Ex Vivo Comparison Of The Manubrium Sterni Bone, Distal Radius And Posterior Mandible Using Micro Computerized Tomography: A Human Cadaver Study. - Info and Reading Options

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This study is a collaboration between the Amsterdam Universitair Medisch Centrum (AUMC), the Academisch Centrum Tandheelkunde Amsterdam (ACTA) and the Antoni van Leeuwenhoek hospital (AVL), and is part of a larger project, organized by the AVL. This project entails the design of an implantable, prosthetic device which will enable laryngectomized patients (people who have had their larynx removed due to cancer in that area) to speak hands-free by providing the necessary pressure to create trachea-esophageal sounds. We have chosen the manubrium sterni bone (MSB) as implantation site due to its proximity, stability and immobility with regard to the tracheostoma. Before we can conduct a clinical trial to explore the feasibility of this concept, it is necessary to gather information on the bony tissue characteristics of the MSB. Because we aim to develop our implantation protocol based on existing dental implantation protocols, we will compare data collected from the MSB to the mandible, on which extensive research with regard to bone quality has been conducted. This comparison also allows for the calculation of reliable measures of dispersion using a relatively small sample size, as a minimum of 30 unique samples measured in a single study would otherwise be needed (1,2). However, this comparison has its limitations: the MSB and mandible differ in embryological origin (3), and in the fact that the mandible is load-bearing and the MSB is not. In addition, we know from a previous study conducted by our team, in which 49 CT-scans of the MSB were analyzed, that the MSB can be classified as a type IV bone according to the Lekholm & Zarb (L&Z) and Norton & Gamble (N&G) classifications (4,5), whereas the mandible can be classified as either type II in edentulous or type III in dentate specimens (6,7) according to the L&Z classification, and as type I and II according to the N&G classification, depending on the region. Because of these dissimilarities, we chose to also sample the distal radius bone, which resembles the MSB in embryological origin and in the fact that it is not load or weight bearing. We hypothesize that, in making these comparisons, the intersample variability of the mandible, the radius and the MSB will be relatively small. Furthermore, although the L&Z is widely used as a clinical tool, its subjective nature warrants further investigation into bone properties associated with implantation success. Implant survival is dependent on a number of aspects, related to the surgeon, the implant and in particular patient-specific factors such as bone strength, which is a complex term that has been explained in multiple ways since its conception but encompasses material and structural properties (8). These can be further divided into a multitude of characteristics including degree of mineralization, geometry and microarchitecture, depending on the classification (9,10). Some of these characteristics and its subcomponents then, are crucial determinants of primary and secondary implant stability (11). Although historically BMD has been widely used as a predictor for bone strength, it only accounts for roughly 70% (12,13). Add to this architectural parameters, material properties and bone turnover, and a more complete assessment can be made (8,14,15). Traditionally, histomorphometry has been the gold standard for the evaluation of bony microarchitecture ex vivo, although its use has declined because it is a labor intensive method as it requires staining procedures and thin sectioning. It continues, however, to be the only method for examining at tissue or even cellular level (16). In addition, although three-dimensional techniques are being developed in this field (17), histomorphometric analysis is still largely based on histologic two-dimensional imaging. As such, quantitative microcomputed tomography (micro-CT) has become a popular method for the examination of bone microarchitecture, and although its application on in vivo tissue is limited to animal studies due to high radiation exposure among others, a number of cadaver studies using micro-CT have shown that microarchitecture can be reliably assessed ex vivo (18). It allows for non-destructive, repeated ex vivo analyses, in which three-dimensional instead of two-dimensional images are created of undecalcified bone specimens (19). It proves to be at least equally reliable in determining certain volumetric and structural indices (20–22), and studies comparing the two techniques have reported high correlations (23,24). In addition, although mineral density is still generally assessed in vivo using conventional CT scanning, micro-CT can be used to measure this in ex vivo specimens (25,26). Whereas our previous study focused primarily on classifying the MSB and determining its geometry, the aim of the present study is to measure microstructural parameters of manubrium sterni bone samples using micro-CT, and to compare them to samples of the distal radius and mandible. These findings will be used to determine the material and design of the implant, implant loading timing and the surgical technique, as well as input in a finite element analysis to evaluate factors such as implant positioning, implant-abutment connection and insertion angles. References: 1. Chang HJ, Huang KC, Wu CH. Determination of sample size in using central limit theorem for Weibull distribution. Int J Inf Manag Sci. 2006 Sep 1;17. 