Jeroen Van Dessel

3-dimensional analysis of regenerative endodontic treatment outcome.

INTRODUCTION A growing body of evidence supports the regeneration potential of dental tissues after regenerative endodontic treatment (RET). Nevertheless, a standard method for the evaluation of RET outcome is lacking. The aim of this study was to develop a standardized quantitative method for RET outcome analysis based on cone-beam computed tomographic (CBCT) volumetric measurements. METHODS Five human teeth embedded in mandibular bone samples were scanned using both an Accuitomo 170 CBCT machine (Morita, Kyoto, Japan) and a SkyScan 1174 micro-computed tomographic (μCT) system (SkyScan, Antwerp, Belgium). For subsequent clinical application, clinical data and low-dose CBCT scans (preoperatively and follow-up) from 5 immature permanent teeth treated with RET were retrieved. In vitro and clinical 3-dimensional image data sets were imported into a dedicated software tool. Two segmentation steps were applied to extract the teeth of interest from the surrounding tissue (livewire) and to separate tooth hard tissue and root canal space (level set methods). In vitro and clinical volumetric measurements were assessed separately for differences using Wilcoxon matched pairs test. Pearson correlation analysis and Bland-Altman plots were used to evaluate the relation and agreement between the segmented CBCT and μCT volumes. RESULTS The results showed no statistical differences and strong agreement between CBCT and μCT volumetric measurements. Volumetric comparison of the root hard tissue showed significant hard tissue formation. (The mean volume of newly formed hard tissue was 27.9 [±10.5] mm(3) [P < .05]). CONCLUSIONS Analysis of 3-dimensional data for teeth treated with RET offers valuable insights into the treatment outcome and patterns of hard tissue formation.

Effects of Immediate and Delayed Loading on Peri‐Implant Trabecular Structures: A Cone Beam CT Evaluation

PURPOSE To develop a method for characterizing trabecular bone microarchitecture using cone beam computed tomography (CBCT) and to evaluate trabecular bone changes after rehabilitation using immediate versus delayed implant protocols. MATERIALS AND METHODS Six mongrel dogs randomly received 27 titanium implants in the maxillary incisor or mandibular premolar areas, following one of four protocols: (1) normal extraction socket healing; (2) immediate implant placement and immediate loading; (3) delayed implant placement and delayed loading; (4) delayed implant placement and immediate loading. The animals were euthanized at 8 weeks, and block biopsies were scanned using high resolution CBCT. Standard bone structural variables were assessed in coronal, middle, and apical levels. RESULTS Coronal and middle regions had more compact, more platelike, and thicker trabeculae. Protocols (2), (3), and (4) had significantly higher values (p < 0.001) than protocol (1) for bone surface density, bone surface volume ratio, and connectivity density, while significantly lower values (p < 0.001) were found for trabecular separation and fractal dimension. However, protocols (2), (3), and (4) did not show significantly different bone remodeling. CONCLUSIONS Compared with normal extraction healing, the implant protocols have an improved bone structural integration. Results do not suggest a different bone remodeling pattern when a delayed versus an immediate implant protocol is used.

A systematic review on the innervation of peri-implant tissues with special emphasis on the influence of implant placement and loading protocols

OBJECTIVES To systematically review the available literature on the influence of dental implant placement and loading protocols on peri-implant innervation. MATERIAL AND METHODS The database MEDLINE, Cochrane, EMBASE, Web of Science, LILACS, OpenGrey and hand searching were used to identify the studies published up to July 2013, with a populations, exposures and outcomes (PEO) search strategy using MeSH keywords, focusing on the question: Is there, and if so, what is the effect of time between tooth extraction and implant placement or implant loading on neural fibre content in the peri-implant hard and soft tissues? RESULTS Of 683 titles retrieved based on the standardized search strategy, only 10 articles fulfilled the inclusion criteria, five evaluating the innervation of peri-implant epithelium, five elucidating the sensory function in peri-implant bone. Three included studies were considered having a methodology of medium quality and the rest were at low quality. All those papers reported a sensory innervation around osseointegrated implants, either in the bone-implant interface or peri-implant epithelium, which expressed a particular innervation pattern. Compared to unloaded implants or extraction sites without implantation, a significant higher density of nerve fibres around loaded dental implants was confirmed. CONCLUSIONS To date, the published literature describes peri-implant innervation with a distinct pattern in hard and soft tissues. Implant loading seems to increase the density of nerve fibres in peri-implant tissues, with insufficient evidence to distinguish between the innervation patterns following immediate and delayed implant placement and loading protocols. Variability in study design and loading protocols across the literature and a high risk of bias in the studies included may contribute to this inconsistency, revealing the need for more uniformity in reporting, randomized controlled trials, longer observation periods and standardization of protocols.

