What does magnetic resonance imaging add to the prenatal ultrasound diagnosis of facial clefts?

OBJECTIVE

Ultrasound is the modality of choice for prenatal detection of cleft lip and palate. Because its accuracy in detecting facial clefts, especially isolated clefts of the secondary palate, can be limited, magnetic resonance imaging (MRI) is used as an additional method for assessing the fetus. The aim of this study was to investigate the role of fetal MRI in the prenatal diagnosis of facial clefts.

METHODS

Thirty-four pregnant women with a mean gestational age of 26 (range, 19-34) weeks underwent in utero MRI, after ultrasound examination had identified either a facial cleft (n = 29) or another suspected malformation (micrognathia (n = 1), cardiac defect (n = 1), brain anomaly (n = 2) or diaphragmatic hernia (n = 1)). The facial cleft was classified postnatally and the diagnoses were compared with the previous ultrasound findings.

RESULTS

There were 11 (32.4%) cases with cleft of the primary palate alone, 20 (58.8%) clefts of the primary and secondary palate and three (8.8%) isolated clefts of the secondary palate. In all cases the primary and secondary palate were visualized successfully with MRI. Ultrasound imaging could not detect five (14.7%) facial clefts and misclassified 15 (44.1%) facial clefts. The MRI classification correlated with the postnatal/postmortem diagnosis.

CONCLUSIONS

In our hands MRI allows detailed prenatal evaluation of the primary and secondary palate. By demonstrating involvement of the palate, MRI provides better detection and classification of facial clefts than does ultrasound alone.

Biodegradable polymer membrane used as septal splint

The treatment of a crooked nose is one of the most challenging rhinoplastic procedures. Correction of the abnormally curved or fractured septum has been reported using mostly scoring techniques, septoplasty and submucous resection techniques; cartilaginous spreader grafts can also be sutured to the distorted septum. Extracorporal septal straightening and repositioning/refixation is another useful but difficult technique. A common problem of septal cartilaginous grafting techniques is to harvest enough straight cartilage to correct the deformity. (Other donor sites such as rib cartilage are used, but harvesting additional cartilage is a time-consuming procedure and carries the risk of donor site morbidity.) Recent studies have been published using alloplastic internal splinting of the deformed septum. The use of poly p-dioxanone foils and porous polyethylene has been suggested before. In this study, a novel grafting material, a PolyMax membrane that has potential advantages over both materials, is presented. This is a porous biodegradable polymer made out of 70:30 poly(L-lactide-co-D,L-lactide) that remains stable for at least 7 months. Poly p-dioxanone loses its stability after only 2 months, whereas porous polyethylene is a permeable material that is controversial due to possible complications in cases of membrane exposure and infection. In this preliminary report the PolyMax membrane was used successfully in 3 patients.

Dysgnathia, orthognathic surgery and spinal posture

The aim of this study was to evaluate the spine by video rasterstereography before and after orthognathic surgery. Twenty-nine patients (17 patients with a skeletal class III, 7 patients with a skeletal class II, and 5 patients with mandibular asymmetry) were evaluated preoperatively and 1 year postoperatively. Video rasterstereography is a method of back surface measurement and shape analysis using the moire topography. Orthognathic surgery in cases of class III and asymmetry did not lead to significant changes in body posture. In class II patients it led to some changes in body posture, but without orthopaedic consequences. It is concluded that orthognathic surgery causes minimal or no change in body posture.

Detection and monitoring of virus infections by real-time PCR

The employment of polymerase chain reaction (PCR) techniques for virus detection and quantification offers the advantages of high sensitivity and reproducibility, combined with an extremely broad dynamic range. A number of qualitative and quantitative PCR virus assays have been described, but commercial PCR kits are available for quantitative analysis of a limited number of clinically important viruses only. In addition to permitting the assessment of viral load at a given time point, quantitative PCR tests offer the possibility of determining the dynamics of virus proliferation, monitoring of the response to treatment and, in viruses displaying persistence in defined cell types, distinction between latent and active infection. Moreover, from a technical point of view, the employment of sequential quantitative PCR assays in virus monitoring helps identifying false positive results caused by inadvertent contamination of samples with traces of viral nucleic acids or PCR products. In this review, we provide a survey of the current state-of-the-art in the application of the real-time PCR technology to virus analysis. Advantages and limitations of the RQ-PCR methodology, and quality control issues related to standardization and validation of diagnostic assays are discussed.

Detection and monitoring of virus infections by real-time PCR

The employment of polymerase chain reaction (PCR) techniques for virus detection and quantification offers the advantages of high sensitivity and reproducibility, combined with an extremely broad dynamic range. A number of qualitative and quantitative PCR virus assays have been described, but commercial PCR kits are available for quantitative analysis of a limited number of clinically important viruses only. In addition to permitting the assessment of viral load at a given time point, quantitative PCR tests offer the possibility of determining the dynamics of virus proliferation, monitoring of the response to treatment and, in viruses displaying persistence in defined cell types, distinction between latent and active infection. Moreover, from a technical point of view, the employment of sequential quantitative PCR assays in virus monitoring helps identifying false positive results caused by inadvertent contamination of samples with traces of viral nucleic acids or PCR products. In this review, we provide a survey of the current state-of-the-art in the application of the real-time PCR technology to virus analysis. Advantages and limitations of the RQ-PCR methodology, and quality control issues related to standardization and validation of diagnostic assays are discussed.

