Endoscopic and ultrasonographic evaluation of the maxillary sinus after combined sinus floor augmentation and implant insertion

OBJECTIVE

The aim of our study was a radiographic, endoscopic, and ultrasound follow-up of the maxillary sinus comparing 2 techniques of sinus floor augmentation.

STUDY DESIGN

Sonograms, radiographs (Waters' view) of the sinuses, and endoscopy served before and during surgery to evaluate the maxillary sinus. One week after the operation, ultrasound and radiograph follow-up (Waters' view) were carried out. Six months after the operation, we performed an ultrasound follow-up along with uncovering the implants. If any pathologic condition was found, we took another x-ray film of the sinuses, performed another endoscopic examination, or both.

RESULTS

In 23 of 63 patients, healing was uneventful. Waters' view revealed opacification of the maxillary sinus 1 week after surgery in 40 cases when the "window technique" was used. Sinusitis occurred 3 times, as a result of migration of bone chips in 2 patients. We lost 11 of 132 inserted implants during the healing and loading periods.

CONCLUSION

Endoscope-controlled sinus floor augmentation may lower the complication rate in a remaining height of the jaws between 4 and 8 mm. In our group of patients, we proved by endoscopic examination that migration of cancellous bone sequestra was the reason for sinusitis. In case of infected bone grafts with antral symptoms, sinoscopy allowed debridement and removal of a sequestrum.

Quantitative analysis of the velopharyngeal sphincter function during speech

OBJECTIVE

This study reports a new concept for quantitative analysis of velopharyngeal function using electromagnetic articulography and simultaneous transoral video endoscopy.

PARTICIPANTS

The velopharyngeal closure mechanism was studied in 16 healthy German subjects during production of the vowel-consonant-vowel sequences /afa/ and /apa/.

DESIGN

Velar movements in the sagittal and vertical direction were measured by electromagnetic articulography (EMA) while video endoscopy was used for recording in the sagittal and transverse directions.

MAIN OUTCOME MEASURE

A transverse sagittal quotient (TSQ) was defined after the measurement of sagittal and transverse diameters of the velopharyngeal port (VPP) in the video-endoscopic pictures on the basis of a frame-by-frame analysis.

RESULTS

The sphincter morphology was objectively determined with the TSQ base value. A terminal sphincter deformation (TSD) for closure phases of articulatory movement was revealed by a qualitative shape analysis of the TSQ curves.

CONCLUSIONS

The assessment of the TSQ of velopharyngeal port diameters and the TSD in the terminal closure period lead to a new dynamic interpretation of velopharyngeal closure patterns.

[Roentgenologic, endoscopic and ultrasound evaluation of the maxillary sinus after sinus lift with simultaneous endosseous implantation]

X-ray, ultrasound, and endoscopy were used in follow-up after sinus floor augmentation. In 23 out of 63 patients, healing was uneventful. Water's view revealed opacification of the maxillary sinus 1 week postoperatively in 40 patients, and opacification persisted in four patients. In these patients, endoscopy showed inflammatory reactions of the mucosa. Ultrasound proved to be a valuable tool in follow-up. Sinusitis occurred in three patients and was due to migration of bone chips in two of these. Out of 132 inserted implants, eight were lost during the healing period and three more during the loading period.

Endoscopically controlled sinus floor augmentation. A preliminary report

Sinus augmentation has been advocated to be a surgical technique with predictable results in peri-implant surgery. Endoscopic surgery of the maxillary sinus so far has been used as diagnostic procedure. In this paper, the use of endoscopy is described as a low invasive adjunctive technique in sinus floor augmentation. After preparation of the mucoperiosteum, bone grafts can be placed under endoscopic control between sinus floor and mucoperiosteum. A laterobasal approach via a small osteotomy and a transalveolar approach are possible for mucosal elevation and graft placement. First clinical results are reported. Endoscopic sinus lift may contribute to a reduction of perioperative morbidity, reduction of oroantral fistulae and control of graft position. The less invasive technique may allow to extend the indication for sinus augmentation.

