Sensitivity of hostile hemodynamics to aneurysm geometry via unsupervised shape interpolation.

BACKGROUND AND OBJECTIVE: Vessel geometry and hemodynamics are intrinsically linked, whereby geometry determines hemodynamics, and hemodynamics influence vascular remodeling. Both have been used for testing clinical outcomes, but geometry/morphology generally has less uncertainty than hemodynamics derived from medical image-based computational fluid dynamics (CFD). To provide clinical utility, CFD-based hemodynamic parameters must be robust to modeling errors and/or uncertainties, but must also provide useful information not more-easily extracted from shape alone. The objective of this study was to methodically assess the response of hemodynamic parameters to gradual changes in shape created using an unsupervised 3D shape interpolation method. METHODS: We trained the neural network NeuroMorph on 3 patient-derived intracranial aneurysm surfaces (labelled A, B, C), and then generated 3 distinct morph sequences (A→B, B→C, C→A) each containing 10 interpolated surfaces. From high-fidelity CFD simulation of these, we calculated a variety of common reduced hemodynamic parameters, including many previously associated with aneurysm rupture, and analyzed their responses to changes in shape, and their correlations. RESULTS: The interpolated surfaces demonstrate complex, gradual changes in branch angles, vessel diameters, and aneurysm morphology. CFD simulation showed gradual changes in aneurysm jetting characteristics and wall-shear stress (WSS) patterns, but demonstrated a range of responses from the reduced hemodynamic parameters. Spatially and temporally averaged parameters including time-averaged WSS, time-averaged velocity, and low-shear area (LSA) showed low variation across all morph sequences, while parameters of flow complexity such as oscillatory shear, spectral broadening, and spectral bandedness indices showed high variation between slightly-altered neighboring surfaces. Correlation analysis revealed a great deal of mutual information with easier-to-measure shape-based parameters. CONCLUSIONS: In the absence of large clinical datasets, unsupervised shape interpolation provides an ideal laboratory for exploring the delicate balance between robustness and sensitivity of nominal hemodynamic predictors of aneurysm rupture. Parameters like time-averaged WSS and LSA that are highly "robust" may, as a result, be effectively redundant to morphological predictors, whereas more sensitive parameters may be too uncertain for practical clinical use. Understanding these sensitivities may help identify parameters that are capable of providing added value to rupture risk assessment.

Improving visualization of three-dimensional aneurysm features via segmentation with upsampled resolution and gradient enhancement (SURGE).

BACKGROUND: Intracranial aneurysm neck width tends to be overestimated when measured with three-dimensional rotational angiography (3DRA) compared with two-dimensional digital subtraction angiography (2D-DSA), owing to high curvature at the neck. This may affect morphological and hemodynamic analysis in support of treatment planning. We present and validate a method for extracting high curvature features, such as aneurysm ostia, during segmentation of 3DRA images. METHODS: In our novel SURGE (segmentation with upsampled resolution and gradient enhancement) approach, the gradient of an upsampled image is sharpened before gradient-based watershed segmentation. Neck measurements were performed for both standard and SURGE segmentations of 3DRA for 60 consecutive patients and compared with those from 2D-DSA. Those segmentations were also qualitatively compared for surface topology and morphology. RESULTS: Compared with the standard watershed method, SURGE reduced neck measurement error relative to 2D-DSA by >60%: median error was 0.49 mm versus 0.17 mm for SURGE, which is less than the average pixel resolution (~0.33 mm) of the 3DRA dataset. SURGE reduced neck width overestimations >1 mm from 13/60 to 5/60 cases. Relative to 2D-DSA, standard segmentations were overestimated by 16% and 93% at median and 95th percentiles, respectively, compared with only 6% and 37%, respectively, for SURGE. CONCLUSION: SURGE provides operators with high-level control of the image gradient, allowing recovery of high-curvature features such as aneurysm ostia from 3DRA where conventional algorithms may fail. Compared with standard segmentation and tedious manual editing, SURGE provides a faster, easier, and more objective method for assessing aneurysm ostia and morphology.

