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[Case of an operated patient with congenital localized supravalvular and valvular aortic stenosis].

The authors presented a rare case with localised congenital supravalvular aortic stenosis associated with bicuspid aortic valvular stenosis which has been surgically treated. The clinical diagnosis was suggested in the presented patient by typical "elfin" face and conformed by left cardiac catheterisation and angiography. The operative procedure with cardiopulmonary by pass consisted of longitudinal aortotomy and insertion of Dacron prosthesis. In addition "open" commissurotomy of partially fused commissures of the bicuspid aortic valve was done. This effectively released the obstruction and enlarged the orifice. The postoperative course was uneventful.

Adult↗

Mitral repair in complete atrioventricular canal. Ease of correction in early infancy.

During the past 5 years all patients with complete atrioventricular (AV) were subjected to surgical correction regardless of age. Thus we were able to assess the ease and reliability of mitral repair in early infancy. Key features of operation include division of bridging leaflets when indicated, selection of a patch sufficiently small to prevent postoperative annular dilation, attachment of the leaflets to the patch with continuous nonpledget-supported sutures at a level determined by the chordal structure, and, based on the size of the mural leaflet, construction of a bicuspid or tricuspid mitral valve. Operative mortality and postoperative morbidity were no greater in patients under 6 months of age than in older patients. Reoperation for mitral regurgitation was required in three patients. In all of them, the primary reason for the failure of repair was that the mitral valve had been left tricuspid; in two of them, the mitral anulus was dilated, as well. Repair was uniformly accomplished by bicuspidization, combined in two instances with a Wooler-type annuloplasty and shortening of the free margin of the aortic leaflet. The absence of secondary scarring of the leaflets in the patients under 6 months of age facilitated repair in this age group. Early repair is possible, and preferable, provided that meticulous attention is paid to the technical features of the repair and a proper decision is made with regard to treatment of the mitral "cleft."

Aging↗

Acute aortic dissection, aortic insufficiency, and a single coronary artery in a patient with Turner's syndrome.

A rare case of acute aortic dissection and aortic regurgitation in a patient with Turner's syndrome is reported. A 25-year-old woman with a history of Turner's syndrome presented to our hospital with complaints of chest pain and dyspnea. Emergent surgery was performed after chest roentgenography and two-dimensional echocardiography. Intraoperatively, the patient was found to have a single coronary artery and a bicuspid aortic valve. The patient was treated successfully with a composite graft consisting of a 24 mm woven dacron graft, a 21 mm St. Jude Medical aortic prosthetic valve, and an equine pericardial skirt. The composite graft was inverted into the ascending aorta and connected to a small coronary artery graft. The patient's postoperative course was uneventful. A cardiac catheterization was performed postoperatively and revealed a competent anastomotic site and no evidence of aortic regurgitation. We provide a brief review of coronary anomalies and aortic diseases associated with patients with Turner's syndrome. The most commonly associated complications include coarctation of the aorta and bicuspid aortic valve disease. The incidence of coronary anomalies in patients with Turner's syndrome is maybe rare.

Acute Disease↗

[Valvuloannuloplasty for atrioventricular valvular regurgitation in complicated cyanotic cardiac anomalies].

Valvuloannuloplasty for atrioventricular (AV) valvular regurgitation was performed in 13 patients with univentricular AV connection and double outlet right ventricle. The suturing-up of free margins of the anterior and posterior common leaflets, which divides the common orifice into two parts, was performed in 4 children with quadricuspid or quintacuspid common AV valve and effectively reduced the regurgitation. The semicircular annuloplasty with a thin GORE-TEX graft was carried out in two patients having tricuspid AV valve, and a favourable result was obtained. In bicuspid AV valvular regurgitation, two patients received the suturing-up of free margins of prolapsed leaflets, and the results were satisfactory. From these results we consider that the semicircular annuloplasty for dilated tricuspid AV valve and the suturing-up of free margins of dilated or prolapsing leaflets in quadricuspid or quintacuspid and bicuspid AV valves are the recommendable procedures. If more than mild AV valvular regurgitation remained after these valvuloplasties, the Kay's and/or DeVega's annuloplasties should be added for eliminating the regurgitation.

Adolescent↗

[Juvenile sudden death from spontaneous aortic rupture].

