se corticectomias das faces laterais dos ramos mandibulares e ostectomias em "V" das bordas inferiores da mandíbula. Não houve complicação pós-operatória. Seis meses após a cirurgia, a face da paciente mostrava-se não só mais arredondada e delicada na vista frontal, mas também com um aumento evidente dos ângulos goníacos nas vistas lateral e oblíqua.

Immunolocalization of osteocyte-derived molecules during bone fracture healing of mouse ribs.

We employed a well-standardized murine rib fracture model to assess the distribution, in the cortical bone, of three important osteocyte-derived molecules-dentine matrix protein 1 (DMP1), sclerostin and fibroblast growth factor 23 (FGF 23). Two days after the fracture, the periosteum thickened, and up to the seventh day post-fracture, the cortical surfaces were promoting neoformation of two tissue types depending on the distance from the fracture site: chondrogenesis was taking place near the fracture, and osteogenesis distant from it. The cortical bones supporting chondrogenesis featured several empty lacunae, while in the ones underlying newly-formed woven bone, empty lacunae were hardly seen. DMP1-immunopositive osteocytic lacunae and canaliculi were seen both close and away from the fracture. In contrast, the region close to the fracture had only few sclerostin- and FGF23-immunoreactive osteocytes, whereas the distant region revealed many osteocytes immunopositive for these markers. Mature cortical bone encompassing the native cortical bone was observed at two-, three- and four-weeks post-fracture, and the distribution of DMP1, sclerostin and FGF23 appeared to have returned to normal. In summary, early stages of fracture healing seem to be important for triggering chondrogenesis and osteogenesis that may be regulated by osteocytes via their secretory molecules.

Remoção de dente deslocado para o espaço bucal / Removal of a tooth displaced into the buccal space

A remoção cirúrgica de terceiros molares impactados é um procedimento cirúrgico comum, que pode ser realizado tanto por dentistas generalistas como por cirurgiões buco-maxilo-faciais. O deslocamento dental para espaços fasciais contíguos, entretanto, é um acidente relativamente raro, associado a exames clínico-radiográficos inadequados, à falta de conhecimentos da anatomia local, a acessos cirúrgicos inadequados, à visibilidade limitada e a movimentos cirúrgicos excessivos ou descontrolados.Embora a remoção de um dente deslocado seja normalmente realizada tardiamente, e, após estudos clínico-radiográficos minuciosos, resgates imediatos também são uma possibilidade. O objetivo deste trabalho é descrever o manejo de um terceiro molar superior deslocado acidentalmente para o espaço bucal após tentativa de exodontia... (AU)

The removal of impacted third molars is a common surgical procedure that may be performed by general dentists and oral and maxillofacial surgeons alike. Tooth displacement into contiguous fascial spaces, however, is a rather uncommon surgical mishap that is associated with inadequate clinical and radiographic examination, lack of sound anatomical knowledge, inadequate surgical access, limited visibility and excessive or uncontrolled surgical movements. While the removal of a displaced tooth is normally performed after thorough clinical and radiographic assessments in a mediate fashion, immediate surgical rescue is also a possibility. The aim of this paper is to describe the management of an upper third molar accidentally displaced into the buccal space after an attempt to extract... (AU)

Reliability, efficacy and reproducibility of the cervical vertebrae maturation index (CVMI) / Validade, efetividade e reprodutibilidade do índice de maturação das vértebras cervicais

Assessing skeletal maturation is an important determinant of successful orthodontic treatment planning for children and adolescents. While several methods are used skeletal maturation assessment, the hand-wrist radiograph is one of the most widely used. However, it does require additional exposing growing patients to additional radiation. Information on skeletal maturation can also be retrieved after evaluation of cervical vertebrae, which are commonly portrayed on the lateral cephalometric radiographs included in standard orthodontic documentation. By means of a systematic review of the available literature, this work aimed to verify the reliability, efficacy, and reproducibility of skeletal age determination based on the evaluation of cervical vertebrae. The LILACS, SciELO and PubMed databases were searched using the keywords "cervical vertebrae" and "cervical maturation". Only texts in Portuguese, Spanish, and English published in the last 10 years were selected. Twenty-nine full articles were retrieved and critically appraised. According to these references, the Cervical Vertebrae Maturation Index appears to be a valid, reliable, and reproducible method for skeletal maturation assessment and may substitute the analysis of hand-wrist radiograph in orthodontic treatment planning.