Aneurysm Neck Overestimation has a Relatively Modest Impact on Simulated Hemodynamics.

INTRODUCTION: Overestimation of intracranial aneurysm neck width by 3D angiography is a recognized clinical problem, and has long been a concern for image-based computational fluid dynamics (CFD). Recently, it was demonstrated that neck overestimation in 3D rotational angiography (3DRA) could be corrected via segmentation with upsampled resolution and gradient enhancement (SURGE). Our aim was to leverage this approach to determine whether and how neck overestimation actually impacts CFD-derived hemodynamics. MATERIALS AND METHODS: A subset of 17 cases having the largest neck errors from a consecutive clinical sample of 60 was segmented from 3DRA using both standard watershed and SURGE methods. High-fidelity, pulsatile CFD was performed, and a variety of scalar hemodynamic parameters that have been associated with aneurysm growth and/or rupture status were derived. RESULTS: With a few exceptions, flow and wall shear stress (WSS) patterns were qualitatively similar between neck-overestimated and corrected models. Sac-averaged WSS values were significantly lower after neck correction (p = 0.0005) but were highly correlated with their neck-overestimated counterparts (R2 = 0.98). Jet impingement was significantly more concentrated in the neck-corrected vs. -uncorrected models (p = 0.0011), and only moderately correlated (R2 = 0.61). Parameters quantifying velocity or WSS fluctuations were not significantly different after neck correction, but this reflected their poorer correlations (R2 < 0.4). Nevertheless, for all hemodynamic parameters, median absolute differences were < 26%, and no parameter had more than 5/17 cases with absolute differences > 50%. CONCLUSION: Differences in hemodynamics due to neck width overestimation were found to be at most equal to, and often less than, those reported for other sources of error/uncertainty in intracranial aneurysm CFD, such as solver settings or assumed inflow rates.

Integrating computational fluid dynamics data into medical image visualization workflows via DICOM.

PURPOSE: Communicating complex blood flow patterns generated from computational fluid dynamics (CFD) simulations to clinical audiences for the purposes of risk assessment or treatment planning is an ongoing challenge. While attempts have been made to develop new software tools for such clinical visualization of CFD data, these often overlook established medical imaging/visualization practice and data infrastructures. Here, leveraging the clinical ubiquity of the DICOM file format, we present techniques for the translation of CFD data to DICOM series, facilitating interactive visualization in standard radiological software. METHODS: Unstructured CFD data (volumetric fields of velocity magnitude, Q-criterion, and pathlines) are resampled to structured grids. Novel raster-based techniques that simulate experimental optical blurring are presented for bringing simulated pathlines into structured image volumes. DICOM series are created by strategically encoding these data into the file's PixelArray tag. Lumen surface information is also strategically encoded into a different range of pixel intensities, allowing hemodynamics and morphology to be co-visualized in a single volume using opacity-based rendering transfer functions. RESULTS: We show that 3D temporal CFD data represented as structured DICOM series can be rendered interactively in Horos, a widely-used medical imaging/radiology software. Our transfer function-based approach allows for representations of scalar isosurfaces, volumetric rendering, and tubular pathlines to be modified in real-time, resembling conventional unstructured visualizations. Careful selection of voxelization ROIs helps to ensure that data are kept lightweight for real-time rendering and minimal storage. CONCLUSION: While our approach inherently sacrifices some of the advanced visualization capabilities of specialized software tools, we believe our closer consideration of standardization can help to facilitate meaningful clinical interaction. This work opens up possibilities for the complete integration of measured and simulated data in established radiological software environments and workflows from PACS storage to 3D/4D visualization.

Spectral Bandedness in High-Fidelity Computational Fluid Dynamics Predicts Rupture Status in Intracranial Aneurysms.