Molecular detection and quantitative analysis of the entire spectrum of human adenoviruses by a two-reaction real-time PCR assay

Adenoviruses (AdV) can cause life-threatening infections in immunosuppressed patients. Reliable diagnostic tests are therefore of paramount importance. Apparently, any of the six AdV species (A to F), currently comprising 51 different serotypes, can play a clinically important role in patients with impaired immune response. It is imperative therefore that diagnostic assays cover the entire spectrum of these viruses. We have sequenced presumably conserved regions of the adenoviral genome in all AdV serotypes. Based on the complete sequence information of the hexon gene, we were able to develop a two-reaction real-time PCR assay covering all human adenoviruses with equally high specificity and sensitivity. The detection systems were tested using reference strains for all 51 serotypes and >1,000 clinical samples derived from peripheral blood and stool specimens from pediatric patients after allogeneic stem cell transplantation. The two-reaction assay presented permits highly specific detection and quantification of adenoviral DNA of any serotype. From the perspective of routine clinical diagnosis, the assay represents an important improvement over existing approaches by providing a sensitive and economic technique for early detection and monitoring of adenoviral infections.

Aggressive fibromatosis of the mandible: a case report

An extensive tumour in a 7-year-old girl, leading to severe disfigurement, proved to be an aggressive fibromatosis on histological examination. Eighteen months after surgery there was no evidence of recurrent disease. This suggests that tumour resection and reconstruction of the mandible had been successful. Contrary to some reports, tumour resection led to curative therapy whereas radiotherapy failed.

Real-time quantitative PCR assays for detection and monitoring of pathogenic human viruses in immunosuppressed pediatric patients

A panel of 23 real-time PCR assays based on TaqMan technology has been developed for the detection and monitoring of 16 different viruses and virus families including human polyomaviruses BK virus and JC virus, human herpesviruses 6, 7, and 8, human adenoviruses, herpes simplex viruses 1 and 2, varicella-zoster virus, cytomegalovirus, Epstein-Barr virus, parvovirus B19, influenza A and B viruses, parainfluenza viruses 1 to 3, enteroviruses, and respiratory syncytial virus. The test systems presented have a broad dynamic range and display high sensitivity, reproducibility, and specificity. Moreover, the assays allow precise quantification of viral load in a variety of clinical specimens. The ability to use uniform PCR conditions for all assays permits simultaneous processing and detection of many different viruses, thus economizing the diagnostic work. Our observations based on more than 50,000 assays reveal the potential of the real-time PCR tests to facilitate early diagnosis of infection and to monitor the kinetics of viral proliferation and the response to treatment. We demonstrate that, in immunosuppressed patients with invasive virus infections, surveillance by the assays described may permit detection of increasing viral load several days to weeks prior to the onset of clinical symptoms. In virus infections for which specific treatment is available, the quantitative PCR assays presented provide reliable diagnostic tools for timely initiation of appropriate therapy and for rapid assessment of the efficacy of antiviral treatment strategies.

Evaluation of candidate control genes for diagnosis and residual disease detection in leukemic patients using 'real-time' quantitative reverse-transcriptase polymerase chain reaction (RQ-PCR) - a Europe against cancer program

Real-time quantitative RT-PCR (RQ-PCR) is a sensitive tool to monitor minimal residual disease (MRD) in leukemic patients through the amplification of a fusion gene (FG) transcript. In order to correct variations in RNA quality and quantity and to calculate the sensitivity of each measurement, a control gene (CG) transcript should be amplified in parallel to the FG transcript. To identify suitable CGs, a study group within the Europe Against Cancer (EAC) program initially focused on 14 potential CGs using a standardized RQ-PCR protocol. Based on the absence of pseudogenes and the level and stability of the CG expression, three genes were finally selected: Abelson (ABL), beta-2-microglobulin (B2M), and beta-glucuronidase (GUS). A multicenter prospective study on normal (n=126) and diagnostic leukemic (n=184) samples processed the same day has established reference values for the CG expression. A multicenter retrospective study on over 250 acute and chronic leukemia samples obtained at diagnosis and with an identified FG transcript confirmed that the three CGs had a stable expression in the different types of samples. However, only ABL gene transcript expression did not differ significantly between normal and leukemic samples at diagnosis. We therefore propose to use the ABL gene as CG for RQ-PCR-based diagnosis and MRD detection in leukemic patients. Overall, these data are not only eligible for quantification of fusion gene transcripts, but also for the quantification of aberrantly expressed genes.

