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Duplex scanning in the postoperative surveillance of patients undergoing total hip arthroplasty.

Color flow duplex imaging is a well-established method for the diagnosis of deep vein thrombosis in symptomatic patients; however, the sensitivity and specificity of duplex scanning compared with venography in high-risk asymptomatic patients are not known. Consecutive patients undergoing total hip arthroplasty who consented to have bilateral venography on days 8 to 12 were included in this prospective study. One hundred and fifty-one venograms were finally obtained in 78 patients. All duplex scanning was performed with the Ultramark 9 ATL (Advanced Technology Laboratories) by one investigator. In the beginning of the study, the first 44 legs, only the femoropopliteal segment was tested and the result was based on B-mode compression; the sensitivity for the duplex was 56% (5/9), and the specificity, 94% (33/35). In the next 107 legs, the addition of color to our criteria improved the sensitivity of the duplex scan from 55% to 93% (13/14) for the femoropopliteal segment and the specificity from 94% to 99% (92/93). For the calf segment, in the same 107 legs, using the color facility of the duplex, the sensitivity and specificity were 79% (15/19) and 97% (85/88), respectively. The color facility of new-generation machines makes duplex scanning reliable for the detection of proximal deep vein thrombosis, even in asymptomatic high-risk patients. For the detection of calf deep vein thrombosis, however, more experience is needed. A larger study is necessary to confirm these preliminary data.

Aged↗

Imaging after endovascular repair of abdominal aortic aneurysm.

Endovascular repair of abdominal aortic aneurysm is a less invasive alternative to open surgery. With the recognition of this new treatment, however, many complications, some of them life-threatening, have been reported. Short-term and mid-term results have shown that this technology is advancing and needs close follow-up. Imaging plays a major role in the evaluation of the aorta after endolumenal repair. This article reviews the roles of different imaging techniques.

Angiography↗

Evaluation of the proximal aortic neck enlargement following endovascular repair of abdominal aortic aneurysm: 3-years experience.

The aim of this study was to evaluate incidence, potential risk factors and effects on stent-graft migration of proximal neck dilatation after endoluminal repair of abdominal aortic aneurysm (EVAR), and the role of ultrasound (US) in detecting neck enlargement. From November 1998 to October 2001, 90 patients underwent EVAR. On follow-up, US and CT angiography (CTA) were performed, and diameters of the suprarenal and infrarenal aortic necks were monitored. Incidence of significant neck enlargement (> or =2.5 mm) and distal stent-graft migration (>10 mm) was calculated. Several factors were evaluated as predictive of neck enlargement. Ultrasound and CTA measurements were compared. The US and CTA examinations were available in 68, 39, and 11 patients at 1, 2, and 3 years follow-up (mean follow-up 15 months). Incidence of significant neck dilatation was 21.8% at the infrarenal level (13, 33, and 36% at 1, 2, and 3 years follow-up) and 13.8% at the suprarenal level (9, 18, and 27% at 1, 2, and 3 years follow-up). Significant stent-graft migration occurred in 14 of 87 patients (16%) and was associated with neck dilatation in 8 (2 suprarenal and 6 infrarenal). No risk factors were identified. Ultrasound was less accurate than CT in measuring neck diameter, in particular at the suprarenal level. Proximal aortic neck enlargement occurs in up to 30% of patients after EVAR and represents the main risk factor for stent-graft migration. The risk of infrarenal neck dilatation is higher at 2 years follow-up, whereas the suprarenal neck enlarges later. Ultrasound is not useful in monitoring neck diameter.

Aged↗

[Ventricular septal defect and aortic regurgitation-pathophysiological aspects and therapeutic consequences].

