This prospective study examined 479 cases of mandibular third molar extraction to determine the incidence of inferior alveolar nerve (IAN) damage and whether panoramic radiographs could accurately predict outcomes. The results found that 5.2% had transient IAN sensation changes and 0.2% had prolonged changes. Panoramic radiographs showed 90.5% specificity and 72% sensitivity in predicting normal versus abnormal outcomes. The kappa value of 0.27 indicated a fair level of agreement between predictions and outcomes. This study supports previous findings on IAN damage rates and confirms panoramic radiography is suitable for assessing IAN proximity prior to third molar removal.
This study compared the effectiveness of Hawley retainers and two protocols for vacuum-formed retainers (VFRs) in maintaining orthodontic treatment results. 90 patients were randomly assigned to receive either a Hawley retainer, VFRs worn for 4 months full-time then nightly, or VFRs worn for 1 week full-time then nightly. Models at debond and 4 and 8 months post-treatment showed the Hawley group had significantly greater loss of upper arch length and increased crowding compared to the VFR groups, though lower arch measurements were similar. Both VFR protocols were more effective than Hawleys in maintaining the upper arch, and 4 months full-time wear provided better lower incis
Complications related to midfacial fractures operative versus non surgical tr...Felix Amarista
This clinical paper examines complications related to midfacial fractures treated either operatively or non-surgically. The authors conducted a retrospective review of 740 patients with midfacial fractures treated between 2001-2003. 57% of single fractures and 75% of multiple fractures underwent surgical treatment. After 6 and 12 months, significantly more complications were seen in surgically treated patients, especially nerve disturbances and meteorosensitivity. The results indicate a need for more prospective studies to establish guidelines for deciding between surgical and non-surgical treatment of midfacial fractures.
This document discusses the rationale for using stimulating versus non-stimulating catheters for continuous peripheral nerve blocks and summarizes the current evidence. It describes how stimulating catheters can help ensure correct placement but studies have shown inconsistent results. Ultrasound guidance has been shown to decrease placement time and failures compared to electrical stimulation techniques alone. While stimulating catheters may provide slightly better analgesia when correctly placed, ultrasound guidance is a good alternative approach. In conclusion, more research is still needed to definitively determine the advantages of different catheter placement techniques.
Regional anesthesia and analgesia are associated with lower postoperative complications, shorter hospital stays, and better functional outcomes compared to general anesthesia alone. Regional techniques like neuraxial blocks and peripheral nerve blocks improve mobility and physical function after surgery. Newer regional techniques like adductor canal blocks aim to provide good pain relief while preserving quadriceps strength. A multimodal, multidisciplinary approach is needed to optimize perioperative care and functional recovery for patients.
CyberKnife radiosurgery is effective for treating single and oligometastatic vertebral metastases with higher doses of radiation (16Gy) providing better pain control and fewer requirements for re-radiation treatment. Phase III studies of over 400 patients are showing promising early results with high dose SRS. However, high dose SRS is also associated with higher risks of myelitis and vertebral fracture. Spinal arteriovenous malformations can also be effectively treated with CyberKnife radiosurgery.
Can brain atrophy measurement help us in monitoring MS progression in routine...MS Trust
This presentation by Dana Horáková, Department of Neurology and Centre of Clinical Neuroscience at the Charles University in Prague, looks at why and how we should measure brain atrophy.
It was presented at the MS Trust Annual Conference in November 2014.
A 28-year-old male patient with pemphigus vulgaris was given 7 pulses of dexamethasone therapy. He later developed avascular necrosis of the head of the femur in both hips, confirmed by x-ray and MRI. Long-term corticosteroid use is a known risk factor for avascular necrosis. The patient's condition was assessed as a severe adverse drug reaction likely caused by the dexamethasone therapy based on standardized causality scales. MRI is an important tool for early diagnosis of avascular necrosis to prevent complications.
- Bone metastases affect up to 70% of breast cancer patients and are a major source of morbidity. They develop through a 'vicious cycle' where tumor cells stimulate bone resorption.
- Bisphosphonates like zoledronic acid and denosumab inhibit bone resorption by targeting RANK ligand, breaking this cycle. They significantly reduce skeletal complications in metastatic breast cancer.
- A large trial found denosumab reduced the risk of first skeletal-related event compared to zoledronic acid and time to first on-study bone metastasis. It provides an effective alternative to bisphosphonates for preventing bone complications.
This study compared the effectiveness of Hawley retainers and two protocols for vacuum-formed retainers (VFRs) in maintaining orthodontic treatment results. 90 patients were randomly assigned to receive either a Hawley retainer, VFRs worn for 4 months full-time then nightly, or VFRs worn for 1 week full-time then nightly. Models at debond and 4 and 8 months post-treatment showed the Hawley group had significantly greater loss of upper arch length and increased crowding compared to the VFR groups, though lower arch measurements were similar. Both VFR protocols were more effective than Hawleys in maintaining the upper arch, and 4 months full-time wear provided better lower incis
Complications related to midfacial fractures operative versus non surgical tr...Felix Amarista
This clinical paper examines complications related to midfacial fractures treated either operatively or non-surgically. The authors conducted a retrospective review of 740 patients with midfacial fractures treated between 2001-2003. 57% of single fractures and 75% of multiple fractures underwent surgical treatment. After 6 and 12 months, significantly more complications were seen in surgically treated patients, especially nerve disturbances and meteorosensitivity. The results indicate a need for more prospective studies to establish guidelines for deciding between surgical and non-surgical treatment of midfacial fractures.
This document discusses the rationale for using stimulating versus non-stimulating catheters for continuous peripheral nerve blocks and summarizes the current evidence. It describes how stimulating catheters can help ensure correct placement but studies have shown inconsistent results. Ultrasound guidance has been shown to decrease placement time and failures compared to electrical stimulation techniques alone. While stimulating catheters may provide slightly better analgesia when correctly placed, ultrasound guidance is a good alternative approach. In conclusion, more research is still needed to definitively determine the advantages of different catheter placement techniques.
