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.

A clinically relevant accuracy study of computer-planned implant placement in the edentulous maxilla using mucosa-supported surgical templates.

PURPOSE: The purpose of the study is to determine the clinically relevant accuracy of implant placement in the edentulous maxilla using computer planning and a mucosa-supported surgical template. MATERIALS AND METHODS: In each of in total 30 consecutive edentulous patients suffering from retention problems of their upper denture, two or four Brånemark MkIII Groovy (Nobel Biocare®, Zürich, Switzerland) implants in the maxilla were installed. Preoperatively, first, a cone-beam computer tomography (cone beam computer tomography) scan was acquired, followed by virtual implant planning. Hereafter, a surgical template was designed to allow flapless implant placement using the template as a guide. To inventory the accuracy of implant placement, a postoperative CBCT scan was obtained and matched to the preoperative scan. The accuracy of implant placement was validated three-dimensionally. The Implant Position Orthogonal Projection validation method was applied to measure the clinically relevant implant deviations (i.e., in both the bucco-lingual and mesio-distal plane). Also, the influence of type of surgery, use of fixation pins, and position on the dental arch were investigated with regard to implant deviations. RESULTS: In total, 104 implants were installed. In bucco-lingual direction, a mean implant deviation of 0.67 mm was scored at the implant tip, of 0.51 mm at the shoulder, of -0.83 mm in depth, as also a mean deviation of angulation of 1.74°. In mesio-distal direction, a mean implant deviation of 0.75 mm was found at the implant tip, of 0.60 mm at the implant shoulder, of -0.75 mm in depth, and a deviation of angulation of 1.94°. Of all implants, 74% was placed not deep enough compared with the planning. Implant position on the dental arch, the use of fixation pins, and type of surgery showed no significant effect on implant deviations. However, a significant difference for implant deviations in both buccal and mesial direction was observed, explained by a nonoptimal positioning of the surgical template. CONCLUSIONS: Computer-aided implant planning showed to be a clinically relevant tool for the placement of two or four implants in the maxilla of fully edentulous patients. Exact positioning of the surgical template in anterior/posterior direction is crucial in reducing implant deviations both in buccal and mesial direction.

A clinically relevant validation method for implant placement after virtual planning.

PURPOSE: To design a relevant method to compare the virtual planned implant position to the ultimately achieved implant position and to evaluate, in case of discrepancy, the cause for this. MATERIALS AND METHODS: Five consecutive edentulous patients with retention problems of the upper denture received four implants in the maxilla. Preoperatively, first a cone-beam CT (CBCT) scan was acquired, followed by virtual implant planning. Then, a surgical template was designed and endosseous implants were flapless installed using the template as a guide. To inventory any differences in position, the postoperative CBCT scan was matched to the preoperative scan. The accuracy of implant placement was validated three-dimensionally (3D) and the Implant Position Orthogonal Projection (IPOP) validation method was applied to project the results to a bucco-lingual and mesio-distal plane. Subsequently, errors introduced by virtual planning, surgical instruments, and validation process were evaluated. RESULTS: The bucco-lingual deviations were less obvious than mesio-distal deviations. A maximum linear tip deviation of 2.84 mm, shoulder deviation of 2.42 mm, and angular deviation of 3.41° were calculated in mesio-distal direction. Deviations included errors in planning software (maximum 0.15 mm), for surgical procedure (maximum 2.94°), and validation process (maximum 0.10 mm). CONCLUSIONS: This study provides the IPOP validation method as an accurate method to evaluate implant positions and to elucidate inaccuracies in virtual implant planning systems.

Own song selectivity in the songbird auditory pathway: suppression by norepinephrine.

BACKGROUND: Like human speech, birdsong is a learned behavior that supports species and individual recognition. Norepinephrine is a catecholamine suspected to play a role in song learning. The goal of this study was to investigate the role of norepinephrine in bird's own song selectivity, a property thought to be important for auditory feedback processes required for song learning and maintenance. METHODOLOGY/PRINCIPAL FINDINGS: Using functional magnetic resonance imaging, we show that injection of DSP-4, a specific noradrenergic toxin, unmasks own song selectivity in the dorsal part of NCM, a secondary auditory region. CONCLUSIONS/SIGNIFICANCE: The level of norepinephrine throughout the telencephalon is known to be high in alert birds and low in sleeping birds. Our results suggest that norepinephrine activity can be further decreased, giving rise to a strong own song selective signal in dorsal NCM. This latent own song selective signal, which is only revealed under conditions of very low noradrenergic activity, might play a role in the auditory feedback and/or the integration of this feedback with the motor circuitry for vocal learning and maintenance.

Implementation of spin-echo blood oxygen level-dependent (BOLD) functional MRI in birds.

