Kurt Busuttil Naudi

The virtual human face: Superimposing the simultaneously captured 3D photorealistic skin surface of the face on the untextured skin image of the CBCT scan

The aim of this study was to evaluate the impact of simultaneous capture of the three-dimensional (3D) surface of the face and cone beam computed tomography (CBCT) scan of the skull on the accuracy of their registration and superimposition. 3D facial images were acquired in 14 patients using the Di3d (Dimensional Imaging, UK) imaging system and i-CAT CBCT scanner. One stereophotogrammetry image was captured at the same time as the CBCT and another 1h later. The two stereophotographs were individually superimposed over the CBCT using VRmesh. Seven patches were isolated on the final merged surfaces. For the whole face and each individual patch: maximum and minimum range of deviation between surfaces; absolute average distance between surfaces; and standard deviation for the 90th percentile of the distance errors were calculated. The superimposition errors of the whole face for both captures revealed statistically significant differences (P=0.00081). The absolute average distances in both separate and simultaneous captures were 0.47 and 0.27mm, respectively. The level of superimposition accuracy in patches from separate captures was 0.3-0.9mm, while that of simultaneous captures was 0.4mm. Simultaneous capture of Di3d and CBCT images significantly improved the accuracy of superimposition of these image modalities.

A novel approach for planning orthognathic surgery: the integration of dental casts into three-dimensional printed mandibular models

A method of producing a composite model consisting of a three-dimensional printed mandible bearing plaster teeth is presented. Printed models were obtained from cone beam computed tomograms (CBCT) of dry human mandibles. The plaster casts of the teeth were obtained from impressions of the teeth of the dry mandibles. The distorted teeth of the printed models were removed and replaced by the plaster casts of the teeth using a simple transfer jig. The accuracy of the composite models obtained from six mandibles was assessed from laser scans. The scans of the dry mandibles and the composite models were superimposed and the magnitude of the discrepancies at six points on the dentition and six on the mandible were obtained. It was concluded that the errors of the method were small enough to be clinically significant. The use of the composite models is illustrated in two clinical cases.

Mandibular reconstruction in the rabbit using beta-tricalcium phosphate (β-TCP) scaffolding and recombinant bone morphogenetic protein 7 (rhBMP-7) – Histological, radiographic and mechanical evaluations

This investigation assesses the histological, radiographic and mechanical properties of regenerated bone in a unilateral critical-size osteoperiosteal mandibular continuity defect in the rabbit model, following the application of beta-tricalcium phosphate (β-TCP) scaffolding and recombinant human bone morphogenetic protein 7 (rhBMP-7). The study was carried out on nine cases; in six cases the critical-size defect was filled with rhBMP-7 in the β-TCP scaffolding, and in three cases the β-TCP was used alone. The cases were sacrificed 3 months post-operatively. Histologically the overall mean of the percentage of regenerated bone volume in the cases that received rhBMP-7 was 29.41% ± 6.25%, which was considerably greater than the 6.35% ± 3.08% in the cases treated with β-TCP alone. Mechanical testing of the cases treated with rhBMP-7 gave failure moments (55 mNm-2.040 Nm) that were consistently greater than those treated with β-TCP alone (0 mNm-48 mNm). In some cases the mechanical properties of the regenerated bone were comparable to those of untreated bone. RhBMP-7 in prefabricated β-TCP scaffolding appeared, radiographically and histologically, to be an effective method for bone regeneration in mandibular critical-size defects in the rabbit model. This points towards possible future clinical applications.

Digital replacement of the distorted dentition acquired by cone beam computed tomography (CBCT): a pilot study

During cone beam computed tomography (CBCT) scanning, intra-oral metallic objects may produce streak artefacts, which impair the occlusal surface of the teeth. This study aimed to determine the accuracy of replacement of the CBCT dentition with a more accurate dentition and to determine the clinical feasibility of the method. Impressions of the teeth of six cadaveric skulls with unrestored dentitions were taken and acrylic base plates constructed incorporating radiopaque registration markers. Each appliance was fitted to the skull and a CBCT performed. Impressions were taken of the dentition with the devices in situ and dental models were produced. These were CBCT-scanned and the images of the skulls and models imported into computer-aided design/computer-aided manufacturing (CAD/CAM) software and aligned on the registration markers. The occlusal surfaces of each dentition were then replaced with the occlusal image of the corresponding model. The absolute mean distance between the registration markers in the skulls and the dental models was 0.09±0.02mm, and for the dentition was 0.24±0.09mm. When the method was applied to patients, the distance between markers was 0.12±0.04mm for the maxilla and 0.16±0.02mm for the mandible. It is possible to replace the inaccurate dentition on a CBCT scan using this method and to create a composite skull which is clinically acceptable.

