Midline Position Research Articles

Anterior interhemispheric vs. pterional approach in the microsurgical management of anterior communicating artery aneurysms: a comparative analysis employing a novel multidimensional matching-tool

The surgical management of anterior communicating artery aneurysms (AcomA) is challenging due to their deep midline position and proximity to complex skull base anatomy. This study compares the pterional craniotomy with the interhemispheric approach based on the specific aneurysm angulation. A total of 129 AcomA cases were analyzed, with 50 undergoing microsurgical clipping via either the pterional or interhemispheric approach. All selected cases had computed tomography-angiography with sagittal imaging slices and 2D-angiography. Using an interactive tool, 14 cases treated via the interhemispheric approach were matched with 14 cases approached pterionally based on clinical and morphological parameters, emphasizing intracranial aneurysm (IA) dome angulation relative to the frontal skull base. Outcomes included IA occlusion, temporary clipping incidence, intraoperative rupture, postoperative strokes, hemorrhages, hydrocephalus, vasospasm, and patient functionality. Matched cohorts had consistent demographics. Both approaches resulted in similar IA occlusion rates, but the interhemispheric approach led to improved clinical outcomes, measured by the modified Rankin Scale. It also had a lower incidence of hydrocephalus and reduced need for permanent ventriculoperitoneal shunt placement. Vasospasms and postoperative infarction rates were comparable between the groups. Our findings suggest potential advantages of the interhemispheric approach in managing AcomA, depending on aneurysm angulation. Despite a small sample size, the results highlight the importance of customized surgical decision-making based on the unique traits of each aneurysm and the surgeon's expertise.

Successful treatment with plasmapheresis of severe Bickerstaff brainstem encephalitis with high cerebrospinal fluid CXCL‐10 levels after COVID‐19 infection: A case report

AbstractBackgroundBickerstaff brainstem encephalitis (BBE) is an autoimmune disease affecting the brainstem, typically caused by a prior infection. However, BBE after coronavirus disease 2019 (COVID‐19) infection is rare. Here, we present a severe case of BBE after COVID‐19 infection, highlighted by increased levels of CXCL‐10.Case PresentationA 28‐year‐old woman presented with symptoms of cold and fever lasting 5 days, accompanied by numbness, weakness and unsteadiness in the distal parts of her limbs before being admitted. Upon admission, her condition was classified with a Glasgow Coma Scale score of E1V1M4, absence of bilateral ocular cephalic reflexes, eyes fixed in the midline position and pathological reflex in lower limbs. COVID‐19 antigen tests were positive, and cerebrospinal fluid CXCL‐10 levels were elevated. Positive serum anti‐GQ1b antibodies, along with other clinical findings, confirmed the diagnosis of BBE. Initial treatment with high‐dose intravenous immunoglobulin was ineffective, leading to mechanical ventilation on day 2 from admission. Additional steroid pulse therapy and plasmapheresis were initiated on day 7. Communication abilities were restored by day 19, and the patient was extubated on day 21. Continuous alleviation of symptoms was observed, with no sequelae at discharge on day 42.ConclusionsBBE related to COVID‐19 with high CXCL‐10 levels can become severe. However, early intensive immunotherapy, including plasmapheresis, might result in favorable prognosis.

Mandibular overdenture with a single implant in the canine region (c-SIMO): a feasibility study

