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Fig 2. A, Application of titanium oxide powder in the mandibular incisor area; B, maxillary impression scanning; C, mandibular impression scanning; D, bite registration scanning. Fig 3. Defining the occlusion: A, digital maxillary model; B, digital mandibular model; C, digital bite registration; D, defining points between the maxillary model and the bite registration; E, defining points between the mandibular model and the bite registration; F, digital model after interarch adjustment.
Three examiners were properly trained to measure the plaster and digital models before the start of the study. Among the examiners was an undergraduate student of dentistry, a master student of orthodontics, and a doctoral student of dentistry.
The digital models where measured using the Ortho Analyzer software with the direct measuring tool Fig 4. To calculate method error, the 3 examiners repeated the measurements on 10 randomly selected plaster models and 10 digital models, 15 days after the first measurement. Table I. Measuring tooth diameters on a digital model with Ortho Analyzer software. All plaster models of the sample were also scanned with the same scanner R to acquire the respective digital models and enable a comparison with digital models from PVS impression scanning.
The bases of the 2 types of digital models were cut apical to the gingival margin. The models were aligned with the dentition using the best-fit surface alignment tool. After alignment, the model edges were trimmed with cutting planes to create common borders. Color displacement maps were generated to confirm accurate crown superimpositions and measure differences between the models.
Geomagic Qualify software outputs the mean and maximum displacements, the positive and negative average differences, and the standard deviations measured in the color map analysis.
These data are obtained by a calculation of the distances of points between each digital model superimposed. The limits used in the color map were 0. Figures 6 and 7 illustrate the design of the study.
Evaluation of the accuracy by superimposition of the digital models with Geomagic Qualify software. Fig 6. The paired t test was used to compare measurements on plaster models and digital models by PVS impression scanning for each examiner. The intraclass correlation coefficient ICC evaluated the reproducibility of the measurements among the examiners for each model.
The paired t test was also used to compare the differences by superimposition of the digital models plaster model scanning vs. PVS impression scanning , according to the time interval of impression taking. The differences between soft putty types were 36 35 compared by paired t tests of superimposition differences between the maxillary models regular viscosity and the mandibular models light viscosity , by also using the superimposition between plaster model scanning and PVS impression scanning for each maxillary and mandibular models.
Differences in measurement were considered to be statistically significant if the p-value was lower than The method error was calculated by comparing the initial measurements and the measurements after 15 days for the selected sample.
The paired t test was used to evaluate the intra-examiner error. Results were considered to be significant when the p-value was lower than RESULTS The intraexaminer errors of each examiner had low values, and all examiners had lower error values in the plaster models compared to the digital models by PVS impression scanning. Examiner 1 had a mean difference of all parameters of 0. Examiner 2 had a mean difference in the error values of 0. Examiner 3 had similar results to those of examiner 2, 0.
Overbite and overjet also showed high ICC values for plaster models 0. In relation to tooth diameter, plaster models had higher ICC values maxillary teeth, 0. Statistically significant differences were found for some measurements. Examiners 1 and 3 had similar results, but examiner 2 had more clinically significant differences.
The maxillary and mandibular tooth diameters showed that examiners 1 and 3 had similar measurements, whereas examiner 2 registered lower values for the measurements on the digital models. Regarding overjet, the 3 examiners registered similar measurements with small differences, whereas measurements of overbite had lower values for digital models for all examiners.
Measurements on digital models showed lower values for all examiners, with average differences between all parameters of mm for examiner 1, mm for examiner 2, and mm for examiner 3 Table III. The difference in measurements for overbite was clinically significant for almost all of the digital models, with exception of examiner 1 in T5. Regarding the influence on the accuracy of digital models of the time interval between PVS impression taking and scanning, the paired t test showed no significant difference in results among the 3 time periods 5, 10, and 15 days compared with the plaster model measurements.
Table IV shows the differences between the digital models according to the scanning interval time after the PVS impression taking.
Digital models by PVS impression scanning of each time interval were superimposed with the respective dental model by plaster model scanning, and the results showed no statistically significant differences in the parameters studied average differences, positive average differences, and negative average differences. The type of soft putty had no influence on the accuracy of digital models; the mean differences in maxillary arch superimpositions and mandibular arch superimpositions were not statistically significant Table V.
Performing measurements on plaster models is more comfortable for the examiner compared to direct measurements of the dentition. A plaster model can be stored, manipulated, and reviewed with excellent lighting and appropriate tools for measurement.
Ovsenik 32 found no statistically significant differences between measurements on plaster models or direct intraoral measurements.
Scanning of plaster models can be used to replace plaster models with some advantages.
