Dissertations / Theses on the topic 'Prosthetic rehabilitation'

Magister Scientiae Dentium - MSc(Dent) (Restorative Dentistry)
Loss of teeth has a negative impact on appearance, nutrition, function and diet. Rehabilitation of tooth loss is an important function of oral health care. Rehabilitation with removable prosthesis of mandibular terminal edentulous areas has been associated with more negative outcomes than of tooth-bounded regions.

Prosthetic development recently has focused mainly on myoelectrically controlled electric hands despite a majority of upper extremity amputees actively choosing body powered devices. Myoelectric hands utilize a small electric pulse generated in muscles when flexing as a signal to the hand to close. Finger flexion in these devices is controlled by electromechanical servos, requiring no strength input from the user. Body powered devices use a cable attached to a shoulder harness which causes mechanical closure of the device via tension placed on a control cable by a shoulder shrug motion or arm extension. Outfitting of active duty service personnel has recently tended to follow the electronic hands which have fragile electronics, have a poor response to user input, and are not fit for harsh outdoor environments. This report will detail the current development of a re-design of a custom left hand prosthesis for an active duty Navy SEAL and the transition from electronic controls to full body power function.

A successful restoration of vision should allow the blind to look, to see and to understand. The engineering of a microelectronic vision prosthesis has come a long way over the last forty years, but the understanding of how the restored form of vision would be interpreted and functionally applied to everyday living has made little progress until recent times. Prosthetic vision is not what most people think it would be; it is a visual scene composed of relatively large, isolated, spots of light so-called "phosphenes", very much like a magnified pictorial print. This thesis dissertation seeks to obtain a complete survey of the visual description of phosphenes from the human trial reports in the literature, simulate it, obtain a measure of the functional capacity of such visual perception, and explain the measured performance against design aspects of phosphene presentation, human perception, cognition and behaviour. Specifically, "visual acuity" (VA) was assessed on normally sighted subjects (N=15) administered with "simulated prosthetic vision". VA is a functional measure of vision highly correlated to many daily activities. Aggregating the results from the study with the other VA studies in prosthetic vision, it is shown that in general, the density of the phosphene field determines the affordable VA; however, design aspects relating to the phosphene field lattice (0.03 10gMAR with the hexagonal lattice as opposed to a square lattice) and image processing routines (0.15 10gMAR at optimised settings) can be further fine-tuned to improve VA performance. Significant performance improvement also arose from learning (0.13 10gMAR over ten visitations) and visual scanning adaptation (0.20 10gMAR with a circular scanning strategy). Performance improvements are likely related to various preferences and perceptual preferences of the human visual system. A rehabilitation program targeting the appropriate behavioural adaptation coupled with image processing routine optimised for image comprehension should provide a vision prosthesis recipient with the best functional experience to restored vision.

The term ‘prosthetic’ is used increasingly across the social sciences and has taken on a theoretical life as a result of debates springing from contemporary studies of science and technology, medical anthropology and citizenship. This research considers whether the usage of ‘prosthetic’ and ‘prosthesis’ has however, become all too distanced from a grounded understanding of these terms, and is now in many ways synonymous with the term ‘cyborg’, therefore obscuring the specific relationships that prostheses represent. It asks if these terms have become a ‘catchall’ of technological subjectivities, without any basis in lived experience. Through ethnographic research into the manufacture, marketing and usage of medical prostheses in a Serbian inpatient rehabilitation centre, as well as interviews with prosthesis manufacturers, salespeople, as well with various citizens young and old, I present a nuanced view of the way in which citizenship itself is enacted. Citizenship is also a process of augmenting the body, both explicitly, such as in the (re)construction of socially acceptable bodies who have the capacity to labour, and implicitly, such as in the process of acquiring passports and identity documents. This process of externalising, and of the distributing of elements of the self into objects and relationships outside of the biological body forms the basis of what I term prosthetic citizenship. In my search for a grounded and ethnographically informed understanding of prostheses, and of prosthetic citizenship, key themes emerge, such as hope, normality, morality and the relationship of technology to the bodies. I find that prostheses are always sites of entanglement and paradox, but that they are also equally full of promise, and that in understanding how, why and in what capacities they are used, they emerge as capable of bridging the divide between theoretically complex abstract relationships, and the pragmatic realities of daily life.

Background Recent conflicts have seen an increase in trauma related military amputees who incur complex injuries which result in varied residual limbs. In many cases these amputees have been provided with state of the art (SOTA) components with the expectation that they will transfer into NHS care after military discharge. However, there is a lack of knowledge around how prosthetic prescriptions are made in both the MOD and NHS, including patient involvement. It is important to explore prosthetic prescription decisions to enhance the quality, consistency and equity of care delivery for trauma amputees. This thesis explores decision making in prosthetic care for trauma amputees in the UK during this period of change. Aims To explore aspects of prosthetic care provision in the UK including clinical decision making, patient experience and the transition of prosthetic care from the MOD to the NHS. Design An exploratory qualitative project informed by decision making and patient involvement theory. Semi-structured interviews were carried out with nineteen clinical staff involved in prosthetic provision, six civilian and five veteran trauma amputees. Thematic analysis was used to analyse the data. Findings Prosthetists used a wide range of factors in making prescription decisions, including physical characteristics, patients’ goals, and predicted activity levels. Prescription decision making varied depending on the prosthetists’ level of experience and the different ‘cues’ identified. In some cases there was a lack of transparency about drivers for the prescription choice. Prescription decisions are influenced by long term relationships between prosthetist and patient, allowing a trial and error approach with increasing patient involvement over time. Patient experiences of their trauma amputation influenced their approach to rehabilitation. Patients reported wanting different levels of involvement in their prosthetic care, however, communication was essential for all. Veteran amputees benefited from peer support opportunities which NHS services were less conducive to. However, NHS amputees were more likely to have been ‘involved’ in care decisions. The expectations that MOD patients had of inferior care in the NHS were not realised in the majority of veteran cases. Recommendations Research is needed to support prosthetists’ decisions to become more consistent and transparent. The NHS should consider introducing a peer support model for trauma patients, and particularly in the early stages of rehabilitation.

Syftet med denna studie är att undersöka erfarenheter och åsikter hos allmäntandläkare samt specialisttandläkare runt om i Sverige genom en omfattande enkätstudie gällande användning av bettskenor i ett skyddande syfte av protetiska konstruktioner. 2771 tandläkarna hämtades ur en kunddatabas registrerade hos dental företaget Unident.Enkäten sammanställdes på Odontologiska fakulteten, Malmö högskola med 22 frågor. Enkäterna skickades ut i digital form i ett mejl genom Unident till tandläkarna. Antalet medverkande tandläkare blev 588.Studien visade att 67 % av tandläkarna ansåg att bettskenor i skyddande syfte vid protetiska konstruktioner ej var nödvändigt. Dock valde 4 av 5 tandläkare att ändå inkludera en skyddande bettskena till patienter med utförd protetik. Dagens litteratur är väldigt snäv i detta ämne och därmed finns ett behov för framtida studier utöver enkätstudier som påvisar evidens för potentiella bettskenor som agerar skyddande på protetiska konstruktioner hos patienter.
This study aimed to investigate the experiences and habits of dentists when prescribing an appliance as protection in prosthetic therapy in patients. Since there is no published scientific evidence showing that an appliance could be used as a protection in prosthetic therapy it was out of interest to know where dentists obtain their knowledge and if they consider themselves having an adequate competence in this field. The study is based on a survey that examines general dentists as well as dental specialists through a questionnaire with 22 questions out of mixed nature. The study covered 2771 dentists from different parts of Sweden, retrieved from a database of customer records handed by Unident, a dental company. A total of 588 dentists participated in the questionnaire. The use of appliances as protection in patients with prosthetic rehabilitation was considered no to be necessary among 67% of the dentists in this study. However, every 4 out of 5 dentists sometimes include an appliance as protection whenever prosthetic therapy is indicated. Today the literature is very sparse in this subject and there is an obvious need for future studies in a different design besides questionnaires, testing the evidence for a potential protective appliance in patients with prosthetic therapy.

amputation, which includes reduced force generation at the knee and ankle, reduced control of the leg, and different mass properties relative to their intact leg. The physical change in the prosthetic leg leads to gait asymmetries that include spatial, temporal, or force differences. This altered gait can lead to an increase in energy consumption and pain due to compensating forces and torques. The asymmetric prosthesis demonstrated in this research aims to find a balance between the different types of asymmetries to provide a gait that is more symmetric and to make it overall easier for an amputee to walk. Previous research has shown that a passive dynamic walker (PDW) with an altered knee location can exhibit a symmetric step length. An asymmetric prosthetic simulator was developed to emulate this PDW with an altered knee location. The prosthetic simulator designed for this research had adjustable knee settings simulating different knee locations. The prosthetic simulator was tested on able-bodied participants with no gait impairments. The kinetic and kinematic data was obtained using a VICON motion capture system and force plates. This research analyzed the kinematic and kinetic data with different knee locations (high, medium, and low) and normal walking. This data was analyzed to find the asymmetries in step length, step time, and ground reaction forces between the different knee settings and normal walking. The study showed that there is symmetry in step lengths for all the cases in overground walking. The knee at the lowest setting was the closest in emulating a normal symmetric step length. The swing times for overground walking showed that the healthy leg swings at almost the same rate in every trial and the leg with the prosthetic simulator can either be symmetric, like the healthy leg or has a higher swing time. Step lengths on the treadmill also showed a similar pattern, and step length of the low knee setting were the closest to the step length of normal walking. The swing times for treadmills did not show a significant trend. Kinetic data from the treadmill study showed that there was force symmetry between the low setting and normal walking cases. In conclusion these results show that a low knee setting in an asymmetric prosthesis may bring about spatial and temporal symmetry in amputee gait. This research is important to demonstrate that asymmetries in amputee gait can be mitigated using a prosthesis with a knee location dissimilar to that of the intact leg. Tradeoffs have to be made to achieve symmetric step length, swing times, or reaction forces. A comprehensive study with more subjects has to be conducted in-order to have a larger sample size to obtain statistically significant data. There is also opportunity to expand this research to observe a wider range of kinetic and kinematic data of the asymmetric prosthesis.