Recent studies using high-fidelity computational fluid dynamics (CFD) have revealed high-frequency flow instabilities consistent with clinical reports of bruits and "musical murmurs", which have been speculated to contribute to aneurysm growth and rupture. We hypothesized that harmonic flow instabilities ("spectral bandedness") in aneurysm CFD data may be associated with rupture status. Before testing this hypothesis, we first present a novel method for quantifying and visualizing spectral bandedness in cardiovascular CFD datasets based on musical audio-processing tools. Motivated by previous studies of aneurysm hemodynamics, we also computed a selection of existing metrics that have demonstrated association with rupture in large studies. In a dataset of 50 bifurcation aneurysm geometries modeled using high-fidelity CFD, our spectral bandedness index (SBI) was the only metric significantly associated with rupture status (AUC = 0.76, p = 0.002), with a specificity of 79% (correctly predicting 19/24 unruptured cases) and sensitivity of 65% (correctly predicting 17/26 ruptured cases). Three-dimensional flow visualizations revealed coherent regions of high SBI to be associated with strong near-wall inflow jets and vortex-shedding/flutter phenomena in the aneurysm sac. We speculate that these intracycle, coherent flow instabilities may preferentially contribute to the progressive degradation of the aneurysm wall through flow-induced vibrational mechanisms, and that their absence in high-fidelity CFD may be useful for identifying intracranial aneurysms at lower risk of rupture.

On the spectrographic representation of cardiovascular flow instabilities.

In the past decade, high-fidelity computational fluid dynamics (CFD) has uncovered the presence of high-frequency flow instabilities (on the order of 100 s of Hz) in a variety of cardiovascular applications. These fluctuations are typically reported as pulsatile velocity-time traces or fast-Fourier-transformed power-frequency spectra, often from a single point or at most a handful of points. Originally inspired by its use in spectral Doppler ultrasound, here we demonstrate the utility of the simplest form of time-frequency representation - the spectrogram - as a more comprehensive yet still-intuitive means of visualizing the potential harmonic complexity of pulsatile cardiovascular flows. After reviewing the basic theory behind spectrograms, notably the short-time Fourier transform (STFT), we discuss the choice of input parameters that inform the appearance and trade-offs of spectrograms. We show that spectrograms using STFT were able to highlight spectral features and were representative of those obtained from more complex methods such as the Continuous Wavelet transforms (CWT). While visualization properties (colourmap, filtering, smoothing/interpolation) are shown to affect the conspicuity of spectral features, the window properties (function, size, overlap) are shown to have the greatest impact on the resulting spectrogram appearance. Using a set of cerebral aneurysm CFD cases, we show that spectrograms can readily reveal the case-specific nature of the time-varying flow instabilities, whether broadband, suggesting intermittent turbulent-like flow, or narrowband, suggesting laminar vortex shedding, or some combination thereof.

Structure-activity relationship of human bone sialoprotein peptides.

In the current study, the relationship between the structure of the RGD-containing human bone sialoprotein (hBSP) peptide 278-293 and its attachment activity toward osteoblast-like (MC3T3) cells was investigated. This goal was accomplished by examining the comparative cell-attachment activities of several truncated forms of peptide 278-293. Computer modeling of the various peptides was also performed to assess the role of secondary structure in peptide bioactivity. Elimination of tyrosine-278 at the N-terminus resulted in a more dramatic loss of cell-attachment activity compared with the removal of either tyrosine-293 or the arg-ala-tyr (291-293) tripeptide. Although replacement of the RGD (arg-gly-asp) peptide moiety with peptide KAE (lys-ala-glu) resulted in a dramatic loss of cell-attachment activity, a peptide containing RGE (arg-gly-glu) in place of RGD retained 70-85% of the parental peptide's attachment activity. These results suggest that the N-terminal RGD-flanking region of hBSP peptide 278-293, in particular the tyrosine-278 residue, represents a second cell-attachment site that stabilizes the RGD-integrin receptor complex. Computer modeling also suggested that a ß-turn encompassing RGD or RGE in some of the hBSP peptides may facilitate its binding to integrins by increasing the exposure of the tripeptide. This knowledge may be useful in the future design of biomimetic peptides which are more effective in promoting the attachment of osteogenic cells to implant surfaces in vivo.