The development of aortic regurgitation (AI) is a rare but serious complication of subaortic ventricular septal defects (VSD). Over a period of 5 years we observed VSD-related AI in 24 patients, a frequency of 4.5% of all isolated VSD's encountered during that time frame. The location of the defects was in the infundibular septum in 59%, it was perimembranous in 25% and in the trabecular septum in 16%. Hemodynamically the defects were small except for 2 where the Q(p)/Q(s) ratio was > 2. Of the 24 pts, 16 had surgical closure of their VSD accompanied in 9 by aortic valvuloplasty. AI was caused by elongation or defect of the right coronary leaflet in 42%, of the noncoronary leaflet in 25% and a combination of both, in 8%. In 6 pts with infundibular VSD absence of part of the aortic valve ring above the defect was the underlying mechanism for AI. Postoperatively AI was improved to moderate in one pt and to none to trivial in 15. LV end-diastolic diameter decreased significantly in all pts operated. Pathogenetic mechanisms for the development of AI are a deficiency in the aorto-infundibular junction with prolaps of the right-or non-coronary leaflet, deficiency of the valve supporting structures including the valve ring as well as suction of the already elongated leaflet into the VSD with further damage to the antiregurgitant mechanism of the semilunar valve at risk. In perimembranous VSD's, late AI is probably related to turbulent flow through the adjacent LVOT. Surgical closure of isolated VSD's with a location immediately beneath the aortic valve is indicated regardless of their size to prevent the development of AI. If AI has occurred, VSD closure including aortic valvuloplasty improves the amount of regurgitation and normalizes LV enddiastolic dimension.

Adolescent↗

Utility of intraoperative transesophageal echocardiography during endovascular stent-graft repair of acute thoracic aortic dissection.

This study was undertaken to evaluate the utility and efficacy of intraoperative transesophageal echocardiography (TEE) in the endovascular management of patients with acute type B aortic dissection. Twelve consecutive patients with acute type B aortic dissection underwent elective endoluminal stent-graft repair in the operating room under angiographic and TEE guidance. The follow-up protocol included spiral CT scanning before discharge from the hospital to assess thrombosis exclusion of the aortic false lumen, perfusion of branch vessels, and the absence of perigraft leak. No complications related to the use of TEE were encountered. TEE clearly demonstrated the presence and extent of the dissection flap in all patients. After the procedure a persistent perigraft leak or residual flow into the false lumen was diagnosed by TEE in 6 patients, whereas intraoperative angiography visualized only 3 cases. Postoperative CT scan confirmed these findings. One patient died 2 months later by aortic rupture secondary to a persistent perigraft leak not treated (8.3% mortality). No postoperative paraplegia or visceral ischaemia were registered, although an asymptomatic occlusion of left subclavian artery was observed. TEE monitoring detects perigraft leakage, identifies the entry tear, and accurately demonstrates sealing of the false lumen. TEE is essential in our practice as an adjuvant to fluoroscopy to achieve optimal results during endovascular stent-graft repair of acute thoracic aortic dissection.

Acute Disease↗

The uses of external nipple-areola prostheses following reconstruction of a breast mound after mastectomy.

Following reconstruction of the breast after mastectomy it is common practice to allow a "settling" period before grafting the nipple-areola complex. A selection of external nipple-areola prostheses are described which can be used until surgical reconstruction can be carried out and which are helpful in determining the correct position of the nipple-areola grafts. It has been found that some patients actually prefer to use the prostheses permanently for dress purposes rather than undergo an additional operation.

Breast↗

Echocardiographic characteristics of successful deployment of the Das AngelWings atrial septal defect closure device: initial multicenter experience in the United States.

The AngelWings device is a newer transcatheter device used for closure of secundum atrial septal defects (ASD) and patent foramen ovale (PFO), which consists of a self-centering, 2-disk system. Transesophageal echocardiography (TEE) plays a pivotal role in the deployment of the 2 disks of this device, on the appropriate sides of the atrial septum. The objective of this study is to describe the echocardiographic findings associated with successful deployment of the AngelWings device for closure of ASD and PFO. We evaluated the TEE studies of 70 patients enrolled in 4 United States centers, for closure of ASD and PFO with the AngelWings device. The TEE characteristics of successful and unsuccessful deployments were analyzed. Residual shunts across the atrial septum were assessed by TEE at the end of the procedure, 24 hours later by transthoracic echocardiography, and at 6 months by TEE. The deployment of the device was successful in 65 patients (93%). In the unsuccessful group, ASD size by TEE was larger (13.4 +/- 3.1 vs 8.9 +/- 4.7 mm, p <0.05). TEE was successful in identifying snagging of the device by intracardiac structures and prolapse of corners of the left or right atrial disk through the ASD, features that were difficult to identify by fluoroscopy. The echocardiographic characteristics outlined here are important guidelines for successful deployment of the AngelWings device.

Adolescent↗

Closure of short, wide patent ductus arteriosus with cardiopulmonary bypass and balloon occlusion.