Regional anesthesia and analgesia are associated with lower postoperative complications, shorter hospital stays, and better functional outcomes compared to general anesthesia alone. Regional techniques like neuraxial blocks and peripheral nerve blocks improve mobility and physical function after surgery. Newer regional techniques like adductor canal blocks aim to provide good pain relief while preserving quadriceps strength. A multimodal, multidisciplinary approach is needed to optimize perioperative care and functional recovery for patients.
CyberKnife radiosurgery is effective for treating single and oligometastatic vertebral metastases with higher doses of radiation (16Gy) providing better pain control and fewer requirements for re-radiation treatment. Phase III studies of over 400 patients are showing promising early results with high dose SRS. However, high dose SRS is also associated with higher risks of myelitis and vertebral fracture. Spinal arteriovenous malformations can also be effectively treated with CyberKnife radiosurgery.
Can brain atrophy measurement help us in monitoring MS progression in routine...MS Trust
This presentation by Dana Horáková, Department of Neurology and Centre of Clinical Neuroscience at the Charles University in Prague, looks at why and how we should measure brain atrophy.
It was presented at the MS Trust Annual Conference in November 2014.
A 28-year-old male patient with pemphigus vulgaris was given 7 pulses of dexamethasone therapy. He later developed avascular necrosis of the head of the femur in both hips, confirmed by x-ray and MRI. Long-term corticosteroid use is a known risk factor for avascular necrosis. The patient's condition was assessed as a severe adverse drug reaction likely caused by the dexamethasone therapy based on standardized causality scales. MRI is an important tool for early diagnosis of avascular necrosis to prevent complications.
- Bone metastases affect up to 70% of breast cancer patients and are a major source of morbidity. They develop through a 'vicious cycle' where tumor cells stimulate bone resorption.
- Bisphosphonates like zoledronic acid and denosumab inhibit bone resorption by targeting RANK ligand, breaking this cycle. They significantly reduce skeletal complications in metastatic breast cancer.
- A large trial found denosumab reduced the risk of first skeletal-related event compared to zoledronic acid and time to first on-study bone metastasis. It provides an effective alternative to bisphosphonates for preventing bone complications.
Purpose: To evaluate the influence of age and severity of keratoconus in the clinical outcomes of implantation of Ferrara intrastromal corneal ring segments (ICRS).
PURPOSE: To analyze the long-term corneal endothelial profile after Ferrara ring implan- tation in keratoconus, post-LASIK ectasia and pellucid degeneration eyes.
Low back pain is very common, affecting 2/3 of adults. While most cases are benign and self-limited, it can be difficult to distinguish serious cases requiring treatment from mild cases. Guidelines recommend focused history and physical exam to classify patients, and conservative treatments like exercise, NSAIDs, and cognitive behavioral therapy as first-line approaches. Imaging like X-rays and MRI are not routinely needed but may help identify rare serious causes; radiation exposure should be minimized. Surgery or injections show limited benefits and are usually not recommended for non-radicular back pain but may help in cases of radiculopathy or stenosis with no improvement from other therapies. A biopsychosocial approach focusing on underlying pain mechanisms rather than just
Proper patient selection, using a system from Johns Hopkins Hospital doctors, will allow an orthopedic or neurosurgeon to increase surgery rate by 50%-63% in their existing patient population.
This document discusses pelvic insufficiency fractures (PIF), which are stress fractures that can occur in the pelvis after radiation therapy for cervical cancer. PIF often presents with low back pain but is commonly underdiagnosed or misdiagnosed. The document outlines risk factors for PIF including post-menopausal status, lower body weight, and higher radiation dose. Diagnosis relies on imaging like CT, MRI, or bone scan showing fracture lines in the sacrum. Treatment is usually conservative with analgesics, calcium supplements, and avoiding stress on the pelvis. Recognizing PIF is important to avoid misdiagnosing it as bone metastasis.
Assessment of lingual nerve injury using different surgical variables for man...DrKamini Dadsena
This document summarizes a journal presentation on a clinical study assessing lingual nerve injury from mandibular third molar surgery. The study examined 1200 patients undergoing third molar removal and found an overall 5.6% temporary lingual nerve impairment rate and 0.3% permanent rate. Factors associated with higher temporary injury rates included lingual flap retraction, tooth sectioning, and buccal guttering. The presentation reviews the study methodology, results, comparisons to other studies, and discusses techniques to reduce lingual nerve injury risk during third molar surgery.
1. Several factors can predict the recovery of erectile function after radical prostatectomy including pre-operative erectile function, patient age, nerve sparing technique, and use of postoperative erectile dysfunction treatments.
2. Studies have shown better recovery of erectile function with younger patient age, higher pre-operative function, more extensive nerve sparing surgery, and use of PDE5 inhibitors after surgery.
3. Robotic surgery has been associated with improved erectile function outcomes compared to open surgery, especially in younger men with high pre-operative function.
This study examined the use of wearable cardioverter-defibrillators (WCDs) after explantation of implantable cardioverter-defibrillators (ICDs) when immediate re-implantation was not feasible. 32 patients used WCDs for a median of 30.5 days, averaging 17 hours of daily use. One patient died of ventricular tachycardia/ventricular fibrillation while in the hospital wearing a WCD. The study concluded that WCDs are a reasonable option after ICD explantation when re-implantation is not immediately possible or desired.
This document summarizes radionuclide therapy for treating bone metastases. It discusses various radiopharmaceuticals used including strontium-89, samarium-153, and rhenium-186. It describes the methodology of dosimetry calculations and pain documentation tools. Clinical indications for pain palliation in breast cancer and prostate cancer are presented. Side effects like bone marrow suppression and potential benefits like increased progression-free interval are covered. New treatment strategies involving combined chemotherapy are also mentioned.
While anesthesiologists globally have had similar interests over the years, the unifying challenge continues to be the selection of outcomes and demonstration of improvement due to the anesthesiologist’s role and/or choice of anesthetic or analgesic technique.
This document discusses metastatic lesions of the spine. Some key points:
- The spine is a common site for bone metastases, with the thoracic spine being the most frequent location.