Nachweis der Osteokalzinexpression osteoblastärer Zellen mandibulären Ursprungs, wachsend auf Biomaterialien, mittels RT-PCR und SDS-PAGE/Western Blotting

A new approach to addressing difficult tissue reconstructive or replacement problems in the oral cavity is to engineer new tissue by using selective cell transplantation on polymer scaffolds. The current study characterized the osteoblastic nature of adherent mandibular cells on biomaterials, which could have a potential use as scaffolds for tissue engineering strategies. Cells of mandibular origin from one patient were cultivated on three different biomaterials (PepGen P-15 trade mark, Frios Algipore, and OsteoGraf/LD-700) for 7 and 14 days and osteocalcin expression was demonstrated by RT-PCR and SDS-PAGE/Western blotting. In order to explicitly characterize only the adherent cells on the biomaterials, we first separated the biomaterials with adherent cells from the culture plate before trypsinization. We could demonstrate that cell growth of adherent mandibular osteoblast-like cells was significantly higher on biomaterials with an organic component (PepGen P-15 trade mark ) in comparison to Frios Algipore and OsteoGraf/LD-700, respectively. In conclusion, only the explicit study of adherent cells at the gene and protein levels gives information about the osteoconductivity of biomaterials.

Preprosthetic vertical distraction osteogenesis of the mandible using an L-shaped osteotomy and titanium membranes for guided bone regeneration

PURPOSE

Vertical osteodistraction is a new alternative method for alveolar ridge augmentation of the mandible. The purpose of this article is describe a technique using an L-shaped osteotomy and titanium membranes for guided bone regeneration (GBR) in the distraction gap.

PATIENTS AND METHODS

Ten patients with severe atrophy of the edentulous molar region of the mandible underwent vertical callus distraction in 13 sites using intraoral microplate distractors. An L-shaped osteotomy with a short vertical part mesially and a longer horizontal part ending in the retromolar region was made, and the osteotomized segment was fixed to the mandibular ramus at its distal edge by a microplate, which became the center of rotation when distraction began. In this way, more callus generation could be achieved mesially than in the distal molar region. Follow-up computed tomography (CT) scans reconstructed axially to the axis of the mandible revealed semilunar excavations of the generated bone buccally in the distraction gap in the first cases. Clinical inspection on removal of the distractors showed fibrous connective tissue in the gap. Therefore, to prevent this from happening, titanium membranes covering the distraction gap were applied in subsequent cases.

RESULTS

Ten patients (13 sites) were treated by vertical callus distraction. In 4 cases, GBR was achieved using titanium membranes. In all cases, the increase in alveolar height was sufficient to make dental implantation possible. In 1 patient, a fracture of the distractor occurred, and dehiscence was observed in 2 cases. These complications did not change the plan of therapy nor did they influence the results. The CT scans showed a homogenous surface on the regenerated mandible in the cases of GBR application.

CONCLUSION

Both an L-shaped osteotomy and the application of titanium membranes for GBR in the distraction gap are of great value for mandibular augmentation, producing a physiologically shaped alveolar ridge.

Principles of computer-assisted arthroscopy of the temporomandibular joint with optoelectronic tracking technology

PURPOSE

This preliminary clinical study evaluated the applicability, accuracy, and benefits of computer-assisted arthroscopy of the temporomandibular joint (TMJ) with optoelectronic tracking technology.

MATERIALS AND METHODS

A hybrid of reality and virtual reality is built as a composite-reality environment by extracting 3-dimensional anatomical structures through use of computed tomography, magnetic resonance imaging, radiography, and other types of imaging procedures commonly used in clinical praxis. These various independent sources of imaging data of a particular patient can be combined with and complemented by complex graphic simulations. Intraoperatively they are merged with online position data of surgical instruments inside the patient's TMJ. This hybrid model of detailed anatomical structures, guidelines, and real-time instrument positions allows the surgeon to accurately plan the arthroscopic intervention as well as to navigate effectively intraoperatively.

RESULTS

In the first 10 cases of computer-assisted TMJ arthroscopy, composite reality environment technology permitted the online visualization of TMJ structures, puncture sites, instrument positions, and virtual pathways in relation to anatomical landmarks with high spatial accuracy (minimum, 0.0 mm; maximum, 2.5 mm; mean, 1.4 mm; SD, 0.6 mm) and high temporal resolution (100 ms). Past, present, and possible future instrument positions can be displayed. The application of computer-assisted arthroscopy caused little immobility for either surgeon or patient.

CONCLUSION

Even experienced surgeons profit from improved precision in the handling of the arthroscope; thus this technology was found to be particularly useful in degenerative temporomandibular disorders and for triangulation procedures.

Impact of hemoglobin level and use of recombinant erythropoietin on efficacy of preoperative chemoradiation therapy for squamous cell carcinoma of the oral cavity and oropharynx

PURPOSE

We assessed the influence of hemoglobin level and r-HuEPO administration on response to chemoradiotherapy, locoregional tumor control, and overall survival in patients treated with neoadjuvant chemoradiotherapy and surgery for a squamous cell carcinoma of the oral cavity or oropharynx.

METHODS AND MATERIALS

The 191 study patients were treated with mitomycin C (15 mg/m(2) day 1), 5-fluorouracil (750 mg/m(2)/day, days 1-5), and radiotherapy (50 Gy in 25 fractions weeks 1-5), followed by resection of the primary tumor bed and neck dissection at the General Hospital Vienna, Austria, between November 1989 and October 1998 for a T2-4, N0-3, M0 SCC of the oral cavity or oropharynx. Starting in May 1996, patients with a low hemoglobin (Hgb) before or during chemoradiotherapy received r-HuEPO 10,000 IU/kg s.c. 3-6 times/week until the week of surgery.