The wide, short patent ductus arteriosus in adults and older adolescents poses an extreme hazard with standard closed ligation techniques. The method of transpulmonary balloon catheter occlusion and repair of pediatric ductus arteriosus is herein reported in older patients using a Foley catheter and normothermic bypass. Transesophageal echocardiography is crucial in assessing the size of the ductus and confirming adequacy of repair. The technique is simple and safe even in the presence of a wide, short ductus.

Adolescent↗

Evaluation of porcine valves prepared by dye-mediated photooxidation.

BACKGROUND: Previous studies demonstrated that dye-mediated photooxidation can stabilize bovine pericardium. Here, photooxidized porcine valve cusp and root tissue were assessed in comparison to fresh and glutaraldehyde-treated samples. METHODS AND RESULTS: In an in vitro tissue solubility test, both photooxidized and glutaraldehyde-treated tissues were resistant to protein extraction compared to fresh tissue. A rat subcutaneous model was used to test in vivo stability and calcification potential. In this study, four of the six fresh leaflets were not visible because of resorption while both photooxidized and glutaraldehyde-treated tissues were biostable. Mineral contents of the rat explants were much lower for both fresh and photooxidized leaflets when compared with glutaraldehyde-treated leaflets. Also, the aortic root calcified whether treated or not with the most mineral being associated with glutaraldehyde-treated root. Analysis of photooxidized porcine valves explanted from the mitral position in sheep indicated a material that was biostable and contained only minor calcification, perhaps due to deformed stents. CONCLUSIONS: Porcine valve tissue treated by dye-mediated photooxidation is biostable and resistant to calcification, and has potential for use in heart valve bioprostheses.

Animals↗

Influence of ceramic and cement thickness on the masking of various types of opaque posts.

STATEMENT OF PROBLEM: Dark-colored posts may negatively affect the esthetics of all-ceramic single unit crowns as the thin layers of luting cement may not be sufficiently opaque. PURPOSE: This in vitro study evaluated the influence of the color of 2 commercially available nonmetallic opaque posts (carbon fiber and zirconia) and an experimental esthetic post, and the shade and thickness of luting cements on the esthetics of all-ceramic restorations. MATERIAL AND METHODS: Sample disks at several thickness values were made in glass-ceramic (IPS-Empress), an experimental ceramic, a zirconia, a carbon fiber post material, a resin composite material (Z100) as reference, and a luting cement (Variolink II). A laboratory procedure, with 3 possible combinations of stapling the disks, was used. This was performed for 4 substrates, 3 cement colors at 2 thickness values, and 3 heights of ceramic disks. For each combination, the shift in color was measured with a spectrophotometer. Readings were performed for 3 conditions: (1) ability of ceramic to mask the aspect of the abutment in relation to its thickness (1.0, 1.5, or 2.0 mm); (2) effect of a change in cement color (W, Y, or B) on the final color of the ceramic; and (3) influence of cement film thickness (0.1 or 0.2 mm) on the final color of the ceramic. RESULTS: When ceramic thickness was 1 mm, all other variables were visually appreciable. For ceramic thickness of 1.5 mm, color differences decreased and most differences were appreciable only with laboratory instruments. For ceramic thickness of 2.0 mm, there were no detectable, clinically relevant differences. CONCLUSION: The final esthetic result of the all-ceramic IPS-Empress glass-ceramic restoration was not affected by the presence of different substrates with different colors when the thickness was more than 2.0 mm. When ceramic thickness decreases to 1.5 mm, it is advised to take the substrate aspects into consideration. If the ceramic thickness is less than 1.0 mm, the use of a full ceramic crown is contraindicated because color matching of the abutment is required to ensure an acceptable esthetic result. Differences in cement thickness (0.1 or 0.2 mm) may slightly affect the final result. As this parameter can be controlled by the operator only to a certain extent, it cannot be considered as a procedure to correct color. Availability of different cement shades allows only minor esthetic corrections, which might be instrumentally detectable but are clinically not relevant.

Aluminum Silicates↗

Precision of fit: the Procera AllCeram crown.

