Advances in interactive craniofacial surgery planning by 3D simulation and visualization

In craniofacial surgery careful preoperative planning is essential. Traditional preoperative work-up consists of cast model surgery, cephalometric prediction tracing and analysis of photographs. Recently, we introduced 3-dimensional (3D) computed tomography (CT) model surgery in our preoperative work-up and presurgical prediction of the postoperative result. However, only limited information can be extracted concerning soft tissue changes which are most important for the patients' postoperative appearance. We propose a new system which will allow a precise preoperative visualization of not only bony structures but also the soft tissue surfaces. 3D CT data of the skull are integrated with 3D surface data acquired by laser scanning. Based on the 3D CT data the bony structures are segmented automatically and processed interactively to simulate the planned surgical procedure. Afterwards, the 3D soft tissue changes resulting from the shifting of bony segments are computed. The postoperative appearance of the patient is visualized using computer animation techniques.

Proliferative activity and loss of function of tumour suppressor genes as 'biomarkers' in diagnosis and prognosis of benign and preneoplastic oral lesions and oral squamous cell carcinoma

Oral cancer is a disease of the elderly and is closely connected with cigarette smoking and alcohol consumption. Since the successful introduction of multidisciplinary treatment, the survival rate has not changed. Because of the high mortality and potentially disfiguring treatment, today's efforts are aimed at eliminating risk factors, chemoprophylaxis, improvement in diagnostic procedures, and understanding of the genetic mechanisms of oral carcinogenesis. Immunohistochemical and molecular biology analysis of biopsy tissue and cell lines of preneoplastic and neoplastic lesions that originate from the oral mucosa have shown that alterations in tumour suppressor genes such as p53 and Rb gene may have an important role in oral carcinogenesis and may be potentially useful prognostic 'biomarkers' in oral carcinogenesis. Statistical analysis of immunohistochemical data from 216 patients did not identify significant or consistent differences of p53, MDM2, or RB expression with respect to stage of disease, malignant transformation, metastatic node involvement, recurrence, or survival. Nevertheless, p53 overexpression seems to correlate strongly with histological progression of the disease, which confirms the importance of p53 alterations in oral carcinogenesis. Overexpression of p53 is usually found in the less differentiated proliferating cells in benign and malignant oral lesions. Assessment of the proliferating activity is possible by immunohistochemical staining with monoclonal antibodies against proliferating nuclear antigen and Ki-67. Statistical analysis shows that overexpression of p53 combined with high proliferative activity predicts a less favourable course of disease in oral squamous cell carcinoma.

Three-dimensional simulation and prediction of craniofacial surgery

The treatment of patients with complex facial deformities is one of the most challenging multidisciplinary tasks in plastic surgery. Due to advancements in medical technology and surgical techniques in the last 20 years correction of severe malformations has become possible and is performed by highly specialized teams frequently in a single operation. Recent developments in three-dimensional (3-D) imaging techniques have already greatly facilitated diagnosis of complex craniofacial deformities. Computer-based simulation methods for surgical procedures that are based on imaging data have the potential to improve surgical treatment by providing the ability to perform 'virtual surgery' preoperatively and thus reduce patient risk and morbidity intraoperatively. A method is presented for interactive computer-assisted craniofacial plastic surgery planning and visualization, especially simulation of soft tissue changes using an experimental Craniofacial Surgery Planner. The system computes non-linear soft-tissue deformation because of bone realignment. It is capable of simulating bone cutting and bone realignment with integrated interactive collision detection. Furthermore, soft-tissue deformation and cutting due to surgical instruments can be visualized. Simulation processes are based on an individual patient's preoperative 3-D computed tomography and on a 3-D, photo-realistic model of the patient's preoperative appearance obtained by a laser range scanner. Very fast and robust prediction of non-linear soft-tissue deformation is computed by optimizing a non-linear cost function.