Validating cone-beam computed tomography for peri-implant bone morphometric analysis

Cone-beam computed tomography (CBCT) has been recently used to analyse trabecular bone structure around dental implants. To validate the use of CBCT for three-dimensional (3D) peri-implant trabecular bone morphometry by comparing it to two-dimensional (2D) histology, 36 alveolar bone samples (with implants n=27 vs. without implants n=9) from six mongrel dogs, were scanned ex vivo using a high-resolution (80 µm) CBCT. After scanning, all samples were decalcified and then sectioned into thin histological sections (∼6 μm) to obtain high contrast 2D images. By using CTAn imaging software, bone morphometric parameters including trabecular number (Tb.N), thickness (Tb.Th), separation (Tb.Sp) and bone volume fraction (BV/TV) were examined on both CBCT and corresponding histological images. Higher Tb.Th and Tb.Sp, lower BV/TV and Tb.N were found on CBCT images (P<0.001). Both measurements on the peri-implant trabecular bone structure showed moderate to high correlation (r=0.65–0.85). The Bland–Altman plots showed strongest agreement for Tb.Th followed by Tb.Sp, Tb.N and BV/TV, regardless of the presence of implants. The current findings support the assumption that peri-implant trabecular bone structures based on high-resolution CBCT measurements are representative for the underlying histological bone characteristics, indicating a potential clinical diagnostic use of CBCT-based peri-implant bone morphometric characterisation.

Sensory innervation around immediately vs. delayed loaded implants: a pilot study

Although neurophysiological and psychophysical proof of osseoperception is accumulating, histomorphometric evidence for the neural mechanisms of functional compensation following immediate and delayed implant loading is still lacking. For this randomized split-mouth study, six mongrel dogs randomly received one of four treatment protocols at 36 implant-recipient sites over 16 weeks (third maxillary incisor, third and fourth mandibular premolar): immediate implant placement and immediate loading (IIP+IL); delayed implant placement and delayed loading (DIP+DL); delayed implant placement and immediate loading (DIP+IL); and natural extraction socket healing (control). Histomorphometry was performed in the peri-implant bone and soft tissues within 300 µm around the implants. Immunocytochemistry and transmission electron microscopy were used to confirm the presence of neural structures and to reveal their ultrastructural characteristics, respectively. Myelinated nerve fibres densely populated the peri-implant crestal gingival and apical regions, although they were also identified in the woven bone and in the osteons near the implant threads. Compared with the control group in the mandible, the group that received IIP+IL showed a higher innervation (in N⋅mm−2, 5.94±1.12 vs. 3.15±0.63, P<0.001) and smaller fibre diameter (in µm, 1.37±0.05 vs. 1.64±0.13, P=0.016), smaller axon diameter (in µm, 0.89±0.05 vs. 1.24±0.10, P=0.009) and g-ratio (0.64±0.04 vs. 0.76±0.05, P<0.001) in the middle region around the implants. Compared with DIP+IL in the mandible, IIP+IL had a higher nerve density (in N⋅mm−2, 13.23±2.54 vs. 9.64±1.86, P=0.027), greater fibre diameter (in µm, 1.32±0.02 vs. 1.20±0.04, P=0.021), greater axon diameter (in µm, 0.92±0.01 vs. 0.89±0.03, P=0.035) and lower g-ratio (0.69±0.01 vs. 0.74±0.01, P=0.033) in the apical region around the implants. It may be assumed that the treatment protocol with IIP+IL is the preferred method to allow optimized peri-implant re-innervation, but further functional measurements are still required.