ObjectivesThe aim of this multi-center pilot study was to assess the viability and feasibility of a novel treatment concept – the canine-positioned single implant mandibular overdenture (c-SIMO), with the single implant placed on the patient's preferred chewing side instead of the midline.Materials and methodsParticipants received a single implant in the canine region of their preferred chewing side, based on an Asymmetry Index observed during mastication. The pre-existing mandibular denture was transformed into a c-SIMO on a spherical attachment. The primary outcome was oral health-related quality of life (OHRQoL), measured with GOHAI and OHIP-EDENT. Secondary outcomes included denture satisfaction index (DSI), chewing efficiency (CE), maximum bite force (MBF), implant survival and success, and prosthetic maintenance. Data analysis included descriptive statistics and bivariate comparison tests.ResultsFifteen participants received the c-SIMO treatment (mean age: 69.9 ± 7.0). Implant success and survival rates were 100% at 1 year. Patient-reported outcome measures improved significantly compared to pre-treatment values (OHIP-EDENT: p = 0.001; DSI: p = 0.001; GOHAI: p = 0.002). Masticatory outcomes also improved significantly (CE: p = 0.001; overall MBF: p = 0.005). Post-implant, MBF was significantly higher in the ipsilateral side compared to the contralateral side at 2 weeks (p = 0.019) and 3 months (p = 0.015), but no longer at T3 (p = 0.730). Common prosthodontic events included denture base adjustments (n = 17) and matrix activation (n = 9).ConclusionsThis pilot study concludes that c-SIMO is a promising treatment option, and a potential alternative to the single midline implant overdenture.Clinical relevanceThe novel treatment concept of a canine-positioned single implant mandibular overdenture could be a viable treatment alternative to the midline positioning.

Palpation Versus Ultrasonography for Identifying the Cricothyroid Membrane in Case of a Laterally Deviated Larynx: A Randomized Trial.

Large neck circumference and displacement of the trachea due to pathology increase the risk of failed identification of the cricothyroid membrane and cricothyroidotomy. We investigated whether ultrasound aids in the successful identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea. We developed silicone neck models that were suitable for both palpation and ultrasonography and where the trachea deviated laterally from the midline to either side. After reading a book chapter and participating in a 25-minute lecture and a 15- to 23-minute hands-on demonstration and rehearsal of ultrasonography for identification of the cricothyroid membrane, anesthesiologists and anesthesiology residents randomly performed identification with either ultrasound or palpation on 1 of 2 neck models. We included 57 participants, of whom 29 and 28 were randomized to palpation and ultrasound, respectively. Correct identification of the cricothyroid membrane was achieved by 21 (75.0%) vs 1 (3.5%) of participants in the ultrasound versus palpation groups (risk ratio [RR], 21.8 [95% confidence interval {CI}, 3.1-151.0]). The tracheal midline position in the sagittal plane was identified correctly by 24 (85.7%) vs 16 (55.2%) of participants in the ultrasound versus palpation groups (RR, 1.6 [95% CI, 1.1-2.2]). Identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea was more often successful with ultrasound compared to palpation. Our study supports the potential use of ultrasound before induction of anesthesia and airway management in this group of patients, and it may even be applied in emergency situations when ultrasound is readily available. Further studies in human subjects should be conducted.

Midline Swaddling and Traditional swaddling Position and Their Influence on Physical and Autonomic sign on Newborn Babies.

The traditional method of swaddling is done with the arms and legs straightened and wrapped tightly with the hips in an adduction position, and the newborns are mostly carried out by traditional swaddling in Indonesia. When swaddling is properly done, infants show less awakening and longer sleep, better neuromuscular development, less physiological stress, better motor organization, and better self-regulation abilities. Improper swaddling can result in conditions that are detrimental for newborns, like SIDS, DDH, which cause stress. The early exposure of the neonates to stress results to residual symptoms in behavior and neurobiological disorders. This study aims to determine the effect of midline position compared to the traditional swaddling regarding physical and autonomics stress sign. The study population consisted of 194 newborns. The midline and traditionally swaddled were observed and recorded, physical and autonomic signs at birth, 10 minutes and 2 hours were documented. This study found that there is statistically significant difference between the groups in terms of cries at 10 minute and 2 hours and so with the heart rate and respiration rate at birth (p<0,05), and a significant difference in oxygen saturation at 10 minutes and 2 hours (p<0,05). Additionally, midline swaddling had a larger average decrease in heart rate and respiration rate, and increase in the oxygen saturation. Therefore, this study can deduce that, midline position swaddling has less stressful effect than the traditional position. The same research elsewhere in Indonesia will be costly. Future research would suggest for larger sample that may suggest a more accurate outcome.