[Indications for dental-CT. Case reports]

Based on case reports, common indications for dental computed tomography are demonstrated and typical findings are analysed. From a group of 110 patients who had a reformatted computed tomography of the maxilla and mandibular, 10 typical cases were chosen as examples and are presented with a detailed description of the findings. The most important indication was the analysis of the morphology of the alveolar ridge needed in presurgical planning for osseointegrated implants as well as in special cases of postsurgical control. Apart from implantology, the method could be used in cases of mandibular cysts and bony destructions. In conclusion, dental computed tomography has become established mainly in implantology. It can provide valuable results in cases where a demonstration of the bone in all dimensions and free of overlappings and distortions is needed.

Midsagittal velar kinematics during production of VCV sequences

We present data on velar speech movements examined by electromagnetic articulography (EMA), a tool for the study of velar kinematics. Based on investigations on 22 normal German subjects (15 male, 7 female), movement paths of the velum using a sensor positioned on the midsagittal anterior surface were recorded using a series of high and low vowel VCV utterances. Maximum velar elevation (mean = 13.5 +/- 0.6 mm [SD]) with the rest position as a reference was observed during the production /iti/. The average maximum articulatory velocity of velar movements during /iti/ production was 141.0 mm/sec. Maximum movement of the velum observed during production of /ana/ averaged 7.5 +/- 1.1 mm. The direction of velar movement ranged between 44.6 degrees and 50.4 degrees relative to the bite plane registered electromagnetically. The influence of loudness variation of sequence production is demonstrated and discussed with the literature.

Complications following arthroscopy of the temporomandibular joint: analysis covering a 10-year period (451 arthroscopies)

451 arthroscopies of the temporomandibular joint (TMJ) have been performed on 373 patients during 10 years of clinical experience. The complication rate was low (1.77%). Most complications were transient, consisting mainly of temporary deficits of the 5th and 7th cranial nerves. No patient required arthrotomy because of complications, but one patient had to undergo angiography and embolization of a traumatic aneurysm of the superficial temporal artery secondary to arthroscopy.

Simultaneous evaluation of articulatory velopharyngeal function under different dynamic conditions with EMA and videoendoscopy

Objective examination of velopharyngeal (VP) sphincter function has been described based on multiple methods. Videofluoroscopy and videoendoscopy represent today's clinical standard. A new concept of analysis of VP functioning is described using electromagnetic articulography (EMA) for midsagittal measurement of velar movement and videoendoscopy in a setting for simultaneous recording. Multidimensional analysis of VP functions using this setting is demonstrated for a normal subject. Timing aspects of VP closure and a transverse-sagittal ratio of VP port diameter are reported under different conditions of speech dynamics.

[Functional palatoraphy and modified chin osteotomy in surgical therapy of sleep-related respiratory disorders with obstruction of the upper airways]

We have developed a new surgical approach, called functional palatoraphy. This procedure preserves the posterior border of the soft palate and allows a controlled repair of the soft palate. It is routinely combined with a chin osteotomy. In selected cases this procedure is an alternative to other surgical methods.

Electromagnetic articulography as a method for detecting the influence of spikes on tongue movement

In orthodontics dysfunctions of the tongue are discussed as a factor in the development of malocclusion. A new objective method for examining tongue movement is the electromagnetic articulography (EMA). This enables movements of the tongue to be followed using the principle of inductive distance measurements. A helmet made of acrylic material serves as a carrier for three transmitter coils. These are located in front of the forehead, in front of the chin, and at the back of the neck. Receiver coils are fixed to the tip of the tongue and at two points on the dorsum of the tongue. The distance between the receiver and the transmitter coils is calculated by means of a personal computer. The movement trajectories are displayed on a computer screen in x-y-coordinates. Tongue movements of one patient with an anterior open bite are shown during characteristic test sounds and during swallowing. The first examination took place without any orthodontic appliance. In a second series in the same session, tongue movement was recorded under the influence of an orthodontic appliance with spikes. While the patient shows vertical combined with sagittal components in the movement pattern of the tongue without an orthodontic appliance, the same patient, under the influence of an orthodontic appliance with spikes, shows a change of the rest and work position of the tongue and in the pattern of tongue movement with a more posterior position of the tongue, and with an increase in the vertical and a decrease in the sagittal components of the movement pattern.