Validation of a novel imaging approach using multi-slice CT and cone-beam CT to follow-up on condylar remodeling after bimaxillary surgery

The main goal of this study was to introduce a novel three-dimensional procedure to objectively quantify both inner and outer condylar remodelling on preoperative multi-slice computed tomography (MSCT) and postoperative cone-beam computed tomography (CBCT) images. Second, the reliability and accuracy of this condylar volume quantification method was assessed. The mandibles of 20 patients (11 female and 9 male) who underwent bimaxillary surgery were semi-automatically extracted from MSCT/CBCT scans and rendered in 3D. The resulting condyles were spatially matched by using an anatomical landmark-based registration procedure. A standardized sphere was created around each condyle, and the condylar bone volume within this selected region of interest was automatically calculated. To investigate the reproducibility of the method, inter- and intra-observer reliability was calculated for assessments made by two experienced radiologists twice five months apart in a set of ten randomly selected patients. To test the accuracy of the bone segmentation, the inner and outer bone structures of one dry mandible, scanned according to the clinical set-up, were compared with the gold standard, micro-CT. Thirty-eight condyles showed a significant (P<0.05) mean bone volume decrease of 26.4%±11.4% (502.9 mm3±268.1 mm3). No significant effects of side, sex or age were found. Good to excellent (ICC>0.6) intra- and inter-observer reliability was observed for both MSCT and CBCT. Moreover, the bone segmentation accuracy was less than one voxel (0.4 mm) for MSCT (0.3 mm±0.2 mm) and CBCT (0.4 mm±0.3 mm), thus indicating the clinical potential of this method for objective follow-up in pathological condylar resorption.

On Speech Problems with Fixed Restorations on Implants in the Edentulous Maxilla: Introduction of a Novel Management Concept

BACKGROUND Little attention has been paid to the effect of implant restorations on speech. PURPOSE The aim of this study was threefold: (1) to find out if speech problems occur after inserting a fixed provisional restoration in the edentulous maxilla; (2) to explore speech adaptation in case articulation problems arise after rehabilitation; and (3) to describe the effect of changing the shape of the restoration on improving speech. MATERIALS AND METHODS Ten patients with an edentulous maxilla were treated with fixed rehabilitation on implants. Speech evaluation was performed at four occasions: before implant surgery, immediately after restoration, and 3 weeks later before and after managing the speech problem by changing the shape of the restoration if speech problems occurred. Comparative three-dimensional-analysis of casts of the restoration before and after changing the shape of the restoration was carried out. RESULTS The majority of patients (n = 7) experienced speech problems immediately after rehabilitation. Three weeks later, none of the seven patients with deteriorated speech returned to baseline speech. Then, volumetric reduction of the palatal aspects of the (pre)molars was performed, which allowed speech to return to baseline levels in five out of seven patients. In the two remaining patients, the intervention resulted in an improvement of speech without reaching their baseline levels. Three-dimensional-analysis showed that reducing the palatal volume of the premolars was effective in correcting speech. CONCLUSIONS Speech problems may frequently occur after fixed rehabilitation of the completely edentulous maxilla. A novel speech management concept, consisting of reducing the palatal volume of the (pre)molars, is introduced, demonstrating to solve speech problems in most cases.

Evaluation of Threshold Values for Root Canal Filling Voids in Micro-CT and Nano-CT Images