The advent of high-field MRI systems has allowed the implementation of blood oxygen level-dependent functional MRI (BOLD fMRI) on small animals. An increased magnetic field improves the signal-to-noise ratio and thus allows an improvement in the spatial resolution. However, it also increases susceptibility artefacts in the commonly acquired gradient-echo images. This problem is particularly prominent in songbird MRI because of the presence of numerous air cavities in the skull of birds. These T(2)*-related image artefacts can be circumvented using spin-echo BOLD fMRI. In this article, we describe the implementation of spin-echo BOLD fMRI in zebra finches, a small songbird of 15-25 g, extensively studied in the behavioural neurosciences of birdsong. Because the main topics in this research domain are song perception and song learning, the protocol implemented used auditory stimuli. Despite the auditory nature of the stimuli and the weak contrast-to-noise ratio of spin-echo BOLD fMRI compared with gradient-echo BOLD fMRI, we succeeded in detecting statistically significant differences in BOLD responses triggered by different stimuli. This study shows that spin-echo BOLD fMRI is a viable approach for the investigation of auditory processing in the whole brain of small songbirds. It can also be applied to study auditory processing in other small animals, as well as other sensory modalities.

MRI in small brains displaying extensive plasticity.

Manganese-enhanced magnetic resonance imaging (ME-MRI), blood oxygen-level-dependent functional MRI (BOLD fMRI) and diffusion tensor imaging (DTI) can now be applied to animal species as small as mice or songbirds. These techniques confirmed previous findings but are also beginning to reveal new phenomena that were difficult or impossible to study previously. These imaging techniques will lead to major technical and conceptual advances in systems neurosciences. We illustrate these new developments with studies of the song control and auditory systems in songbirds, a spatially organized neuronal circuitry that mediates the acquisition, production and perception of complex learned vocalizations. This neural system is an outstanding model for studying vocal learning, brain steroid hormone action, brain plasticity and lateralization of brain function.

Own-song recognition in the songbird auditory pathway: selectivity and lateralization.

The songbird brain is able to discriminate between the bird's own song and other conspecific songs. Determining where in the brain own- song selectivity emerges is of great importance because experience-dependent mechanisms are necessarily involved and because brain regions sensitive to self-generated vocalizations could mediate auditory feedback that is necessary for song learning and maintenance. Using functional MRI, here we show that this selectivity is present at the midbrain level. Surprisingly, the selectivity was found to be lateralized toward the right side, a finding reminiscent of the potential right lateralization of song production in zebra finches but also of own-face and own-voice recognition in human beings. These results indicate that a midbrain structure can process subtle information about the identity of a subject through experience-dependent mechanisms, challenging the classical perception of subcortical regions as primitive and nonplastic structures. They also open questions about the evolution of the cognitive skills and lateralization in vertebrates.

Functional MRI of auditory responses in the zebra finch forebrain reveals a hierarchical organisation based on signal strength but not selectivity.

BACKGROUND: Male songbirds learn their songs from an adult tutor when they are young. A network of brain nuclei known as the 'song system' is the likely neural substrate for sensorimotor learning and production of song, but the neural networks involved in processing the auditory feedback signals necessary for song learning and maintenance remain unknown. Determining which regions show preferential responsiveness to the bird's own song (BOS) is of great importance because neurons sensitive to self-generated vocalisations could mediate this auditory feedback process. Neurons in the song nuclei and in a secondary auditory area, the caudal medial mesopallium (CMM), show selective responses to the BOS. The aim of the present study is to investigate the emergence of BOS selectivity within the network of primary auditory sub-regions in the avian pallium. METHODS AND FINDINGS: Using blood oxygen level-dependent (BOLD) fMRI, we investigated neural responsiveness to natural and manipulated self-generated vocalisations and compared the selectivity for BOS and conspecific song in different sub-regions of the thalamo-recipient area Field L. Zebra finch males were exposed to conspecific song, BOS and to synthetic variations on BOS that differed in spectro-temporal and/or modulation phase structure. We found significant differences in the strength of BOLD responses between regions L2a, L2b and CMM, but no inter-stimuli differences within regions. In particular, we have shown that the overall signal strength to song and synthetic variations thereof was different within two sub-regions of Field L2: zone L2a was significantly more activated compared to the adjacent sub-region L2b. CONCLUSIONS: Based on our results we suggest that unlike nuclei in the song system, sub-regions in the primary auditory pallium do not show selectivity for the BOS, but appear to show different levels of activity with exposure to any sound according to their place in the auditory processing stream.

Functional magnetic resonance imaging in zebra finch discerns the neural substrate involved in segregation of conspecific song from background noise.