Loose bodies in the temporomandibular joint. The advantages of arthroscopy

Loose bodies are a rare cause of temporomandibular joint symptoms. Their main source is synovial chondromatosis. We report on clinical findings, diagnostic methods, treatment choices and outcome following the removal of loose bodies in 10 patients. Seven patients were evaluated and treated by means of arthroscopy, while in three patients open arthrotomy was performed. In five patients, no diagnostic imaging technique had demonstrated the presence of loose bodies prior to arthroscopy. In six patients, histology revealed synovial chondromatosis. In four patients, osteochondral fragments alone were found. Until now, the recommended treatment of choice for the removal of all loose bodies and of affected synovial tissue required open arthrotomy. We conclude that the advantages of arthroscopy consist in locating loose bodies that are not detectable radiologically and in reducing operative trauma.

Diagnostic accuracy of TMJ arthroscopy in correlation to histological findings

From 1987-1993, 356 arthroscopic examinations of the temporomandibular joint were performed on 295 patients. During 69 examinations, biopsies were obtained to correlate arthroscopic findings with histology. In the overall group, histology confirmed in 78.9% the arthroscopic findings. Correlation was better in joints with degenerative changes (81.5%) than in those with a synovitic/hyperaemic appearance (61.5%). Chondroid metaplasia, detritus synovitis and synovial chondromatosis were additional diagnoses given by histological examination. In 11 joints, open arthrotomy was performed after arthroscopy with biopsy was carried out. The excised tissue was also investigated microscopically and correlates to the biopsy-result. Because no different pathological changes were found, it is concluded that biopsies performed during arthroscopy of the temporomandibular joint are representative for histological investigation. An additional perforation for introducing the biopsy forceps is not necessary, because results obtained with different techniques appeared to be equally accurate.

[Simultaneous electromagnetic articulography and video endoscopy. A case contribution to the objective diagnosis of the velopharyngeal sphincter]

An objective examination of velopharyngeal sphincter function (VP) is possible using a variety of signal and pictorial methods to differing degrees. Video endoscopy and videofluoroscopy are the currently accepted clinical standard. With the help of a new concept described here it is possible both to analyze VP function in the midsagittal plane using electromagnetic articulography (EMA) and also to examine simultaneously the horizontal plane video endoscopically. This multidimensional analysis of VP function is presented in a case study of a healthy test person and the timing aspects of VP closure and transverse-sagittal ratio of VP port-diameters ist reported.

An experimental study of new diagnostic methods for the examination of osseous lesions in the temporomandibular joint

Digital subtraction radiography, tomosynthesis, bone uptake of radionuclide, and arthroscopy were evaluated for detection and quantification of bony lesions induced unilaterally in the condyles of six dogs. A stereotaxic head-holder facilitated acquisition of reproducible radiographs suitable for subtraction and for circular tomosynthesis. Bone uptake of technetium-99m methylene diphosphonate was measured with a hand-held collimated miniature detector. Arthroscopy was performed with an arthroscope of 2.4 mm diameter. Bone defect mass determined by subtraction radiography correlated highly (r = 0.92, p less than 0.001) with the calcium content of removed bone measured by atomic spectroscopy. Both subtraction radiography and tomosynthesis indicated reshaping of the condyle into a more anterior position over a 10-week follow-up period. Radionuclide uptake was significantly elevated (p less than 0.04) from 2 to 10 weeks after surgery and correlated (r = 0.73, p less than 0.05) with regained bone mass measured by subtraction radiography. Arthroscopy revealed progressive degeneration of cartilage with denudation in the fossa. Both radiographic techniques demonstrated the lesions and bone remodeling, but only subtraction provided quantitative results. Radionuclide uptake predicted quantitatively future bone mass changes, and arthroscopy revealed cartilage and soft tissue status not otherwise observable.