The purpose of this study was to develop an intuitive software that aids in the field of prosthetic training and rehabilitation by creating an individualized visualization of joint angles. This software is titled “the prosthetic training software (PTS) for individualized joint angle representation”, and it enables the individualized portrayal of predicted or pre-recorded joint angles. The PTS is an intuitive program for clinicians and prosthesis users that produces an animation of a virtual avatar reflecting the user’s segment lengths and amputation for rehabilitation and training purposes. The PTS consists of a graphical user interface (GUI) and a 3D visualization of the information input into the GUI. This software was developed in Microsoft Visual Studio (Microsoft, Redmond, Washington) as well as the Unity game engine (Unity Technologies, San Francisco, California) in the programming language C#. Four GUI tabs were created consisting of a patient input tab, a patient measurements tab, a prosthesis view and search tab, and a tab dedicated to editing a list of prostheses. Code was developed to take information input into these tabs to create an individualized 3D human model for the visualization. Twenty-four models were created in order to allow for unique portrayal of that input data. The models consisted of small, medium and large sizes, both male and female genders, and able-bodied, transradial left side, and transradial right side amputation variations. A generic transradial prosthesis was created for the use in the variations of these models. An additional six stick figure models were generated in order to give additional perspective of the portrayed joint angles. Code was also developed in order to animate these models accurately to the joint angles that are sent to them. Playback speed, viewing orientation, and perspective control functionalities were developed in order to assist in the comprehensiveness of the displayed joint angles. The PTS is not meant to be standalone software, however, the functionalities that it needed to encapsulate in order to work in conjunction with research currently being conducted at USF were tested. The intuitiveness of the GUI and visualization was evaluated by ease of use surveys, as well as volunteer commentary, in order to find how easily the interface that can be operated in a home setting without the oversight of an experienced operator. On average, subjects agreed that the PTS was intuitive to use, both for inputting information and utilizing the visualization. Feedback from these surveys will be used to further improve the PTS in the future. The feasibility of learning from the visualization output from the PTS was tested by comparing motions from five able-bodied subjects before and after having been taught three motions comprising pre-recorded joint angles animated by the PTS. Joint angles were calculated from recorded marker positions. It was found that after viewing the animation, the joint angles were markedly closer to the joint angles portrayed to them. This shows that the PTS is fully capable of showing joint angles in a comprehensive way. Future work will include additional testing of these functionalities, including the testing of prosthesis users, as well as the introduction and testing of new features of prosthesis recommendation and predictive joint angle production when later combined with future research.

This dissertation focuses on the investigation and development of an effective prosthetic training and rehabilitation platform with the use of virtual reality to facilitate an effective process to return amputees to the highest level of independence and functioning possible. It has been reported that approximately 10 million people live with a limb loss worldwide, with around 30% being an upper-extremity amputee. The sudden loss of a hand or arm causes the loss of fine, coordinated movements, reduced joint range of motion (ROM), proprioceptive feedback and aesthetic appearance, all which can be improved with the use of a prosthesis and proper training. Current literature has shown prosthetic devices to provide limited function to users in a variety of areas including hand operation, functionality and usability, all which could be improved with proper rehabilitation and training. It has been exhibited that a large percentage of amputees abandon or reject prosthesis use mostly due to limited function and lack of training or knowledge of the device. It has been reported that untrained amputees will adjust their body in an awkward or compensatory body motion rather than repositioning a joint position while performing a task with a prosthetic device. This causes misuse and improper function that has been shown to lead to significant injuries. An effective prosthetic training and rehabilitation regime would be advantageous in returning the patient to the highest level of independence and functioning possible, with proper use of their prosthetic device. A successful training and rehabilitation program would allow an amputee to improve their ability to perform with optimal motion and use all prosthetic control capabilities. This dissertation describes the development of a stick figure model of the user’s motion in real-time and a character avatar animating the individualized optimal goal motions. The real-time model directly corresponds to the user’s motion, with the option to have the character avatar simultaneously animating an optimal goal motion for the user to follow. These were implemented into the Computer Assisted Rehabilitation Environment (CAREN) system (Motek Medical, Amsterdam, Netherlands) to provide real-time visual feedback to the users while performing specified training and rehabilitating tasks. A ten camera Vicon (Oxford, UK) optical motion captured system was used with the CAREN system capabilities to track body and upper extremity prosthetic segments during range of motion (ROM), activities of daily living (ADL), and return to duty (RTD) tasks, with and without the use of the virtual reality visual feedback. Data was collected on five able-bodied subjects and five subjects with a unilateral transradial amputation using their personal prosthetic device. Through investigation and development, a preferred and effective way to display the visualization of the real-time and optimal models were revealed. Testing the subjects with and without the virtual reality visualization, exhibited the effectiveness of providing visual feedback. Results showed subject’s to have improved positing, movement symmetry, joint range of motion, motivation, and overall an improved performance of the series of tasks tested. With the integration of the optimal model visualization, real-time visual feedback, and additional CAREN system capabilities, upper-extremity training and rehabilitation techniques were shown to enhance with the use of virtual reality, through improved task performance, and functional advances. The results of this dissertation introduce an alternative means for clinicians to consider for effectively rehabilitating and training upper-limb amputees. Findings of this dissertation sought to provide useful guidelines and recommendation to aid in the development of a small-scale adaptable option for rehabilitation practitioners and at home use. The techniques investigated in this study could also be applicable for lower-limb amputee, post-stroke, traumatic brain injury, poly-trauma, and other patients with physically limiting disabilities. The techniques investigated in this study are expected to aid in the development of training and rehabilitation procedures for a variety of patient populations, to enhance the effectiveness and assist in improving the overall quality of life of others.

The aim of this thesis is to inform clinicians and researchers of the reliability and responsiveness of the most commonly used outcome measures in prosthetic rehabilitation in the UK. In addition, this thesis supports the call for more studies of high methodological quality to provide evidence of the psychometric properties of outcome measures of physical function in lower limb amputees. A survey (study I) of Allied Health Professionals established that the outcome measures used most often during prosthetic rehabilitation in the UK were: the Timed Up and Go (TUG), a timed walk test, the Locomotor Capability Index (LCI) and its modified version (LCI-5), the Socket Comfort Score (SCS) and the Special Interest Group in Amputee Medicine (SIGAM) Mobility Grades. A standardised quality checklist (COSMIN) was used in a systematic review (study II) to measure the methodological quality and strength of evidence of the published literature that reported on the psychometric properties of outcome measures used to measure physical function during prosthetic rehabilitation. The review found mixed methodological quality ratings and many studies with small sample sizes rendering the strength of the evidence indeterminate. A limited number of studies commented on limits of agreement and measurement error when reporting on reliability. Even fewer studies reported on responsiveness with only one reporting minimally clinically important difference (MCID) values. Values for consistency, agreement and measurement error, were calculated for the top five commonly used outcome measures as identified from the survey, using a test-retest study design with a period of 7 days between tests (study III). Minimum detectable change (MDC) values were calculated for the SIGAM, LCI-5, TUG and 2MWT. The EQ-5D-5LTM, a measure of the global health of the respondent, was also included as knowledge of its psychometric properties in a population of pwLLA is unknown. However, reliability could not be confirmed for the EQ-5D-5L or the SCS in this population. A longitudinal study (study IV), based during the early rehabilitation period (mean 84 days) following provision of a primary prosthesis, gathered data to calculate indices of responsiveness for the same six outcome measures. Effect sizes were presented for five measures: SIGAM, LCI-5, TUG, 2MWT, SCS and EQ-5D-5L. Minimal clinically important difference values were also presented for the first time for all the outcome measures in this population. A patient reported change questionnaire was used as the anchor in a Receiver Operator Characteristic (ROC) curve analysis to establish the MCID values.

Nesta pesquisa, foi avaliado o hábito alimentar de pacientes senescentes totalmente desdentados, antes e após a reabilitação por próteses totais bimaxilares convencionais. A avaliação foi realizada por meio de exame clínico, entrevista e a aplicação de questionários pela própria pesquisadora. O trabalho foi conduzido em três fases distintas: a primeira, desenvolvida antes do início de qualquer procedimento relacionado com a confecção das próteses e consistiu no preenchimento de ficha clínica, avaliação protética e da realização de uma anamnese alimentar, sendo essa última elaborada com a orientação de uma nutricionista. Já a segunda e a terceira fases foram executadas em períodos compreendidos entre aproximadamente dois a três meses e cinco a seis meses após a reabilitação protética respectivamente, quando novos exames clínicos eram realizados. Os dados coletados nesses três períodos distintos foram processados por um computador utilizando-se do software BioEstat 3.0,sendo o nível de significância estabelecido para p< 0,05, em uma prova bilateral. Os resultados demonstraram que após a instalação de uma nova prótese total convencional confeccionada no rigor da técnica tivemos, não só melhora funcional do aparelho protético, como alteração positiva na habilidade mastigatória dos indivíduos, além de alteração da consistência da dieta acompanhada da introdução de novos alimentos. Os resultados demonstraram ainda, que quando o aparelho protético apresentava retenção e estabilidade consideradas satisfatórias, aquele acabava influenciando positivamente o hábito intestinal do paciente.Contudo, através desse estudo, não foi possível identificar se houve uma real modificação da dieta dos pacientes com inserção de nutrientes, uma vez que para obtermos esses dados seriam necessários exames complementares.
In this research, the alimentary attitude of senescent edentulous patients was evaluated, before and after the rehabilitation by new complete dentures. A clinical exam, an interview and a survey were performed. The work was accomplished in three different phases: the first was developed before the beginning of any procedure related to the construction of the new dentures and consisted of a clinical record, a prosthetic evaluation and an alimentary anamnesis. The second and the third phases took place after the prosthetic rehabilitation and were done in periods between two to three months and five to six months respectively, together with new clinical exams. The data collected during those three different periods were processed using software BioEstat 3.0 ; the level of significant was p <0,05, in a bilateral proof. The results demonstrated that after the installation of new complete dentures made according to the technique there was a functional improvement of the dentures noticed as a better performance in the individuals' masticatory ability. It was reported also changes in the consistence of the diet associated to the increasing of different nutrients to the diet. It was also possible to verify that when the prostheses presented satisfactory retention and stability, intestinal habit was influenced positively. However, through this study only, it was not possible to identify if there was a real modification in patients’ alimentary habit or if different nutrients were inserted to it. To make sure those modifications had happened complementary exams should have been performed as well.