Oral squamous cell carcinomas are characterized by a rather uniform pattern of genomic imbalances detected by comparative genomic hybridisation

Total genomic DNA sampled from 20 oral squamous cell carcinomas (SCCs) and from four SCC cell lines, was examined for genomic imbalances using comparative genomic hybridisation (CGH). Gains and losses of DNA copy number aberrations (CNAs) were found in the primary tumours, but also in the cell lines at a varying number. The patterns of CNAs proved to be rather peculiar in oral SCCs, gains of genetic material clearly dominating compared with losses, and a rather high uniformity of these patterns was an impressive finding. Hypersomies of whole chromosomes, e.g. numbers 17 and 19 or of whole chromosome arms, e.g. 20q, were particularly evident. The segments most frequently gained in oral SCCs were 3q26-q27, 5p15 and 9q34 (16 of 20 tumours each), as well as 1p36.3, 8q24, 10q26, 19 and 20q (15/20 each). Among the 15 tumours with more than 10 CNAs, all showed these imbalances. 11q13 was a band often involved in increases (14/20 tumours), but in several tumours was involved in amplification of DNA copy number. Several other chromosomal segments over represented in more than 60% of the tumours, as, for example, 12q24, 15q22-q24, 16p13.2 and 17q (14/20 tumours each), 6q26-qter, 7p22, 12p12.2-p13, 14q31-q32.2 (13/20) and 1q32-q41, 2q37, 16q23-q24 (12/20 each). In contrast, loss of material affected only a few chromosomal segments, as, for example, 3p12 (12 of the 20 tumours), 5q21 (10/20), 6q13 (8/20). The peculiarities of these findings, in some respect, differ from those found in other epithelial tumours, suggesting a high impact of environmental factors in the generation and progression of these tumours.

Computer-aided 3-D simulation and prediction of craniofacial surgery: a new approach

BACKGROUND

In plastic and reconstructive craniofacial surgery, careful preoperative planning is essential. In complex cases of craniofacial synostosis, rapid prototyping models are used to simulate the surgery and reduce operating time. Recently, 3-D CT model surgery has been introduced for presurgical planning and prediction of the postoperative result.

OBJECTIVE

For simulation of craniofacial surgery a computer-based system was developed that allows visualization and manipulation of CT-data using computer graphics techniques. Surgical procedures in all areas of the bony skull can be performed interactively.

RESULTS

The case of a child with scaphocephalus is presented. Surgery is planned using the craniofacial surgery simulator described above.

CONCLUSION

The computer-based interactive surgery simulation systems presented here allow precise visualization of craniofacial surgery. The accurate computer-aided 3-D simulation of bone displacements is also the prerequisite for transfer of the simulated surgery using a navigation system for surgery. Thus the preoperatively planned procedure could be transferred directly to the operating table.

Phospholipid composition and surface-active properties of tracheobronchial secretions from patients with cystic fibrosis and chronic obstructive pulmonary diseases

Among the various components of tracheobronchial secretions, lipids and particularly phospholipids have been shown to influence rheological properties of airway secretions in patients with cystic fibrosis. We studied the phospholipid composition of tracheobronchial secretions, collected from patients suffering from cystic fibrosis (CF) and other chronic obstructive pulmonary diseases (COPD), and we analyzed the possible relationship between the phospholipid profile and the wettability of tracheobronchial secretions evaluated by the measurement of contact angle. Although total phospholipid content and contact angle of tracheobronchial secretions were significantly increased (P less than 0.01) in CF compared to COPD, no significant relationship existed between these two parameters. The concentrations of the different phospholipid subclasses were not homogeneously modified according to the origin of the secretions. Compared to COPD secretions, the CF secretions were characterized by a significant (P less than 0.001) increase in rigidifying fractions such as sphingomyelin and phosphatidylserine/phosphatidylinositol and a significant (P less than 0.001) decrease in surface-active fractions, such as phosphatidylcholine and phosphatidylglycerol (PG) (P less than 0.001). In the two groups, the surface-active phospholipid fraction, PG, was negatively correlated to the contact angle of tracheobronchial secretions. These results suggest that a decrease in PG content in CF secretions may be one factor responsible for an increase in their adhesivity to the respiratory mucosa, and, consequently, for mucus stasis and severity of bronchial obstruction in cystic fibrosis.

p53 and Ki 67 expression in preneoplastic and neoplastic lesions of the oral mucosa