UNLABELLED: In the time interval 1979-1991, 150 cases of juvenile sudden death (< or = 35 years) were studied. Among these, 9 were due to aortic rupture within the pericardial cavity. Two were mycotic and 7 dissecting aneurysms. The latter, all male, age ranging from 17 to 31 years (mean 24), presented the following risk factors: Marfan syndrome in 2, isthmal coarctation associated with bicuspid aortic valve (BAV) in 3, isolated and normally functioning BAV in 2. Histology of the dissected aortic wall showed an equal severity of degenerative changes consisting of elastic fragmentation, cystic medial necrosis and medionecrosis. By reviewing our anatomical collection of dissecting aneurysm we found a 12% frequency of BAV. Taking into consideration that the frequency in normal population of BAV is near 1%, the association between bicuspid aortic valve and dissecting aneurysm should not be casual (p < 0.001). IN CONCLUSION: a) natural history of BAV entails the risk of spontaneous aortic laceration and sudden death in the youth, either in the isolated form or in association with isthmal coarctation; b) the aortic tunica media in these conditions shows an intrinsic structural weakness very similar to that observed in Marfan syndrome, as to suggest a congenital, most probably genetic defect with phenotype expression not only at valve level, but also within the aortic wall; c) aortic dissection occurs nearly ten times more frequently in patients with BAV than in normal population.

Adolescent↗

Use of oversized homografts for right ventricular outflow tract reconstruction in infants.

A surgical technique for reducing the size of large diameter homografts in order to make them suitable for right ventricular outflow reconstruction in infants was clinically introduced by us at the Department of Cardiac Surgery, University of Padova in 1990. The method consists of two longitudinal incisions along the oversized homograft root removing one cusp with the relevant part of the aortic annulus and aortic wall. The remaining, flat "bicuspid" homograft is closed into a tube again around a mandrel of appropriate size. Preliminary experiences with the first three patients were excellent and have already been reported. The current study includes five additional patients (two male, three female) ranging in age from 20 days to 11 months (mean 8.3 months) and in weight from 3.2 to 7.4 kg (mean 6.2 kg) who underwent right ventricular outflow tract reconstruction with this surgical technique. There were no operative deaths and no instances of valve related complications at a mean follow up of 18 months. Serial echocardiography showed mild homograft stenosis in one patient (15 mmHg) and mild regurgitation in another. Although a longer follow up is necessary to determine whether the durability of these surgically modified "bicuspid homografts" can match that of the intact valves, we believe that our technique represents a valuable therapeutic alternative at least in the short term to the use of synthetic grafts in infants when an appropriately small homograft is not available.

Bioprosthesis↗

A retrospective six-months clinical trial of adhesive precoated brackets and bonding system.

This study investigated bond failures in two groups of 75 patients. Either adhesive precoated (APC) or control brackets were bonded from bicuspid to bicuspid in the mandibular and maxillary arch by a single experienced operator. Observations on failure were recorded at initial arch wire insertion and for the first six months of treatment. The APC bracket failed significantly more often than the control at initial arch wire insertion in both maxillary and mandibular teeth. Further examination disclosed that the APC bracket, when bonded to mandibular teeth, also failed significantly more often than the control during the subsequent six months of treatment. At the six-month point of the study, a total of 53 bond failures had occurred at 671 bond sites in the APC group (7.89 per cent failure rate), compared to 27 bond failures at 977 bond sites in the control group (2.76 per cent failure rate). Fourteen patients in the APC group and two patients in the control group experienced bond failure at initial arch wire insertion. Twenty-eight patients in the APC group and 13 in the control group experienced bond failures within the first six months following initial arch wire insertion.

Adhesiveness↗

A modified, lingually supported cantilevered Herbst appliance.

This new, fixed-functional appliance/Herbst/Bioprogressive system is designed for patient comfort and mandatory compliance. It also combines the positive clinical effects of four fixed-functional systems. It allows rapid palatal expansion of the upper arch, alveolar uprighting of the lower arch, upper and lower incisor alignment, and sagittal correction of Class II malocclusions to occur simultaneously with one appliance fixed in both arches. It is indicated for use in growing patients with skeletal Class II malocclusions. The ideal timing for treatment is the late mixed dentition. Being able to remove the appliance after one year with the upper second bicuspids erupting slightly Class III so the clinician can immediately begin fixed finishing mechanics would be ideal. This new Herbst design will reduce the frequency of orthognathic surgery and upper bicuspid extraction to camouflage Class II malocclusions. At the same time, it gives total control to the clinician in treating some more difficult, non-compliant patients. Fixed-functional appliances, which improve treatment efficiency and treatment results and provide for patient comfort, while at the same time give the treating clinician almost total control of the three planes of facial growth will open new doors for orthodontic treatment and research in the next century.

