THE USE OF THE OPERATING MICROSCOPE IN DENTAL PRACTISE: POSTURAL ANALYSIS AND CLINICAL EVALUATION

THE USE OF OPERATING MICROSCOPE IN DENTAL PRACTISE: POSTURAL ANALYSIS AND CLINICAL EVALUATION Abstract Author: Alberto Pispero Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Universit\ue0 degli Studi di Milano The study is in collaboration with Politecnico di Milano, Dipartimento di Ingegneria Elettronica, prof. Marco Marcon Study design: randomized controlled clinical trial. Setting of the clinical trial: Dental Clinic G. Vogel, via Beldiletto ASST Santi Carlo e Paolo Ospedale. Dr. Alberto Pispero, the surgeon for all the interventions; Prof. Giovanni Lodi is the head of research. PURPOSE The study investigates the effectiveness of microscope in dental practice in terms of posture improvement for the operator and clinical advantages for the patients. We carried out 4 studies: 1. Postural assessment in dentistry based on multiple markers tracking 2. The use of magnifying instrument for the extraction of lower third molar: Postural assessment 3. The use of magnifying instrument for the extraction of lower third molar: Clinical assessment 4. The influence of dental loupes on the quality of adhesive removal in orthodontic debonding: in vitro study. Background Attention and awareness towards MSDs in the dental profession has increased considerably in last years. From recent literature reviews, it is learned that prevalence of MSDs in dentists is 64-93%. Use of magnification systems improves the operator's visual capabilities, improves posture, and helps to prevent the onset of back and neck disorders. Moreover, the goal of dental treatment is to preserve tissues with minimally invasive prosthetics, conservatives and endodontics therapies, and to reconstruct periodontal soft and hard tissues performing microsurgery treatments in order to get the best aesthetic results and the least pain and complications. Over time, the degree of precision required immediately calls for magnification. METHODS Study 1: First, we conducted a study (study 1) on posture assessment to find an innovative method of postural analysis. In order to do that we worked with Politecnico of Milano. We presented a novel approach for upper limb posture assessment based on the tracking of a set of planar markers placed on the clothes of the worker. Thanks to this non-invasive approach, we were able to follow the 3D position and orientation of all the limbs involved in a speci\ufb01c activity during the job execution. Data will be evaluated through the index RULA (rapid upper limb assesment) to define whether there is a change in exposure to the risk of MSDs (Muskolo - skeletal - disease). Study 2: We used the method mentioned above in a randomized controlled three arms clinical trial where the surgeons performed 90 intervention. It was evaluated dentist posture during extraction of third lower molars depending on whether the operator performs the intervention by the use of surgical loupes or surgical microscope systems or performs a naked eyes surgery. Static and dynamic operator\u2019s posture has been monitored by markers positioned on a slim fit t-shirt and high definition cameras acquired data in real time (study 2). Study 3: To evaluate whether the use magnifying system, could influence the postoperative course of a patient after extraction of a lower third molar. Each patient will be recalled for follow-up visits at 7 days. During this session will be carried out the removal of stitches and data will be recorded as follows: VAS pain and trismus, number of painkillers taken, control photographs, Posse Scale. These data were analyzed considering type of magnification and difficulty of extraction (study 3). Study 4: In order to investigate the effect of using different magnifying systems for removal of composite residues and in the prevention of iatrogenic enamel damage we conducted an in vitro study. 27 permanent extracted teeth were used, The teeth were randomized into 3 groups named. Each tooth was photographed and scanned with the intraoral scanner CS3600-Carestream before bracket placement (T0), post bracket positioning (T1), after removal of bracket (T2) and after debonding (T3). RESULTS Study 1: The analysis that we performed can be easily integrated into classical ergonomics assessment tools like RULA providing an objective methodology that does not involve an operator in a subjective interpretation of the monitored job. Study 2: From step 1 to step 8 in RULA worksheet, we put the same score in all cases, in the same way in steps 11, 13 and 14. By the use of magnification system, the operator\u2019s posture didn\u2019t change in terms of leg positioning or arm raising and wrist twist. We verified that despite the big range between neck bending, from 40 to 3 degrees, the final RULA score is the same for all interventions. Study 3: From the results obtained it is clear that the methods taken into consideration, the operating microscope, the surgical loupes with coaxial illumination and the naked eye, do not have a statistically significant influence on pain intensity (VAS), quality of life (PoSSe) or the number of painkillers taken by patients. The complexity of the magnifying system does not increase the duration of the operating time Study 4: There is a statistically significant difference between the procedures performed with the naked eye and those performed with surgical loupes. This result can be explained by greater attention and accuracy in removing the residual composite from the operator when using magnification systems. Microscope and surgical loupes were slower but got the best results in removal of composite remnants. Intraoral scanner that we used to evaluate the teeth surfaces does not appear useful to discriminate damage to the enamel. CONCLUSION We developed a new approach for posture assessment, precise and accurate, and we have had 3d data of the whole body, which can discriminate differences of one degree. We need long term studies conducted on many dentists (male and female) and a new method of posture data analysis to define the correlation between upper limbs posture and WMSDs accurately. We wanted to test magnification systems in fields of dentistry different from endodontics in which microscope is generally used. Even if data had no statistical significance, on the other hand microscope didn't affect the operating time. Despite common perceptions, the use of the microscope in oral surgery didn't slow down the intervention. We decided to test the microscope potential in debonding. In our research, the procedures performed without a magnification system are on average faster than those performed with the aid of a magnification. This result can be explained by greater attention and accuracy in removing the residual composite from the operator when using magnification systems. Microscope and surgical loupes were slower but got the best results in removal of composite remnants