STATEMENT OF PROBLEM: Strength, color stability, and precision of fit are requirements for all-ceramic restorations. The Procera AllCeram crown system, composed of a densely sintered high-purity alumina core combined with a low fusing surface porcelain, appears to satisfy most of these requirements. However, evaluation of marginal fit has not been reported. PURPOSE: This study measured the precision of fit of the Procera AllCeram crown fabricated with Procera CAD/CAM technology for the premolar and molar teeth fit to a die. MATERIAL AND METHODS: Five ivorine maxillary first premolars and first molars were prepared for full-coverage crowns. Preparations were standardized with a convergence angle of 10 degrees, chamfer margins of 1.3 to 1.5 mm circumferentially, and occlusal reduction of 2.0 mm. AllCeram crowns were fabricated for the dies, and the fit of the crown to the die was determined by using a standardized procedure with a silicone impression material that served a dual role: (1) as a retrievable luting agent, and (2) to replicate the internal aspects of the crown. Laser videography was used to measure the gap dimension between the crowns and the dies at the marginal opening, the axial wall, the cusp tip, and the occlusal adaptation measurement locations. Mean gap dimensions and standard deviations (SDs) were calculated for marginal opening, internal adaptation, and precision of fit. RESULTS: Mean gap dimensions and standard deviations at the marginal opening for the premolar and molar crowns were 56.0 microns SD +/- 21 and 63.0 microns SD +/- 13 microns, respectively. The mean gap dimensions and SDs of the internal adaptation were 69.0 microns SD +/- 17 microns for axial wall, 48.0 microns SD +/- 12 microns for cusp tip, and 36.0 microns SD +/- 7 microns for occlusal adaptation for the premolar crowns; and 49.0 microns SD +/- 3 microns axial wall, 67.0 microns SD +/- 21 microns cusp tip, and 74.0 microns SD +/- 29 microns occlusal adaptation for molar crowns. Precision of fit and SDs for premolar and molar crowns were 52.0 microns SD +/- 19 microns and 63.0 microns SD +/- 20 microns, respectively. Mean marginal openings and precision of fit gap dimensions for the crown groups were not significantly different at the .05 level. However, gap dimensions that defined the internal adaptation at the measurement locations were different (P < or = .05). CONCLUSION: Mean gap dimensions for marginal openings, internal adaptation, and precision of fit for the crown groups were below 70 microns. These findings show that the crowns studied can be prescribed with confidence knowing that the precision of fit will consistently be less than 70 microns.

Aluminum Oxide↗

Black diaphragm aniridia intraocular lens for congenital aniridia: long-term follow-up.

PURPOSE: To present long-term results of implantation of a black diaphragm aniridia intraocular lens (IOL) in eyes with congenital aniridia. SETTING: Eye Hospital, Heinrich-Heine-University, Düsseldorf, Germany. METHODS: Cataract surgery was performed in 19 eyes of 14 patients with congenital aniridia. The black diaphragm aniridia IOL was implanted in front of the capsular bag in the ciliary sulcus. Mean patient age was 30 years (range 10 to 59 years) and mean follow-up, 46 months (range 12 to 84 months). Before surgery, corneal epithelial disorders; corneal pannus; cataract; hypoplasia of the macula, optic nerve, or both; and nystagmus were present in all 19 eyes. Clinically detectable glaucoma was present in 5 eyes. RESULTS: Despite the presence of amblyopia and nystagmus, visual acuity improved in 14 of the 19 eyes. The main postoperative problems were glaucoma deterioration (4 of 19 eyes) or development (4 of 19 eyes), cystoid macular edema (2 of 11 eyes), chronic endothelial cell loss (3 of 11 eyes), and progression of corneal epithelial disorders (4 of 19 eyes). Glaucoma was controlled by medical or surgical therapy in all patients. Intraocular lens explantation was performed in 2 eyes with glaucoma. CONCLUSION: Implantation of the black diaphragm aniridia IOL improved visual acuity in the majority of patients with a variety of endogenous problems in addition to aniridia.

Adolescent↗

Osseintegration following treatment of peri-implantitis and replacement of implant components. An experimental study in the dog.

AIM: The aim of the present experiment was to study if the quality of the titanium surface is a decisive factor for osseointegration and re-osseointegration. MATERIAL AND METHODS: 2 Labrador dogs were used. The mandibular 1st molars and all premolars were removed bilaterally. 3 months later, 1 standard fixture and 3, 2-part "test fixtures" were installed in each side of the mandible. The text fixtures consisted of 1 6-mm long apical and 1 4-mm long coronal part connected with an internal screw. After 4 months, abutment connection was performed. 5 months later, a period of experimental peri-implantitis was initiated during which about 50% of the supporting bone tissue was lost. The dogs were later subjected to a treatment that included (i) systemic administration of antibiotics and (ii) surgical debridement of all implant sites. The abutments and the coronal parts of the text fixtures were removed. All parts of the exposed portion of the standard fixtures, the connecting screw and the apical part of the test fixtures were meticulously cleaned by mechanical means. A pristine, coronal fixture part was via the connecting screw attached to the apical fixture part of each text fixture. All fixtures were submerged. 2 weeks later, a fluorochrome was injected intravenously. After 4 months, biopsies of the implant sites were dissected and prepared for ground sectioning and analysis. RESULTS: It was demonstrated that re-osseointegration failed to occur to implant surfaces (standard) exposed to bacterial contamination, but did consistently occur at sites where a pristine implant component was placed in the bone defect following surgical debridement. CONCLUSION: The above findings seem to imply that the quality of the titanium surface is of decisive importance for both osseointegration and re-osseointegration.