Heat and radiofrequency plasma glow discharge pretreatment of a titanium alloy promote bone formation and osseointegration.

Orthopedic and dental implants manifest increased failure rates when inserted into low density bone. We determined whether chemical pretreatments of a titanium alloy implant material stimulated new bone formation to increase osseointegration in vivo in trabecular bone using a rat model. Titanium alloy rods were untreated or pretreated with heat (600°C) or radiofrequency plasma glow discharge (RFGD). The rods were then coated with the extracellular matrix protein fibronectin (1 nM) or left uncoated and surgically implanted into the rat femoral medullary cavity. Animals were euthanized 3 or 6 weeks later, and femurs were removed for analysis. The number of trabeculae in contact with the implant surface, surface contact between trabeculae and the implant, and the length and area of bone attached to the implant were measured by histomorphometry. Implant shear strength was measured by a pull-out test. Both pretreatments and fibronectin enhanced the number of trabeculae bonding with the implant and trabeculae-to-implant surface contact, with greater effects of fibronectin observed with pretreated compared to untreated implants. RFGD pretreatment modestly increased implant shear strength, which was highly correlated (r(2) = 0.87-0.99) with measures of trabecular bonding for untreated and RFGD-pretreated implants. In contrast, heat pretreatment increased shear strength 3-5-fold for both uncoated and fibronectin-coated implants at 3 and 6 weeks, suggesting a more rapid increase in implant-femur bonding compared to the other groups. In summary, our findings suggest that the heat and RFGD pretreatments can promote the osseointegration of a titanium alloy implant material.

Heat and radiofrequency plasma glow discharge pretreatment of a titanium alloy: evidence [corrected] for enhanced osteoinductive properties.

It is believed that orthopedic and implant longevity can be improved by optimizing fixation, or direct bone-implant contact, through the stimulation of new bone formation around the implant. The purpose of this study was to determine whether heat (600°C) or radiofrequency plasma glow discharge (RFGD) pretreatment of Ti6Al4V stimulated calcium-phosphate mineral formation in cultures of attached MC3T3 osteoprogenitor cells with or without a fibronectin coating. Calcium-phosphate mineral was analyzed by flame atomic absorption spectrophotometry, scanning electron microscopy (SEM)/electron dispersive X-ray microanalysis (EDAX) and Fourier transformed infrared spectroscopy (FTIR). RFGD and heat pretreatments produced a general pattern of increased total soluble calcium levels, although the effect of heat pretreatment was greater than that of RFGD. SEM/EDAX showed the presence of calcium-and phosphorus-containing particles on untreated and treated disks that were more numerous on fibronectin-coated disks. These particles were observed earliest (1 week) on RFGD-pretreated surfaces. FTIR analyses showed that the heat pretreatment produced a general pattern of increased levels of apatite mineral at 2-4 weeks; a greater effect was observed for fibronectin-coated disks compared to uncoated disks. The observed findings suggest that heat pretreatment of Ti6Al4V increased the total mass of the mineral formed in MC3T3 osteoprogenitor cell cultures more than RFGD while the latter pretreatment hastened the early deposition of mineral. These findings help to support the hypothesis that the pretreatments enhance the osteoinductive properties of the alloy.

Effects of coating a titanium alloy with fibronectin on the expression of osteoblast gene markers in the MC3T3 osteoprogenitor cell line.