General report & recommendations in predictive, preventive and personalised medicine 2012: white paper of the European Association for Predictive, Preventive and Personalised Medicine

This report is the collective product of word-leading experts working in the branches of integrative medicine by predictive, preventive and personalised medicine (PPPM) under the coordination of the European Association for Predictive, Preventive and Personalised Medicine. The general report has been prepared as the consortium document proposed at the EPMA World Congress 2011 which took place in Bonn, Germany. This forum analyzed the overall deficits and trends relevant for the top-science and daily practice in PPPM focused on the patient. Follow-up consultations resulted in a package of recommendations for consideration by research units, educators, healthcare industry, policy-makers, and funding bodies to cover the current knowledge deficit in the field and to introduce integrative approaches for advanced diagnostics, targeted prevention, treatments tailored to the person and cost-effective healthcare

The Development of a Novel Pitching Assessment Tool

Posture based ergonomic assessment tools are widely used to evaluate posture and injury risk for many workplace/occupational tasks. To date, there is no validated equivalent that can be used to assess the posture of a pitcher during baseball pitching. Therefore, the purpose of this study was to develop an inexpensive tool which can allow for the rapid assessment of a pitcher’s posture at lead foot strike, and establish the inter- and intra- rater reliability of the tool. For this study, 11 participants threw 30 pitches (15 fastballs, 15 curveballs) off an indoor pitching. Full body 3D kinematics were measured using reflective markers attached to anatomical landmarks and rigid bodies attached to body segments using a 10-camera Vicon Motion Capture system along with two high-speed video cameras (rear and side view) to record each pitch during the experimental trials. The kinematic data was analyzed, after which the highest velocity fastball of each of the 11 pitchers was selected for further analysis. A Pitching Mechanics Tool was designed to evaluate 16 different parameters at lead foot strike. Each of the 16 parameters had posture ranges or categories established based on scientific literature. Six evaluators with at least five years of experience working with adult pitchers completed the Pitching Mechanics Tool. Findings showed moderate to good levels of repeatability across multiple sessions as well as across multiple evaluators. Additionally, PMT results suggested that 2D qualitative analysis is a viable alternative to 3D motion capture