Digital models can reduce the space needed for actual storage of 42 41 plaster models and the time needed to retrieve plaster models required for evaluation during treatment.
Halsted, por exemplo, quando em visita clnica vienense de Billroth, em , fez anotaes alusivas ao uso das pinas hemostticas, que comeavam a ser usadas rotineiramente. O nmero de instrumentos cirrgicos incontvel; ao longo dos tempos os cirurgies vm criando e modificando novos elementos, que so incorporados aos j existentes.
Quase sempre levam o nome de seus idealizadores, muitas vezes diferindo apenas em detalhes muito pequenos. Alm disso, a montagem da mesa cirrgica, com a eventual organizao das peas, imprescindvel. Portanto, nas prximas pginas, revisaremos os principais instrumentos utilizados na prtica cirrgica, fazendo aluso s suas respectivas funes no que diz respeito aos fundamentos de todos os atos operatrios, isto , d i r e s e , h e m o s t a s i a e s n t e s e.
Esses princpios da Tcnica Operatria englobam todos os procedimentos realizados desde a inciso cutnea e da parede, o ato operatrio principal a finalidade da operao , at o fechamento da parede. Em algumas situaes em que a operao determina a extirpao de um rgo ou de um segmento tecidual, a esses fundamentos se acrescenta a e x r e s e.
P i n a A d s o n - B r o w n : so retas ou com pontas anguladas e serrilhadas e com mltiplos microdentes, tambm com 12 cm. As ranhuras da pina Adson-Brown, diferentemente da Adson, so apenas at a metade das garras.
P i n a d e C u s h i n g : So retas ou curvilneas, com cm e com ou sem dentes.
So mais pontiagudas que as pinas de Potts-Smith. P i n a d e B a k e y : retas ou curvas, com pontas delicadas e atraumticas, variando entre 15 e 30 em de comprimento; originalmente, foram concebidas para uso em Cirurgia Vascular, mas apresentam grande aplicao na preenso de tecidos delicados, como a mucosa intestinal, vias biliares etc.
Morphological and physiological predictors of fetal aortic coarctation. Z-scores of the fetal aortic isthmus and duct: an aid to assessing arch hypoplasia. Ultrasound Obstet Gynecol.
Prenatal diagnosis of congenital heart disease in the Naples area during the years the experience of a joint fetal-pediatric cardiology unit. Prenat Diagn.
Timing of presentation and postnatal outcome of infants suspected of having coarctation of the aorta during fetal life. Left superior caval vein: a powerful indicator of fetal coarctation. Aortic coarctation: prognostic indicators of survival in the fetus. Right axillary minithoracotomy approach, by avoiding the breast growth region, is an option for correction of these defects that may provide better aesthetic results at low cost.
Objectives: To evaluate the efficacy of this method in children undergoing correction of VSD and ASD, to compare perioperative clinical outcomes with those repaired by median sternotomy, and to evaluate the aesthetic result.
Methods: Perioperative clinical data of 25 patients submitted to axillary thoracotomy were compared with data from a paired group of 25 patients with similar heart defects repaired by median sternotomy, from October to August Results: Axillary approach was possible even in infants. The VSD size varied from 7 to 15 mm in axillary group. Cannulation of the aorta and vena cavae was performed through the main incision, whose size ranged from 3 to 5 cm in the axillary group, with excellent aesthetic results.
Conclusion: The axillary thoracotomy was effective, allowing for a heart defect repair similar to the median sternotomy, with more satisfactory aesthetic results and reduced blood transfusion, and it can be safely used in infants. Descriptors: Heart Septal Defects, Ventricular. Heart Septal Defects, Atrial. Surgical Procedures, Minimally Invasive. A sequela ventricular nos pacientes do grupo axilar variou de 7 a 15 mm. They demonstrated this technique to us, which we modified by opening the chest in the third intercostal space, cross-clamping the aorta and applying cardioplegic solution.
This strategy has allowed us to repair more complex cases. The horizontal right axillary minithoracotomy HRAMT has shown even more superior cosmetic results when compared to conventional incisions by staying hidden under the resting arm, avoiding any interference in the development of breasts, as well as preventing the sectioning of muscles and glands and allowing for the treatment of restrictive VSDs[12,13]. However, its use in patients under 15 kg was not recommended by some authors, due to the difficulty of direct cannulation of the aorta.
Since October , we have been employing this technique for correction of VSD, ASD and associated defects, extending its use to younger children 5 months , with direct cannulation of the vessels through the same incision in all patients.
The treatment of congenital heart defects has evolved with gradual reduction of morbidity and mortality, but the scar resulting from surgical treatment may be disturbing.