[The importance of electromagnetic articulography in studying tongue motor function in the framework of an orthodontic diagnosis]

Objective data are required for assessing the influence of movements of the tongue on the position of the teeth. Electromagnetic articulography (EMA) makes it possible to track movements of the tongue using the principle of inductive distance measurement. A helmet made of light but robust acrylic material serves as a carrier for three transmitter coils; these latter are located in front of the forehead, in front of the chin, and at the back of the neck. Receiver coils are fixed to the tip of the tongue and at various points on the dorsum of the tongue. The distance between the receiver coils and the transmitter coils is calculated in real time by means of a personal computer. The movement trajectories are displayed on the computer screen in different colors in X-Y coordinates. The movements of the tongue are recorded in patients with correctly positioned front teeth and compared with those in patients with a frontal open bite. The significance of electromagnetic articulography for dental research and functional treatment is demonstrated.

Delayed endodontic and prosthetic treatment of two traumatized incisors

This case report describes the delayed endodontic and prosthetic treatment of two maxillary central incisors in a 16-year-old patient. Both teeth had been traumatized eight years previously. The examination revealed arrested root formation with wide open apices, periapical inflammation and inflammatory resorption. Endodontic treatment with calcium hydroxide led to formation of hard tissue barriers in both teeth so that definite obturation could be performed. One tooth was lost due to a deep crown-root-fracture and replaced by an intraosseous implant, whereas the other incisor was retained for nearly four years.

[The value of double contrast arthrotomography combined with cinematography in the diagnosis of functional and structural TMJ alterations]

Double contrast arthrotomography combined with cinematography as a diagnostic instrument establishing functional and structural TMJ alterations is evaluated for its diagnostic value and reliability within the chain of diagnostic measures applied. In 131 patients double-contrast arthrotomography was followed by a comprehensive history of joint problems, and verification of the clinical findings as well as the arthrographic diagnosis and the post-arthrographic TMJ alterations. Our interest was focussed, among others, on the question whether arthrography alone would have any therapeutic effect or produce an alteration in TMJ function.

Assessment of bone remodeling in the temporomandibular joint by serial uptake measurement of technetium 99m-labeled methylene diphosphonate with a cadmium telluride probe

Regional uptake of technetium 99m-labeled methylene diphosphonate was measured serially over time to follow the healing course of surgically generated lesions, induced unilaterally in the condyles of beagles. A small portable cadmium telluride probe was used for radiation detection, with and without a gold collimator attached. Radioactivity was measured at six periarticular sites on both the operated and the contralateral control sides and expressed as a ratio with respect to a reference site over the sagittal suture. The use of a collimator was crucial to separate the activity associated with bone mineralization in the condylar head from that arising in the adjoining bones. The uptake in the condylar region increased 2 weeks after surgery and remained at a constant level above the presurgery baseline (p less than 0.05) until termination of the study (10 weeks). Postmortem histologic examinations confirmed the high bone turnover level by revealing newly formed bone as well as the presence of osteoclasts. The time course of nuclide uptake in the temporomandibular joint is different from the general pattern of rise and fall of activity displayed in other bones and indicates the persistence of bone remodeling processes during a prolonged period of at least 10 weeks.

Condylar movements in clicking joints before and after arthrography

The aim of this study was to investigate whether anaesthesia and contrast medium injection alter the biomechanics of the TMJ, thus influencing the arthrographic diagnosis in patients with anterior disc displacement with reduction. Opening and closing movements were recorded in nine patients by means of an opto-electronic motion recorder (Jaws 3D) before anaesthesia, after anaesthesia and after arthrography. The system computed the trajectories of a condylar point in the sagittal, frontal and horizontal plane. Data were analysed for changes in the position of the clicks, for the amount of condylar translation and for changes of the trajectories between recording conditions. The results indicated that arthrography had a significant effect on the position of the opening clicks in all nine patients. After injection, the clicks occurred on average 1.6 mm later than before injection. This was probably due to the excursive movements required for defusion of the contrast medium in the joint. The other parameters examined were not affected by the joint anaesthesia and the arthrographic procedure. The interventions influenced the shape and the incline of the sagittal condylar movement in three of the nine patients. In conclusion, arthrography altered the joint biomechanics, but not sufficiently to invalidate the arthrographic diagnosis.