Smile esthetic

Most patients require orthodontic treatment to improve the esthetics of their smile. Orthodontists must consider how some parameters of mini-esthetics can influence the patient’s esthetic perception. Methods: A photograph of the smile of a young female was taken and some modifications were made to the buccal corridor, gingival exposure, smile arc and midline position to assess the influence of these variables on smile attractiveness. Two hundred examiners were selected from four groups: orthodontists (O), dental students (DS), orthodontic patients (OP) and surgical-orthodontic patients (SOP). Each examiner was asked to complete the questionnaire with an approval rating from 1 to 10. Significant level was set at P ≤ 0.05. Results: Only orthodontists considered buccal corridors of 4mm and midline deviation of 1mm as non-esthetic; all other examiners considered gingival exposures ≥3 mm and midline angulation as non-esthetic. All examiners assigned higher satisfaction values to the photo with the concordant smile arc and defined as non-esthetic the covered smile and the reverse smile arc. Patients perceived as non-esthetic only midline deviations of 4mm. The surgical orthodontic patients assigned lower values to the photos and showed greater attention to evaluating the esthetics of the smile than the orthodontic patients. Conclusion: Smile arc, gingival exposure and midline angulation influence smile esthetics; the role of buccal corridors and midline deviation is dependent on the type of examiner.

Unilateral Fixation of the Bony Pyramid in Deviated Nose Correction.

Deviated nose correction is one of the most challenging procedures in rhinoplasty. Recent studies proposed effectiveness of preservation techniques even for patients with crooked nose deformity, although the long-term results are still controversial. Obviously, only addressing the blocking points is not enough to achieve stable midline position in crooked nose. To ensure consistent long-term results, we proposed a unilateral suturing of the bony pyramid along with unilateral resection of the excessive bone along the lateral osteotomy line. The first results of described surgical technique have proven its simplicity, reliability, and high efficiency both in primary and in revision surgeries. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Influence of Oculomotor Visual Abilities, Balance and Postural Control on the Praxis Abilities of Atypical Children Aged 7-12 Years

The main problems in dyspraxia are problems in coordination patterns and motor skills that require skills and rhythmic movements (motor skills). The foundation of children's motor skills is visual oculomotor abilities as a function of visual perception which is able to influence the midline position of the body so that children are able to achieve a position of static balance (balance) and also dynamic balance (postural control). The aim of this research is to analyze the influence of the three motor skill foundations on praxis events in atypical school-aged children. The research was conducted on 102 samples of children aged 7-12 years at the Asya Therapy Center Mojokerto. Samples were taken at simple random and divided into 2 groups, namely the case group (n=54) and the control group (n=48). The research design uses a case control study where researchers analyze the risk of praxis problems in terms of the influence of visual oculomotor factors, balance and postural control. Data analysis used logistic regression analysis which showed a significant value of 0.000 (0.000<0.05) so that from these results it can be seen that visual oculomotor factors, balance and postural control have a significant influence on praxis problems in atypical children aged 7-12 year. Apart from that, from the results of calculating the ods ratio, it was found that the highest ods ratio value was owned by the control ability

Predictors of Skip Laminotomy for Placement of Paddle Leads for Spinal Cord Stimulation