2. Central Limit Theorem [Internet]. [cited 2023 Jun 26]. Available from: https://sphweb.bumc.bu.edu/otlt/mph-modules/bs/bs704_probability/BS704_Probability12.html 3. Galea GL, Zein MR, Allen S, Francis‐West P. Making and shaping endochondral and intramembranous bones. Dev Dyn. 2021 Mar;250(3):414–49. 4. U. Lekholm, G.A. Zarb. Patient Selection and Preparation. In: PI Brånemark, GA Zarb, T Albrektsson Tissue-integrated Prostheses: Osseo-integration in Clinical Dentistry. Chicago: Quintessence Publishing Company.; 1985. p. 199–209. 5. Norton MR, Gamble C. Bone classification: an objective scale of bone density using the computerized tomography scan. Clin Oral Implants Res. 2001 Feb;12(1):79–84. 6. Shemtov-Yona K. Quantitative assessment of the jawbone quality classification: A meta-analysis study. PloS One. 2021;16(6):e0253283. 7. Oliveira MR, Gonçalves A, Gabrielli MAC, de Andrade CR, Vieira EH, Pereira-Filho VA. Evaluation of Alveolar Bone Quality: Correlation Between Histomorphometric Analysis and Lekholm and Zarb Classification. J Craniofac Surg. 2021 Sep 1;32(6):2114–8. 8. Felsenberg D, Boonen S. The bone quality framework: determinants of bone strength and their interrelationships, and implications for osteoporosis management. Clin Ther. 2005 Jan;27(1):1–11. 9. Ammann P, Rizzoli R. Bone strength and its determinants. Osteoporos Int. 2003 Mar 1;14(3):13–8. 10. Torres-del-Pliego E, Vilaplana L, Güerri-Fernández R, Diez-Pérez A. Measuring Bone Quality. Curr Rheumatol Rep. 2013 Sep 27;15(11):373. 11. Chrcanovic BR, Albrektsson T, Wennerberg A. Bone Quality and Quantity and Dental Implant Failure: A Systematic Review and Meta-analysis. Int J Prosthodont. 2017;30(3):219–37. 12. Nakashima D, Ishii K, Nishiwaki Y, Kawana H, Jinzaki M, Matsumoto M, et al. Quantitative CT-based bone strength parameters for the prediction of novel spinal implant stability using resonance frequency analysis: a cadaveric study involving experimental micro-CT and clinical multislice CT. Eur Radiol Exp. 2019 Jan 22;3:1. 13. Wachter NJ, Augat P, Krischak GD, Sarkar MR, Mentzel M, Kinzl L, et al. Prediction of strength of cortical bone in vitro by microcomputed tomography. Clin Biomech Bristol Avon. 2001 Mar;16(3):252–6. 14. Topoliński T, Mazurkiewicz A, Jung S, Cichański A, Nowicki K. Microarchitecture Parameters Describe Bone Structure and Its Strength Better Than BMD. Sci World J. 2012 May 1;2012:e502781. 15. Wang F, Zheng L, Theopold J, Schleifenbaum S, Heyde CE, Osterhoff G. Methods for bone quality assessment in human bone tissue: a systematic review. J Orthop Surg. 2022 Mar 21;17(1):174. 16. Chavassieux P, Chapurlat R. Interest of Bone Histomorphometry in Bone Pathophysiology Investigation: Foundation, Present, and Future. Front Endocrinol. 2022 Jul 28;13:907914. 17. Yeh SCA, Wilk K, Lin CP, Intini G. In Vivo 3D Histomorphometry Quantifies Bone Apposition and Skeletal Progenitor Cell Differentiation. Sci Rep. 2018 Apr 3;8(1):5580. 18. Monje A, Chan HL, Galindo-Moreno P, Elnayef B, Suarez-Lopez del Amo F, Wang F, et al. Alveolar Bone Architecture: A Systematic Review and Meta-Analysis. J Periodontol. 2015 Nov;86(11):1231–48. 19. Bouxsein ML, Boyd SK, Christiansen BA, Guldberg RE, Jepsen KJ, Müller R. Guidelines for assessment of bone microstructure in rodents using micro-computed tomography. J Bone Miner Res Off J Am Soc Bone Miner Res. 2010 Jul;25(7):1468–86. 20. Thomsen JS, Laib A, Koller B, Prohaska S, Mosekilde Li, Gowin W. Stereological measures of trabecular bone structure: comparison of 3D micro computed tomography with 2D histological sections in human proximal tibial bone biopsies. J Microsc. 2005;218(2):171–9. 21. González-García R, Monje F. Is micro-computed tomography reliable to determine the microstructure of the maxillary alveolar bone? Clin Oral Implants Res. 2013 Jul;24(7):730–7. 22. Ibrahim N, Parsa A, Hassan B, van der Stelt P, Rahmat RA, Ismail SM, et al. Comparison of anterior and posterior trabecular bone microstructure of human mandible using cone-beam CT and micro CT. BMC Oral Health. 2021 May 8;21(1):249. 23. Müller R, Van Campenhout H, Van Damme B, Van Der Perre G, Dequeker J, Hildebrand T, et al. Morphometric analysis of human bone biopsies: a quantitative structural comparison of histological sections and micro-computed tomography. Bone. 1998 Jul;23(1):59–66. 24. Chappard D, Retailleau-Gaborit N, Legrand E, Baslé MF, Audran M. Comparison insight bone measurements by histomorphometry and microCT. J Bone Miner Res Off J Am Soc Bone Miner Res. 2005 Jul;20(7):1177–84. 25. Bodic F, Amouriq Y, Gayet-Delacroix M, Maugars Y, Hamel L, Baslé MF, et al. Relationships between bone mass and micro-architecture at the mandible and iliac bone in edentulous subjects: a dual X-ray absorptiometry, computerised tomography and microcomputed tomography study. Gerodontology. 2012 Jun;29(2):e585-594. 26. Mashiatulla M, Ross RD, Sumner DR. Validation of cortical bone mineral density distribution using micro-computed tomography. Bone. 2017 Jun 1;99:53–61.

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