Recently, fMRI was introduced in a well-documented animal model for vocal learning, the songbird. Using fMRI and conspecific signals mixed with different levels of broadband noise, we now demonstrate auditory-induced activation representing discriminatory properties of auditory forebrain regions in anesthetized male zebra finches (Taeniopygia guttata). Earlier behavioral tests showed comparable calling responses to the original conspecific song stimulus heard outside and inside the magnet. A significant fMRI response was elicited by conspecific song in the primary auditory thalamo-recipient subfield L2a; in neighboring subareas L2b, L3, and L; and in the rostral part of the higher-order auditory area NCM (caudomedial nidopallium). Temporal BOLD response clustering revealed rostral and caudal clusters that we defined as "cluster Field L" and "cluster NCM", respectively. However, because the actual border between caudal Field L subregions and NCM cannot be seen in the structural MR image and is not precisely reported elsewhere, the cluster NCM might also contain subregion L and the medial extremes of the subregions L2b and L3. Our results show that whereas in cluster Field L the response was not reduced by added noise, in cluster NCM the response was reduced and finally disappeared with increasing levels of noise added to the song stimulus. The activation in cluster NCM was significant for only two experimental stimuli that showed significantly more behavioral responses than the more degraded stimuli, suggesting that the first area within the auditory system where the ability to discern song from masking noise emerges is located in cluster NCM.

Neural representation of spectral and temporal features of song in the auditory forebrain of zebra finches as revealed by functional MRI.

Song perception in songbirds, just as music and speech perception in humans, requires processing the spectral and temporal structure found in the succession of song-syllables. Using functional magnetic resonance imaging and synthetic songs that preserved exclusively either the temporal or the spectral structure of natural song, we investigated how vocalizations are processed in the avian forebrain. We found bilateral and equal activation of the primary auditory region, field L. The more ventral regions of field L showed depressed responses to the synthetic songs that lacked spectral structure. These ventral regions included subarea L3, medial-ventral subarea L and potentially the secondary auditory region caudal medial nidopallium. In addition, field L as a whole showed unexpected increased responses to the temporally filtered songs and this increase was the largest in the dorsal regions. These dorsal regions included L1 and the dorsal subareas L and L2b. Therefore, the ventral region of field L appears to be more sensitive to the preservation of both spectral and temporal information in the context of song processing. We did not find any differences in responses to playback of the bird's own song vs other familiar conspecific songs. We also investigated the effect of three commonly used anaesthetics on the blood oxygen level-dependent response: medetomidine, urethane and isoflurane. The extent of the area activated and the stimulus selectivity depended on the type of anaesthetic. We discuss these results in the context of what is known about the locus of action of the anaesthetics, and reports of neural activity measured in electrophysiological experiments.

IR-SE and IR-MEMRI allow in vivo visualization of oscine neuroarchitecture including the main forebrain regions of the song control system.

Songbirds share with humans the capacity to produce learned vocalizations (song). Recently, two major regions within the songbird's neural substrate for song learning and production; nucleus robustus arcopallii (RA) and area X (X) are visualized in vivo using Manganese Enhanced MRI (MEMRI). The aim of this study is to extend this to all main interconnected forebrain Song Control Nuclei. The ipsilateral feedback circuits allow Mn2+ to reach all main Song Control Nuclei after stereotaxic injection of very small doses of MnCl2 (10 nl of 10 mM) into HVC of one and MAN (nucleus magnocellularis nidopallii anterioris) of the other hemisphere. Application of a high resolution (80 micron) Spin Echo Inversion Recovery sequence instead of conventional T1-weighted Spin Echo images improves the image contrast dramatically such that some Song Control Nuclei, ventricles, several laminae, fibre tracts and other specific brain regions can be discerned. The combination of this contrast-rich IR-SE sequence with the transsynaptic transport property of Manganese (Inversion Recovery based MEMRI (IR-MEMRI)) enables the visualization of all main interconnected components of the Song Control System in telencephalon and thalamus.

Spatiotemporal properties of the BOLD response in the songbirds' auditory circuit during a variety of listening tasks.

Auditory fMRI in humans has recently received increasing attention from cognitive neuroscientists as a tool to understand mental processing of learned acoustic sequences and analyzing speech recognition and development of musical skills. The present study introduces this tool in a well-documented animal model for vocal learning, the songbird, and provides fundamental insight in the main technical issues associated with auditory fMRI in these songbirds. Stimulation protocols with various listening tasks lead to appropriate activation of successive relays in the songbirds' auditory pathway. The elicited BOLD response is also region and stimulus specific, and its temporal aspects provide accurate measures of the changes in brain physiology induced by the acoustic stimuli. Extensive repetition of an identical stimulus does not lead to habituation of the response in the primary or secondary telencephalic auditory regions of anesthetized subjects. The BOLD signal intensity changes during a stimulation and subsequent rest period have a very specific time course which shows a remarkable resemblance to auditory evoked BOLD responses commonly observed in human subjects. This observation indicates that auditory fMRI in the songbird may establish a link between auditory related neuro-imaging studies done in humans and the large body of neuro-ethological research on song learning and neuro-plasticity performed in songbirds.