ObjectivesPlacement of a standard paddle lead for spinal cord stimulation (SCS) requires a laminotomy for positioning of the lead within the epidural space. During initial placement, an additional laminotomy or laminectomy, termed a “skip” laminotomy, may be necessary at a higher level to pass the lead to the appropriate midline position. Patient and radiographic factors that predict the need for a skip laminotomy have yet to be identified. Materials and MethodsParticipants who underwent SCS paddle placement at Albany Medical Center between 2016 and 2017 were identified. Operative reports were reviewed to identify the paddle type, level of initial laminotomy, target level, and skip laminotomy level. Preoperative thoracic magnetic resonance images (MRIs) were reviewed, and spinal canal diameter, interpedicular distance, and dorsal cerebral spinal fluid thickness were measured for each participant when available. ResultsA total of 106 participants underwent thoracic SCS placement. Of these, 97 had thoracic MRIs available for review. Thirty-eight participants required a skip laminotomy for placement of the paddle compared with 68 participants who did not. There was no significant difference in demographic features including age, sex, body mass index, and surgical history. Univariate analyses that suggested trends were selected for further analysis using binary logistic regression. Level of initial laminotomy (odds ratio [OR] = 1.51, p = 0.028), spinal canal diameter (OR = 0.71, p = 0.015), and dorsal cerebrospinal fluid thickness (OR = 0.61, p = 0.011) were correlated with skip laminotomy. Target level (OR = 1.27, p = 0.138) and time from trial (1.01, p = 0.117) suggested potential association. The multivariate regression was statistically significant, X2(10) = 28.02, p = 0.002. The model explained 38.3% of the variance (Nagelkerke R2) and predicted skip laminectomy correctly in 73.3% of cases. However, for the multivariate regression, only a decrease in spinal canal diameter (OR = 0.59, p = 0.041) was associated with a greater odds of skip laminotomy. ConclusionsThis study aims to characterize the patient and radiographic factors that may predict the need to perform a skip laminotomy during the initial placement of SCS paddles. Here, we show that radiographic and anatomic variables, primarily spinal canal diameter, play an important role in predicting the need for a skip laminotomy. Furthermore, we suggest that target level for placement and level of initial laminotomy also may contribute. Further investigation of the predictive factors for performing a skip laminotomy would help optimize surgical planning and preoperative patient selection and counseling.

Evaluation of accuracy of maxillary repositioning surgery using an observer-independent method

ObjectiveTo evaluate the accuracy of maxillary repositioning in two-jaw surgery using computer-aided surgical simulation (CASS) and computer-aided design/manufacturing (CAD/CAM) splints by using a highly accurate observer-independent method. MethodsA retrospective evaluation was conducted of 30 consecutive adults who underwent Le Fort I osteotomy by a single surgeon. Surgical planning and fabrication of occlusal splints were performed using custom-developed CASS software. Preoperative images with landmarks were superimposed on postoperative images to evaluate discrepancies between the planned and actual position of the maxilla following surgery. Translational and rotational differences were expressed as the root mean square deviation (RMSD). The number of cases that exceeded the clinically acceptable limits (2 mm for the translational difference at the centroid, 4° for the rotational difference, and 1 mm for the mediolateral difference at the dental midline) were also evaluated. ResultsPostoperative anteroposterior translation and pitch values were significantly different to and negatively correlated with the planned values, respectively. The largest translational RMSDs at the centroid and the dental midline were 1.04 mm and 1.03 mm, respectively, in the anteroposterior direction. The largest rotational RMSD was 1.86° in pitch. The percentage of discrepancies exceeding the clinically acceptable limit was 3.3% for the centroid, 3.3% for rotation, 20.0% for the midline, and 26.7% for any one criterion. ConclusionWhile maxillary repositioning using CASS and CAD/CAM splints was accurate on a population level, there remains potential for clinically significant errors to occur on an individual level, particularly in controlling the dental midline position and occlusal plane angle.

Immediate Closed Reduction Technique for Cervical Spine Dislocations.

Retrospective study. This research aimed to assess the clinical outcomes of patients with traumatic cervical spine dislocation who underwent closed reduction employing our approach. Bedside closed reduction is the quickest procedure for repairing traumatic cervical spine dislocations; nevertheless, it also possesses the risk of neurological deterioration. For closed reduction, the patient's head was elevated on a motorized bed, the cervical spine was placed at the midline, traction of 10 kg was applied, the motorized bed was gradually returned to a flat position, the head was lifted off the bed, and the cervical spine was slowly adjusted to a flexed position. The weight of traction was elevated by 5-kg increments until the positional shift was attained. Subsequently, the bed was gradually tilted while traction was applied again to return the cervical spine to the midline position. Of the 43 cases of cervical spine dislocation, closed reduction was carried out in 40 cases, of which 36 were successful. During repositioning, three patients experienced a temporary worsening of their neck pain and neurological symptoms that enhanced when the cervical spine was flexed. Closed reduction was conducted while the patient was awake; nevertheless, sedation was needed in three cases. Among the 24 patients whose pretreatment paralysis had been characterized by American Spinal Injury Association Impairment Scale (AIS) grades A-C, seven patients (29.2%) demonstrated an enhancement of two or more AIS grades at the last observation. Our closed reduction approach safely repaired traumatic cervical spine dislocations.