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Medicina Dentária
As pessoas estão a viver vidas mais longas e saudáveis. Estima-se que a proporção de pessoas com idade igual ou superior a 65 anos duplique entre os anos de 2010-2050, prevendo-se que em 2050 as pessoas pertencentes a esta faixa etária correspondam a mais de um quarto (27%) da população mundial. Em Portugal é esperado que até 2060, a população desta faixa etária residente no país atinja os 3344 milhares de pessoas. Com o envelhecimento aumenta a incidência de doenças e consequentemente o uso de polimedicação. Neste sentido deve ser dada a devida atenção as interacções entre a medicação e a alimentação. A sinergia entre saúde oral e nutrição é evidente pois, doenças infecciosas orais, doenças sistémicas agudas, crónicas e terminais com manifestações orais afectam não só a capacidade mastigatória mas também a dieta dos indivíduos, podendo não comprometer o seu estado nutricional mas implicando alterações quer na escolha de alimentos como no conforto oral e podendo mesmo afectar a qualidade de vida. O comprometimento da capacidade mastigatória é evidente com a perda de dentes sem substituição destes por próteses ou nos casos em que os indivíduos usam próteses mal adaptadas. No que diz respeito a nutrição, as limitações da função mastigatória proporcionam o défice no consumo de carnes, frutas e legumes que são fontes ricas em provitaminas (caroteno), vitaminas A, C, E, várias vitaminas do complexo B, proteínas (albumina), fibras e minerais como cálcio, ferro e potássio. Optando por consumir dietas a base de gorduras que aumentam a predisposição para doenças como: obesidade e diabetes mellitus. Com a análise destes dados é fundamental a criação de programas de promoção e de prevenção para a saúde oral, saúde geral e nutrição que são primordiais para o bem-estar dos idosos, no âmbito de evitar procedimentos médicos mais invasivos e malnutrição. People are living longer and healthier lives. It is estimated that the proportion of people aged over 65 will double between the years 2010-2050, it is expected that in 2050 people belonging to this age group accounted for more than a quarter (27%) of the population world. In Portugal it is expected that by 2060, the population of this age group living in the country will reach 3344 thousand people. With aging increases the incidence of disease and thus the use of polypharmacy. In this regard due consideration the interactions between medication and food should be given. The synergy between oral health and nutrition is evident therefore oral infectious diseases, acute systemic diseases, chronic and terminal with oral manifestations affect not only the chewing ability but also the diet of individuals and could not compromise their nutritional status but implies changes in either the choice of food on oral as comfort and can even affect the quality of life. The impairment of chewing ability is evident with the loss of teeth without replacing them with dentures or in cases in which individuals wear ill-fitting dentures. Regarding nutrition, the limitations of the masticatory function provide the shortfall in consumption of meat, fruit and vegetables that are rich sources in provitamin (carotene), vitamins A, C, E, several B vitamins, protein (albumin), fiber and minerals like calcium, iron and potassium. Choosing to consume diets based on fats that increase the predisposition to diseases such as obesity and diabetes mellitus. With the analysis of these data is crucial to create promotion and prevention programs for oral health, general health and nutrition that are essential to the welfare of the elderly in the context of malnutrition and avoid more invasive medical procedures.

Ce travail s’intéresse aux liens existants entre la santé bucco-dentaire de la personne âgée édentée et son alimentation. En effet, chez la personne âgée, une prise alimentaire régulière et diversifiée est à rechercher pour éviter une dénutrition protéino-énergétique. Cependant, la réhabilitation de l’édentement par prothèses amovibles n’optimise pas ou peu la diversification de l’alimentation. La mise en place d’implants par prothèse implanto-retenue ou portée reste restreinte au sein de cette population. A ce titre, une des solutions thérapeutiques envisageables est la transformation de la prothèse amovible en prothèse implanto-retenue par mini implants. L’impact de cette nouvelle procédure sur la fonction masticatoire et la qualité de vie orale des patients a été évaluée par une étude de suivi. Cette évaluation a montré que la prothèse implanto-retenue permet d’améliorer la capacité masticatoire du sujet et sa qualité de vie orale mais l’efficacité masticatoire reste bien en deçà de celle observée chez un sujet âgé denté.Consécutivement, de nouvelles procédures thérapeutiques utilisant la CFAO (Conception et la Fabrication Assistée par Ordinateur) ont été développées et évaluées chez des sujets réhabilités au sein du service d’Odontologie du CHU Estaing. Les avantages qu’apporte la CFAO dans le maintien de la santé bucco-dentaire de la personne âgée ont ainsi été objectivés. Dans la continuité de ce travail, de nouvelles procédures CFAO de réhabilitation orale du sujet édenté sont actuellement en cours d’évaluation.Par ailleurs une prise alimentaire de qualité implique la mise en jeu des différentes perceptions orales. Les interactions existantes entre l’altération de la santé bucco-dentaire chez la personne âgée, la mastication et les perceptions orosensorielles sont donc mises en évidence par une revue de littérature. Des facteurs impactant la prise alimentaire de la personne âgée sont également identifié. L’objectif à terme est de travailler sur les caractéristiques de l’aliment consommé (nature et texture) pour faciliter sa mastication, modifier sa perception orosensorielle et donc certainement favoriser sa consommation
This work focuses on the links between the edentulous elderly person oral health and his or her diet. Indeed, in the elderly, a regular and diversified food intake is to be sought to prevent protein-energy malnutrition. However, the rehabilitation of denture by removable dentures does not optimize or little diversification of food. The placement of implants by implant-retained prosthesis or scope remains restricted in this population. As such, one of the possible therapeutic solutions is the transformation of the removable prosthesis in implant-retained prosthesis by mini implants. The impact of this new procedure on masticatory function and patients' oral quality of life was evaluated by a follow-up study. This evaluation showed that the implant-retained prosthesis improves the masticatory capacity of subjects and its oral quality of life, but the masticatory efficiency remains well below that observed in elderly dented subjects.Subsequently, new therapeutic procedures using CAD / CAM (Design and Computer Aided Manufacturing) were developed and evaluated in rehabilitated subjects in the Odontology Department of the Estaing Hospital. The benefits of CAD / CAM in maintaining the oral health of the elderly were thus objectified. As a continuation of this work, new CAD / CAM procedures for the oral rehabilitation of the edentulous subject are currently being evaluated.Moreover, a quality food intake involves the bringing into play of different oral perceptions. The interactions between oral health impairment in the elderly, chewing and orosensory perceptions are therefore highlighted by a review of the literature. Factors affecting the food intake of the elderly are also identified. The ultimate goal is to work on the characteristics of the consumed food (nature and texture) to facilitate its chewing, modify its orosensory perception and thus certainly promote its consumption

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Medicina Dentária
Apesar da cavidade oral ser um local de fácil acesso e observação, a realidade é que a incidência do cancro oral no nosso país é cada vez mais elevada. O mais preocupante é, sem dúvida, o tardio diagnóstico deste tipo de patologia que acaba por contribuir para taxas de morbilidade e mortalidade elevadas. Desta forma, o conhecimento da sintomatologia adjacente ao cancro oral, quer por parte dos profissionais de saúde, quer por parte da população em geral, assume uma importância crucial para a minimização das taxas bem como das sequelas a que este tipo de patologia se associa. O tratamento do cancro oral assume diversas modalidades, entre as quais a cirurgia, a quimioterapia e a radioterapia, todavia é a cirurgia que se assume como tratamento de primeira linha, na maioria dos casos. Desta, resultam defeitos cirúrgicos que, quando acometem a maxila, designam-se por defeitos maxilares e que causam danos estéticos e funcionais que comprometem não só o estado físico do paciente como também o seu estado psicológico e funcional. A qualidade de vida dos pacientes maxilectomizados é, em muito, minimizada e a cura desta patologia passa não só pela erradicação da doença como também pela reabilitação estética e funcional do paciente permitindo o restabelecimento de funções básicas como a mastigação, deglutição e fonética. Assim sendo, e numa época em que o cancro oral é, cada vez mais, retratado é primordial que o médico dentista conheça, de forma abrangente, as diversas abordagens e procedimentos existentes que permitem a reabilitação do paciente, desde a cirurgia reconstrutiva, à reabilitação protética e até mesmo à reabilitação com implantes. Na busca por respostas para questões como “ O que fazer a um paciente após-maxilectomia?” ou “ Quais as opções de reabilitação que posso apresentar?” foi realizada uma revisão bibliográfica, tendo sido encontrados artigos relativos a esta temática publicados entre 1998 e 2014, pesquisados com palavras-chave como: oral cancer; oral rehabilitation; maxillary defects classifications; maxillofacial defects; prosthodontic rehabilition; prosthetic rehabilition in maxillary defects; inflatable hollow obturator; dental implants in maxillectomized patients; zigomatic dental implants; maxillectomy patient; e history of obturators. Como resultados desta foi possível constatar que a reabilitação oral do paciente maxilectomizado é ainda uma temática controversa nos dias de hoje. Apesar de tal facto, conclui-se que não existe apenas uma opção reabilitadora para estes pacientes, sendo diversas as abordagens que podem ser realizadas pelo que a existência de uma equipa multidisciplinar que integre profissionais de diversas áreas, desde a oncologia, cirurgia oral, prostodontia entre outras, é fundamental. De uma forma geral, foram abordadas três opções reabilitadoras à disposição destes pacientes sendo elas a cirurgia reconstrutiva com enxertos, a reabilitação protética destes defeitos, abordando-se os tipos de próteses obturadoras existentes; bem como a reabilitação com implantes dentários usando como recurso não só os implantes convencionais como também os implantes zigomáticos. Although the oral cavity is a place of easy access and observation, the reality is that the incidence of oral cancer in our country is increasingly high. The most principal problem is, undoubtedly, late diagnosis of this type of pathology that ultimately contributes to high rates of morbidity and mortality. Thus the knowledge of the symptomatology adjacent to oral cancer, which by health professionals or by general population, is very important for the minimization of rates and injuries that this disease provokes. The treatment of oral cancer could be surgery, chemotherapy and radiotherapy, however surgery is the first treatment, in the most of cases. When the maxilla is affect, the surgical defects are termed maxillary defects and these cause cosmetic and functional impairment that compromises not only the physical condition of the patient but also their psychological and functional status. The quality of life of maxillectomy patients are very low and the cure of this disease involves not only the eradication of the disease as well as the aesthetic and functional rehabilitation of the patient allowing the restoration of basic functions such as chewing, swallowing and speech. This way is essential that dentists know the various approaches and procedures for rehabilitate these patients as like reconstructive surgery, prosthetic rehabilitation and rehabilitation with implants. In this search, with the objective to answer a questions as like “What can I do in maxillectomized patients?” and “What are the options that I have to rehabilitate these patients?” were made a review with keys-words: oral cancer; oral rehabilitation; maxillary defects classifications; maxillofacial defects; prosthodontic rehabilition; prosthetic rehabilition in maxillary defects; inflatable hollow obturator; dental implants in maxillectomized patients; zigomatic dental implants; maxillectomy patient; e history of obturators. With this review was possible conclude that the oral rehabilitation of these patients is controversial. Despite this fact, the conclusion is that doesn´t exist only one option for these patients so is important have a multidisciplinary team that should integrate an oncologic specialists, oral surgeons, prosthetics and others. In general, three rehabilitative options are available to these patients wich are reconstructive surgery with grafts, prosthetic rehabilitation (obturator prosthesis) and the rehabilitation with dental implants that can be resorted with conventional implants or zygomatic implants.