Child↗

Evolution of P3 morphology in Australopithecus afarensis.

The Australopithecus afarensis dental sample exhibits a wide range of variation, which is most notable in the morphology of the lower third premolar (P3). P3 morphology in the A. afarensis sample ranges from the primitive sectorial extreme in AL 128-23 to the derived, bicuspid (molarized) extreme in AL 333w-1. In this paper, the degree and patterning of variation of the 20 known A. afarensis P3s are examined and the evolutionary implications are discussed. Initially, a series of dental and mandibular metric criteria are evaluated to determine whether this sample may be analyzed as a single species. From the metrics, it is clear that the single species hypothesis cannot be rejected. Next, a series of morphological criteria is devised to measure P3 molarization. Taken as a whole, the A. afarensis P3 sample displays more variation than a sample of modern hominoids (Pan troglodytes) and shows a slight trend toward increased molarization through time. When separated by sex, the A. afarensis sample still displays greater variation than the chimpanzee sample; however, only the male A. afarensis specimens show a trend toward increased molarization. Additionally, the male A. afarensis P3s are more molarized than the female, a pattern that is seen as well (though less markedly) in the chimpanzee sample. The trend toward increased molarization over time indicates selection for grinding in A. afarensis. The sexual differences parallel those seen in the postcrania (cf. Stern and Susman: Am. J. Phys. Anthropol. 60:279-318, 1983), as the females tend to retain the primitive condition, while the males display the derived morphology. Consequently, a model of sexual differences in niche exploitation, with the females exploiting a more arboreal environment, would seem to be supported by both the dental and postcranial evidence.

Africa↗

[Dental caries in the support area and the therapeutic problem of the positioning of the canines and premolars in the dental arches].

The purpose of this study was to analyse the health of teeth in the buccal segments following space loss resulting from approximal caries of deciduous molars. The sum of the mesiodistal diameters of unerupted cuspids and bicuspids was predicated with the help of tables and calculated on the basis of correlation with the total width of the lower incisors. On average boys had 5.1 carious deciduous cuspids and molars as compared with 4.8 for girls. The results concluded that 60 to 70% of the cases of space loss resulting from carious lesions of approximal surfaces of deciduous molars occurred in the maxilla and 46 to 54% in the mandible, when factors including which jaw, side and sex were taken into account.

Bicuspid↗

Mandibular symphyseal contouring in mild mandibular prognathism.

Kölle's mandibular segmental osteotomy, with extraction of the bilateral first bicuspids, is often used in cases of mild mandibular prognathism. While mandibular prognathism is usually corrected by mandibular ramus osteotomy and the mandible is set back en bloc, the premolar region alone is set back by segmental osteotomy, retaining the protruding mental area. In Asians, particularly, the protruding chin is not preferred by our concepts of beauty. In mandibular segmental osteotomy, the entire mandibular symphyseal shape should be considered. Mandibular symphyseal contouring constitutes setting back the premolar region by segmental osteotomy, recession genioplasty, and chiseling out the protruding middle portion of the protruding chin. In 18 series of mild manibular prognathism in Asians patients, this procedure was used and satisfactory aesthetic results were obtained.

Adolescent↗

Parathyroid hormone(1-34) mediates proliferative and apoptotic signaling in human periodontal ligament cells in vitro via protein kinase C-dependent and protein kinase A-dependent pathways.