PURPOSE: A number of environmental and patient-related factors contribute to implant failure. A significant fraction of these failures can be attributed to limited osseointegration resulting from poor bone healing responses. The overall goal of this study was to determine whether surface treatment of a titanium-aluminum-vanadium alloy (Ti-6Al-4V) implant material in combination with a biomimetic protein coating could promote the differentiation of attached osteoblastic cells. The specific aims of the study were to investigate whether osteoprogenitor cells cultured on a rigorously cleaned implant specimen showed a normal pattern of differentiation and whether preadsorbed fibronectin accelerated or enhanced osteoblast differentiation. MATERIALS AND METHODS: Ti-6Al-4V disks were rigorously cleaned, passivated in nitric acid, and dry heat- sterilized; some of the disks were then coated with 1 nmol/L fibronectin. MC3T3 osteoprogenitor cells were then cultured on the pretreated disks for several weeks. Quantitative real-time polymerase chain reaction was performed to measure changes over time in the mRNA levels of osteoblast genes. RESULTS: Fibronectin increased the peak expression of all analyzed osteoblast gene markers. "Early" genes that normally mark the proliferative phase (0 to 10 days) of osteoblastic development showed peak expression within the first 10 days after cell attachment to the titanium alloy. In contrast, "late" genes that normally mark the differentiation (10 to 20 days) and mineralization (20 to 36 days) phases of osteoblastogenesis achieved peak expression only after approximately 3 to 4 weeks of culture. CONCLUSIONS: Osteoprogenitors cultured on a rigorously cleaned Ti-6Al-4V alloy were found to demonstrate a normal pattern of osteoblast differentiation. Preadsorbed fibronectin was observed to stimulate osteoblast differentiation during the mineralization phase of osteoblastogenesis.

Heat or radiofrequency plasma glow discharge treatment of a titanium alloy stimulates osteoblast gene expression in the MC3T3 osteoprogenitor cell line.

PURPOSE: The purpose of this study was to determine whether increasing the Ti6Al4V surface oxide negative charge through heat (600℃) or radiofrequency plasma glow discharge (RFGD) pretreatment, with or without a subsequent coating with fibronectin, stimulated osteoblast gene marker expression in the MC3T3 osteoprogenitor cell line. METHODS: Quantitative real-time polymerase chain reaction was used to measure changes over time in the mRNA levels for osteoblast gene markers, including alkaline phosphatase, bone sialoprotein, collagen type I (α1), osteocalcin, osteopontin and parathyroid hormone-related peptide (PTH-rP), and the osteoblast precursor genes Runx2 and osterix. RESULTS: Osteoprogenitors began to differentiate earlier on disks that were pretreated with heat or RFGD. The pretreatments increased gene marker expression in the absence of a fibronectin coating. However, pretreatments increased osteoblast gene expression for fibronectin-coated disks more than uncoated disks, suggesting a surface oxide-mediated specific enhancement of fibronectin's bioactivity. Heat pretreatment had greater effects on the mRNA expression of genes for PTH-rP, alkaline phosphatase and osteocalcin while RFGD pretreatment had greater effects on osteopontin and bone sialoprotein gene expression. CONCLUSIONS: The results suggest that heat and RFGD pretreatments of the Ti6Al4V surface oxide stimulated osteoblast differentiation through an enhancement of (a) coated fibronectin's bioactivity and (b) the bioactivities of other serum or matrix proteins. The quantitative differences in the effects of the two pretreatments on osteoblast gene marker expression may have arisen from the unique physico-chemical characteristics of each resultant oxide surface. Therefore, engineering the Ti6Al4V surface oxide to become more negatively charged can be used to accelerate osteoblast differentiation through fibronectin-dependent and independent mechanisms.

Titanium alloy surface oxide modulates the conformation of adsorbed fibronectin to enhance its binding to α(5) ß(1) integrins in osteoblasts.