Some lesions of the oral mucosa such as leukoplakia and erythroplakia may develop into squamous cell carcinoma (SCC). At present, however, there is no method available to predict malignant transformation. It is known that the grade of dysplasia is related to the potential malignant development, but this is unreliable as the only indicator. In 64 hyperplastic lesions and 85 SCC of the oral mucosa, a correlation between the expression of the mutated tumor-suppressor gene p53 and the dysplasia of the lesions was found. Ki 67 was used as a proliferation marker. The results imply that expression of mutated p53 is an indicator for potential malignant development in benign lesions of the oral mucosa.

p53 and PCNA expression in carcinogenesis of the oropharyngeal mucosa

Hyperplastic lesions of the oral mucosa such as leukoplakia and oral lichen planus can eventually develop into squamous cell carcinomas (SCC) and provide an excellent model for multistage carcinogenesis. The development of carcinomas is assumed to be the result of interaction of genetic factors, locally applied carcinogens and immunological unresponsiveness. The purpose of this study was, therefore, to determine the role of alterations of the tumour suppressor gene p53, and the proliferation status of the lesions determined by PCNA expression. We investigated p53 and PCNA expression in 265 tissue sections of normal mucosa, premalignant, malignant and metastatic lesions of the oral mucosa by immunohistology. Quantitative analysis showed a gradual increase in PCNA expression from normal mucosa to moderately differentiated SCC. p53 expression was detectable in benign premalignant lesions. The increase in the number of p53-positive biopsies was correlated with the dysplasia and loss of differentiation in the premalignant and malignant lesions.

The fascicular structure of the lingual nerve and the chorda tympani: an anatomic study

Damage of the lingual nerve is one of the most common problems in oral surgery, especially during removal of the third molar. After microsurgery of the lingual nerve, there is a lack of regeneration of the gustatory fibers in comparison with the sensory fibers. The histologic investigation of ten human lingual nerve preparations showed that the chorda tympani fibers distribute widely in the fascicles of the lingual nerve. Therefore, after microsurgical reconstruction of the lingual nerve in the third molar region, the chance of the gustatory fibers meeting and regenerating is very low.

On-line direct determination of the second virial coefficient of a natural polysaccharide using size-exclusion chromatography and multi-angle laser light scattering

By combining a size-exclusion chromatographic (SEC) separation and an on-line multi-angle light scattering (MALLS) analysis, we have elaborated an original methodology permitting on-line direct determination of the second virial coefficient of molar mass fractions of polydisperse polysaccharides. By assimilating the SEC-MALLS data to a batch mode acquisition, we have obtained on-line the complete Zimm plot of the eluted fractions, leading to knowledge of their weight-average molar mass Mw, radius of gyration r(g) and second virial coefficient A2. Our methodology was successfully applied to a iota carrageenan sample in LiCl 100 mM, EDTA 1 g/l.

Deformable modeling of facial tissue for craniofacial surgery simulation

While deformable object modeling has been studied by computer graphics specialists for more than two decades, only a few applications in the field of surgical simulation have been developed which provide both real-time and physically realistic modeling of complex, nonlinear tissue deformations. Particularly in craniofacial surgery, the prediction of soft-tissue changes--which result from alterations in the underlying bone structure--is critical to the surgical outcome. The prediction these tissue changes and, therefore, the prognosis of the postoperative appearance of the patient, is still based on empirical studies of the relationship between bone and tissue movements: There exists no physical model which takes into account the individual patient anatomy to simulate the resulting tissue changes during craniofacial surgery. In this article we present two different deformable tissue models which are intergrated in an interactive surgical simulation test bed. Both techniques allow precise preoperative simulation of the resulting soft tissue changes during craniofacial surgery and visualization of the patient's postoperative appearance. The different deformable models are described in detail and both are applied to the same craniofacial case study. The simulation results are shown and compared with regard to the speed and accuracy of the prediction of the patient's postoperative appearance.

Identification of phospholipids in secretory granules of human submucosal gland respiratory cells

Although it has been shown that tracheal epithelial cells in culture synthesize and secrete phospholipids, no direct evidence for in situ phospholipid storage in human respiratory secretory epithelial cells has been demonstrated. We used a high-resolution cytochemical enzyme-gold technique to identify and precisely localize phospholipids in human submucosal gland secretory cells. In addition, lysozyme, a specific serous cell marker, was identified using the biotinstreptavidin gold technique with lysozyme antiserum. This double labeling of phospholipids and lysozyme was performed using gold particles of diameters 15 nm and 5 nm, respectively. Quantitation of phospholipid labeling was performed on an image analyzer. Phospholipids were identified in serous granules (8.87 +/- 2.21 gold particles/microns 2) in a significantly (p less than 0.05) higher density than in mucous granules (5.57 +/- 3.07 gold particles/microns 2). These results support the hypothesis that submucosal human airway serous and mucous secretory cells produce phospholipids which may be secreted in the airway lumen.