Periodontal ligament (PDL) cells exhibit several osteoblastic traits and are parathyroid hormone (PTH)-responsive providing evidence for a role of these cells in dental hard-tissue repair. To examine the hypothesis that PDL cells respond to PTH stimulation with changes in proliferation and apoptotic signaling through independent but convergent signaling pathways, PDL cells were cultured from human bicuspids obtained from six patients. PDL cells at different states of maturation were challenged with PTH(1-34) intermittently for 0, 1, or 24 h/cycle or exposed continuously. Specific inhibitors to protein kinases A and C (PKA, PKC) and the mitogen-activated protein kinase cascade (MAPK) were employed. At harvest, the cell number, BrdU incorporation, and DNA fragmentation were determined by means of cell counting and immunoassays. Intermittent PTH(1-34) caused a significant increase in cell number in confluent cells as opposed to a reduction in pre-confluent cells. In confluent cells, the effect resulted from a significant increase in proliferation, whereas DNA fragmentation was reduced when PTH(1-34) was administered for 1 h/cycle but increased after PTH(1-34) for 24 h/cycle. Inhibition of PKC inhibited PTH(1-34)-induced proliferation but enhanced apoptosis. Inhibition of PKA enhanced proliferation and DNA fragmentation. Similar results were obtained in less mature cells, although, in the presence of the PKA inhibitor, the PTH(1-34)-induced changes were more pronounced than in confluent cells. In the presence of the MAPK inhibitor, all of the parameters examined were reduced significantly in both maturation states. Thus, PTH(1-34) mediates proliferative and apoptotic signaling in human PDL cells in a maturation-state-dependent manner via PKC-dependent and PKA-dependent pathways.

Adolescent↗

A 2-year clinical study of composite and ceramic inlays.

Objective long-term clinical data are necessary to evaluate the performance of dental restorations. This prospective clinical trial evaluated composite and ceramic inlays for clinical acceptability as restorative materials in posterior teeth and provided 2-year results. The study involved 7 student operators placing 47 composite inlays (Tetric, blend-a-lux, Pertac) and 24 ceramic inlays (Empress) under the supervision of an experienced dentist. Clinical assessment of 56 inlays (78.9%) was performed after 2 years with modified USPHS criteria and statistically analyzed using the Mann-Whitney U test and Fisher's exact test. All the ceramic inlays and 90% of the composite inlays were considered clinically excellent or acceptable. During the first year 3 composite inlays failed and during the second evaluation period 1 had to be replaced. Ceramic inlays produced significantly better "anatomic form of the surface" (P = 0.038) and "integrity of the restoration" values (P = 0.043). Inlays in small cavities exhibited superior "marginal integrity" (P = 0.026) and "marginal discoloration" values (P = 0.034). Fisher's test revealed a significantly higher failure rate in molars than in bicuspids (P = 0.034). Posterior tooth-colored inlays exhibited a success rate of 100% for ceramic inlays and 90% for composite inlays even if placed by relatively inexperienced but supervised student operators.

Adult↗

A developing complex odontome associated with delayed premolar formation.

Delayed development of a bicuspid in the right premolar region of the mandible was observed radiographically in a 16-year-old male patient following surgical removal of a developing odontome. Whilst odontomes are commonly associated with a failure of eruption of permanent teeth, this case was unusual in that there was both failure and marked delay of adjacent permanent tooth germ development, suggesting that the odontome was associated with a regional disturbance of odontogenic tissues in the neonatal period.

Adolescent↗

Efficacy of composite surface sealers in sealing cavosurface marginal gaps.

OBJECTIVES: The ability of commercially available composite surface sealers to penetrate and seal a controlled gap formed in all-enamel margin, Class V in vitro resin composite restorations in human bicuspids was examined. METHODS: A fluorescent red dye (Rhodamine B) was incorporated to a variety of commercially available composite surface sealers. The teeth were restored using acid etching, a dentin bonding agent, and a photo-activated microfilled composite, finished, polished, and sealed. The teeth were thermocycled and then immersed in an aqueous solution of a green fluorescent dye (Dextran-Fluorescein) to evaluate the sealing ability and penetration of surface sealers into the controlled gaps formed at unbonded margins. Teeth were embedded, sectioned, and images recorded using confocal microscopy. RESULTS: All sealers leaked, and use of a dentin-bonding agent to seal the gap performed better than the commercial sealing products. CONCLUSIONS: Commercial surface sealers evaluated were not able to totally seal controlled-size cavosurface gaps, and sealer penetration into the controlled gap varied greatly. Composite restorative procedures should be performed to obtain ideal marginal sealing, minimizing the need for composite surface sealers, which were found to not totally seal an exposed cavosurface margin. Use of a dentin-bonding agent may provide better sealing than commercial products developed specifically for this purpose.

Analysis of Variance↗

Effect of operator skill in relation to microleakage of total-etch and self-etch bonding systems.