A determinação da fase de maturação esquelética é ponto fundamental no tratamento ortodôntico de crianças e adolescentes, e muitos métodos são utilizados com este objetivo, sendo a análise da radiografia de mão e punho o mais comumente difundido no meio ortodôntico. Entretanto, esta informação também pode ser obtida por meio de radiografias cefalométricas laterais, com base na avaliação das vértebras cervicais, eliminando a necessidade de exposição a mais de radiação e o custo associado de novos exames. O objetivo deste trabalho foi checar, com base na literatura, a confiabilidade, a efetividade e a reprodutibilidade do método de estimativa da idade esquelética, por meio das vértebras cervicais. Para tanto, foi realizada uma revisão crítica da literatura, utilizando as palavras-chave "vértebras cervicais" e "maturação cervical". Foram encontrados 29 artigos nas bases de dados LILACS, PubMed e SciELO. De acordo com as referências encontradas, o Índice de Maturação das Vértebras Cervicais pode ser considerado um método válido, confiável e reprodutível na análise da maturação óssea, podendo ser utilizado na prática ortodôntica, em substituição à análise da radiografia de mão e punho.

Osteonecrose dos maxilares relacionada ao uso de bisfosfonatos orais: relato de caso / Oral bisphosphonate-related osteonecrosis of the jaws: a case report

Os bisfosfonatos são uma classe de medicamentos caracterizados como potentes inibidores da reabsorção óssea conduzida por osteoclastos e têm sido empregados para o tratamento de diversas entidades patológicas que atingem o tecido ósseo, como osteoporose e metástases ósseas de tumores malignos. Porém, vem aumentando o número de publicações em relação a um efeito colateral destas drogas: a osteonecrose dos maxilares relacionada aos bisfosfonatos (OMARB). Este trabalho relata o caso de uma paciente que fazia uso de alendronato por via oral, por um período de aproximadamente dez anos, para tratamento de osteoporose. Na evolução do caso, verificou-seexposição óssea em região de palato duro e corpo de mandíbula, associada a quadro de dor. Foi conduzida uma revisão da literatura pertinente e o manejo da condição é discutido.

Bisphosphonates are a class of drugs characterized by being potent inhibitors of osteoclast-driven bone resorption, and are currently used for treatment of various conditions such as osteoporosis and metastatic lesions in bone. There has been an increase in reports of a serious side effect of these drugs, the bisphosphonate-related osteonecrosis ofthe jaws (BRONJ). We report on the case of a female patient who had been in use of oral alendronate for over 10 years due to osteoporosis. She presented to our outpatient clinics with painful exposure of bone intra-orally (hard palate and mandibular body). In this work, the pertinent literature is reviewed and the management of the condition is discussed.

Uso de proteínas recombinantes na reconstrução de maxilares / Use of recombinant proteins for maxillary reconstruction

Reconstrução óssea dos maxilares após ressecções tumorais, avulsões traumáticas ou mesmo reabsorção por desuso é uma das tarefas maisdifíceis na clínica do implantodontista e do cirurgião bucomaxilofacial. As propriedades osteogênicas, osteoindutoras, osteocondutoras enão-antigênicas do osso autógeno o colocam como o padrão-ouro para a solução de problemas de disponibilidade óssea. Entretanto, anecessidade de um segundo sítio cirúrgico para a coleta do enxerto, aumenta significativamente o custo e a morbidade associados aoprocedimento reconstrutivo. A enxertia óssea ganhou uma excelente ferramenta com a descoberta das proteínas ósseas morfogenéticas(conhecidas como BMP, do inglês bone morphogenetic proteins) na década de 60. O benefício da obtenção de matriz óssea verdadeira efuncional sem a necessidade de um segundo sítio cirúrgico parece ser a grande vantagem do uso das proteínas ósseas morfogenéticas. Noentanto, aspectos importantes da utilização de proteínas recombinantes humanas tais como controle da taxa de liberação da proteína ao longodo processo de reparo ósseo, ainda necessitam de estudos aprofundados para que parâmetros clínicos de utilização possam ser estabelecidos. Além disso, estudos clínicos de longa duração avaliando as características biomecânicas do osso neoformado após administração de proteínas ósseas morfogenéticas ainda são escassos. Embora promissora, a utilização das proteínas morfogenéticas ósseas na clínica implantodôntica e bucomaxilofacial ainda necessita de maior respaldo científico.

Jaw bone reconstruction after tumour resection, traumatic avulsion or even atrophy due to disuse is one of the most challenging clinical tasksfor implantologists and maxillofacial surgeons. Autogenous bone, with its osteogenic, osteoinductive and non-antigenic properties, has beenconsidered the gold standard in the resolution of bone availability problems. However, the need for a second surgical site in order to harvestthe bone graft significantly increases both the cost and the morbidity related to reconstructive procedures. Bone grafting gained an importanttool with the discovery of bone morphogenetic proteins (BMPs) in the 1960s. Obtaining a true, functional bone matrix without bone harvestingmay be the greatest benefit from BMP usage. Nevertheless, fundamental aspects of BMP application such as the control of protein releasethroughout the process of bone repair are yet to be fully understood, with clinical guidelines for usage of the protein remaining uncertain.Moreover, long-term clinical studies assessing the biomechanical properties of bone formed after BMP application are sporadic. Althoughpromising, the widespread use of bone morphogenetic proteins by implantologists and maxillofacial surgeons demands greater scientificsupport.