Applying neuromuscular techniques in the orthodontic setting

Introduction: Neuromuscular orthodontic techniques that investigate the interrelatedness of the muscles, bones, joints and teeth involved in oral function, hold promise for the treatment of a spectrum of oral disorders. Indeed, such technologies will help patients receive a more targeted level of care. Here we present a case report concerning an 11-year-old boy who underwent orthodontic treatment for recurrent pain of the right temporomandibular joint (TMJ), misaligned teeth, and irregular clicking noises (associated with the right TMJ) during mouth opening. The basic principles of the use of mandibular tracking, surface electromyography, and transcutaneous electrical nerve stimulation (TENS) to diagnose malocclusions and determine the cranio-mandibular relationship are outlined. Case presentation: Pre-treatment status, progress, post-treatment status and 8-year follow-up data are shown. Conclusion: As neuromuscular orthodontics can provide detailed functional analyses through a combination of technologies, the clinician is better placed to evaluate the needs of the patient and deliver treatment. Further deployment of such techniques should, therefore, be encouraged to increase orthodontic health and practice

How to Obtain an Orthodontic Virtual Patient through Superimposition of Three-Dimensional Data: A Systematic Review

Background: This systematic review summarizes the current knowledge on the superimposition of three-dimensional (3D) diagnostic records to realize an orthodontic virtual patient. The aim of this study is to analyze the accuracy of the state-of-the-art digital workflow. Methods: The research was carried out by an electronic and manual query eectuated from ISS (Istituto Superiore di Sanit\ue0 in Rome) on three dierent databases (MEDLINE, Cochrane Library and ISI WEB OF SCIENCE) up to 31st January 2020. The search focused on studies that superimposed at least two dierent 3D records to build up a 3D virtual patient\u2014information about the devices used to acquire 3D data, the software used to match data and the superimposition method applied have been summarized. Results: 1374 titles were retrieved from the electronic search. After title-abstract screening, 65 studies were selected. After full-text analysis, 21 studies were included in the review. Dierent 3D datasets were used: facial skeleton (FS), extraoral soft tissues (ST) and dentition (DENT). The information provided by the 3D data was superimposed in four dierent combinations: FS + DENT (13 papers), FS + ST (5 papers), ST + DENT (2 papers) and all the types (FS + ST + DENT) (1 paper). Conclusions: The surface-based method was most frequently used for 3D objects superimposition (11 papers), followed by the point-based method (6 papers), with or without fiducial markers, and the voxel-based method (1 paper). Most of the papers analyzed the accuracy of the superimposition procedure (15 papers), while the remaining were proof-of-principles (10 papers) or compared dierent methods (3 papers). Further studies should focus on the definition of a gold standard. The patient is going to have a huge advantage from complete digital planning when more information about the spatial relationship of anatomical structures are needed: ectopic, impacted and supernumerary teeth, root resorption and angulations, cleft lip and palate (CL/P), alveolar boundary conditions, periodontally compromised patients, temporary anchorage devices (TADs), maxillary transverse deficiency, airway analyses, obstructive sleep apnea (OSAS), TMJ disorders and orthognathic and cranio-facial surgery

A framework for secondary cognitive and motor tasks in dual-task gait testing in people with mild cognitive impairment

Background: Cognition is a key factor in the regulation of normal walking and dual-task gait assessment is an accepted method to evaluate the relationship. The objective of this study was to create a framework for task complexity of concurrent motor and cognitive tasks with gait in people with mild cognitive impairment (MCI). Methods: Community-dwelling people with MCI (n = 41, mean age = 76.20 ± 7.65 years) and cognitively normal controls (n = 41, mean age = 72.10 ± 3.80 years) participated in this study. Gait velocity was collected using an instrumented walkway under one single task and six combined tasks of motor and cognitive activities. The cognitive cost was the difference between the single gait task and each of the concurrent motor and cognitive challenges. A repeated two-way measure ANOVA assessed the effect of cognitive group and walking test condition for each gait task test. Results: Gait velocity was significantly slower in the MCI group under all tasks. For both groups, the concurrent motor task of carrying a glass of water conferred a challenge not different from the cognitive task of counting backwards by ones. Performance of the complex cognitive task of serial seven subtractions reduced gait velocity in both groups, but produced a greater change in the MCI group (31.8%). Conclusions: Not all concurrent tasks challenge cognition-motor interaction equivalently. This study has created a framework of task difficulty which allows for the translation of dual-task test conditions to future research and clinical practice to ensure the accuracy of assessing patient deficits and risk