- Common primary cancers that metastasize to the spine include lung cancer, breast cancer, and prostate cancer.
- Patients typically present with pain, spinal deformity, or neurological deficits. Imaging studies like plain radiographs, CT, MRI, and bone scans are used to evaluate lesions.
- Treatment depends on factors like life expectancy, stability, and neurological status, and may include analgesics, radiation, surgery, vertebroplasty/kyphoplasty, or a combination. The goals are pain relief, decompression, and spinal
Dental implants in patients with type 2 diabetesssuser19a491
This document summarizes a clinical study on the outcomes of dental implants in patients with type 2 diabetes mellitus. The study included 41 patients who received a total of 141 dental implants to support overdentures. The success rates after 1 and 5 years were 97.2% and 94.4%, respectively. Most patients reported improved function with the new treatment. A high correlation was found between good mucosal health and improved function, but no correlation was found between failed implants and glucose levels. The results suggest that dental implants can provide satisfactory outcomes for selected patients with well-controlled type 2 diabetes.
Microwave ablation was used to treat epiphyseal osteoid osteomas in 7 patients. All patients experienced complete pain relief within 1 week of the procedure and had no complications, except for 1 patient who experienced back pain for 2 months. MRI scans after treatment showed ablation areas averaging 21 x 12 x 14 mm. The study demonstrated that microwave ablation can safely and effectively treat epiphyseal osteoid osteomas with a single needle insertion and without complications. However, more research with larger patient groups is still needed to validate these promising initial results.
CT-Guided Percutaneous Radiofrequency Thermal Ablation of Osteoid Osteoma-Cri...CrimsonPublishersOPROJ
CT-Guided Percutaneous Radiofrequency Thermal Ablation of Osteoid Osteoma by Pedro Manuel Serrano* in Crimson Publishers: Orthopedic Research and Reviews Journal
Course 8 medical tests used to diagnose painfulNelson Hendler
Medical Tests Used to Diagnose Painful Conditions is a power point which outlines the correct medical tests to use to diagnose chronic pain problems. These are the tests used by the top academic medical institutions in the country, and the efficacy of these tests is documented by clinical outcome studies. The presentation is heavily illustrated, so the reader can really understand what a test measures.
The document discusses follow up procedures after 5 years of osteoporosis treatment, including reevaluating patients through clinical risk factors, DXA scans, and checking for new vertebral fractures. It recommends continuing or switching treatment based on risk level, and monitoring again in 2-3 years or if new fractures occur. Long term trial results are presented showing maintenance of bone mineral density gains and low fracture risk with continued denosumab treatment out to 8 years.
This study evaluated the long-term clinical and radiological outcomes of 126 patients with 239 osteoporotic vertebral fractures treated with balloon kyphoplasty compared to a conservatively treated control group. Patients undergoing kyphoplasty had significantly reduced pain scores and improved disability scores that were maintained at the 2-year follow-up, while the control group showed no significant changes. Kyphoplasty also significantly restored vertebral height and alignment, while conservative treatment did not significantly impact radiographic measures. This study demonstrates the long-term benefits of balloon kyphoplasty over conservative care for osteoporotic vertebral fractures.
The document describes the development and validation of the Post-operative Infection Treatment Score for the Spine (PITSS), a predictive model for determining whether patients require single versus multiple irrigation and debridement procedures for spinal surgical site infections. Key predictors in the model include wound culture microbiology, spine location, medical comorbidities, distant site infections, instrumentation, and bone graft. Internal validation showed the model has an AUC of 0.84. External validation on subsequent years of data showed acceptable discrimination with an AUC of 0.70. The model can help guide clinical decisions around appropriate treatment for spinal surgical site infections.
This study examined the association between darkening of third molar roots seen on preoperative panoramic radiographs and exposure of the inferior alveolar nerve during surgery. 116 patients with darkening of third molar roots were selected as the case group, and 193 patients with other high-risk radiographic signs near the roots were selected as the control group. The nerve was exposed in 27.6% of cases with isolated darkening and 7.8% of controls. Darkening alone or with other signs significantly increased the risk of nerve exposure compared to other signs alone. Having both darkening and other adjacent signs carried the greatest risk of exposure compared to darkening alone or other signs alone or combined. Differentiating between isolated dark
This study examined the association between darkening of third molar roots seen on preoperative panoramic radiographs and exposure of the inferior alveolar nerve during surgery. 116 patients with darkening of third molar roots were selected as the case group, and 193 patients with other high-risk radiographic signs near the roots were selected as the control group. The nerve was exposed in 27.6% of cases with isolated darkening and 7.8% of controls. Darkening alone or with other signs significantly increased the risk of nerve exposure compared to other signs alone. The risk was greatest for darkening accompanied by other adjacent signs, with an odds ratio over 5 times higher than for other signs alone. This suggests differentiating
This study evaluated the diagnostic accuracy of cone beam computed tomography (CBCT) and panoramic radiography in predicting exposure of the inferior alveolar nerve during third molar extraction surgery. The study assessed 59 impacted third molar extraction sites, examining pre-operative panoramic and CBCT images for signs suggesting nerve exposure. During surgery, actual nerve exposure was evaluated and compared to the radiographic predictions. CBCT correctly classified nerve exposure in 93.3% of cases, significantly more accurately than panoramic radiography which correctly classified 67.7% of cases. CBCT demonstrated high sensitivity, specificity, and predictive values, while panoramic radiography had lower sensitivity but high positive predictive value. This study indicates CB
This document summarizes a study on locating impacted maxillary canines in patients. The study analyzed orthopantomogram x-rays of 1,956 patients and found 57 impacted maxillary canines in 47 patients. The mean angulation of the impacted canines was 29.54 degrees and the mean vertical distance from the occlusal plane was 13.1 mm. The study found no significant correlation between the angulation and vertical distance of impacted canines. Both factors are important individually in determining treatment complexity, but they influence treatment planning independently of each other.
Purpose: To evaluate the influence of age and severity of keratoconus in the clinical outcomes of implantation of Ferrara intrastromal corneal ring segments (ICRS).