Loss of speech is one important factor which contributes to a decrease of life quality for patients who undergo larynx removal following for example advanced laryngeal cancer. Several devices such as the electrolarynx and the tracheo-esophageal valve prosthesis (without oscillation) have been commercialized in order to restore speech. However, such voice restoration prosthesis are still limited for certain patients. The development of a new device using a valve of variable resistance entrained by a linear electromechanical transducer was investigated as a way to produce speech for patients with total laryngectomy (ablation of vocal folds). The concept was to undertake the design of a varying air flow resistance valve, built around existing Blom-Singer valves. The oscillating valve features a spherical head making it possible to block the opening in the wall between the trachea and the esophagus in a sinusoidal periodic fashion. A physical model of the vocal tract was built and used for preliminary in-vitro verification studies. The relationship between pressure and flow rate through the valve was determined from pressure measurements. The orifice discharge coefficient of the orifice was then calculated and the parameters of a variable resistor model were identified. Radiated sound pressure produced from the change in flow rate at the valve orifice was then compared to the original voice output to assess the accuracy of the design prototype. Results showed that the forced oscillating valve prosthesis model has lower power efficiency but can produce better sound quality than the electrolarynx.

Loss of limb through amputation presents a significant, life changing, circumstance for individuals. The prosthetist as the gate keeper to the health-care system and the facilitator of rehabilitation is essential to positive adjustment post-amputation. As yet, however, commonalities and differences in the understandings of each of these parties of the experience of limb loss, prosthesis use and rehabilitation remain unexamined. This comparison provides the focus for this study. Fifteen individuals post amputation and 13 prosthetists were interviewed on their perceptions of limb loss and prosthesis use. Semi structured interviews were conducted, face to face, via telephone or via email. Data were audio-recorded and transcribed as necessary and thereafter analysed using Interpretative Phenomenological Analysis (IPA) in order to gain an understanding of the subjective experiences of individuals with limb loss and of prosthetists of the post-amputation process. Analysis of the data led to identification of four key themes, namely Personal Identity, Social Identity, The Prosthesis and Communication. These themes were relevant for both groups. The meanings that they held for the two groups, however, differed in relation to key elements of the post-amputation experience. Both groups have a shared interest in the process of prosthetic limb fitting and rehabilitation and yet come from very differing perspectives. The fitting and use of a prosthetic device is not a simple, technical process but rather involves a combination of psychological, social and practical components all of which must be recognized in the rehabilitation process. The differing expectations and understandings held by both groups become especially evident in interactions between individuals with limb loss and prosthetists. Communications between members of these groups can provide a central point for addressing differences in their understandings of living with limb loss and might provide a focus for further developments in research and practice.

Background There are more than 300,000 persons in the U.S. living with transfemoral amputation (TFA). Persons with TFA use a knee prosthesis for gait and mobility. Presently, the C-Leg microprocessor knee prosthesis is the standard of care. C-Leg has significantly improved safety and cost efficacy and has created modest gains in gait efficiency. Recently, a new prosthesis has introduced a new sensor array and processor that reportedly improves knee motion, stair function and standing stability. Early claims of the reported functional benefits of the new Genium knee (formerly X2) have not been validated in a rigorous clinical trial. Therefore, the purpose of this project was to determine if the Genium knee improves safety, function and quality of life compared to the current standard of care (C-Leg). Methods The study is a randomized AB crossover with a control group. Subjects must have used (and still be using) a C-Leg for a minimum of 1yr prior to enrollment. Inclusion criteria beyond this are unilateral transfemoral or knee disarticulation amputation for any etiology, community level ambulation (Medicare level 3 or above), independent ambulation and ability to independently provide written, informed consent. Once enrolled subjects utilize their same socket but receive a study foot (Trias or Axtion). Subjects are randomly assigned to either stay with their C-Leg or be fit with a Genium knee. Subjects accommodate and test (A phase) then crossover to the other knee condition and repeat the testing (B phase). A follow up phase of the study beyond the B phase is ongoing to study longer term preference. For AB assessment, three domains were assessed: Safety, function and quality of life. For safety, the PEQ-A survey of stumbles and falls, posturography (Biodex SD limits of stability and postural stability tests), 4 square step test and 2 minute ramp stand test were completed. For function, a series of timed walking tests, the amputee mobility predictor, kinematic gait assessment and physical functional performance-10 tests were conducted. For quality of life, the socioemotional and situational satisfaction domains of the population specific and validated PEQ (prosthesis evaluation questionnaire) were completed. Results Safety: Posturographic assessment revealed impairment between transfemoral amputees and non-amputees. Stumbles and semi-controlled falls decreased with Genium but were not significantly different. Four square step testing was significantly (p 0.05) improved from 12.2s(3.3) to 11.1s(3.4) for the C-Leg and Genium respectively. Function: Kinematic asymmetry was minimally different between knee conditions. The AMP mean(SD) scores while subjects used C-Leg was 40.8(3.6; 33-45) and 43.3(2.6) [p<0.001]. PFP scores (cumulative), upper body function and endurance scores were improved with Genium compared with C-Leg at 9.1%(p=0.03), 8.7%(0.01) and 10.3%(0.04) respectively. Quality of Life: For quality of life, situational satisfaction favored Genium (p<0.001) which included subject's satisfaction with gait, training and quality of life in general. Conclusion C-Leg and Genium promote static weight bearing beyond asymmetric values reported in the literature. In terms of limits of stability, TFA's are clearly impaired, primarily over the amputated side posteriorly however the Genium seems to enable posterior compensations that coincide with multi-directional stepping improvements. Anteriorly, the C-Leg's toe triggering requirements seem to improve limits of stability but come at the cost of discomfort on ramp ascent. With regard to safety, it seems that both knee systems represent good options for the community ambulating TFA. The largest improvements with Genium were in the activities of daily living assessment; predominantly balance and upper body function. It seems that the combination of multi-direction stepping with starts and stops and stair ascent are key areas of improvement. In conclusion, the sensor array in the Genium knee prosthesis promotes improved function in activities of daily living. Specifically improved in this context were balance, endurance, multi-directional stepping, stair ascent and upper limb function in highly active transfemoral amputees.

Testing gait rehabilitation devices on humans can be a difficult task, due to the effects of the neurological controls of the human body. This thesis advances the use of a passive dynamic walker (PDW) tuned to have asymmetric gait patterns similar to those with physical impairments to test rehabilitation devices. A passive dynamic walker is a multipendulum system that has a stable gait pattern when walking down a slope without any energy inputs except the forces due to gravity. A PDW model is better suited for testing rehabilitation devices because it has been shown to resemble human gait and separates the human neurological controls from the purely dynamic aspects of walking. This research uses different asymmetric gait patterns based on an asymmetric PDW to aid in the design of current and future rehabilitation methods. There are four major parts to this research: (1) the derivation of the current nine mass PDW model, (2) the effects of changing the moment of inertia and center of mass on each leg, (3) the effects of having a leg that is longer than the other and adding masses on the opposite leg to generate a symmetric gait, and (4) the design of a theoretical prosthesis that will break the assumption that the knee on the prosthetic leg should be in the same location as the intact leg. The result of changing the moment of inertia and center of mass on each leg in the nine mass model showed that it is an improvement over the previously used five mass model. This is because the five mass model forces the center of mass to change with the moment of inertia, while the nine mass model allows these to be changed independently of each other. A theoretical prosthesis has been developed in this research that is is significantly lighter while maintaining a symmetric gait. This was accomplished by moving the knee of the prosthetic limb below the location of the intact knee.