OBJECTIVES: To evaluate the influence of operator skill on microleakage in class V restorations using two-step bonding systems. METHODS: Two standardized box cavities were made on the buccal and lingual surfaces of 54 human bicuspid teeth, with the cervical margin in dentin. The teeth were randomly assigned to two groups according to the operator's skill. Students group: undergraduate students. Expert group: a dentist with 20 years of clinical experience in dental adhesion. The buccal cavities of each tooth were treated with Prime&Bond NT (two-step total-etch system); the lingual cavities were treated with AdheSE (two-step self-etch system). All cavities were restored by a single calibrated operator with one bulk increment of resin composite (InTens; Ivoclar Vivadent). Specimens were thermocycled, immersed in 2% methylene blue and sectioned in a bucco-lingual plane in the middle of the restorations. They were then examined under a stereomicroscope and scored according to microleakage by two operators who were blind to the specimen preparation. The data was subjected to a multilevel statistical model. RESULTS: The microleakage resulting from the self-etch adhesive was similar in the student and in the expert groups. On the other hand, the total-etch adhesive microleakage within the expert group resulted lower than that within the student group. However, the interaction term skill x adhesive resulted statistically significant at the dentin margin (p=0.0474) but not at the enamel margin (p=0.1267). CONCLUSION: While the total-etch adhesive used in this study showed to be skill-sensitive, the self-etch one proved to be less skill-sensitive in obtaining a reliable seal with dentin.

Acid Etching, Dental↗

The influence of canal curvature on the mechanical efficacy of root canal irrigation in vitro using real-time imaging of bioluminescent bacteria.

There are no quantitative data on the mechanical efficacy of irrigation in the removal of bacteria from curved canals. This study quantitatively analyzed the effects of root canal curvature and preparation size on the mechanical efficacy of irrigation using 33 mandibular single-rooted bicuspids allocated to groups according to root canal curvatures, group 1 (straight) 4 to 8 degrees, group 2 (intermediate curvature) 15 to 19 degrees, and group 3 (greatest curvature) 24 to 28 degrees. Teeth were sequentially instrumented to sizes 27/.04, 36/.04, and 46/.04 using a crown-down technique. Suspensions of the bioluminescent reporter strain Pseudomonas fluorescens 5RL (1.5 x 10(6) cells) were inoculated into canals of sterilized teeth after each sequential instrumentation. Canals were irrigated with 6 ml of irrigant delivered 1 mm from working length using a 30-gauge needle. Remaining bacteria were quantified using real-time bioluminescent imaging. Irrigation was significantly less effective in 24 to 28 degrees curvature canals prepared to size 27/.04 compared to 46/.04 (p < 0.007, repeated-measures ANOVA).

Bicuspid↗

Reduction in tooth stiffness as a result of endodontic and restorative procedures.

Endodontically treated teeth are thought to be more susceptible to fracture as a result of the loss of tooth vitality and tooth structure. This study was designed to compare the contributions of endodontic and restorative procedures to the loss of strength by using nondestructive occlusal loading on extracted intact, maxillary, second bicuspids. An encapsulated strain gauge was bonded on enamel just above the cementoenamel junction on both the buccal and lingual surfaces, and the teeth were mounted in nylon rings leaving 2 mm of root surface exposed. Under load control, each tooth was loaded at a rate of 37 N per s for 3 s and unloaded at the same rate in a closed loop servo-hydraulic system to measure stiffness. A stress-strain curve was generated from each gauge prior to alteration of the tooth and after each procedure performed on the tooth. Cuspal stiffness, as a measure of tooth strength, was evaluated on one of two series of sequentially performed procedures: 1. (a) unaltered tooth, (b) access preparation, (c) instrumentation, (d) obturation, and (e) MOD cavity preparation; or 2. (a) unaltered tooth, (b) occlusal cavity preparation, (c) two-surface cavity preparation, (d) MOD cavity preparation, (e) access, (f) instrumentation, and (g) obturation. Results on 42 teeth indicate that endodontic procedures have only a small effect on the tooth, reducing the relative stiffness by 5%. This was less than that of an occlusal cavity preparation (20%). The largest losses in stiffness were related to the loss of marginal ridge integrity. MOD cavity preparation resulted in an average of a 63% loss in relative cuspal stiffness.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of Variance↗