The Feasibility of Square-Stepping Exercise as a Universal Intervention for Older Adults with Chronic Disease to Improve Cognitive and Physical Function

Square-stepping exercise (SSE) is a cognitive training program with a physical component. An instructor demonstrates a stepping pattern across a gridded mat and participants are required to memorize and repeat the patterns on their own. In community-dwelling older adults, SSE has demonstrated some benefits on global cognitive functioning (GCF), balance, functional fitness, and social interaction. Aims: to investigate the feasibility and efficacy of SSE in varied populations and settings to improve mobility and cognition. Populations included older adults with: knee osteoarthritis (OA), type 2 diabetes mellitus (T2DM) and self-reported cognitive complaints (sCC), and those living in long-term care (LTC) and continuum care (CC) homes. Methods: We conducted 3 pilot randomized controlled trials ranging from 12- to 24-weeks of SSE. Feasibility was determined through recruitment and attendance. Participants were assessed on a host of cognitive, functional, and gait outcomes before and after SSE. Results: We found that SSE was not feasible in older adults with knee OA and results were inconclusive whether it effected mobility in this population. SSE demonstrated improvements in the planning domain in older adults with T2DM and sCC. However, attendance remained a challenge in this group due to high disease burden (i.e. appointments and illness), and therefore it was not feasible. In LTC and CC homes, SSE was not feasible because recruitment and attendance were low. However, we showed that adults living with dementia improved on mood and behaviour symptom scores. Conclusions: Square-stepping exercise is not a feasible program as implemented in this thesis and SSE showed limited benefit to cognitive and mobility outcomes. These pilot studies demonstrated the challenges of feasibility in adults with diverse cognitive and mobility impairments. Future studies should focus on addressing recruitment and adherence strategies for chronic disease populations

Conceptual Framework of a Novel Intervention to Improve Mobility in Children with Cerebral Palsy: The Successes and Challenges of Implementing a Large Amplitude Movement Protocol

While cerebral palsy remains one of the most common childhood disabilities, clinicians continue to face significant challenges developing effective treatment strategies for the widely variable presentation of motor function impairments associated with cerebral palsy. A large gap exists between current research based evidence and feasible clinical practice. The purpose of this paper is to introduce a novel intervention protocol, explore the theoretical framework behind the protocol and provide insight to clinicians about the successes and challenges faced while pilot testing the intervention. The novel intervention was adapted and implemented by researchers combining a large amplitude movement protocol with the well-researched concepts of task specific, goal oriented and high intensity practice. A previous feasibility study conducted on the large amplitude movement protocol showed subjects demonstrating improvements in multiple gait characteristics and mobility. While data were collected during this study, it will be reported separately to allow this paper to focus on the theoretical framework of the intervention and the clinical implications of the intervention. The discussion of the successes and challenges faced by researchers during the implementation of the protocol give guidance for clinical adaptation of the protocol as well as direction for future studies

Validation, optimization and exploitation of orientation measurements issued from inertial systems for clinical biomechanics