Human gait is a complex process that involves the coordination of the central nervous and muscular systems. A disruption to the either system results in the impairment of a person’s ability to walk. Impairments can be caused by neurological disorders such as stroke and physical conditions like amputation. There is not a standardized method to quantitatively assess the gait asymmetry of affected subjects. The purpose of this research is to understand the fundamental aspects of asymmetrical effects on the human body and improve rehabilitation techniques and devices. This research takes an interdisciplinary approach to address the limitations with current rehabilitation methodologies. The goal of my Doctoral research is to understand the fundamental effects of asymmetry caused by physical and neurological impairments. The methods discussed in this document help in developing better solutions to rehabilitate impaired individuals’ gait. I studied four major hypothesis in regards to gait asymmetry. The first hypothesis is the potential of asymmetric systems to have symmetric output. The second hypothesis is that a method that incorporates a wider range of gait parameter asymmetries can be used as a measure for gait rehabilitation. The third hypothesis is that individuals can visually identify subtle gait asymmetries. Final hypothesis is to establish the relationship between gait quality and function. Current approaches to rehabilitate impaired gait typically focus on achieving the same symmetric gait as an able-body person. This cannot work because an impaired person is inherently asymmetric and forcing them to walk symmetrically causes them to adopt patterns that are not beneficial long term. Instead, it is more prudent to embrace the asymmetry of the condition and work to minimize in specific gait parameters that may cause more harm over the long run. Combined gait asymmetry metric (CGAM) provides the necessary means to study the effect of the gait parameters and it is weighted to balance each parameter’s effect equally by normalizing the data. CGAM provides the necessary means to study the effect of the gait parameters and is weighted towards parameters that are more asymmetric. The metric is also designed to combine spatial, temporal, kinematic, and kinetic gait parameter asymmetries. It can also combine subsets of the different gait parameters to provide a more thorough analysis. CGAM will help define quantitative thresholds for achievable balanced overall gait asymmetry. The studies in this dissertation conducted on able-body and impaired subjects provides better understanding of some fundamental aspects of asymmetry in human gait. Able body subjects test devices that aim to make an individual’s gait more asymmetric. These perturbations include a prosthetic and stroke simulator, addition of distal mass, and leg length alterations. Six able-body subjects and one amputee participated in the experiment that studied the effect of asymmetric knee height. The results which consisted of analyses of individual gait parameters and CGAM scores revealed that there is evidence of overall reduction of asymmetry in gait for both able-body subject on prosthetic simulators and transfemoral amputee. The transfemoral amputee also walked with a combination of distal mass with lowered knee height. Although this configuration showed better symmetry, the configuration is detrimental in terms of energy costs. Analyzing the data of gait with the stroke simulator showed that the subject’s gait does undergo alterations in terms of overall gait asymmetry. The distal mass and leg length alteration study has revealed some significant findings that are also reflected in the prosthetic study with distal mass. A leg length discrepancy (LLD) or the change of limb mass can result in asymmetric gait patterns. Although adding mass and LLD have been studied separately, this research studies how gait patterns change as a result of asymmetrically altering both leg length and mass at a leg’s distal end. Spatio-temporal and kinetic gait measures are used to study the combined asymmetric effects of placing LLD and mass on the opposite and same side. There were statistically significant differences for the amount of mass and leg length added for all five parameters. When LLD is added to longer leg, the temporal and kinetic gait parameters of the shorter limb and the altered limb’s spatial parameter become more asymmetric. Contrary to the hypothesis, there was no significant interaction between the amount of mass and leg length added. There were cases in all perturbations where a combination of mass and LLD make a gait parameter more symmetric than a single effect. These cases exhibit the potential for configurations with lower overall asymmetries even though each parameter has a slight asymmetry as opposed to driving one parameter to symmetry and other parameters to a larger asymmetry. CGAM analysis of the results revealed that the addition of distal mass contributes more towards overall asymmetry than LLD. Analyzing 11 gait parameters for LLD and mass on the same side showed that the overall asymmetry decreased for the combination of small LLD and mass. This is consistent with the findings from analyzing five individual gait parameters. Impaired subjects include individuals with stroke and amputees. The clinical trials for individuals with stroke involve training with the Gait Enhancing Mobile Shoe (GEMS) that pro- vides an asymmetric effect on the subject’s step length and time. Training with the GEMS showed improvement in clinical measures such as timed up and go (TUG), six minute walk test (6MWT), and gait velocity. The subjects also showed lower step length symmetry as intended by the GEMS. The ground reaction force asymmetries became more asymmetric as the spatial and temporal parameters became more symmetric. This phenomenon shows evidence that when an individual with stroke is corrected, for spatial and temporal symmetry is at the expense of kinetic symmetry. The CGAM scores also reflected similar trends to that of spatial and temporal symmetry and the r2 correlation with the gait parameters proved that double limb support asymmetry has no correlation with CGAM while ground reaction force asymmetry has a weak correlation. Step length, step, and swing time showed high correlation to CGAM. I also found the r2 correlation between the clinical measures and the CGAM scores. The CGAM scores were moderately correlated to 6MWT and gait velocity but had a weak correlation with TUG. CGAM has positive correlation with TUG and has negative correlation with 6MWT and gait velocity. This gives some validation to CGAM as a potential metric that can be used to evaluate gait patterns based on their asymmetries. Transfemoral amputees were tested for their gait with varied prosthetic knee heights to study the asymmetrical effects and trained split-belt treadmill. Asymmetric knee heights showed improvement in multiple gait parameters such as step length, vertical, propulsive, and braking force asymmetry. It also decreased hip and ankle angle asymmetries. However, these improvements did lead other parameters to become more asymmetric. The CGAM scores reflect this and they show overall improvement. Although the lowest knee height showed improvement, the input from the amputee suggested that the quality of gait decreased with the lowest knee height. These exploratory results did show that a slightly lower knee height may not affect the quality of gait but may provide better overall symmetry. Another exploratory study with split-belt treadmill training, similar to the protocol followed for individuals with stroke, showed definitive improvement in double limb support, swing time, step length and time symmetry. This was also reflected in the improvements seem post training in the CGAM scores as well. I found the r2 correlation of the CGAM and the gait parameters including gait velocity. Step length and swing time show consistent correlation for individual subjects and all the data combined to CGAM. Gait velocity shows a moderate correlation to CGAM for one subject and a high correlation to the other one. However, the combined data of gait velocities does not have any correlation with CGAM. These results show that CGAM can successfully represent the overall gait parameter asymmetry. The trends seen in the gait parameters is closely reflected in the CGAM scores. This research combines the study of asymmetry with people’s perception of human gait asymmetry, which will help in estimating the thresholds for perceivable asymmetrical changes to gait. Sixteen videos were generated using motion capture data and Unity game engine. The videos were chosen to represent the largest variation of gait asymmetries. Some videos were also chosen based on CGAM values that were similar but had large variation in underlying gait parameters. The dataset consisted of results of perturbation experiments on able-body subjects and asymmetric knee height prosthesis on transfemoral amputee. These videos were rated on a seven point Likert scale by subjects from 7 being normal to 1 being abnormal. Thirty one subjects took part in the experiment, out of which only 22 subject’s data was used because they rated at least 3 videos. The results show that the subjects were able to differentiate asymmetric gait with perturbations to able-body gait without perturbation at a self-selected speed. r2 correlation analysis showed that hip angle had mild correlation to the Likert scale rating of the 16 different gait patterns. Multivariate linear regression analysis with a linear model showed significant contribution of ankle and hip angles, vertical, propulsive, and braking forces. It is interesting that the majority of parameters that showed significance are not perceivable visually. Ankle and hip angles are visually perceivable and this significance revealed that subjects seemed to perceive asymmetric ankle and hip angles as abnormal. However, the subjects do not perceive asymmetric knee angles as completely abnormal with evidence of no significance, no correlation, and neutral Likert rating for gait patterns that perturbed knee angles.

Magister Scientiae (Physiotherapy) - MSc(Physio)
Persons with lower limb amputations (LLA) experience different challenges in the community. These challenges include the physical, psychological and social function of an individual. Little is known in Malawi on what persons with lower limb amputations go through in the communities where they live. Therefore, the study aimed at exploring and determining community experiences of persons with LLA in Malawi. The study sought to address the following objectives: 1) To determine the functional and psychological status of persons with LLA in the community; 2) To explore and describe experiences on social participation of persons with LLA in the community; 3). To explore experiences on community re-integration following LLA.

>Magister Scientiae - MSc
Persons with lower limb amputations (LLA) experience different challenges in the community. These challenges include the physical, psychological and social function of an individual. Little is known in Malawi on what persons with lower limb amputations go through in the communities where they live. Therefore, the study aimed at exploring and determining community experiences of persons with LLA in Malawi. The study sought to address the following objectives: 1) To determine the functional and psychological status of persons with LLA in the community; 2) To explore and describe experiences on social participation of persons with LLA in the community; 3). To explore experiences on community re-integration following LLA. A mixed method approach was applied where quantitative and qualitative data were collected simultaneously to provide a more holistic overview of the experiences of persons with LLA at one point in time. The study setting was Queen Elizabeth Central Hospital (QECH) and Kamuzu Central Hospitals (KCH) (500 miles), located in Malawi. A sample of 180 participants was recruited to participate in the study. Three self-administered questionnaires (socio-demographic questionnaire, OPUS module of lower extremity functional status, and a Beck’s depression inventory scale) and a semi-structured interview guide were used for data collection. Thematic data analysis was used to analyze qualitative data, while quantitative data was analyzed using descriptive and inferential statistics. Ethical clearance was obtained from the University of the Western Cape Biomedical Research Ethics Committee (BMREC) and College of Medicine Research Ethics Committee (COMREC). Permission to conduct the study was obtained from KCH (500 miles) and QECH. Privacy andconfidentiality was strictly observed such that data obtained was anonymous. It was kept in a secure place, and electronic data was secured using a password.

ITC/USA 2009 Conference Proceedings / The Forty-Fifth Annual International Telemetering Conference and Technical Exhibition / October 26-29, 2009 / Riviera Hotel & Convention Center, Las Vegas, Nevada
Even after rehabilitation, patients with lower-limb amputation may continue to exhibit suboptimal gait. A wireless telemetry system, featuring force sensors, accelerometers, control electronics and a Bluetooth transmission module was developed to measure plantar pressure information and remotely monitor patient mobility. Plantar pressure characterization studies were performed to determine the optimal sensor placement. Finally, the wireless telemetry system was integrated with a previously developed haptic feedback system in order to allow remote monitoring of patient mobility during haptic system validation trials.

Introdução: A reconstrução de grandes defeitos da face nem sempre é passível de correção cirúrgica, podendo ser restaurados com as próteses faciais. Apesar da prótese óculopalpebral apresentar uma aparência natural, ela é facilmente notada, pois não apresenta os movimentos palpebrais de abertura e fechamento sincronizadas com o olho contralateral, tornando assim a reconstrução protética um grande desafio. Objetivos: Planejar, desenhar, viabilizar e construir um protótipo com recurso mecânico/elétrico possibilitando sincronia dos movimentos palpebrais com o olho sadio para utilização em prótese óculopalpebral. Material e Métodos: Confecção de uma prótese óculopalpebral com um dispositivo de pálpebra móvel em silicone médico capaz de conectar-se a um sistema mecânico-elétrico responsável por realizar movimentos de abertura e fechamento da pálpebra móvel da prótese. Resultados e Discussão: Foi confeccionada uma prótese óculo-palpebral em resina acrílica termicamente ativada, criando-se um nicho para a acomodação de um sistema elétrico e possibilitar a livre movimentação de uma fina pálpebra em silicone interligada ao dispositivo tornando possível a conexão desse sistema com um sensor que capta o movimento palpebral de um olho saudável. Conclusão: No presente estudo um protótipo mecânico - elétrico foi planejado, desenhado e desenvolvido acoplado a uma prótese óculopalpebral estabelecendo e sincronizando seus movimentos palpebrais com o olho sadio.
Introduction: Surgical reconstruction of large facial defects may not be always possible. Extraoral maxillofacial prosthesis are a good restorative option. Even though when the oculopalpebral prosthesis presents a natural appearance, it can be easily noticed because its eyelids do not move. It is desirable for the eyelids to open and close synchronously with contralateral eye. Thus, prosthetic reconstruction of oculopalpebral region is a great challenge. Objectives: To plan, design, enable and build a oculopalpebral prosthesis prototype with mechanical and electric features allowing eyelid motion with synchronization with the sound eye. Material and method: Fabrication of an oculopalpebral prosthesis with a medical grade silicone movable eyelid which has the capability to connect itself to an mechanical-eletrical system responsible to make opening and closing movements on prosthesis movable eyelid. Results and discussion: An oculopalpebral prosthesis was made in thermoactivated acrylic resin. A gap was created to accomodate an electrical system and also allow free motion of a thin silicone eyelid attached to the dispositive. This system can be connected to a sensor which captured the eyelid motion of a sound eye. Conclusion: A mechanical-electrical prototype was planned, designed and developed attached to an oculopalpebral prosthesis stablishing and synchronizing its eyelid movements with the sound eye.