PURPOSE: To analyze the long-term corneal endothelial profile after Ferrara ring implan- tation in keratoconus, post-LASIK ectasia and pellucid degeneration eyes.
Low back pain is very common, affecting 2/3 of adults. While most cases are benign and self-limited, it can be difficult to distinguish serious cases requiring treatment from mild cases. Guidelines recommend focused history and physical exam to classify patients, and conservative treatments like exercise, NSAIDs, and cognitive behavioral therapy as first-line approaches. Imaging like X-rays and MRI are not routinely needed but may help identify rare serious causes; radiation exposure should be minimized. Surgery or injections show limited benefits and are usually not recommended for non-radicular back pain but may help in cases of radiculopathy or stenosis with no improvement from other therapies. A biopsychosocial approach focusing on underlying pain mechanisms rather than just
Proper patient selection, using a system from Johns Hopkins Hospital doctors, will allow an orthopedic or neurosurgeon to increase surgery rate by 50%-63% in their existing patient population.
This document discusses pelvic insufficiency fractures (PIF), which are stress fractures that can occur in the pelvis after radiation therapy for cervical cancer. PIF often presents with low back pain but is commonly underdiagnosed or misdiagnosed. The document outlines risk factors for PIF including post-menopausal status, lower body weight, and higher radiation dose. Diagnosis relies on imaging like CT, MRI, or bone scan showing fracture lines in the sacrum. Treatment is usually conservative with analgesics, calcium supplements, and avoiding stress on the pelvis. Recognizing PIF is important to avoid misdiagnosing it as bone metastasis.
Assessment of lingual nerve injury using different surgical variables for man...DrKamini Dadsena
This document summarizes a journal presentation on a clinical study assessing lingual nerve injury from mandibular third molar surgery. The study examined 1200 patients undergoing third molar removal and found an overall 5.6% temporary lingual nerve impairment rate and 0.3% permanent rate. Factors associated with higher temporary injury rates included lingual flap retraction, tooth sectioning, and buccal guttering. The presentation reviews the study methodology, results, comparisons to other studies, and discusses techniques to reduce lingual nerve injury risk during third molar surgery.
1. Several factors can predict the recovery of erectile function after radical prostatectomy including pre-operative erectile function, patient age, nerve sparing technique, and use of postoperative erectile dysfunction treatments.
2. Studies have shown better recovery of erectile function with younger patient age, higher pre-operative function, more extensive nerve sparing surgery, and use of PDE5 inhibitors after surgery.
3. Robotic surgery has been associated with improved erectile function outcomes compared to open surgery, especially in younger men with high pre-operative function.
This study examined the use of wearable cardioverter-defibrillators (WCDs) after explantation of implantable cardioverter-defibrillators (ICDs) when immediate re-implantation was not feasible. 32 patients used WCDs for a median of 30.5 days, averaging 17 hours of daily use. One patient died of ventricular tachycardia/ventricular fibrillation while in the hospital wearing a WCD. The study concluded that WCDs are a reasonable option after ICD explantation when re-implantation is not immediately possible or desired.
This document summarizes radionuclide therapy for treating bone metastases. It discusses various radiopharmaceuticals used including strontium-89, samarium-153, and rhenium-186. It describes the methodology of dosimetry calculations and pain documentation tools. Clinical indications for pain palliation in breast cancer and prostate cancer are presented. Side effects like bone marrow suppression and potential benefits like increased progression-free interval are covered. New treatment strategies involving combined chemotherapy are also mentioned.
While anesthesiologists globally have had similar interests over the years, the unifying challenge continues to be the selection of outcomes and demonstration of improvement due to the anesthesiologist’s role and/or choice of anesthetic or analgesic technique.
This document discusses metastatic lesions of the spine. Some key points:
- The spine is a common site for bone metastases, with the thoracic spine being the most frequent location.
- Common primary cancers that metastasize to the spine include lung cancer, breast cancer, and prostate cancer.
- Patients typically present with pain, spinal deformity, or neurological deficits. Imaging studies like plain radiographs, CT, MRI, and bone scans are used to evaluate lesions.
- Treatment depends on factors like life expectancy, stability, and neurological status, and may include analgesics, radiation, surgery, vertebroplasty/kyphoplasty, or a combination. The goals are pain relief, decompression, and spinal
Dental implants in patients with type 2 diabetesssuser19a491
This document summarizes a clinical study on the outcomes of dental implants in patients with type 2 diabetes mellitus. The study included 41 patients who received a total of 141 dental implants to support overdentures. The success rates after 1 and 5 years were 97.2% and 94.4%, respectively. Most patients reported improved function with the new treatment. A high correlation was found between good mucosal health and improved function, but no correlation was found between failed implants and glucose levels. The results suggest that dental implants can provide satisfactory outcomes for selected patients with well-controlled type 2 diabetes.
Microwave ablation was used to treat epiphyseal osteoid osteomas in 7 patients. All patients experienced complete pain relief within 1 week of the procedure and had no complications, except for 1 patient who experienced back pain for 2 months. MRI scans after treatment showed ablation areas averaging 21 x 12 x 14 mm. The study demonstrated that microwave ablation can safely and effectively treat epiphyseal osteoid osteomas with a single needle insertion and without complications. However, more research with larger patient groups is still needed to validate these promising initial results.
CT-Guided Percutaneous Radiofrequency Thermal Ablation of Osteoid Osteoma-Cri...CrimsonPublishersOPROJ
CT-Guided Percutaneous Radiofrequency Thermal Ablation of Osteoid Osteoma by Pedro Manuel Serrano* in Crimson Publishers: Orthopedic Research and Reviews Journal
Course 8 medical tests used to diagnose painfulNelson Hendler
Medical Tests Used to Diagnose Painful Conditions is a power point which outlines the correct medical tests to use to diagnose chronic pain problems. These are the tests used by the top academic medical institutions in the country, and the efficacy of these tests is documented by clinical outcome studies. The presentation is heavily illustrated, so the reader can really understand what a test measures.