RESULTS

On multivariate analysis, Hgb level and use of r-HuEPO were independent prognostic factors for response to chemoradiotherapy and locoregional tumor control (p < 0.01). Pathologic response to neoadjuvant therapy was also predictive of locoregional control (p < 0.001). Patients with a pretreatment Hgb > or = 14.5 g/dL had significantly higher complete response, locoregional control, and survival rates than the patients with a pretreatment Hgb < 14.5 g/dL who did not receive r-HuEPO (p < 0.05). The response, control, and survival rates in patients with a pretreatment Hgb < 14.5 g/dL given r-HuEPO were significantly higher than in low Hgb patients not given r-HuEPO (p < or = 0.001) and equivalent to patients with a pretreatment Hgb > 14.5 g/dL (p > or = 0.3).

CONCLUSION

Low pretreatment Hgb is a negative prognostic factor for oral cavity and oropharyngeal SCCA patients, but was completely abrogated by r-HuEpo administration during neoadjuvant chemoradiotherapy. Randomized trials of radiation and/or chemotherapy with or without r-HuEPO for patients whose Hgb level is either low at the start of therapy or is anticipated to become low during therapy are indicated.

Quantification of mRNA expression by competitive PCR using non-homologous competitors containing a shifted restriction site

Despite the recent introduction of real-time PCR methods, competitive PCR techniques continue to play an important role in nucleic acid quantification because of the significantly lower cost of equipment and consumables. Here we describe a shifted restriction-site competitive PCR (SRS-cPCR) assay based on a modified type of competitor. The competitor fragments are designed to contain a recognition site for a restriction endonuclease that is also present in the target sequence to be quantified, but in a different position. Upon completion of the PCR, the amplicons are digested in the same tube with a single restriction enzyme, without the need to purify PCR products. The generated competitor- and target-specific restriction fragments display different sizes, and can be readily separated by electrophoresis and quantified by image analysis. Suboptimal digestion affects competitor- and target-derived amplicons to the same extent, thus eliminating the problem of incorrect quantification as a result of incomplete digestion of PCR products. We have established optimized conditions for a panel of 20 common restriction endonucleases permitting efficient digestion in PCR buffer. It is possible, therefore, to find a suitable restriction site for competitive PCR in virtually any sequence of interest. The assay presented is inexpensive, widely applicable, and permits reliable and accurate quantification of nucleic acid targets.

Comparative analysis of ras proto-oncogene mutations in selected mammalian tumors

Point mutations within ras proto-oncogenes are frequently detected in human malignancies and in different types of experimentally induced tumors in animals. In contrast to findings in experimental animal models of carcinogenesis, little is known about the incidence of ras mutations in naturally occurring animal tumors. In the present study, we investigated whether point mutations, particularly within the mutational hot-spot codons 12, 13, and 61, occur at comparable frequencies in human malignancies and spontaneously occurring tumors in other mammalian species. Two hundred seventy-nine of the most frequent canine and feline neoplasms were analyzed for changes in mutational hot-spot regions of the N-, Ki-, and Ha-ras genes. DNA fragments from exons 1 and 2 of all three ras genes were amplified by polymerase chain reaction, and the presence of point mutations was assessed by single-strand conformation polymorphism analysis and direct sequencing of amplified products. Only one sample, a case of canine melanoma, exhibited an Ha-ras mutation. Thus, our data strongly suggested that ras mutations at the hot-spot loci are apparently very rare and do not play a major role in the pathogenesis of the spontaneously occurring canine and feline tumors investigated. These observations were in marked contrast to those in experimental rodent models of carcinogen-induced mammary and skin tumors that described a consistent association with Ha- or Ki-ras activation. The role of ras oncogene activation in related human malignancies therefore cannot be readily inferred from studies of experimental carcinogenesis in animal models.

Placement of endosteal implants in the zygoma after maxillectomy: a Cadaver study using surgical navigation

Endosteal implants facilitate obturator prosthesis fixation in tumor patients after maxillectomy. Previous clinical studies have shown, however, that the survival of implants placed into available bone after maxillectomy is generally poor. Nevertheless, implants positioned optimally in residual zygomatic bone provide superior stability from a biomechanical point of view. In a pilot study, the authors assessed the precision of VISIT, a computer-aided surgical navigation system dedicated to the placement of endosteal implants in the maxillofacial area. Five cadaver specimens underwent hemimaxillectomy. The cadaver head was matched to a preoperative high-resolution computed tomograph by using implanted surgical microscrews as fiducial markers. The position of a surgical drill relative to the cadaver head was determined with an optical tracking system. Implants were placed into the zygomatic arch, where maximum bone volume was available. The results were assessed using tests for localization accuracy and postoperative computed tomographic scans of the cadaver specimens. The localization accuracy of landmarks on the bony skull was 0.6 +/- 0.3 mm (average +/- SD), as determined with a 5-df pointer probe; the localization accuracy of the tip of the implant burr was 1.7 +/- 0.4 mm. The accuracy of the implant position compared with the planned position was 1.3 +/- 0.8 mm for the external perforation of the zygoma and 1.7 +/-1.3 mm for the internal perforation. Eight of 10 implants were inserted with maximal contact to surrounding bone, and two implants were located unfavorably. Reliable placement of implants in this region is difficult to achieve. The technique described in this article may be very helpful in the management of patients after maxillary resection with poor support for obturator prostheses.