Our laboratory has previously demonstrated that heat (600°C) or radiofrequency plasma glow discharge (RFGD) pretreatment of a titanium alloy (Ti6Al4V) increased the net negative charge of the alloy's surface oxide and the attachment of osteoblastic cells to adsorbed fibronectin. The purpose of the current study was to investigate the biological mechanism by which these surface pretreatments enhance the capacity of fibronectin to stimulate osteoblastic cell attachment. Each pretreatment was found to increase the binding (measured by ELISA) of a monoclonal anti-fibronectin Ig to the central integrin-binding domain of adsorbed fibronectin, and to increase the antibody's inhibition of osteogenic cell attachment (measured by hexosaminidase assay). Pretreatments also increased the binding (measured by ELISA) of anti-integrin IgG's to the α(5) and ß(1) integrin subunits that became attached to fibronectin during cell incubation. These findings suggest that negatively charged surface oxides of Ti6Al4V cause conformational changes in fibronectin that increase the availability of its integrin-binding domain to α(5) ß(1) integrins.

Surface oxide net charge of a titanium alloy: modulation of fibronectin-activated attachment and spreading of osteogenic cells.

In the current study, we have altered the surface oxide properties of a Ti6Al4V alloy using heat treatment or radiofrequency glow discharge (RFGD) in order to evaluate the relationship between the physico-chemical and biological properties of the alloy's surface oxide. The effects of surface pretreatments on the attachment of cells from two osteogenic cell lines (MG63 and MC3T3) and a mesenchymal stem cell line (C3H10T1/2) to fibronectin adsorbed to the alloy were measured. Both heat and RFGD pretreatments produced a several-fold increase in the number of cells that attached to fibronectin adsorbed to the alloy at a range of coating concentrations (0.001-10nM FN) for each cell line tested. An antibody (HFN7.1) directed against the central integrin binding domain of fibronectin produced a 65-70% inhibition of cell attachment to fibronectin-coated disks, indicating that cell attachment to the metal discs was dependent on fibronectin binding to cell integrin receptors. Both treatments also accelerated the cell spreading response manifested by extensive flattening and an increase in mean cellular area. The treatment-induced increases in the cell attachment activity of adsorbed fibronectin were correlated with previously demonstrated increases in Ti6Al4V oxide negative net surface charge at physiological pH produced by both heat and RFGD pretreatments. Since neither treatment increased the adsorption mass of fibronectin, these findings suggest that negatively charged surface oxide functional groups in Ti6Al4V can modulate fibronectin's integrin receptor activity by altering the adsorbed protein's conformation. Our results further suggest that negatively charged functional groups in the surface oxide can play a prominent role in the osseointegration of metallic implant materials.

Surface oxide net charge of a titanium alloy: comparison between effects of treatment with heat or radiofrequency plasma glow discharge.

In the current study, we have compared the effects of heat and radiofrequency plasma glow discharge (RFGD) treatment of a Ti6Al4V alloy on the physico-chemical properties of the alloy's surface oxide. Titanium alloy (Ti6Al4V) disks were passivated alone, heated to 600 °C, or RFGD plasma treated in pure oxygen. RFGD treatment did not alter the roughness, topography, elemental composition or thickness of the alloy's surface oxide layer. In contrast, heat treatment altered oxide topography by creating a pattern of oxide elevations approximately 50-100 nm in diameter. These nanostructures exhibited a three-fold increase in roughness compared to untreated surfaces when RMS roughness was calculated after applying a spatial high-pass filter with a 200 nm-cutoff wavelength. Heat treatment also produced a surface enrichment in aluminum and vanadium oxides. Both RFGD and heat treatment produced similar increases in oxide wettability. Atomic force microscopy (AFM) measurements of metal surface oxide net charge signified by a long-range force of attraction to or repulsion from a (negatively charged) silicon nitride AFM probe were also obtained for all three experimental groups. Force measurements showed that the RFGD-treated Ti6Al4V samples demonstrated a higher net positive surface charge at pH values below 6 and a higher net negative surface charge at physiological pH (pH values between 7 and 8) compared to control and heat-treated samples. These findings suggest that RFGD treatment of metallic implant materials can be used to study the role of negatively charged surface oxide functional groups in protein bioactivity, osteogenic cell behavior and osseointegration independently of oxide topography.