The document discusses follow up procedures after 5 years of osteoporosis treatment, including reevaluating patients through clinical risk factors, DXA scans, and checking for new vertebral fractures. It recommends continuing or switching treatment based on risk level, and monitoring again in 2-3 years or if new fractures occur. Long term trial results are presented showing maintenance of bone mineral density gains and low fracture risk with continued denosumab treatment out to 8 years.
This study evaluated the long-term clinical and radiological outcomes of 126 patients with 239 osteoporotic vertebral fractures treated with balloon kyphoplasty compared to a conservatively treated control group. Patients undergoing kyphoplasty had significantly reduced pain scores and improved disability scores that were maintained at the 2-year follow-up, while the control group showed no significant changes. Kyphoplasty also significantly restored vertebral height and alignment, while conservative treatment did not significantly impact radiographic measures. This study demonstrates the long-term benefits of balloon kyphoplasty over conservative care for osteoporotic vertebral fractures.
The document describes the development and validation of the Post-operative Infection Treatment Score for the Spine (PITSS), a predictive model for determining whether patients require single versus multiple irrigation and debridement procedures for spinal surgical site infections. Key predictors in the model include wound culture microbiology, spine location, medical comorbidities, distant site infections, instrumentation, and bone graft. Internal validation showed the model has an AUC of 0.84. External validation on subsequent years of data showed acceptable discrimination with an AUC of 0.70. The model can help guide clinical decisions around appropriate treatment for spinal surgical site infections.
This study examined the association between darkening of third molar roots seen on preoperative panoramic radiographs and exposure of the inferior alveolar nerve during surgery. 116 patients with darkening of third molar roots were selected as the case group, and 193 patients with other high-risk radiographic signs near the roots were selected as the control group. The nerve was exposed in 27.6% of cases with isolated darkening and 7.8% of controls. Darkening alone or with other signs significantly increased the risk of nerve exposure compared to other signs alone. Having both darkening and other adjacent signs carried the greatest risk of exposure compared to darkening alone or other signs alone or combined. Differentiating between isolated dark
This study examined the association between darkening of third molar roots seen on preoperative panoramic radiographs and exposure of the inferior alveolar nerve during surgery. 116 patients with darkening of third molar roots were selected as the case group, and 193 patients with other high-risk radiographic signs near the roots were selected as the control group. The nerve was exposed in 27.6% of cases with isolated darkening and 7.8% of controls. Darkening alone or with other signs significantly increased the risk of nerve exposure compared to other signs alone. The risk was greatest for darkening accompanied by other adjacent signs, with an odds ratio over 5 times higher than for other signs alone. This suggests differentiating
This study evaluated the diagnostic accuracy of cone beam computed tomography (CBCT) and panoramic radiography in predicting exposure of the inferior alveolar nerve during third molar extraction surgery. The study assessed 59 impacted third molar extraction sites, examining pre-operative panoramic and CBCT images for signs suggesting nerve exposure. During surgery, actual nerve exposure was evaluated and compared to the radiographic predictions. CBCT correctly classified nerve exposure in 93.3% of cases, significantly more accurately than panoramic radiography which correctly classified 67.7% of cases. CBCT demonstrated high sensitivity, specificity, and predictive values, while panoramic radiography had lower sensitivity but high positive predictive value. This study indicates CB
This document summarizes a study on locating impacted maxillary canines in patients. The study analyzed orthopantomogram x-rays of 1,956 patients and found 57 impacted maxillary canines in 47 patients. The mean angulation of the impacted canines was 29.54 degrees and the mean vertical distance from the occlusal plane was 13.1 mm. The study found no significant correlation between the angulation and vertical distance of impacted canines. Both factors are important individually in determining treatment complexity, but they influence treatment planning independently of each other.
1) The study assessed the reliability of panoramic radiographs in determining the relationship between impacted mandibular third molars and the mandibular canal by comparing panoramic findings to CBCT scans.
2) Panoramic radiographic markers such as interrupted white lines and darkened tooth roots were statistically associated with direct contact between teeth and the mandibular canal as seen on CBCT.
3) Horizontal and mesioangular impactions showed the strongest association with direct contact between teeth and the mandibular canal, increasing the risk of nerve injury during extraction.
This study aimed to determine the prevalence of impacted maxillary canines in the Palestinian population visiting a dental center in Israel between 2006-2013. The researchers examined 4250 patient records and found an overall prevalence of impacted canines to be 3.7%, higher than previous studies. Specifically, the prevalence was 0.8% in males and 1.1% in females, suggesting a higher rate in females. Most impacted canines were palatally positioned. The results differed slightly from other studies, possibly due to differences in sample selection, study methods, and patient populations examined. Accurate assessment of an impacted canine's position is important to determine the appropriate treatment approach.
Digital images of oral cavities were analyzed by 7 raters to test inter-rater reliability of measurements. Raters measured areas of the total oral cavity, tongue, teeth, and empty spaces. Low average standard deviations and variances between raters demonstrated high inter-rater reliability for the digital imaging analysis method. This objective analysis technique aims to improve predictions of difficult intubation by eliminating subjectivity compared to prior subjective tests.
Prediction of Plantar Plate Injury using MRIWenjay Sung
Magnetic resonance imaging (MRI) is useful for diagnosing plantar plate tears but may not reliably rule out tears. A prospective study of 41 patients underwent MRI of the foot before surgery for suspected plantar plate pathology. MRI correctly identified 39 of 41 tears but missed 2 tears, giving it a sensitivity of 95% and specificity of 100%. MRI appears good for confirming a tear but may miss some, with a negative predictive value of 67%. MRI can help clinicians diagnose plantar plate tears but ultrasound may also be useful to evaluate.
EDIC is pleased to announce a webinar with Dr. R. Bruce Donoff, the Dean at Harvard Dental School. Dr. Donoff’s presentation will cover the risk factors for inferior alveolar and lingual nerve injury after third molar extraction, as well as the proper documentation and follow up of nerve injuries. Dr. Donoff will also discuss the potential for recovery from paresthesia after surgical intervention. The webinar will be held on May 10, 2011 at 7:00 PM.