Left bronchial compression after aortic arch reconstruction for coarctation of the aorta.

This study aimed to investigate the preoperative positional relationships between the blood vessels and the left bronchus during the development of left bronchial compression (LBC) after aortic arch reconstruction for coarctation of the aorta (CoA). We retrospectively reviewed data from 29 patients with CoA who underwent aortic arch reconstruction via median sternotomy between 2009 and 2019. The patients were divided into those who underwent aortic arch advancement (AAA) with (C group, six patients) or without (N group, 10 patients) postoperative LBC and those who underwent extended end-to-end anastomosis (E group, 13 patients). We determined the sterno-spinal axis (SSA) of the patients and evaluated the preoperative and postoperative positions of the vessels on the axial and three-dimensional multidetector row computed tomography (CT) angiographic images. The distance between the ascending and descending aortas was significantly smaller in both C and N groups postoperatively than preoperatively. The distance between the descending aorta and SSA in the C group was markedly smaller compared with that in the other groups preoperatively and was increased postoperatively. Preoperatively, the distance from the left bronchus to the aortic arch in the C group was significantly larger than that in the other groups and was decreased postoperatively. The postoperative arch angle in the C group was significantly smaller than that in the other groups. A preoperative midline position of the descending aorta and highly displaced aortic arch in relation to the left bronchus on preoperative CT images could cause the postoperative LBC after AAA.

ID: 219385 Predictors of Skip Laminotomy for Placement of Paddle Leads for Spinal Cord Stimulation

Paddle lead placement for spinal cord stimulation (SCS) requires a laminotomy for positioning of the lead within the epidural space. During initial placement, an additional laminotomy or laminectomy, termed a “skip” laminotomy, may be necessary at a higher level to pass the lead to the appropriate midline position. Patient and radiographic factors that predict the need for a skip laminotomy have yet to be identified.

Impact of probe-induced abdominal compression on two-dimensional shear wave elastography measurement of split liver transplants in children.

To evaluate the effect of probe-induced abdominal compression of split liver transplants (SLT) in children on 2D-shear wave elastography (SWE) values. Data from 11 children (4.7 ± 4.8years) who had undergone SLT and SWE were evaluated retrospectively. Elastograms were obtained with probes placed in an epigastric, midline position on the abdominal wall, with no and slight compression, using convex and linear transducers. For each identically positioned probe and condition, 12 serial elastograms were obtained and the SLT diameter was measured. Liver stiffness and degree of SLT compression were compared. Slight probe pressure resulted in SLT compression, with a shorter distance between the cutis and the posterior margin of the liver transplant than in the measurement with no pressure (curved array, 5.0 ± 1.1 vs. 5.9 ± 1.3 cm, mean compression 15 %± 8 %; linear array, 4.7 ± 0.9 vs. 5.3 ± 1.0 cm, mean compression 12 %± 8 %; both p < 0.0001). The median liver stiffness was significantly greater with slight pressure than with no pressure (curved transducer, 13.38 ± 3.0 vs. 7.02 ± 1.7 kPa, p < 0.0001; linear transducer, 18.53 ± 7.1 vs. 9.03 ± 1.5 kPa, p = 0.0003). Slight abdominal compression can significantly increase SWE values in children with left-lateral SLT. To obtain meaningful results and reduce operator dependency in free-hand examinations, probe pressure must be controlled carefully. · Probe-induced compression can increase elastography values in split liver transplants in children. · In free-hand examination, probe pressure must be controlled carefully. · Pressure loading can be determined indirectly by the anteroposterior transplant diameter. · Groth M, Fischer L, Herden U et al. Impact of probe-induced abdominal compression on two-dimensional shear wave elastography measurement of split liver transplants in children. Fortschr Röntgenstr 2023; 195: 905 - 912.