Assessment of cellular viability on calcium sulphate/hydroxyapatite injectable scaffolds

Cements for maxillofacial reconstruction of jaw defects through calcification of rotated muscle have been tested. The objective of this study was to investigate the visibility of loading of two types of commercially available cements, Cerament™ Spine Support and Cerament Bone Void Filler with mesenchymal cells and cytokines (bone morphogenetic protein) to act as a biomimetic scaffolding for future clinical application. Determination of basic biocompatibility (cell viability) using methyl thiazolyl tetrazolium and live/dead assay was carried out using MG-63 cells at various time points. Next, in order to inform potential subsequent in vivo experiments, a collagen tissue mimic was used for characterization of rabbit mesenchymal stromal cells using immunofluorescent cytoskeleton staining, and simultaneous and then sequential injection of Cerament Spine Support cement and cells into collagen gels. Results indicated that Cerament Spine Support was more biocompatible and that sequential injection of cement and then rabbit mesenchymal stromal cells into the tissue mimics is an optimal approach for clinical applications.

Radiological assessment of bioengineered bone in a muscle flap for the reconstruction of critical-size mandibular defect

This study presents a comprehensive radiographic evaluation of bone regeneration within a pedicled muscle flap for the reconstruction of critical size mandibular defect. The surgical defect (20 mm×15 mm) was created in the mandible of ten experimental rabbits. The masseter muscle was adapted to fill the surgical defect, a combination of calcium sulphate/hydroxyapatite cement (CERAMENT™ |SPINE SUPPORT), BMP-7 and rabbit mesenchymal stromal cells (rMSCs) was injected inside the muscle tissue. Radiographic assessment was carried out on the day of surgery and at 4, 8, and 12 weeks postoperatively. At 12 weeks, the animals were sacrificed and cone beam computerized tomography (CBCT) scanning and micro-computed tomography (µ-CT) were carried out. Clinically, a clear layer of bone tissue was identified closely adherent to the border of the surgical defect. Sporadic radio-opaque areas within the surgical defect were detected radiographically. In comparison with the opposite non operated control side, the estimated quantitative scoring of the radio-opacity was 46.6% ±15, the mean volume of the radio-opaque areas was 63.4% ±20. Areas of a bone density higher than that of the mandibular bone (+35% ±25%) were detected at the borders of the surgical defect. The micro-CT analysis revealed thinner trabeculae of the regenerated bone with a more condensed trabecular pattern than the surrounding native bone. These findings suggest a rapid deposition rate of the mineralised tissue and an active remodelling process of the newly regenerated bone within the muscle flap. The novel surgical model of this study has potential clinical application; the assessment of bone regeneration using the presented radiolographic protocol is descriptive and comprehensive. The findings of this research confirm the remarkable potential of local muscle flaps as local bioreactors to induce bone formation for reconstruction of maxillofacial bony defects.

The clinical application of rhBMP-7 for the reconstruction of alveolar cleft

In this study, radiographic assessment was performed to find out the effectiveness of bone regeneration following the application of recombinant human bone morphogenetic protein 7 (rhBMP-7) for the reconstruction of alveolar cleft defects in 11 cases: nine unilateral and two bilateral alveolar clefs. Reconstruction of the alveolar cleft was performed by using 3.5 mg of rhBMP-7 (Osigraft OP1) on a type I collagen carrier. Radiographs were taken 6 months post operation using a Gendex Intraoral Unit with Agfa Dentus M2 Comfort occlusal film. The amount of bony infill was graded on a Kindelan four-point scale. The patients were followed up for an average of 6.6 years. Based on the radiographic analysis, eight out of the nine unilateral alveolar cleft cases received a score of grade I and one patient had a grade II score, using the Kindelan scale. In the two bilateral alveolar clefts, only one side had bone formation. The radiographic appearance showed a normal trabecular pattern similar to the adjacent bone. Thus, rhBMP-7 was radiographically and clinically successful in regenerating the bone at the alveolar cleft which resulted in shortening of the operation time, absence of donor-site morbidity and a shorter hospital stay. The promising results of this preliminary study should encourage a phase II trial to compare bone grafts with BMP for the reconstruction of alveolar defects.

Engineered Coatings for Titanium Implants To Present Ultralow Doses of BMP-7

The ongoing research to improve the clinical outcome of titanium implants has resulted in the implemetation of multiple approches to deliver osteogenic growth factors accelerating and sustaining osseointegration. Here we show the presentation of human bone morphogenetic protein 7 (BMP-7) adsorbed to titanium discs coated with poly(ethyl acrylate) (PEA). We have previously shown that PEA promotes fibronectin organization into nanonetworks exposing integrin- and growth-factor-binding domains, allowing a synergistic interaction at the integrin/growth factor receptor level. Here, titanium discs were coated with PEA and fibronectin and then decorated with ng/mL doses of BMP-7. Human mesenchymal stem cells were used to investigate cellular responses on these functionalized microenvironments. Cell adhesion, proliferation, and mineralization, as well as osteogenic markers expression (osteopontin and osteocalcin) revealed the ability of the system to be more potent in osteodifferentiation of the mesenchymal cells than combinations of titanium and BMP-7 in absence of PEA coatings. This work represents a novel strategy to improve the biological activity of titanium implants with BMP-7.