This study examined the prevalence of impacted maxillary canines in the Arab population in Israel. The researchers reviewed records of 4250 patients and found 82 cases of impacted canines, a prevalence of 3.7%. Females had a higher prevalence than males, at 1.1% versus 0.8%. Most cases were unilateral, with the left side being more commonly impacted. The results suggest racial and genetic factors may influence canine impaction rates, as this population had a higher prevalence than previous studies in other areas. Early diagnosis and treatment of impacted canines can help guide them into proper alignment and avoid more complex treatment needs.
Nora e reversal colorato slideshare; NaPoli i SIA 2016Claudio Melloni
This document discusses complications that can occur during MRI, endoscopy, and dental procedures when sedation or anesthesia is used. It provides data on adverse events and deaths from studies in the United States and United Kingdom. Risk factors discussed include the type of sedation used, the age of the patient, and procedures occurring outside of an operating room. The need for proper patient monitoring during non-operating room anesthesia is emphasized.
Stereotactic Radiotherapy for the Treatment of Acoustic Neuromas Clinical Whi...Brainlab
Learn more: https://www.brainlab.com/radiosurgery-products/
Acoustic neuromas (AN) have an annual incidence of approximately one per 100,000 people and may account for up to 8% of all new tumors presenting to a neurosurgical referral practice. Acoustic neuromas are benign tumors arising from Schwann cells from the vestibular branch of the eighth cranial nerve. Nevertheless, they can pursue a potentially aggressive course, with uncontrolled local growth resulting in compression of the brainstem and fourth ventricle, cranial nerve and other neurological deficits.
Why should we start from mamndibula fracture in pffDr. SHEETAL KAPSE
The document summarizes a study analyzing 107 patients with panfacial fractures treated with a "bottom-up and outside-in" surgical sequence beginning with the mandible. The most common mandibular fracture sites were the symphysis and condyle, with the majority being isolated linear fractures. Compared to general mandibular fractures, mandibular fractures in panfacial fractures had a simpler distribution and less severity. Most patients treated with the proposed sequence had satisfactory outcomes with respect to facial symmetry, occlusion, mouth opening, and local deformities. The results support initiating treatment of panfacial fractures from the mandible.
Dental Patterns in Peruvians: A Panoramic Radiography StudyIván E Pérez
The dental pattern is defined as the combination of distinct codes assigned to describe specific tooth conditions including virgin, missing, and restored teeth that comprise the complete dentition or from discrete groups of teeth. This pattern can be then compared to the dentition of individual/s in an attempt to determine positive identification. The aims of the present investigation were to study and determine the diversity of dental patterns in Peruvian citizens based on a sample of panoramic radiographs. Digital panoramic radiographs of 900 adult Peruvian patients (450 female and 450 male) were evaluated to determine the dental patterns. The most frequent dental patterns found in the complete dentition, maxillae, upper-anterior and lower-anterior sextants were all-virgin-teeth (0.3%), all-extracted teeth (1.9%), all-virgin teeth (1%) and all-virgin-teeth (34.2% and 72.3%) respectively. The diversity was calculated by the use of the Simpson´s diversity index, the resulting values for the full-dentition, maxilla and mandible were over the 99.8% value and were similar to those previously reported in the scientific literature. This study demonstrates the positive benefit of dental patterns in the process of identification. Additionally a combination of codes is proposed that could prove useful in cases where a better radiographic description is required.
Background: Perforated tympanic membrane and middle ear infection are among common complications treated by tympanoplasty. This study was aimed to compare the effects of underlay and overlay tympanoplasty on the improvement of hearing and tympanic membrane landmarks and post-operative complications as well.
This document summarizes a study that evaluated radiographic measurements as prognostic indicators for healing of class II furcation defects following regenerative therapy. 33 class II furcation defects in 17 patients were treated using barrier membranes. Radiographs were taken before and 6 and 24 months after therapy and analyzed digitally. Several radiographic distances were measured, including the distance from the cemento-enamel junction to the alveolar crest and furcation fornix, as well as furcation width. Statistical analysis identified baseline probing depth and 3 radiographic distances - distance from furcation fornix to cemento-enamel junction, furcation width, and distance from furcation fornix to alveolar crest
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Australian dental j_97_-_ian_damage_following_removal_of_mandibular_3rd_molar_teeth_-_a_prospective_study_using_panoramic_radiography
1. Scientific papers
Australian Dental Journal 1997;42:(3):149-52
Inferior alveolar nerve damage following removal of
mandibular third molar teeth. A prospective study
using panoramic radiography
Andrew C. Smith, BDS, FDSRCS, FDSRCPS, FRACDS(OMS)*
Susan E. Barry, BDSc†
Allan Y. Chiong, BDSc†
Despina Hadzakis, BDSc†
Sung-Lac Kha, BDSc†
Steven C. Mok, BDSc†
Daniel L. Sable, BDSc†
Abstract
Permanent alteration of sensation in the lip after the
removal of mandibular third molar teeth is an
unusual but important complication. Studies have
been performed to assess the risk of nerve damage
but most of these have been retrospective and
poorly controlled.
This prospective trial predicted the outcome of
altered sensation prior to surgery based on assessment of a panoramic radiograph and correlated this
with the result postoperatively in the consecutive
removal of 479 third molar teeth.
Results indicated that 5.2 per cent had transient
alteration in sensation but only one patient (0.2 per
cent) had prolonged anaesthesia. As 94.8 per cent
of teeth extracted had no neurological sequelae the
figures for prediction were skewed and a kappa
statistical analysis of 0.27 illustrated a fair level of
agreement between prediction and outcome.
This study supports previously reported levels of
neurological damage and confirms that panoramic
radiography is the optimum method for radiological
assessment for mandibular third molar teeth prior to
their removal.
Key words: Inferior alveolar nerve, injury, incidence,
recovery, prognosis.
(Received for publication January 1996. Accepted
February 1996.)
Introduction
Many complications can occur from the removal
of mandibular third molar teeth. Damage to the
inferior alveolar nerve (IAN) is an unusual but
important one. The IAN runs in a bony canal within
the mandible in close proximity to the root tips of
mandibular molar teeth. Damage to the nerve manifests itself as a sensory disturbance of the lower lip
and chin up to the midline.