Perception of discrepancy in the upper midline position in conjunction with the gingival display according to various occupations in Iran.

This study evaluated the influence of various gingival displays on the esthetic perception in the presence of upper dental midline discrepancy. A smiling image of a male subject was altered digitally to produce five image series: normal smile (series A), decreased tooth show (series B), increased gingival show (series C), maxillary cant (series D), and asymmetric upper lip elevation (series E). In each image series, the midline was deviated to the right and left incrementally. A total of 210 raters (four professional groups and laypersons, n = 42 in each group) determined the midline deviation threshold and the attractiveness of midline position in each series. The right and left thresholds were statistically similar for the symmetrical series (A, B, and C), while for series D, the right threshold was significantly lower. In most rater groups, the mean threshold order was: B > A > E > C > D. In all the series, the raters selected the coincident midline as the most attractive series except for series D, for which 1-2-mm deviations to the left were selected as the most attractive by almost all the groups. It is crucial to establish the coincident midline position in a symmetrical smile, especially when a gummy smile exists. In the asymmetrical gingival show, a coincident midline might not be the most esthetic midline position.

Sliding Spine Relocation Surgery with Anterior Septal Reconstruction.

Study Design: Technical note. Objective: The lower nasal architecture is dependent on caudal septal integrity. Deviations of the caudal septum can compromise nasal airflow. The presence of anterior nasal spine deviations contributes to septal and medial crural shifting with ipsilateral encroachment. It is essential to identify nasal spine deviation during surgery in order to reconstruct the septum in a midline position at its base. This allows an appropriate management plan that creates a better functional and aesthetically pleasing outcome. A stable midline anterior nasal spine is warranted to support the newly reconstructed straight caudal strut, which can be effectively corrected by anterior septal reconstruction. Methods: The proposed method intends to combine anterior nasal spine centralization with correcting caudal septal deviation and nasal obstruction through a modified extracorporeal septoplasty technique. We describe a novel technique to centralize the deviated anterior nasal spine using the piezoelectric device by performing a contralateral adjacent ostectomy and en-bloc relocation and fixation of the anterior nasal spine with microplates and screws. Results: This surgical approach creates a stable caudal septum and a centrally positioned anterior nasal spine, which improves nasal airflow and ensures a stable repair. Conclusion: Sliding spine relocation surgery with anterior septal reconstruction repositions a deviated anterior nasal spine and corrects caudal septum deviation, that can impair the nasal airway.

Hyperbaric Bupivacaine for Spinal Anaesthesia in Adults Patients: Comparison of Isobaric Bupivacaine 0.5% in 80mg/Ml and 40 Mg/Ml Glucose Solutions

Background: The Baricity of bupivacaine is one of the most important factors to influence the characteristics of distribution of the local anaesthetic and spread of the blockade. Bupivacaine is rendered hyperbaric by adding glucose. The effect of differing degrees of hyperbaricity remains to be evaluated in term of spinal anesthesia blockade. Methods: Hundred patients who underwent lower abdominal, hips, and lower extremity surgeries were randomized into two groups in a double-blind, randomised, parallel group, prospective study. Group I received 0.5% isobaric bupivacaine with 80 mg/ml of glucose, while Group II received 0.5% isobaric bupivacaine with 40 mg/ml of glucose. Injection was made intrathecally in midline position at L3-4 and L4-L5 interspace in sitting position. The measured sensory blockade and motor blockade are the onset and duration. Duration of sensory block was the time measured from the time of the highest block for the regression to the S2 dermatome. Results: Success rate, spread and duration of sensory block were similar in both groups. The highest median level of sensory block was T3 (T2-T7) (median (10th/90th percentiles)) in both groups. Time to reach T10 did not differ between the groups. Power analysis suggested that a total number of 100 adults were required in both groups for a 90% chance at the 0.05 level of significance of detecting a10% difference in success between groups. Categorical data were tested using the chi square test. For continuous data the Mann–Whitney test was used. Results are presented as median (10–90th percentiles), number (%) of cases, the significance was set as P&lt;0.05. Conclusion: These results demonstrate that bupivacaine in 80mg/ml glucose provides reliable spinal anaesthesia of shorter duration and with less hypotension than bupivacaine in 40 mg/ml glucose. The recovery profile for ropivacaine may be of interest given that more surgery is being performed in the day-case setting.