Guided bone regeneration with titanium membranes: a clinical study

Guided bone regeneration using barrier membranes is useful in bone augmentation. Because the commonly used polytetrafluoroethylene (PTFE, Gore-Tex (R), WL Gore, Flagstaff, AZ, USA) membranes or resorbable membranes tend to collapse, more stable membranes are desirable. A titanium membrane (FRIOS(R) BoneShield, Friatec, Mannheim, Germany) was evaluated in a clinical study of 52 patients. Most of them had particulate bone grafts or phycogene hydroxyapatite (Algipore(R), Friatec, Mannheim, Germany) or both stabilized with titanium membranes. In 78 procedures, 23 membranes (29%) became exposed, but only seven of these (9%) led to failure of the graft with a considerable loss of augmented material. The time interval between operation and possibly exposure was responsible for the result. Early exposures (within a few weeks) led to poor formation of new bone within the grafts, whereas if exposure was later, results were as good as in procedures in which the membranes did not become exposed.

Histomorphologic findings on human bone samples six months after bone augmentation of the maxillary sinus with Algipore

Sinus grafting, a popular and standard treatment for maxillary atrophy, uses a variety of grafting materials. In this study, specimens obtained 6 months after sinus grafting with Algipore were evaluated under light microscopy and showed osseoformation, xenograft degradation, and bone ingrowth into particles. Osteoblastic cells were embedded in the intracorpuscular bone matrix, which indicated that xenograft particles are an osseoconductive scaffold and stimulate matrix deposition. Acute inflammatory responses after insertion of Algipore did not occur. Particles were degraded during physiologic bone remodeling, and newly formed bone gradually replaced resorbed biomaterial.

Horseshoe Le Fort I osteotomy: an augmentation technique for the severely atrophied maxilla--an eight-year follow-up

Twenty-three patients (19 female, 4 male; 37-69 years old; mean age, 52 years) underwent horseshoe Le Fort I osteotomy from 1989 to 1997; 178 iMZ implants were placed either simultaneously by horseshoe Le Fort I osteotomy (76 implants) or in a second operation 6-12 months later (102 implants). Removable overdentures were made. Twenty-two patients wear an implant-borne overdenture; 1 patient refused an additional operation for placing implants and received a conventional, mucosally supported, upper-jaw prosthesis. The anteroposterior relationship satisfactorily improved in all patients, allowing for class I occlusion. All patients were satisfied with the aesthetic results, denture retention, speech, and mastication. Nevertheless, we lost 8 implants in 1 patient. We placed 178 endosteal implants in 22 patients; 8 were lost in 1 patient, and 7 more implants have been lost in 5 patients.

The L-shaped osteotomy for vertical callus distraction in the molar region of the mandible: a technical note

The following report refers to a well described surgical procedure using a prototype vertical distractor developed in Cologne in cooperation with Martin Medizintechnik GmbH. The surgical technique has been refined by an L-shaped osteotomy stabilized posteriorly by a miniplate to limit the amount of callus regeneration in the molar region where no increase in vertical height is required. The surgical technique with its advantages and one complication is described as used in four patients undergoing six distraction treatments.

[Telenavigation and expert consultation using a stereotaxic surgical videoserver]

The exponential increase of medical information creates a need for new methods in the visualization of medical imaging modalities for diagnosis and therapy. In this sense, visualization includes the display of medical image data and image-guided stereotaxic navigation as well as the advice of an expert. The Artma Virtual Patient System enables a remote expert to observe the surgical procedure via the Internet and interactively modify the interoperative visualization from the remote location. The expert in the remote location receives the planning data almost in real time over TCP/IP from a stereotaxic videoserver. In addition to live video streaming, stereotaxic navigation data are sent over the network as rigid body coordinates. The expert modifies the surgical simulation on the remote computer and the modified operating plan is sent back to the operating site. By teleconsulting, the composite images and overlapping graphics--instruments, target structures, landmarks, contour--can be seen in affiliated clinics with the possibility of interactive graphical assistance. With this image fusion technology the knowledge of a remote expert is included in virtual data structures and visualized by the overlay with live video data (augmented reality) in real time during surgery.

Cryptic splice site activation during RNA processing of MLL/AF4 chimeric transcripts in infants with t(4;11) positive ALL

Co-expression of multiple variants of the MLL/AF4 fusion transcript is a common phenomenon in patients with acute lymphoblastic leukemia (ALL) with t(4;11)(q21;q23). Different transcriptional and post-transcriptional mechanisms were found to contribute to the heterogeneity of the chimeric transcripts. Multiple splice variants are generated by utilizing alternative splice sites that result in the joining of different MLL-exons within the breakpoint cluster region to one of three exons in the AF4 fusion partner. To address the question of how splice site selection occurs during RNA processing, we investigated der(11) transcripts in 10 infants with t(4;11) positive ALL. Specific RT-PCR products were analyzed by Southern blot hybridization, SSCP, endonuclease digestion, cloning and sequencing. In patients co-expressing as many as six different chimeric mRNA species, activation of cryptic splice sites has been detected in MLL-exons 8 and 10. This led to the formation of four novel transcript variants, three of which maintained open reading frames (ORFs). Patients with cryptic donor site activation in MLL-exon 8 did not have any MLL-exon 8/AF4 transcripts using the authentic 5' splice site, although this site is 100% homologous to the consensus sequence. However, since MLL-exon 8 does not end in-phase, the use of the authentic splice site would result in loss of the ORF of the fusion message. The activated cryptic splicing sites are located in the vicinity of the polypurine stretches present in MLL-exons 8 and 10, which are known to function as splicing enhancers recognized by SR proteins. We postulate that both the nonsense-mediated decay eliminating correctly spliced MLL-exon 8/AF4 mRNAs and activation of suboptimal splicing sites contribute to the diversity of MLL/AF4 RNA species.