Studies of the relationship of the IAN to third
molar teeth have been reported.1-3 Rood and
Nooraldeen Sheehab4 defined seven radiological
markers that suggest an intimate relationship
between mandibular third molar teeth and the IAN
(Table 1). At present these markers are the standards used for the assessment of the likelihood of
risk of damage to the IAN and the basis for gaining
informed consent from the patient.
A panoramic radiograph is frequently used as the
radiological investigation of choice prior to third
molar surgery. The criteria previously mentioned are
identifiable on this projection, but like other conventional radiographs it is unable to give complete
information in three dimensions. The most accurate
method of prediction with precision of the position
Table 1. Radiological markers of proximity of
tooth roots to IAN
Root related
*Oral and Maxillofacial Surgery, School of Dental Science, The
University of Melbourne.
†Final Year Student Research Group, 1995, School of Dental
Science, The University of Melbourne.
Australian Dental Journal 1997;42:3.
Canal related
Darkening
Narrowing
Deflection
Bifid apex
Diversion
Narrowing
Loss of lamina dura
149
2. Table 2. Classification of nerve injury
Table 4. Predictions of alteration in sensation
Injury
Type of damage
Prognosis
Neuropraxia
Axonotmesis
No axonal degeneration
Axonal degeneration and
regeneration
Neural separation, healing
with cicatrisation
Excellent
1
2
3
4
5
Neurotmesis
Fair
Poor
of the IAN pre-operatively is the use of computerized tomography; however, unnecessary radiation
dosage and cost/benefit analysis need to be
considered.
Nerves consist of fasciculi held together by a
protective areolar connective tissue that coalesces to
form the nerve sheath. This sheath is strengthened
by linear collagen bands. The outcome of damage to
a nerve depends on the nature of the injury. Merrill5
outlined the classification defined by Sneddon and
this is the standard used for neurological assessment
(Table 2). Prognosis also depends on other factors
including the age of the patient and adequacy of the
local vascular supply.
The subjective and objective assessment of nerve
damage is problematic. It is possible to classify
patterns of sensory loss6 (Table 3).
The exact aetiology of IAN injury is also imprecise
and multi-factorial. Kipp, Goldstein and Weiss7
considered that mechanical injury from chisels, burs
or elevators was most likely. Howe and Poyton2
concluded that crushing or tearing of the nerve from
movements of the teeth was more likely, particularly
if the IAN grooved or perforated the third molar
tooth (Fig. 1). Crushing of the roof of the IAN canal
onto the IAN has also been implicated.8
Howe and Poyton2 also suggested that there was
an increased risk of IAN damage with advancing age
and difficulty of extraction. There is no substantiation
of these factors in the literature.
The incidence of transient IAN damage ranges
from 0.41 per cent to 8.4 per cent and permanent
damage is reported to occur in 0.014 per cent to 1.5
per cent of cases.9 Studies vary in size from less than
100 to over 1400 teeth, but most have been
performed retrospectively, possibly resulting in data
collection inaccuracy.
The aims of this study were to identify the
incidence of IAN damage following the removal of
mandibular third molar teeth and to assess whether
the panoramic radiograph is valuable in predicting
outcome.
Table 3. Patterns of sensory loss
Hypoaesthesia
Hyperaesthesia
Paraesthesia
Dysaesthesia
Anaesthesia
150
No anticipated change
Hypoaesthesia
Hyperaesthesia
Dysaesthesia or paraesthesia
Anaesthesia
Decreased sensitivity to stimulation
Increased sensitivity to stimulation
Abnormal sensation, spontaneous or evoked
Unpleasant abnormal sensation, spontaneous
or evoked
Total loss of sensation
Materials and methods
Male and female patients aged 17 to 35 years,
undergoing general anaesthesia for the removal of
mandibular third molar teeth, were recruited for the
trial. Exclusion occurred if they did not meet these
criteria or if they required the removal of other
mandibular teeth, had other associated mandibular
pathosis, or any neurological disorder that might
unfairly influence the outcome. Patients who failed
to attend for follow-up appointments or were otherwise lost to the study were also excluded. After
consultation with a statistician, a sample size of 500
third molars was selected.
Prior to surgery, the surgeon was asked to predict
from a panoramic radiograph any change in sensation
to the lower lip that might be present postoperatively. The prediction categories are displayed
(Table 4). At the postoperative check, two weeks
later, the patient was questioned by another surgeon
and any altered sensation scored on the same
scheme (Table 4).
To allow for comparison of accuracy and consistency of prediction, a sample of thirty radiographs
from the study population were selected for 15 sites
assessed pre-operatively as no change (Category 1,
Table 4) and 15 within the predicted categories of
altered sensation (Category 2-5, Table 4). These
radiographs were presented to postgraduate trainee
oral and maxillofacial surgeons who were asked to
predict alteration in IAN sensation after removal of
mandibular third molar teeth. This procedure was
repeated twice with a one-month time gap.
Data collection and statistical analysis were
performed. It was felt inappropriate to apply
conventional correlation coefficient and chi-squared
analyses on the data, as these tests are not designed
to assess agreement. After advice a kappa analysis
was chosen. This does have inherent problems in
that the prevalence of the outcome in each category
is important and if there is a large proportion of one
outcome then this can skew the kappa result. Advice
from a statistician was that this analysis was still the
most appropriate for this study.
Table 5. Data and statistical analysis (2)
Prevalence of abnormality
Outcome
Normal
Abnormal
Prediction
Normal
Abnormal
Total
411
43
454
7
18
25
Total
418
61
479
Australian Dental Journal 1997;42:3.
3. Table 6. Data and statistical analysis
Predictions
Correct %
Sensitivity
Specificity
72
90.5
Results
Five-hundred sites were entered into the study.
Twelve patients with 21 sites failed to attend for
follow-up.
Prevalence
From a total of 479 third molar removals, 25
patients (5.2 per cent) reported having transient
alteration in IAN sensation. Within two weeks of
surgery only one patient (0.2 per cent) had a
residual neurological deficit. This patient’s
hypoaesthesia has persisted (Table 5).