Cysts associated with long-standing impacted third molars

Three patients are described in whom large cysts developed around third molars that had purposely been left in place. The cases presented emphasize the need for an adequate prospective study to evaluate the long-term morbidity of asymptomatic third molars that are left in place.

p53 expression in the carcinogenesis in the oral mucosa

Hyperplastic lesions of the oral mucosa such as leukoplakia and oral lichen planus can eventually develop into squamous cell carcinomas. In the clinical treatment of these lesions it would be very important to be able to predict the biological behaviour of an individual lesion. In 64 hyperplastic lesions and 85 squamous cell carcinomas of the oral mucosa, the expression of the mutant tumor suppressor gene p53 was investigated. A positive correlation was seen between the expression of the mutant tumor suppressor gene p53 and the grade of dysplasia of the lesions.

Role of phospholipid lining on respiratory mucus clearance by cough

Phospholipid lining, present at the respiratory mucus-mucosa interface, may have an important role in the protective function of the airways by its abhesive properties and may also facilitate mucus transport. To mimic respiratory mucus-mucosa interface, monolayers of three different forms of phosphatidylglycerol (PG) have been deposited on glass slides by the Langmuir-Blodgett technique. Mucus adhesion and clearance by cough of mucus on these PG-coated or noncoated surfaces have been analyzed and compared, using frog respiratory mucus as "normal" mucus. Among the three PG types studied, the phosphatidylglycerol distearoyl, which is the phospholipid with the longest saturated fatty acid chain, was found to significantly improve the mucus cough clearance by decreasing the mucus work of adhesion compared with the noncoated surfaces. On the other hand, phosphatidylglycerol dipalmitoyl did not improve mucus cough clearance although it decreased mucus adhesion, and phosphatidylglycerol dioleyl did not improve either mucus cough clearance or mucus adhesion.

Cell viability after osteotomy and bone harvesting: comparison of piezoelectric surgery and conventional bur

The aim of this study was to evaluate and compare the influence of a piezoelectric device versus a conventional bur on osteocyte viability and osteoblast and osteoclast activity using an in vivo mouse model. Osteotomies were created and bone grafts were harvested using either a conventional bur or a piezoelectric device; the resulting injuries and bone grafts were evaluated over an extended time-course using molecular and cellular assays for cell death (TUNEL assay), cell viability (4',6-diamidino-2-phenylindole (DAPI) staining), the onset of mineralization (alkaline phosphatase activity), and bone remodelling (tartrate-resistant acid phosphatase activity). Osteotomies created with a piezoelectric device showed greater osteocyte viability and reduced cell death. Bone grafts harvested with a piezoelectric device exhibited greater short-term cell viability than those harvested with a bur, and exhibited slightly more new bone deposition and bone remodelling. The difference in response of osteocytes, osteoblasts, and osteoclasts to bone cutting via a bur and via a piezoelectric device is negligible in vivo. Given the improved visibility and the margin of safety afforded by a piezoelectric device, they are the instrument of choice when cutting or harvesting bone to preserve soft tissue.

How to demonstrate that eSET does not compromise the likelihood of having a baby?

BACKGROUND

In several randomized studies, elective single embryo transfer (eSET) has proven its effectiveness in reducing twin pregnancy rates while obtaining acceptable overall pregnancy rates. However, there is no outcome measurement consensus to evaluate the effectiveness of eSET versus double-embryo transfer (DET).

METHODS

This study evaluated whether or not adopting an eSET strategy instead of a DET strategy lowers the probability of having at least one live-born infant in good prognosis couples. Seven hundred and twenty-six couples were divided into two groups. The retrospective arm of the study was undertaken on the first group of couples (n = 483, DET group) and the prospective arm performed on the second group of couples (n = 243, SET group). In these specific populations, the probability of a woman having at least one live-born infant and the probability that one embryo utilized leads to a child were the main outcome measures.