Les centrales inertielles (triade de capteurs inertiels dont la fusion des données permet l’estimation de l’orientation d’un corps rigide) sont de plus en plus populaires en biomécanique. Toutefois, les qualités métrologiques des centrales inertielles (CI) sont peu documentées et leur capacité à identifier des incapacités liées à la mobilité, sous-évaluée. Objectifs : (i) Caractériser la validité de la mesure d’orientation issue de CI ; (ii) Optimiser la justesse et la fidélité de ces mesures; et (iii) Proposer des métriques de mobilité basées sur les mesures d’orientation issues de CI. Méthodologie et résultats : La validité de la mesure d’orientation de différents types de CI a d’abord été évaluée en conditions contrôlées, à l’aide d’une table motorisée et d’une mesure étalon. Il a ainsi été démontré que les mesures d’orientation issues de CI ont une justesse acceptable lors de mouvements lents (justesse moyenne ≤ 3.1º), mais que cette justesse se dégrade avec l’augmentation de la vitesse de rotation. Afin d’évaluer l’impact de ces constatations en contexte clinique d’évaluation de la mobilité, 20 participants ont porté un vêtement incorporant 17 CI lors de la réalisation de diverses tâches de mobilité (transferts assis-debout, marche, retournements). La comparaison des mesures des CI avec celles d’un système étalon a permis de dresser un portrait descriptif des variations de justesse selon la tâche exécutée et le segment/l’articulation mesuré. À partir de ces constats, l’optimisation de la mesure d’orientation issue de CI est abordée d’un point de vue utilisateur, démontrant le potentiel d’un réseau de neurones artificiel comme outil de rétroaction autonome de la qualité de la mesure d’orientation (sensibilité et spécificité ≥ 83%). Afin d’améliorer la robustesse des mesures de cinématique articulaire aux variations environnementales, l’ajout d’une photo et d’un algorithme d’estimation de pose tridimensionnelle est proposé. Lors d’essais de marche (n=60), la justesse moyenne de l’orientation à la cheville a ainsi été améliorée de 6.7° à 2.8º. Finalement, la caractérisation de la signature de la cinématique tête-tronc pendant une tâche de retournement (variables : angle maximal tête-tronc, amplitude des commandes neuromusculaires) a démontré un bon pouvoir discriminant auprès de participants âgés sains (n=15) et de patients atteints de Parkinson (PD, n=15). Ces métriques ont également démontré une bonne sensibilité au changement, permettant l’identification des différents états de médication des participants PD. Conclusion : Les mesures d’orientation issues de CI ont leur place pour l’évaluation de la mobilité. Toutefois, la portée clinique réelle de ce type de système ne sera atteinte que lorsqu’il sera intégré et validé à même un outil de mesure clinique.Abstract : Inertial measurement of motion is emerging as an alternative to 3D motion capture systems in biomechanics. Inertial measurement units (IMUs) are composed of accelerometers, gyroscopes and magnetometers which data are fed into a fusion algorithm to determine the orientation of a rigid body in a global reference frame. Although IMUs offer advantages over traditional methods of motion capture, the value of their orientation measurement for biomechanics is not well documented. Objectives: (i) To characterize the validity of the orientation measurement issued from IMUs; (ii) To optimize the validity and the reliability of these measurements; and (iii) To propose mobility metrics based on the orientation measurement obtained from IMUs. Methods and results: The criterion of validity of multiple types of IMUs was characterized using a controlled bench test and a gold standard. Accuracy of orientation measurement was shown to be acceptable under slow conditions of motion (mean accuracy ≤ 3.1º), but it was also demonstrated that an increase in velocity worsens accuracy. The impact of those findings on clinical mobility evaluation was then assessed in the lab, with 20 participants wearing an inertial suit while performing typical mobility tasks (standing-up, walking, turning). Comparison of the assessed IMUs orientation measurements with those from an optical gold standard allowed to capture a portrait of the variation in accuracy across tasks, segments and joints. The optimization process was then approached from a user perspective, first demonstrating the capability of an artificial neural network to autonomously assess the quality of orientation data sequences (sensitivity and specificity ≥ 83%). The issue of joint orientation accuracy in magnetically perturbed environment was also specifically addressed, demonstrating the ability of a 2D photograph coupled with a 3D pose estimation algorithm to improve mean ankle orientation accuracy from 6.7° to 2.8º when walking (n=60 trials). Finally, characterization of the turn cranio-caudal kinematics signature (variables: maximum head to trunk angle and neuromuscular commands amplitude) has demonstrated a good ability to discriminate between healthy older adults (n=15) and early stages of Parkinson’s disease patients (PD, n=15). Metrics have also shown a good sensitivity to change, enabling to detect changes in PD medication states. Conclusion: IMUs offer a complementary solution for mobility assessment in clinical biomechanics. However, the full potential of this technology will only be reached when IMUs will be integrated and validated within a clinical tool