The effective repair of ventricular septal defect VSD and atrial septal defect ASD , with less aggressive approach to the patient, is the goal of minimally invasive surgery. Newer minimally invasive approaches such as ministernotomy, trans-xiphoid approach without MS[3,4] and posterolateral thoracotomy[5,6] have been proposed for the treatment of children, attempting to avoid the distortion of breast growth that can be caused by RAT when applied in pre-pubescent girls[7,8].
The axillary minithoracotomy, originally proposed for thoracic surgery was used as a vertical infra axillary minithoracotomy, associated with cardiopulmonary bypass CPB and ventricular fibrillation for ASD repair without clamping of the aorta. Subsequently, its use was expanded to approach other heart diseases.
It offers the aesthetic benefit without increasing surgical costs, since it does not require special tools. Schreiber et al. The heart was exposed adequately by opening the pericardium, and placing suitable stay sutures. The thymus gland was preserved. The pericardial incision was extended toward the aorta and a stabilizing 5.
A Cooley-Satinsky clamp was tested for partial aortic clamping at the cannulation site, just in case it became necessary. After heparin infusion, two standard purse-string 5. Tapes were passed around the vena cavae. After placing standard purse-string sutures in superior vena cava and in the junction of the inferior vena cava with the right atrium, both vena cavae were cannulated and CPB was initiated.
After mild systemic cooling, the aorta was cross clamped and blood cardioplegic solution was infused in the aortic root. The right atrium was opened longitudinally and some stay sutures were placed at the right atrium edge, which were gently pulled toward the chest opening, exposing the ASD.
Usually, tricuspid valve leaflet proximal detachment is required for better subaortic VSD exposure. The subaortic region was explored in all patients and any subaortic membrane was resected when present. The tricuspid valve was reattached.
Saline solution was injected in the left ventricle to check for residual VSD. Mitral valve repair was carried out in one patient, with chordal reduction and annuloplasty with multiple interrupted sutures plicature at different locations of the mitral annulus.
In one patient with previous diagnosis of partial anomalous pulmonary vein connection to the superior vena cava associated with ASD, the superior vena cava cannulation was made at a higher level. In this case the right atrial appendage was used to enlarge the superior vena cava, after redirection of pulmonary veins flow to the left atrium with a PTFE patch used to close the ASD.
In order to balance the prognostic factors, the MS paired case control group patients were selected among the patients undergoing treatment for the same types of heart defects from October to August by the same surgical team.
The defects covered in each group and their features are presented in the Table 1. Surgical technique HRAMT Group The patients were placed under mixed general anesthesia inhalation plus intravenous and continuous blood pressure monitoring was established by a left radial artery catheter placement. In addition, a double lumen catheter was placed either in the femoral vein or in the right subclavian vein.
Pen marking of anterior and posterior axillary lines was done. The skin incision was performed in the middle portion of this line contained between the anterior and posterior axillary lines. This almost horizontal incision 3 to 5 cm was done between the anterior and posterior axillary lines bikini line in girls and it may be at more cranial level in males nipple level.
The skin and subcutaneous tissues were retracted toward higher and anterior direction, without muscle section sparing technique. The third intercostal space was opened and a retractor was placed. The pericardium was opened at 2 cm anterior to the Table 1. Preoperative characteristics of groups. CPB was interrupted after heartbeat ressumption and the entire blood was reinfused through the aortic cannula.
The cannulas were removed and protamine infusion was done. Hemostasis was carefully done and the pericardium edges were partially approximated with interrupted polyester sutures, leaving holes to drain any liquid into the pleural space.
One drainage tube was installed in right pleural space. The intercostal space was closed with a single absorbable suture 2. Bupivacain anesthetic was injected in adjacent intercostal spaces, in the anterior and posterior region of the chest incision.
The previously spared muscles were approximated with interrupted sutures.
Subcutaneous tissue and skin were sutured with absorbable filaments. Figure 1 shows the view of the operative field, with the position of the cannulas in aorta and vena cavae, the clamped aorta, and the VSD exposure through the right atriotomy. Thymus gland was preserved. Heparin solution was infused and two standard purse-string 5. Snaring tapes were passed around both vena cavae. After placing standard purse-string suture in the superior vena cava and in the junction of the inferior vena cava with the right atrium, bicaval cannulation was performed and CPB was initiated.
The aorta was cross-clamped and cardioplegic solution was infused in aortic root. The right atrium was opened. The atrial septum and the tricuspid valve were exposed by stay sutures placement at the right atriotomy edges, which were gently pulled toward the chest opening. In subaortic VSD cases, the leaflet of tricuspid valve was detached at its basal aspect for better exposure.
After the tricuspid valve reattachment, saline solution was injected in left ventricle to test if VSD was completely closed. The ASD was closed with patch in all patients, when present.