Clinical experience with interactive teleconsultation and teleassistance in craniomaxillofacial surgical procedures

PURPOSE

The objective of this study was to evaluate the clinical value and feasibility of surgical telenavigation and teleassistance technology in the field of craniomaxillofacial surgery.

MATERIALS AND METHODS

The technology is based on the principles of augmented reality environment technology and remote stereotactic visualization. A consultant surgeon in a remote location receives video, audio, and stereotactic navigation data from the operation site almost in real-time and, using a head-mounted display, is emerged in the surgical augmented reality environment. By telepresence or teleconsultation, the composite images and superimposed graphics (instruments, target structures, landmarks, contours) can be seen and discussed in connected clinics with the possibility of interactive manipulation and assistance.

RESULTS

Interactive teleassistance was used in 27 cases of various types craniomaxillofacial surgery. The principles of computer-aided telenavigation were applied successfully. Technical problems in 6 cases did not cause a breakdown of overall system performance.

CONCLUSION

Teleconsultation with remote experts is a useful tool, although some shortcomings exist. The financial and personal effort involved is considerable.

Computer-aided surgery in distraction osteogenesis of the maxilla and mandible

When using unidirectional intraoral distraction devices, it is desirable to be able to determine the final position of the bone fragment after the distraction procedure. However, additional constraining forces from adjacent tissues render the prediction of the distraction direction difficult. We have utilised computer-aided surgery in three patients for intraoperative control of the distraction direction. In one cleft palate patient, suffering from maxillary hypoplasia and anterior open bite, a modified Le Fort I osteotomy and maxillary distraction was performed. Despite a ventrocaudal position of the distraction device, intraoperative computer visualisation showed an unfavourable caudal vector of distraction without any anterior movement. The final result confirmed the direction indicated by the computer. Maxillary advancement remained insufficient. In two patients suffering from mandibular hypoplasia, intraoperative assessment revealed a favourable direction of distraction. The distraction procedure led to a satisfactory result in both cases. Computer-aided surgery is helpful in assessing the vector of distraction intraoperatively, making the result of the distraction procedure more predictable and allowing instant correction by adequate reapplication of the device.

[Horse shoe Le Fort I osteotomy. Surgical technique for reconstruction of the extremely atrophied maxilla]

Twenty-three patients with class VI atrophy of the maxilla were treated with horseshoe Le Fort I osteotomy. In ten patients, simultaneous placement of the implants was carried out, and in 12 the implantation was done in a second procedure 6-9 months later. A total of 178 implants were placed, and 15 were lost. In one patient, five implants were lost due to an oronasal fistula, leading to loss of part of the bone graft. The implant survival rate for all the implants was 89.0-88.2% in the one-step procedure and 90.0% in the two-step procedure. There was no difference between the one-step and the two-step procedure with respect to the peri-implant soft tissues in follow-up of least 2 years after implantation. We favor the two-step procedure because it allows more precise positioning of implants.

Positioning of dental implants using computer-aided navigation and an optical tracking system: case report and presentation of a new method

A navigation system for computer-aided surgery (Virtual Patient System, VPS) has been described in previous studies for different indications in oral and maxillofacial surgery. The aim of the system is the intraoperative transfer of preoperative planning on radiographs or CT scans on the patient, in real-time, and independent of the position of the patient's head. Until now an electromagnetic tracking system has been used for intra-operative position measurement. For placement of dental implants, the electromagnetic tracking system is not suitable since the motor of the implant drill leads to a considerable distortion of the magnetic field, thus direct visualization of drilling the implant socket was not possible. To overcome this problem, an optical tracking system which is not disturbed by conductive materials was integrated in the VPS system. The first patient operated on with this system had a posttraumatic loss of the upper incisors; three implants have been placed according to the prosthetic axis previously planned on radiographs and CT scans. The experience gained in this intervention led to the conclusion that computer-aided surgery provides a valuable tool in implant dentistry.