Alveolar Bone Loss↗

Identification and implications of transgraft microleaks after endovascular repair of aortic aneurysms.

PURPOSE: The purpose of this report is to describe an interesting cause of endoleak and detail-specific techniques for identifying small transgraft defects, which we have termed microleaks. METHODS: Four patients underwent endovascular repair of abdominal aortic aneurysms with modular nitinol/polyester endoprostheses and were studied after 6 to 30 months. All patients were enrolled in standard follow-up radiographic surveillance protocols. RESULTS: Three of the four abdominal aortic aneurysms continued to expand after endograft repair. Standard computed tomography imaging with precontrast, dynamic contrast, and delayed imaging frequently identifies endoleak, although it fails to precisely identify microleaks as the source. Color flow duplex ultrasound scan was performed on three patients and perigraft "jets," small areas of color flow adjacent to the endograft, were identified in all. Microleaks were identified in one patient who underwent digital subtraction arteriography with directed efforts to completely opacify the prosthesis lumen and multiple oblique projections. In another patient, contrast arteriography with balloon occlusion of the distal endograft clearly depicted midgraft microleaks that might otherwise be mistaken for graft porosity or cuff junction endoleaks. No microleaks were diagnosed on angiograms when these directed efforts were not performed. Aneurysm exploration before aortic clamping provided conclusive determination of the presence of blood flow through the wall of the endoprosthesis in two patients. CONCLUSIONS: Microleaks occur up to 2.5 years after endovascular repair of aortic aneurysms. Although computed tomography demonstrates the presence of an endoleak in these patients, the exact site of origin usually remains obscure. Doppler ultrasound scan and directed arteriography appear to be of greater utility for identifying the presence and location of microleaks. Balloon occlusion arteriography and aneurysm exploration without arterial clamping provide definitive evidence of microleaks. Although the clinical significance of microleaks remains unclear, long-term monitoring of patients is imperative to diagnose and treat these and other modes of endograft failure before they progress to aneurysm rupture.

Aged↗

Evaluation of soft tissue around single-tooth implant crowns: the pink esthetic score.

AIM: In this study, the reproducibility of a newly developed pink esthetic score (PES) for evaluating soft tissue around single-tooth implant crowns was assessed. The effect of observer specialization was another point of interest. MATERIAL AND METHODS: Twenty observers (five prosthodontists, five oral surgeons, five orthodontists and five dental students) were given photographs of 30 single-tooth implant crowns. Seven variables were evaluated vs. a natural reference tooth: mesial papilla, distal papilla, soft-tissue level, soft-tissue contour, alveolar process deficiency, soft-tissue color and texture. Using a 0-1-2 scoring system, 0 being the lowest, 2 being the highest value, the maximum achievable PES was 14. Each observer was requested to make two assessments at an interval of 4 weeks. At the second assessment, the photographs were scored in the reverse order. RESULTS: The mean PES of evaluations at the first assessment (n=600) was 9.46 (+/-3.81 SD), and 9.24 (+/-3.8 SD) at the second one. The difference between these two means was not significant statistically (P=0.6379). Implant-related mean PES for single-tooth implants varied from 2.28 to 13.8, with standard deviations between 0.46 and 3.51. Very poor and very esthetic restorations showed the smallest standard deviations. The mean total PES was 10.6 for the prosthodontists, 9.2 for the oral surgeons, 9.9 for the dental students and 7.6 for the orthodontists. CONCLUSIONS: The PES reproducibly evaluates peri-implant soft tissue around single-tooth implants. Thus, an objective outcome of different surgical or prosthodontic protocols can be assessed. Orthodontists were clearly more critical than the other observers.

Adult↗