Orientador: Bruno Livani
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: A escolha do nível de amputação e da técnica cirúrgica a ser adotada nas amputações dos membros inferiores deve ser avaliada com muita atenção, pois influenciará diretamente na reabilitação física e na protetização do amputado. A preservação da articulação do joelho permitirá ao amputado uma marcha mais fisiológica e o processo de reabilitação mais funcional. Em situações específicas como nos traumas ortopédicos com lesão grave do membro inferior, a opção por uma amputação transtibial realizada imediatamente abaixo da tuberosidade tibial com manutenção da inserção do tendão patelar, pode resultar em cotos extremamente curtos, porem cotos funcionais. Amputados com cotos transtibiais extremamente curtos, com comprimento ósseo médio de 4,4cm, ao final do tratamento encontravam-se plenamente adaptados as próteses e satisfeitos com a qualidade de marcha após a reabilitação. Em situações eletivas, a indicação de amputações transtibiais clássicas podem ser substituídas por amputações com periosteoplastia tibio-fibular ou amputações com o uso do retalho plantar neuro-vascular pediculado e com fusão do calcâneo à tíbia. Os pacientes submetidos à técnica de periosteoplastia apresentaram grande capacidade na realização de descarga distal sem dor, durante a utilização de suas próteses. Pacientes submetidos às amputações transtibiais com uso do retalho plantar neuro-vascular pediculado e com fusão do calcâneo à tíbia, apresentaram como resultado um coto ósseo distal bastante estável, com maior área terminal para descarga de peso e fixação do próprio soquete protético, contribuindo muito no processo de reabilitação. Nestas três situações distintas, realizadas com técnicas cirúrgicas não convencionais, como nos cotos transtibiais extremamente curtos, na perioplastia tibio-fibular e com uso retalho plantar neuro-vascular pediculado e fusão do calcâneo à tíbia; excelentes resultados puderam ser observados no processo de reabilitação e na confecção customizada das próteses, quando comparada com as amputações transtibiais clássicas
Abstract: The choice of the level of amputation and surgical technique to be adopted in lower limb amputations should be assessed carefully, because it will influence directly on the fitting and physical rehabilitation of the amputee. The preservation of the knee joint renders the amputee a more physiological gait and a more functional process of rehabilitation. In specific situations, such as orthopedic trauma with severe lower limb injury, the option for a transtibial amputation performed just below the tibial tuberosity, with maintenance of the insertion of the patellar tendon, can result in extremely short, stumps, but functional stumps. Transtibial amputees with stumps extremely short, with an average bone length of 4.4cm, were fully adapted to the prostheses and satisfied with the quality of gait after rehabilitation. In elective situations, the classical transtibial amputations can be substituted by amputations with tibio-fibular periosteoplasty or the use of a neuro-vascular pediculated plantar flap graft, with fusion of the calcaneous to the tibia. Patients undergoing periosteoplasty technique presented a painless and high capacity terminal discharge during use of the prostheses. Patients submitted to a neuro-vascular pediculated plantar flap graft with fusion of the calcaneous to the tibia, presented a stable distal bone stump with a larger distal bearing area and better fixation of the prostheses, contributing positively to the rehabilitation process. In these three different situations, that made use of no convencional surgical techniques, as in the extremely short leg stumps, tibio-fibular periosteoplasty and the use of a neuro-vascular pediculated plantar flap graft, with fusion of the calcaneous to the tibia; excellent results may be achieved in the rehabilitation process and in the fitting of custom prostheses, when compared with traditional transtibial amputations
Doutorado
Fisiopatologia Cirúrgica
Doutor em Ciências

Recent interest in using passive dynamic walkers (PDWs) for gait rehabilitation studies has presented a need for a robust, easily built mechanism. Unfortunately, these passive robots are hypersensitive to many variables outside of the usual design considerations that are studied when constructing them. By accentuating previous failures instead of suppressing them, this thesis presents a number of problematic situations commonly experienced when testing and tuning a PDW. Further, through a complete design of a 4-legged PDW with knees, simple design axioms brought about by myself and others are put into a practical context and applied directly to design. This thesis aspires to present a systematic design process, and highlight how a computational model can be used with both hand calculations and CAD packages. Using the insight from those researchers before me, I strive to further their designs and present relevant information in a design compendium that makes it more useful to those who have an application for the device. This thesis resulted in two novel designs for a PDW. First, a changing radius foot was developed to increase knee flexion upon toe off. The decrease in radius increases joint angular velocity resulting in ramp up. Further investigation of these feet could result in more stable and efficient walking patterns. The other design brought to attention is the planar crossbar mechanism for coupling the inner and outer legs. The crossbar provides a rigid coupling without changing the rotational inertia between the coupled pair about the hip axis.

En los últimos años, la tendencia en la odontología restauradora es la conservación al máximo de los tejidos dentarios remanentes, siendo esto así, lo que se buscan son alternativas diferentes para poder rehabilitar la perdida de piezas en los pacientes que se acercan a la consulta. Las prótesis híbridas adhesivas combinan una prótesis fija convencional (coronas) con aditamentos de un mínimo desgaste (carillas). Se presenta un caso clínico de un paciente de 43 años de edad de sexo masculino que acudió a la clínica de la Universidad Peruana de Ciencias Aplicadas (UPC) en el año 2018 por presentar fractura corono radicular de un incisivo central superior, pilar de una prótesis parcial fija que provocaba la movilidad de la prótesis y alteraba la estética. Se planificó una prótesis híbrida que combinó una corona cerámica libre de metal en el incisivo central y carillas cerámicas (vestibular y palatino) en el incisivo lateral. El caso clínico evidenció una mejora de la estética, preservó tejidos dentarios y mejoró la satisfacción por parte del paciente con respecto a su sonrisa. La combinación de una prótesis convencional libre de metal y las carillas cerámicas son una alternativa eficiente para el manejo del edentulismo parcial antero superior con un mínimo de desgaste de las piezas dentarias.
In recent years, the trend in restorative dentistry is the maximum conservation of the remaining dental tissues, and this being so, what are sought are different alternatives to be able to rehabilitate the loss of parts in patients who come to the consultation. The hybrid adhesive prostheses combine a conventional fixed prosthesis (crowns) with minimal wear attachments (veneers). We present a clinical case of a 43-year-old male patient who attended the clinic of the Peruvian University of Applied Sciences (UPC) in 2018 for presenting a radicular crown fracture of an upper central incisor, a pillar of a fixed partial prosthesis that it caused the mobility of the prosthesis and altered the aesthetics. We planned a hybrid prosthesis that combined a metal-free ceramic crown in the central incisor and ceramic veneers (buccal and palatal) in the lateral incisor. The clinical case evidenced an improvement in aesthetics, preserved dental tissues and improved patient satisfaction with respect to his smile. The combination of a conventional metal-free prosthesis and ceramic veneers is an efficient alternative for the management of upper partial anterior edentulism with minimal wear of the teeth.
Trabajo académico