Systematic distortions in magnetic position digitizers

Medical devices equipped with position sensors enable applications like image guided surgical interventions, reconstruction of three-dimensional 3D ultrasound (US) images, and virtual or augmented reality systems. The acquisition of three-dimensional position data in real time is one of the key technologies in this field. The systematic distortions induced by various metals, surgical tools, and US scan probes in different commercial electromagnetic tracking systems were assessed in the presented work. A precise nonmetallic six degree-of-freedom measurement rack was built that allowed a quantitative comparison of different electromagnetic trackers. Also, their performance in the presence of large metallic structures was quantified in a phantom study on an acrylic skull model in an operating room (OR). The trackers used were alternating current (ac) and direct current (dc) based systems. The ac trackers were, on average, distorted by 0.7 mm and 0.5 degree by metallic objects positioned at a distance greater than 120 mm between the geometrical center of the sample and the sensor. In the OR environment, the ac system exhibits mean errors of 3.2 +/- 2.4 mm and 2.9 degrees +/- 1.9 degrees. The dc trackers are more sensitive to distortions caused by ferromagnetic materials (averaged value: 1.6 mm and 0.5 degree beyond a distance of 120 mm). The dc tracker shows no distortions from other conductive materials but was less accurate in the OR environment (typical error: 6.4 +/- 2.5 mm and 4.9 degrees +/- 2.0 degrees). At distances smaller than approximately 100 mm between sample and sensor error increases quickly. It is also apparent from our measurements that the influence of US scan probes is governed by their shielding material. The results show that surgical instruments not containing conductive material are to be preferred when using an ac tracker. Nonferromagnetic instruments should be used with dc trackers. Static distortions caused by the OR environment have to be compensated by precise calibration methods.

Calibration of tracking systems in a surgical environment

The purpose of this paper was to assess to what extent an optical tracking system (OTS) used for position determination in computer-aided surgery (CAS) can be enhanced by combining it with a direct current (dc) driven electromagnetic tracking system (EMTS). The main advantage of the EMTS is the fact that it is not dependent on a free line-of-sight. Unfortunately, the accuracy of the EMTS is highly affected by nearby ferromagnetic materials. We have explored to what extent the influence of the metallic equipment in the operating room (OR) can be compensated by collecting precise information on the nonlinear local error in the EMTS by using the OTS for setting up a calibration look-up table. After calibration of the EMTS and registration of the sensor systems in the OR we have found the average euclidean deviation in position readings between the dc tracker and the OTS reduced from 2.9+/-1.0 mm to 2.1+/-0.8 mm within a half-sphere of 530-mm radius around the magnetic field emitter. Furthermore we have found the calibration to be stable after re-registration of the sensors under varying conditions such as different heights of the OR table and varying positions of the OR equipment over a longer time interval. These results encourage the further development of a hybrid magnetooptical tracker for computer-aided surgery where the electromagnetic tracker acts as an auxiliary source of position information for the optical system. Strategies for enhancing the reliability of the proposed hybrid magnetooptic tracker by detecting artifacts induced by mobile ferromagnetic objects such as surgical tools are discussed.

High sequence similarity within ras exons 1 and 2 in different mammalian species and phylogenetic divergence of the ras gene family

We have determined the canine and feline N-, K-, and H-ras gene sequences from position +23 to +270 covering exons I and II which contain the mutational hot spot codons 12, 13, and 61. The results were used to assess the degree of similarity between ras gene DNA regions containing the critical domains affected in neoplastic disorders in different mammalian species. The comparative analyses performed included human, canine, feline, murine, rattine, and, whenever possible, bovine, leporine (rabbit), porcelline (guinea pig), and mesocricetine (hamster) ras gene sequences within the region of interest. Comparison of feline and canine nucleotide sequences with the corresponding regions in human DNA revealed a sequence similarity greater than 85% to the human sequence. Contemporaneous analysis of previously published ras DNA sequences from other mammalian species showed a similar degree of homology to human DNA. Most nucleotide differences observed represented synonymous changes without effect on the amino acid sequence of the respective proteins. For assessment of the phylogenetic evolution of ras gene family, a maximum parsimony dendrogram based on multiple sequence alignment of the common region of exons I and II in the N-, K-, and H-ras genes was constructed. Interestingly, a higher substitution rate among the H-ras genes became apparent, indicating accelerated sequence evolution within this particular clade. The most parsimonious tree clearly shows that the duplications giving rise to the three ras genes must have occurred before the mammalian radiation.

Extensive facial vascular malformations and haemangiomas: a review of the literature and case reports

We present 6 selected cases of extensive facial vascular anomalies extending to the skull base or actually involving it. These patients are compared with other cases in the literature. The spontaneous course of these vascular lesions is different and so variable treatment modalities are suggested depending on the age of the patient and the type of lesion. In young children, haemangiomas are common and spontaneous involution is characteristic. Conservative treatment in the sense of a wait-and-see approach is thereby favoured if there is no urgent indication such as involvement of essential structures, e.g. blockage of an orifice as demonstrated in one case or complications such as excessive bleeding. Vascular malformations most commonly appear in adults, there is no tendency to spontaneous involution and resection is usually necessary, especially in arteriovenous malformations. Nowadays, preoperative superselective embolization is recommended to minimize intraoperative blood loss. Superselective embolization is the treatment of choice in cases of a-v fistulae. Proximal ligation of the supplying arteries should be avoided because this may make embolization more difficult, and may be responsible for the common occurrence of rapid revascularization.