While several materials and techniques have been used to assess the quality of root canal fillings in micro-CT images, the lack of standardization in scanning protocols has produced conflicting results. Hence, the aim of this study was to determine a cutoff voxel size value for the assessment of root canal filling voids in micro-CT and nano-CT images. Twenty freshly extracted mandibular central incisors were used. Root canals were prepared with nickel titanium files to an ISO size 40/0.06 taper and then filled with a single cone (40/0.06 taper) and AH Plus sealer. The teeth were scanned with different voxel sizes with either micro-CT (5.2, 8.1, 11.2, and 16.73 μm) or nano-CT (1.5 and 5.0 μm) equipment. Images were reconstructed and analyzed with the NRecon and CTAn software. Void proportion and void volume were calculated for each tooth in the apical, middle, and coronal thirds of the root canal. Kruskal-Wallis and post hoc Mann–Whitney U tests were performed with a significance level of 5%. In micro-CT images, significantly different results were detected among the tested voxel sizes for void proportion and void volume, whereas no such differences were found in nano-CT images (p > 0.05). Micro-CT images showed higher void numbers over the entire root length, with statistically significant differences between the voxel size of 16.73 μm and the other sizes (p < 0.05). The values of the different nano-CT voxel sizes did not significantly differ from those of the micro-CT (5.2, 8.1, and 11.2 μm), except for the voxel size of 16.73 μm (p < 0.05). All tested voxel sizes enabled the detection of root canal filling voids except for the voxel size of 16.73 μm. Bearing in mind the limitations of this study, it seems that a voxel size of 11.2 μm can be used as a reliable cutoff value for the assessment of root canal filling voids in micro-CT imaging.

Waiting impulsivity: a distinctive feature of ADHD neuropsychology?

ABSTRACT Impulsivity is a core feature of attention-deficit hyperactivity disorder (ADHD). It has been conceptualized in a number of different ways. In the current article, we examine how the new concept of “waiting impulsivity”, which refers to premature responding before a scheduled target appears, adds to our understanding of impulsivity in ADHD. Sixty children (8–12 years old; 30 ADHD; 30 typically developing controls) completed the 4-choice serial reaction time task, a measure of waiting impulsivity, alongside tasks measuring inhibitory control and temporal discounting and questionnaires measuring behavioral disorder symptoms, delay aversion, and various aspects of impulsivity. A multiple logistic regression model was used to explore the contribution of the primary task outcomes to predict group membership. Children with ADHD displayed more waiting impulsivity and less inhibitory control; they did not differ in temporal discounting. There was no correlation between waiting impulsivity and inhibitory control. Waiting impulsivity was correlated with parent-reported ratings of hyperactivity/impulsivity, inattention, oppositional defiant disorder (ODD), and conduct disorder (CD) and with self-reported delay aversion ratings. Only waiting impulsivity was a significant predictor of ADHD status. In conclusion, waiting impulsivity is distinct from inhibitory control deficits and predicts ADHD status independently of it. Future research needs to examine the relationship with delay aversion and ODD/CD more thoroughly.

Computer-based automatic classification of trabecular bone pattern can assist radiographic bone quality assessment at dental implant site

OBJECTIVE: To develop and validate an automated classification method that determines the trabecular bone pattern at implant site based on three-dimensional bone morphometric parameters derived from CBCT images. METHODS: 25 human cadaver mandibles were scanned using CBCT clinical scanning protocol. Volumes-of-interest comprising only the trabecular bone of the posterior regions were selected and segmented for three-dimensional morphometric parameters calculation. Three experts rated all bone regions into one of the three trabecular pattern classes (sparse, intermediate and dense) to generate a reference classification. Morphometric parameters were used to automatically classify the trabecular pattern with linear discriminant analysis statistical model. The discriminatory power of each morphometric parameter for automatic classification was indicated and the accuracy compared to the reference classification. Repeated-measures analysis of variances were used to statistically compare morphometric indices between the three classes. Finally, the outcome of the automatic classification was evaluated against a subjective classification performed independently by four different observers. RESULTS: The overall correct classification was 83% for quantity-, 86% for structure-related parameters and 84% for the parameters combined. Cross-validation showed a 79% model prediction accuracy. Bone volume fraction (BV/TV) had the most discriminatory power in the automatic classification. Trabecular bone patterns could be distinguished based on most morphometric parameters, except for trabecular thickness (Tb.Th) and degree of anisotropy (DA). The interobserver agreement between the subjective observers was fair (0.25), while the test-retest agreement was moderate (0.46). In comparison with the reference standard, the overall agreement was moderate (0.44). CONCLUSION: Automatic classification performed better than subjective classification with a prediction model comprising structure- and quantity-related morphometric parameters. ADVANCES IN KNOWLEDGE: Computer-aided trabecular bone pattern assessment based on morphometric parameters could assist objectivity in clinical bone quality classification.