Orientador: Renata Cunha Matheus Rodrigues-Garcia
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba
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Resumo: Estudos revelam melhora na mastigação após o uso de próteses sobre implantes osseointegrados. Entretanto, poucos são aqueles que avaliam a mastigação de pacientes parcialmente edêntulos, comparando a função mastigatória após a reabilitação por meio de diferentes próteses parciais, o qual foi o objetivo deste ensaio clínico pareado. Para tanto, foram selecionados 12 voluntários (8 gênero feminino, idade média 62.6 ± 7.8 anos), apresentando edentulismo total superior e parcial inferior (classe I de Kennedy), os quais receberam, de forma sequencial, próteses parciais removíveis (PPR), PPR com encaixe implanto-retido (PPRI) e prótese parcial fixa sobre implantes (PPFI). Todos os tratamentos foram realizados na mandíbula e utilizados por 2 meses antes da avaliação mastigatória, enquanto a maxila recebeu uma nova prótese total que foi utilizada durante todo o estudo. A mastigação foi avaliada por meio da mensuração da performance mastigatória (PM), índice de trituração dos alimentos (ITA), força máxima de mordida (FMM), espessura dos músculos masseter e temporal, movimento mastigatório, limiar de deglutição (LD), habilidade mastigatória, estado nutricional, qualidade de vida (QV) e satisfação do paciente. Foi realizada a análise exploratória dos dados e aplicada análise de variância para medidas repetidas seguido de teste de Tukey-Kramer para as comparações múltiplas entre os tratamentos. Todas as análises foram realizadas utilizando SAS software (release 9.1, 2003; SAS Institute Inc., Cary, USA) (p ? 0.05). A PM melhorou consideravelmente após o uso de PPRI e PPFI com aumento de 85% e 87%, respectivamente. Resultados similares foram observados em relação ao ITA e à FMM com aumento (p ? 0.0001) de 91% e 62% no ITA de 79% e 62% na FMM após o uso de PPRI e PPFI, respectivamente. Independente do tipo de prótese, o uso de PPRI e PPFI aumentou a espessura do masseter durante a contração voluntária máxima (p ? 0.0001) e alterou o movimento mastigatório, reduzindo o tempo total do ciclo, bem como a duração das fases de abertura e fechamento (p ? 0.05). A habilidade mastigatória melhorou após o uso da PPRI e PPFI, independente do alimento avaliado. O LD foi alterado pelo tratamento reabilitador, com redução no número de ciclos e tamanho da partícula triturada, sendo os menores valores observados com o uso da PPFI. Houve aumento no consumo de fibras (p = 0.007), cálcio (p = 0.001) e ferro (p = 0.02) após o uso de PPFI, além da redução no consumo de alimentos com altos níveis de colesterol (p = 0.02). A satisfação aumentou (p ? 0.05) e o impacto da saúde oral na QV reduziu, tanto no score geral (p = 0.04) quanto no domínio de dor física (p = 0.02) após o uso da PPFI. A reabilitação de pacientes parcialmente edêntulos com PPRI e PPFI melhorou significativamente a função mastigatória e a magnitude do efeito relacionou-se ao tipo de prótese
Abstract: Studies revealed the masticatory improvement after the use of prosthesis over dental implants. However, few are those who evaluated the chewing of partially edentulous patients, comparing the masticatory function after treatment with different partial dentures, which was the aim of this paired clinical trial. Therefore, 12 volunteers (8 females, mean age 62.6 ± 7.8 years) presenting total edentulism in maxilla and partial edentulism in the mandible (Kennedy class I) were selected and received, in a sequential way, a conventional removable partial dentures (RPD), implant-retained partial dentures (IRPD) and implant fixed partial denture (IFPD). All treatment were assembled in the mandible and used for 2 months, while the edentulous maxilla received a new complete denture which was used throughout the study. Mastication was assessed by measuring masticatory performance (MP), food comminution index (FCI), maximum bite force (MBF), masseter and temporal muscle thickness, chewing movements, swallowing threshold (ST), masticatory ability, nutritional status, quality of life (QOL) and patient satisfaction. Data were analyzed and repeated measures analysis of variance was applied followed by Tukey-Kramer multiple for comparisons between treatments. All analyzes were performed using SAS software (release 9.1, 2003, SAS Institute Inc., Cary, USA) (p ? 0.05). MP greatly improved after IRPD and IFPD use with an increase of 85% and 87% respectively. Similar results were observed in respect to FCI and MBF with an increase (p ? 0.0001) of 91% and 62% in FCI and of 79% and 62% in MBF after the IRPD and IFPD use, respectively. Regardless the prosthesis type, the use of IRPD and IFPD increased the masseter thickness during maximum voluntary clenching (p ? 0.0001) and altered the chewing movements, reducing the total cycle time, as well as the duration of opening and closing phases (p ? 0.05). MA improved after IRPD and IFPD use, irrespectively of the food rated. ST was affected by prosthetic treatment, showing a reduction in the number of chewing cycles and in the size of the comminuted particle, with the lowest values observed after IFPD use. There was a raise in fiber (p = 0.007), calcium (p = 0.001) and iron (p = 0.02) intake after the IFPD use and a reduction in the intake of food with high cholesterol levels (p = 0.02). Patients satisfaction also increased (p ? 0.05) and the impact of oral health on QOL decreased in overall score (p = 0.04) and in the physical pain domain (p = 0.02) after the IFPD use. The rehabilitation of partially edentulous patients with IRPD and IFPD significantly improved masticatory function and the magnitude of the effect was related to the prosthesis type
Doutorado
Protese Dental
Doutora em Clínica Odontológica

Este estudo foi realizado com o objectivo de avaliar a existência ou não de relação entre a adaptação de próteses auditivas e o acréscimo da qualidade de vida nos idosos. Para tal, foram analisados dois grupos, sendo um designado de grupo controlo, com 30 pessoas que necessitam de prótese auditiva, mas que não foram protetizados; e o outro de grupo teste, com 30 pessoas que necessitam de próteses e que foram protetizados. Na primeira consulta, em ambos os casos, foram realizados exames auxiliares de diagnóstico e a aplicação de um questionário de investigação do handicap auditivo. Após 3 meses, o questionário foi novamente aplicado nos dois grupos e os resultados foram comparados. Por último, foi realizada a análise dos dados de acordo com as variáveis observadas, cujos resultados sugerem a melhoria da qualidade de vida "auditiva" nos idosos. ABSTRACT; This study was carried out by with objective of assessing the existence of a relationship between the adaptation of hearing prosthesis and the improvement in the quality of life in the elderly. Two groups were stipulated: a control control, with 30 persons who needed, but did not have hearing aids; and the test group, comprised of 30 persons who needed and had hearing aids. During the first consultation, both groups, underwent auxiliary diagnostic tests and were given a questionnaire to assess their hearing handicap. After 3 months, the questionnaire was once again administered to both groups, and the results were compared. Lastly, the analysis of the data was carried out in accordance with the observed variables.

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The loss of hip mobility, spontaneous or surgical, is an important and frequent functional impairment. In the evolvement of operative techniques of the muscoskeletal system, the cemented total hip replacement is pointed out since it improves the patients quality of life. Physiotherapy is an important resource in the patients care after Total Hip Replacement (THR) to aid their functional return. Objective: to analyze the physiotherapy intervention in the improvement of pain, gait, mobility and quality of life in the postoperative period of patients who have undergone THR, moreover, comparing the physiotherapic ambulatory rehabilitation with orientations and self-care guide.Casuistics and Method: This is a randomized clinical trial and double blinded study, in which patients with osteoarthritis submitted to THR in the period of May to October 2005 were evaluated. They were objectively evaluated either for pain, gait or mobility, according to D´Aubigné and Postel´s criteria in the preoperative, with 1 month and 3 months of postoperative, respectively. Life quality was evaluated by means of the questionnaire SF-36. The patients were randomly divide into two groups: the study group and the control group. The patients of the study group were submitted to a protocol of physiotherapic treatment during twelve weeks, with two-week sessions. The control group did not receive the guide of instructions related to postoperative cares. Mood´s median test was used to evaluate the results for the non-parametric values to compare the results between the groups. Wilcoxon´s test was used to compare the evolution of the groups. A level of significance of p=0.05, with a confidence interval (CI) of 95% was used. Results: Twenty patients, 10 from the study group and 10, the control group, finished the study. In the first evaluation, there was a significance just regarding the general state of health. This showed a smaller median in the study group (p=0.025), In the second, at the 30th PO period, there was statistical significance in relation to the study group regarding both the gait (p=0.007) and the mobility (p=0.001). In the third, there was a statistical significance after three months of postoperative, and at the end of the physiotherapeutic intervention in the study group: in the functional capacity (p<0.0005), in the physical aspects (p=0,002), in the pain (p=0,019), in the vitality (p=0,025), in the emotional aspects (p<0.0005), in the gait (p=0.001) and in the mobility (p=0.010). Regarding the evolution, after three months of postoperative period, a greater median was observed in the study group according to the physical capacity (p=0.006), physical aspects (p=0,002), general state of health (p<0,0005), vitality (p=0,025) and emotional aspects (p=0,001). Conclusion: Early physiotherapy procedures can improve the rehabilitation process of patient´s submitted to THR.
A perda de mobilidade do quadril, espontânea ou cirúrgica, é um comprometimento funcional importante e freqüente. Na evolução das técnicas operatórias do aparelho locomotor, destacam-se as relacionadas com a substituição da articulação do quadril por uma prótese total de quadril cimentada que melhora a qualidade de vida dos pacientes. A fisioterapia é um importante recurso nos cuidados de pacientes após a Artroplastia Total de Quadril (ATQ) para auxiliar o retorno funcional. Objetivos: analisar a intervenção da fisioterapia na melhora da dor, marcha, mobilidade e qualidade de vida no pós-operatório de pacientes que realizaram ATQ cimentada, além de comparar a reabilitação fisioterapêutica ambulatorial com um guia de orientações e auto-cuidados. Casuística e Método: Trata-se de um ensaio clínico aleatorizado, mono-cego, no qual foram avaliados os pacientes portadores de osteoartrose submetidos a ATQ no período de maio a outubro de 2005. Os pacientes foram avaliados objetivamente quanto à dor, marcha e mobilidade, de acordo com os critérios estabelecidos por DAubigné e Postel no pré-operatório, com 1 mês e 3 meses de pós-operatório, respectivamente.A qualidade de vida foi avaliada por meio do questionário SF-36. Os pacientes foram divididos, de forma aleatória em dois grupos - o grupo de estudo e o grupo controle. Os pacientes do grupo de estudo foram submetidos a um protocolo de tratamento fisioterapêutico durante doze semanas, com duas sessões semanais. O grupo controle não recebeu intervenção fisioterapêutica padronizada precocemente, tendo recebido apenas o guia de instruções quanto aos cuidados pós-operatórios. Os resultados foram avaliados pelo teste de Mediana de Mood para valores não paramétricos a fim de comparar os resultados entre os grupos. Nota de Resumo A evolução dos grupos foi comparada utilizando-se o teste estatístico de Wilcoxon. Adotou-se um nível de significância de p= 0,05, com intervalo de confiança (IC) de 95%. Resultados: 20 pacientes terminaram o estudo, 10 pertenciam ao grupo de estudo e 10 ao grupo controle. Na avaliação inicial, houve significância apenas com relação ao estado geral de saúde, que demonstrou uma menor mediana no grupo de estudo (p=0.025).Na segunda avaliação, realizada no 30 PO, houve significância a favor do grupo de estudo com relação à marcha (p=0,007) e com relação à mobilidade (p=0,001). Na terceira avaliação, realizada após três meses de pós-operatório e ao término da intervenção fisioterápica no grupo de estudo, houve significância na capacidade funcional (p<0,0005), nos aspectos físicos (p=0,002), na dor (p=0,019), na vitalidade (p=0,025), nos aspectos emocionais (p<0,0005), na marcha (p=0,001) e na mobilidade (p=0,010). Quanto à evolução, após três meses de pós operatório, percebeu-se uma maior mediana no grupo de estudo quanto à capacidade física (p=0,006), aspectos físicos (p=0,002), estado geral de saúde (p<0,0005), vitalidade (p=0,025) e aspectos emocionais (p=0,001). Conclusão: A fisioterapia precoce auxilia no processo de recuperação dos pacientes submetidos a ATQ.