RESULTS

The probability of a woman having at least one live-born infant was 60.5% in the DET group compared with 60.8% in the SET group. The probability of a live-born child per embryo utilized was not significantly different between the SET and the DET groups, 18.9% and 17.6%, respectively. In addition, the cumulative multiple live birth rate was significantly lower in the SET compared with the DET group.

CONCLUSIONS

In this observational study, using appropriate cryopreservation techniques, the chance of delivering a live baby, per utilized embryo, in an elective SET strategy is as good as that for DET.

Retinoid actions and implications for prevention and therapy of oral cancer

Squamous cell carcinomas of the oral cavity can be preceded by clinically obvious premalignant changes, and they have a high rate of incidence of development of second primary tumors. Recent studies suggest retinoids not only for the treatment of oral eukoplakia, but also for the prevention of second primaries. Although retinoids are promising therapeutic agents, their therapeutic potential has been limited by their undesirable side-effects. A complete network of nuclear receptors has now been identified that mediate the action of retinoids and can interfere directly with cell proliferation signals by interacting with transcription factors. It has recently been shown that retinoids with receptor-selective activities can be obtained that are likely to have fewer side-effects because of their restricted biologic activities.

Viability and Functionality of Bovine Chromaffin Cells Encapsulated into Alginate-PLL Microcapsules with a Liquefied Inner Core

Implantation of adrenal medullary bovine chromaffin cells (BCC), which synthesize and secrete a combination of pain-reducing neuroactive compounds including catecholamines and opioid peptides, has been proposed for the treatment of intractable cancer pain. Macro- or microencapsulation of such cells within semi-permeable membranes is expected to protect the transplant from the host's immune system. In the present study, we report the viability and functionality of BCC encapsulated into microcapsules of alginate-poly-L-lysine (PLL) with a liquefied inner core. The experiment was carried out during 44 days. Empty microcapsules were characterized in terms of morphology, permeability, and mechanical resistance. At the same time, the viability and functionality of both encapsulated and nonencapsulated BCC were evaluated in vitro. We obtained viable BCC with excellent functionality: immunocytochemical analysis revealed robust survival of chromaffin cells 30 days after isolation and microencapsulation. HPLC assay showed that encapsulated BCC released catecholamines basally during the time course study. Taken together, these results demonstrate that viable BCC can be successfully encapsulated into alginate-PLL microcapsules with a liquefied inner core.

Transverse stability of the proximal segment after bilateral sagittal split ramus osteotomy for mandibular setback surgery

This study aimed to evaluate the correlation between the transverse displacement of the proximal segment after bilateral sagittal osteotomy for mandibular setback and the amount and design of the mandibular setback. Patients who underwent either bilateral sagittal split ramus osteotomy (BSSRO) alone or two-jaw surgery were selected, and cephalographic postero-anterior (PA) measurements were taken pre-operatively (T1), immediately post-operatively (T2), and at follow-up (T3). The inter-gonal (IG) and inter-ramal (IR) width increased immediately after surgery, but decreased to the initial value during follow-up (P=0.002; IR, P=0.046). Only the immediate IG changes after surgery correlated with the amount of mandibular setback (P=0.009). The IG changes were significant in the symmetric group, but not in the asymmetric group. There was no difference in the IG and IR changes between the symmetric group and the asymmetric group. The immediate IG change in two-jaw patients with symmetric setback showed correlation with the setback amount. The gonial width of the deviated group showed more significant changes than that of the non-deviated group. There was no difference in the unilateral gonial width between the deviated and the non-deviated group, but the difference was significant for the unilateral ramal angle between the two groups. These correlations will be helpful in predicting post-surgical results for patients.