The effects of COX-1 and COX-2 inhibitors on prostaglandin synthesis and the formation of heterotopic bone in a rat model.

INTRODUCTION: Traumatic heterotopic ossification (HO) is a common clinical condition associated with various orthopedic procedures that involve injury to soft tissues near bone. In this study, we tested the hypothesis that the prophylactic effects of NSAID's in the treatment of HO are mediated via inhibition of the COX-2 enzyme. Here we describe a rat model that simulates HO in the human that was used to test the above hypothesis. MATERIALS AND METHODS: Heterotopic ossification was surgically induced in the quadriceps by injury to the muscle and femoral periosteum and transplantation of donor bone marrow cells containing osteoprogenitors into the site of injury. HO was imaged and quantified by micro-CT scanning of femurs removed from sacrificed animals at 6 weeks post-injury, three-dimensional computer reconstructions of the scanned bones and computer-assisted morphometric analysis. Prostaglandin E(2) (PGE(2)) synthesis was quantified using an enzyme immunoassay system. The effects of a nonselective COX inhibitor or specific inhibitors of COX-1 or COX-2 following oral administration on the content of ectopic bone and PGE(2) were also measured. RESULTS: Micro-CT and histological analyses demonstrated that all of the femurs in operated limbs developed HO in the vastus lateralis muscle belly of the quadriceps close to the anterior femur. Only the COX-1,2 nonselective and COX-2 inhibitors significantly decreased HO formation (by about one-third in each case; P < 0.05). PGE(2) synthesis at the site of injury was increased 50- and 100-fold (to 25 ng/g tissue) within 1 and 7 days, respectively, post-injury with the levels declining to near baseline within 2 weeks of surgery. Both the COX-1,2 nonselective and COX-2 inhibitors significantly decreased PGE(2) levels to 25% of control HO levels within 24 h of the first administration, even at low dosages. The COX-1 inhibitor only produced the same effect after 1 week of administration. CONCLUSION: These findings suggest that although inhibitors of COX-2 or COX-1 reduced PGE(2) synthesis, only the COX-2 enzyme plays a role in the mechanism of traumatic HO.

Electronic percussive testing of the stability of an immediately provisionalized implant placed into a fresh extraction socket: a pilot evaluation.

It is important to achieve primary stabilization of dental implants that will be immediately loaded. Noninvasive devices that test the stability of immediately provisionalized implants placed into fresh extraction sockets are discussed. A titanium threaded implant was placed into a fresh extraction socket of a patient's nonrestorable mandibular right canine. The implant received an interim restoration immediately following its placement. The stability of the bone-implant complex was evaluated from the day of implant insertion through day 246 using an electronic percussive testing instrument. During the first month the bone-implant complex became progressively less stable reaching a peak measured level of instability at 30 days postimplantation. This was followed by progressive stabilization first measured on day 46 as the implant continued to osseointegrate. These findings suggest that the bone-implant complex became less stable during the first month after implant placement and was followed by a period of progressive stabilization reflecting bone maturation around the implant. A search of the literature found similar results in a study of single-stage implants (not immediately provisionalized) using resonance frequency analysis. The known sequence of wound healing around dental implants is reviewed to explain the findings of this pilot evaluation. Studies that use noninvasive testing devices to assess implant stability at placement and during healing may provide information that can help to optimize implant treatment outcomes.

Principles of geriatric dentistry and their application to the older adult with a physical disability.

The older adult living with a physical disability faces many daily challenges. Limited hand function or impaired cognition often has profound effects on activities of daily life including oral hygiene. This article explores age-related changed in dentition and common causes of pathology of the oral cavity with special emphasis in populations with impaired hand function or cognition. This article will also assist the treating physician as it relates to oral diagnosis and patient management.