A non-invasive treatment option in solitary median maxillary central incisor syndrome

Solitary median maxillary central incisor (SMMCI) syndrome (OMIM #147250) is a disorder characterized by developmental defects of midline structures with variable expressivity. It presents dentally as a single symmetrical central incisor in the midline position. This is a case report of a child with the isolated dental feature of a single maxillary central incisor, with no medical features of SMMCI syndrome. Under the management of a multidisciplinary dental team, a non-invasive approach was undertaken to improve aesthetics. This case report describes the dental options for managing SMMCI including a non-invasive option that has not previously been reported in detail. CPD/Clinical Relevance: Dentists should be aware of SMMCI and its potential medical sequelae.

Acceptable deviation of labial tubercle and anterior tooth midlines relative to facial midline in smile aesthetics: A retrospective observational study.

Smile aesthetics are mainly influenced by the relative position of facial midline (FC-line), anterior tooth midline (AT-line) and labial tubercle midline (LT-line). However, the acceptable deviation of LT-line and AT-line relative to FC-line is unknown. This study aims to fill the critical gap. We adopted the method of cross-sectional study, the frontal full-face smile photographs of 1 subject set (1 male) were enrolled. Taking the FC-line as the center line, twelve images with 1-mm increment relative to FC-line (right or left deviation, the maximum deviation distance was 3-mm) in LT-line deviation model or LT + AT-line deviation model (LT-line coincided with AT-line basing on LT-line deviation model) were produced. Basing on Q-sort assessment, the images were evaluated by 160 dentists, 165 orthodontic patients and 163 freshmen. And the collected Q-sort scores were subjected to nonparametric comparative analysis using SPSS 18.0. There were significant differences in Q-sort scores among different groups (P < .01). When the deviation distance was 1 mm in dentist and orthodontic patient or 2 mm in freshman group, there was no significant difference in smile attractiveness scores between the LT line deviation model and the LT + AT line deviation model (P > .05). We also found that the score of male dentist significantly higher than female dentist (P < .05). However, the scores of right deviation in dentists and orthodontic patients were significantly lower than those in left deviation (P < .05). The acceptable deviation of LT-line and AT-line relative to FC-line should be kept within 2 mm. Besides, raters’ occupation and gender, and deviation direction of model may influence the smile aesthetics.

P-031 AN UNUSUAL CASE OF AN INCARCERATED 5MM PORT SITE HERNIA FOLLOWING LAPAROSCOPIC FUNDOPLICATION

Abstract Aim Port site hernias are a rare, but recognised risk of laparoscopic surgery. Literature supports fascial closure at port sites of 10mm or greater. However, there are few reported cases of herniation through 5mm port sites. Methods This case report focuses on a 67-year-old female who underwent an uncomplicated primary laparoscopic Toupet's fundoplication. 11 days post procedure she presented with an incarcerated port site hernia. CT scan demonstrated high grade small bowel obstruction with a transition point at the site of the 5mm right sided port. A laparotomy was performed, the hernia reduced, small bowel was viable, and the port site hernia was closed internally using vicryl sutures. Results The incidence of 5mm trocar-site hernias is rare. A recent literature review found only 10 such cases related to general surgery (cholecystectomy:6; appendicectomy: 2; right hemicolectomy: 1; paraesophageal hernia:1). Risk factors for port-site hernias include: high BMI, midline position, size, number and type of trocar tip. The limited current literature identifies excessive trocar manipulation as the major risk factor for developing 5mm port-site hernias, yet routine fascial closure is not supported. Conclusion Herniation at 5mm port sites is rare but attention should be paid when patients present with symptoms suggesting its occurrence.