Radiosensitivity and double-strand break rejoining in tumorigenic and non-tumorigenic human epithelial cell lines

Radiosensitivity and repair of DNA damage induced by ionizing radiation and restriction enzymes were investigated in three human epithelial cell lines: two tumorigenic squamous carcinoma cell lines (SCC-4 and SCC-25), and a non-tumorigenic epidermal keratinocyte cell line (RHEK-1). Sensitivity to ionizing radiation was determined using a clonogenic cell survival assay, which showed SCC-4 to be more radiosensitive than SCC-25 and RHEK-1, which in turn displayed about equal sensitivity. Using DNA precipitation under alkaline conditions for the analysis of induction and repair of DNA single-strand breaks (ssb), an increased level of ssb induction was found for SCC-4 while the efficiency of ssb repair was about equal in all three cell lines. Using pulsed-field gel electrophoresis (PFGE) for the measurement of induction and repair of DNA double-strand breaks (dsb), no consistent differences were detected between the three cell lines. A plasmid reconstitution assay was used to determine the capacity to rejoin restriction enzyme-induced dsb in whole-cell extracts prepared from the three cell lines. In these experiments, dsb rejoining was shown to be significantly reduced in the most radiosensitive SCC-4 cell line while it was about equal in RHEK-1 and SCC-25. The results indicate that plasmid reconstitution in cell-free extracts is a sufficiently sensitive assay to detect differences in repair capacity among tumour cell lines of different radiosensitivity which remain undetectable by DNA precipitation and PFGE.

Semi-automatic quantitation of dense markers in cytochemistry

The quantitation of electron dense labelling is very tedious when it is done "by hand". Accordingly we developed software allowing, at electron microscopic level, a semi-automatic counting of dense markers in biological specimens. It includes the digitization of images and extraction of dense particles from the grey level of the background. The definition of the areas of interest was carried out by the observer but all quantitative calculations were done automatically. This method was applied to different biological materials (phospholipid and lysozyme labelling in secretory granules of human submucosal bronchial gland cells). The results obtained by this semi-automatic procedure were in good agreement with those obtained by manual counting of colloidal gold labelling (r = 0.97).

p53 and PCNA expression in malignant melanomas of the head and neck

Mutation in the p53 tumor suppressor gene is the most common genetic alteration in human cancer. As in mutant p53 the protein is stabilised and the half-life is extended, it becomes detectable by immunohistological staining. p53 immunoreactivity thus seems to be a potential biomarker for the assessment of the oncogenic potential of malignant melanomas. In 103 tissue sections of primary and metastatic malignant melanomas of the head and neck detectable levels of p53 were only found in 3 of the primary tumors and in none of the metastases. At the same time the proliferation status of the malignant melanoma lesions was determined using the cell cycle specific antibody PCNA. 55 primary and metastatic tumors were stained with a PCNA-MAb to determine the proliferation activity of the tumors. The results of our immunohistochemical investigation suggest that immunoreactivity of p53 cannot be used to determine the malignant potential of melanomas in the head and neck. PCNA staining showed that the majority of the tumors and metastases were proliferating rapidly.

Relationship between conformation of polysaccharides -in the dilute regime and their interaction with a phospholipid bilayer

Interactions between polysaccharides and phospholipid bilayers have already been demonstrated in the literature but little is known about the influence of macromolecule conformations related to the solvent characteristics (pH, ions, ionic strength). In this study we have investigated the conformation of iono- and thermo-sensitive polysaccharides, iota- and kappa-carrageenans, and their interaction with a dimyristoylphosphatidylcholine (DMPC) model bilayer. The study was performed in two different media (NaCl 150 mmol/L, pH 6.5, and NaCl 300 mmol/L, pH 6.5). In the first part, the iota- and kappa-carrageenan samples have been characterized by size exclusion chromatography (SEC) coupled with a multi-angle laser light-scattering detector (MALLS). The SEC-MALLS results clearly show polysaccharide chain association at high ionic strength. In the second part, the polysaccharide-membrane interaction has been studied, using fluorescent probes embedded in the membrane. The thermotropic properties of the membrane were investigated by fluorescence depolarization of 1-(4-trimethylammonium-phenyl)-6-phenyl-1,3,5-hexatriene (TMA-DPH). The membrane surface accessibility was evaluated by fluorescence quenching of 2-(9-anthroyloxy) stearic acid (2-AS). Whatever the ionic strength tested, the polysaccharide presence notably enhances the membrane fluidity below the T(m). This sign of an interaction in the polar level of the membrane is more marked at low NaCl concentration. In contrast, the liposomes bilayer accessibility is drastically lowered when increasing the ionic strength. This is induced by macromolecular chain adsorption on the liposome surface, enhanced by the polysaccharide chain association. An ionic strength enhancement induces a conformational modification of the polysaccharide chains which modifies their ability to interact with the bilayer.