Predictability
Of the 454 normal outcomes (94.8 per cent) 411
were predicted from the radiographs to be normal.
This shows a 90.5 per cent specificity. Of the 25
outcomes with altered sensation, 18 were predicted
from the radiograph showing a 72.0 per cent
sensitivity (Table 6).
Kappa value
Table 7 shows the distribution of pre-operative
prediction compared with the actual outcome. The
last row and column of the chart show the incidence
of IAN damage predicted compared with the incidence of IAN damage that resulted. The diagonals
on the table represent the agreement between the
prediction and the actual outcome. The kappa value
tests the strength of agreement along this diagonal
and was 0.27 with a 95 per cent upper and lower
confidence interval of 0.45 and 0.10 respectively
(Table 8). This shows a statistically fair level of
agreement between prediction and actual outcome.
To confirm accuracy and consistency of prediction,
the results of repetitive testing of postgraduate oral
and maxillofacial surgery trainees show a statistically
good level of agreement (-0.06) between the tests
conducted with a time interval (Table 8).
Discussion
Information obtained from the Defence
Committee of the Australian Dental Association
Fig. 1. – Mandibular third molar with root perforated by IAN. The
tooth was sectioned during surgery to preserve the contents of the
neurovascular bundle and the tooth has been repaired with acrylic for
this illustration.
Victorian Branch reveals that from 1990-1994 third
molar removal was responsible for 18.1 per cent of
all litigation and that 43.7 per cent of this was due to
neurological damage.
It is therefore important to be able to predict and
assess the risk of nerve damage. Previous studies
have reported a large variability in outcome which
may be due to operative technique dependent on or
influenced by the design of the investigation. This
study is prospective and overcomes these problems.
There are difficulties in statistical analysis, however,
and it would be inaccurate to derive any further
statistical significance than those figures presented
in the results section. As there was a large number of
normal outcomes, the data are skewed; however, the
results do show that panoramic radiography is useful
in predicting a normal outcome from surgery.
Operating surgeons would be aware of the low
incidence of neurological damage and so their
Table 7. Data distribution comparing prediction with actual outcome
No change
Hypoaesthesia
Hyperaesthesia
Para/Dysaesthesia
No change
Hypoaesthesia
Hypaesthesia
Para/Dysaesthesia
Anaesthesia
411
31
1
7
4
6
9
1
1
5
Total
454
17
Australian Dental Journal 1997;42:3.
2
Anaesthesia
1
1
6
1
Total
418
46
1
10
4
479
151
4. Table 8. Data and statistical analysis (3)
Kappa value
Kappa
Upper confidence interval
Lower confidence interval
A
0.27
0.45
0.10
B
-0.06
0.10
-0.17
A=Agreement between prediction and postoperative assessment including
confidence intervals.
B=Agreement between first trial and second trial on panoramic radiographs
including confidence intervals.
estimations might be biased towards a prediction of
normal outcome. Patients who failed to attend for
follow-up might be assumed to have a normal
outcome, but it was felt that in terms of accuracy
these patients should be excluded from the study.
It is clear that panoramic radiography, being
readily available and relatively low in radiation dose,
provides the optimum method of predicting neurological damage. At present coronal computerized
tomographic scans are the only way to image, with
precision, the relationship of the tooth root to the
IAN. Radiation dosage and cost to the community
preclude this investigation as a routine, particularly
as the outcome of neurological deficit does not just
necessarily depend on direct contact of IAN with
tooth root. Surgical techniques of bone crushing or
the use of neurotoxic materials during surgery may
cause damage to the IAN even if it is distant from
tooth root. This enhances the unpredictable nature
of the certainty of outcome in mandibular third
molar surgery.
Conclusion
Despite many studies and reports in the literature
there is still debate about the aetiology, incidence
and outcome of neurological damage during third
molar surgery. This study confirms the previously
reported prevalence rates.
In order to ensure adequate informed consent
prior to the removal of mandibular third molar teeth
the patient should be educated in the risks and
benefits of surgery. It has been shown by this study
that the panoramic radiograph is a valuable but by
152
no means infallible guide to the prediction of a
successful outcome with no neurological deficit in
sensation to the lower lip.
Acknowledgements
Thanks are due to the Statistics Department of
the University of Melbourne and the Commonwealth Scientific and Industrial Research
Organization for valuable advice in the design of this
study.
References
01. Main J. Further roentgenographic study of mandibular third
molars. J Am Dent Assoc 1938;25:1993.
02. Howe GL, Poyton HG. Prevention of damage to the inferior
dental nerve during the extraction of mandibular third molars.
Br Dent J 1960;109:355-63.
03. Merrill RG. Prevention, treatment and prognosis for nerve injury
related to the difficult impaction. Dent Clin North Am
1979;23:471-3.
04. Rood JP, Nooraldeen Shehab BAA. The radiological prediction
of inferior alveolar nerve injury during third molar surgery. Br J
Oral Maxillofac Surg 1990;28:20-5.
05. Merrill RG. Decompression for inferior alveolar nerve injury. J
Oral Surg 1964;22:291-30.
06. Klineberg I. Craniomandibular disorders and orofacial pain:
Diagnosis and management. London: Wright, 1991:144-9.
07. Kipp DP, Goldstein BH, Weiss WW Jr. Dysesthesia after
mandibular third molar surgery: a retrospective study and
analysis of 1377 surgical procedures. J Am Dent Assoc
1980;100:185-90.
08. Rud J. Third molar surgery: relationship of root to mandibular
canal and injuries to inferior dental nerve. Danish Dent J
1983;87:619-31.
09. Carmichael FA, McGowan DA. Incidence of nerve damage
following third molar removal: a West Scotland oral surgery
research group study. Br J Oral Surg 1992-30:78-82.
Address for correspondence/reprints:
A. C. Smith,
School of Dental Science,
The University of Melbourne,
711 Elizabeth Street,
Melbourne, Victoria 3000.
Australian Dental Journal 1997;42:3.