Computer-aided navigation in secondary reconstruction of post-traumatic deformities of the zygoma

Augmented reality technology was used in 5 patients for secondary reconstruction of post-traumatic unilateral deformities of the zygomaticomaxillary complex. Three electromagnetic sensors interfaced to a computer-aided navigation system (ARTMA Biomedical Inc.) were utilized. The computer navigation procedure was planned by drawing graphic lines on the CT scan at the level of the zygomatic arch, representing the outer surface of the zygoma. The desired position of the displaced zygoma was planned by mirroring from the healthy side, using a virtual mid-sagittal plane. These virtual graphics were presented intraoperatively on a TV monitor and also on the surgeon's see-through head-mounted display. Correct reduction was assumed when the virtual line representing the position of the zygoma before the osteotomy reached the virtual line defined preoperatively as the desired position. The advantages of the technique presented are that a complete exposure of the zygomatic bone is no longer necessary, and coronal and subciliary incisions may be avoided unless enophthalmos correction has to be carried out, which was in fact necessary in 2 patients. The results of zygomatic reconstruction have been satisfactory in all 5 patients.

Remote stereotactic visualization for image-guided surgery: technical innovation

Additional data from imaging sources using computer navigation assistance enables virtual visualization of anatomical structures in three dimensions for stereotactic navigation during an operation. Recent developments in communication technology enable the broadcasting not only of video data, but also of stereotactic navigation data via the network. By telepresence/teleconsulting, the composite images and overlapping graphics (instrument, target structure, landmark, contour) can be seen in connected clinics, with the possibility of interactive graphic assistance. In cranio-maxillofacial surgery, the first surgical teleconsultation in real time via telecommunication of stereotactic data was performed in August 1996. A patient suffering from a post-traumatic deformity following multiple comminuted midface fractures was re-osteotomized with the aid of image-guided surgery using teleconsultation: the intraoperative position achieved could be discussed with different surgeons with regard to symmetry, hard/soft tissue relationships and occlusal details, with the possibility of on-screen planning interaction and real time evaluation of the results, over a distance of 500 km.

Horseshoe Le Fort I osteotomy in combination with endosteal implants--a median-term follow-up study

Fourteen patients with Class VI resorption of the maxilla were treated with horseshoe Le Fort I osteotomy. In 11 cases, the procedure was followed by the placement of endosteal implants. In six patients, simultaneous placement of implants was carried out, while in five patients this was done in a second procedure. Ten patients wore their implant-supported dentures. In one patient, 5/8 implants were lost due to nonintegration. Three patients lost one implant each. The total number of implants placed was 76, and the survival rate of the implants was 88.1%. In the one-step procedure (n = 42), the survival rate was 84.8%; in the two-step procedure (n = 34), 92.3%. In comparison of the one-step to the two-step procedure, there was no statistically significant difference (P > 0.11) between the amount of marginal peri-implant bone loss and the condition of the peri-implant soft tissues as measured 2 years after implantation.

Endosteal implants in the irradiated lower jaw

Since 1990 Endosteal implants have been inserted in the irradiated lower jaw at our clinic. IMZ implants have been used for dental rehabilitation in 26 patients (21 male, 5 female) suffering from squamous cell carcinomas stage T2-T4 136. The implants were either placed in local bone and soft tissue (group 1, n = 60 implants), or in local bone after marginal mandibulectomy and transplanted soft tissue (group 2, n = 26 implants), or in transplanted bone and soft tissue (group 3, n = 52 implants). Life-table analysis according to Kaplan-Meier demonstrated a 3-year implant survival rate of 87.8% in Group 1, 69.1% in Group 2 and 58.3% in Group 3. There was no statistical significant difference in the amount of marginal bone loss and the degree of marginal infection between the three groups (P > 0.29). Major complications: A mandibular fracture passing through an empty implant socket 8 months after implant loss (Group 2) was caused by postradiation-osteonecrosis; implant removal and bone resection was mandatory. The poor results of the bone graft group may be explained by two patients, in whom simultaneous placement of implants in nonvascularized bone grafts was carried out, intraoral tissue breakdown led to graft failure and loss of the implants (n = 10).

Absence of N-ras mutations in myeloid and lymphoid blast crisis of chronic myeloid leukemia

Mutations within N-ras oncogene codons 12, 13, and 61 occur in approximately 25-30% of patients with acute nonlymphocytic leukemia and at a lower frequency (6-20%) in patients with acute lymphocytic leukemia. Moreover, N-ras mutations have been described in patients with chronic myeloid leukemia (CML) in blast crisis but have not been observed during the chronic phase of the disease. In view of the morphological and clinical similarities between acute leukemia and the blast crisis of CML, the question was raised whether the presence of N-ras mutations is associated with the phenotype of acute leukemia. We investigated leukemic cells from 100 patients with CML for the presence of N-ras mutations in the mutational hot spot codons. The cases analyzed included 87 diagnosed with different types of blast crisis and 13 cases in accelerated or chronic phase of the disease. Fragments from N-ras exons I and II containing the codons of interest were amplified by polymerase chain reaction and analyzed for the presence of point mutations by three different technical approaches, including specific oligonucleotide hybridization, direct sequencing, and single-strand conformation polymorphism analysis. N-ras mutations were not detected in any of the CML patients investigated. Only one patient, in whom the initial diagnosis of CML-blast crisis had been revised to chronic myelomonocytic leukemia, displayed an N-ras mutation within codon 13. Our data strongly suggest that N-ras mutations do not play a role in myeloid or lymphoid blast crisis of CML.