Introdução: Desde as primeiras laringectomias totais, a perda da voz natural é considerada uma das principais consequências. Durante décadas, têm-se desenvolvido mecanismos e próteses na tentativa de conseguir a reabilitação vocal com taxas variáveis de sucesso. Após a introdução das punções traqueoesofágicas e passagem da prótese fonatória, esta passou a ser o método de escolha. A passagem primária (PTE1) traz a vantagem da utilização mais precoce da voz, no entanto, existe a preocupação com o risco aumentado de complicações. Objetivo: Comparar as complicações e o sucesso na reabilitação vocal de pacientes submetidos à reabilitação por punção tráqueoesofágica (PTE) primária e secundária por meio de uma revisão sistemática. Métodos: Foram incluídos estudos que compararam a eficácia da PTE primária e secundária quanto a reabilitação fonatória e taxas de complicações. Foi consultada a base de dados eletrônica MedLine via Pubmed, Scielo, Lilacs, Cochrane e Websco até junho de 2016, utilizando-se a estratégia de busca com descritores os \"laryngectomy AND (tracheoesophageal puncture OR punctures)\", \"(laryngeal neoplasms OR laryngectomy) AND (pharyngocutaneous fistula OR cutaneous fístula)\" no PubMed e EMBASE; e \"(neoplasias laríngeas OR laringectomia) AND (fistula cutânea)\" no MEDLINE. Resultados: Para o vazamento ao redor da prótese, o grupo PTE1 apresentou índice maior que o PTE2 (22,5% vs. 6,9%), p=0,03. Houve maior ocorrência de infecção de ferida operatória (9,1% vs. 3,9%) e para estenose de traqueostoma (8,5% vs. 4,5%) no grupo PTE1 em relação ao PTE2, porém, sem significado estatístico. A avaliação da qualidade de voz não foi possível devido à heterogeneidade dos estudos. Conclusão: Há redução do risco de vazamento ao redor da prótese de aproximadamente 10% no grupo de pacientes submetidos à punção traqueoesofágica secundária
Introduction: Since the first total laryngectomy was performed, the loss of natural voice has been considered one of its main consequences. For decades, mechanisms and prosthesis have been developed in an attempt to achieve speech rehabilitation with varying rates of success. After the introduction of the tracheoesophageal puncture and placement of the voice prosthesis, this has become the method of choice. The primary passage (TEP1) has the advantage of earlier use of the voice; however, there is the concern about the possible increased risk of complications. Objective: To compare the complications and success in speech rehabilitation of patients undergoing rehabilitation after primary and secondary tracheoesophageal puncture (TEP1 and TEP2) through a systematic review. Methods: The literature survey included research in MedLine, Scielo, Lilacs, Cochrane and Websco until June, 2016 considering the descriptors \"laryngectomy AND (tracheoesophageal puncture OR punctures)\", \"(laryngeal neoplasms OR laryngectomy) AND (pharyngocutaneous fistula OR cutaneous fistula)\" in PubMed and EMBASE; and \"(neoplasias laríngeas OR laringectomia) AND (fístula cutânea)\" in MedLine. The intervention analyzed was rehabilitation with TEP1 and TEP2 regarding complications and speech rehabilitation. Results: The rate of leakage around the prosthesis was higher in TEP1 (22.5% vs. 6.9%), p=0.03. There were higher rates of wound infection (9.1% vs. 3.9%) and tracheal stenosis (8.5% vs. 4.5%) in TEP1 group in relation to TEP2, with no statistical significance, however. The evaluation of speech quality was not possible due to the heterogeneity of the studies. Conclusion: There is a reduction of the risk of leakage around the prosthesis of approximately 10% among TEP2 patients

Este estudo avaliou a qualidade dos preparos de boca para confecção de próteses parciais removíveis (PPRs), comparando os preparos realizados na graduação da Faculdade de Odontologia da Universidade de São Paulo (FOUSP), sob supervisão de Docentes, com os preparos realizados por cirurgiões dentistas que solicitaram a confecção dessas próteses a dois laboratórios de Prótese Dentária de São Paulo. As análises foram realizadas em 92 modelos de trabalho, divididos em dois grupos: grupo I, modelos obtidos de pacientes que foram reabilitados na Disciplina de Prótese Removível da FOUSP, por alunos de graduação, e grupo II, modelos obtidos de pacientes que foram reabilitados por vários profissionais, e que foram recolhidos dos referidos laboratórios. Foi utilizado como instrumento de avaliação, o Índice de Preparo de Boca modificado (IPB), com o objetivo de avaliar comparativamente, os dois grupos, quanto a Distribuição, Localização e Forma dos descansos oclusais e de cíngulo; Presença, Distribuição e Paralelismo dos planos-guia; Características dos pontos de calibragem; e a diferença estatística dos valores do IPB, entre os grupos. Ainda foi investigada a prevalência da classificação de Kennedy (para pacientes desdentados parciais), nos dois grupos de modelos. O método estatístico utilizado foi o teste não paramétrico de Mann-Whitney. Baseado nos resultados encontrados, concluiu-se que os preparos de boca dos trabalhos realizados na Faculdade de Odontologia da Universidade de São Paulo (grupo I, modelos-USP) foram significativamente melhores do que aqueles elaborados por profissionais, cirurgiões dentistas que enviaram os modelos de seus pacientes aos laboratórios, para confecção de PPRs (grupo II, modelos-Laboratórios). Não houve associação estatisticamente significante entre os grupos de modelos no que se refere à classificação de Kennedy.
This study analysed the quality of mouth preparations for manufacturing removable parcial dentures (RPDs) by comparing preparations made by undergraduates at Faculdade de Odontologia da Universidade de São Paulo (FOUSP) working under the supervision of staff teachers with preparations made by dentist surgeons who had sent prostheses to two dental prosthesis laboratories in São Paulo for manufacturing. Analyses were carried out in 92 models divided in two groups: group I, models obtained from patients rehabilitated by undergraduates in the subject Removable Prosthesis at FOUSP and group II, models obtained from patients rehabilitated by several professional dentist surgeons and collected at the two laboratories mentioned above. The instrument of assessment used was the modified Mouth Preparation Ratio (IPB), aiming at assessing the two groups comparatively concerning the Distribution, Location and shape of rest bite and cingulum occlusion, Presence, Distribution and Paralelism of guide planes; Characteristics of the calibration points; and the statistical difference in IPB values between the two model groups. The prevalence of the Kennedy classification (for parcially toothless patients) was also investigated in both model groups. The statitical method used in both groups was the Mann-Whitney non-parametric test. Based on the results achieved, it was concluded that mouth preparations made at Faculdade de Odontologia da Universidede de São Paulo (group I, USP models) were significantly better than those made by professional dentist surgeons who had sent their patients models to the dental laboratories for manufacturing RPDs (group II, lab models). There was no statistically significant association between both groups concerning the Kennedy classification.

Próteses auriculares tem o objetivo de proporcionar uma maior confiança a pacientes com perdas parciais ou totais da orelha. A aparência realista de uma prótese é fator fundamental para a recuperação psicossocial dos pacientes, pois auxilia na dissimulação da perda. O procedimento convencional de elaboração de próteses auriculares envolve o trabalho de um especialista que utiliza processos manuais para recriar a forma singular de uma orelha. Este é um processo lento, complexo e naturalmente pode ocasionar imperfeições. Este estudo apresenta um procedimento que, a partir de exames de imagem, utiliza técnicas computacionais de reconstrução, espelhamento e inversão de modelos tridimensionais para manufatura aditiva (impressão 3D) de moldes. Os resultados mostram que a prótese elaborada utilizando o processo exibe alto grau de realismo, apresentando 97,8% de similaridade dimensional comparada com a orelha sã do paciente.
Auricular prostheses are intended to provide confidence to patients with partial or total loss of the ear. The realistic appearance of a prosthesis is a key factor for the psychosocial recovery helping in dissimulation of loss. The standard procedure of auricular prosthesis design involves the work of an expert using manual processes to recreate the complex shape of the ear. This slow and complex process can easily lead to imperfections. This study presents a procedure that starting from an image exam uses computational techniques of reconstruction, mirroring and inversion of three-dimensional models for additive manufacturing (3D printing) of molds. The results show that the designed prosthesis using the process has a high level of realism, with 97.8% of similarity compared to the healthy ear of the patient.

A finalidade desse trabalho é desenvolver um protótipo de uma prótese antropomórfica multifuncional para membros superiores para pacientes amputados. Seu objetivo é substituir a mão natural perdida, de forma a auxiliar a realização de algumas tarefas diárias do usuário. A prótese possuirá características antropomórficas, tais como aparência e movimentação semelhantes às da mão humana, e características naturais inerentes à mesma, por exemplo, o arco reflexo. Além disso, contará também com meios de realimentação táteis das informações de forças aplicadas pela prótese em objetos, bem como sua temperatura para o paciente, suprindo assim uma das carências das próteses convencionais. Esse dispositivo terá incorporado na sua construção sensores diversos para realizar as funções propostas e contará com um algoritmo baseado em redes neurais artificiais, capaz de identificar padrões dos sinais mioelétricos do paciente, que serão utilizados como sinais de controle, possibilitando ao paciente um comando natural. Todas essas implementações visam contribuir para a redução da taxa de rejeição de próteses para membros superiores e possibilitar uma maior reabilitação e reintegração do paciente à sociedade.
The purpose of this assignment is to develop a multifunctional and anthropomorphic upper limb prosthesis prototype for amputated patients. Its objective is to substitute the natural lost hand, in a way to improve the performance of regular activities. This prosthesis will have anthropomorphic characteristics, like appearance and movement, similar to the ones of the human hand, and natural characteristics inherent to it, for example the reflected arc. Another characteristic will be the tactile feedback ways of obtaining the information of the forces applied by the prosthesis in objects, as well as their temperature for the patient, overcoming therefore one of the traditional prosthesis\' deficiency. This device will have incorporated in its construction many sensors in order to do the proposed functions and it will use an algorithm based on the artificial neural network that is able to recognize patterns of myoelectric signals of the patient, which will be used as control signals, making possible to the patient a natural command. All of these implementations objective to contribute for the reduction of the rejection rate of prostheses for upper limb members and make possible a better rehabilitation and reintegration of the patient in the society.

This thesis proposes an algorithm that determine the geometry of 3D-printed, custom-designed spring element bands made of thermoplastic elastomer (TPE) for use in a wearable orthotic device to aid in the physical therapy of a human hand exhibiting spasticity after stroke. Each finger of the hand is modeled as a mechanical system consisting of a triple-rod pendulum with nonlinear stiffness at each joint and forces applied at the attachment point of each flexor muscle. The system is assumed quasi-static, which leads to a torque balance between the flexor tendons in the hand, joint stiffness and the design force applied to the fingertip by the 3D-printed spring element. To better understand material properties of the spring element’s material, several tests are performed on TPE specimens printed with different infill geometries, including tensile tests and cyclic loading tests. The data and stress-strain curves for each geometry type are presented, which yield a nonlinear relationship between stress and strain as well as apparent hysteresis. Polynomial curves are used to fit the data, which allows for the band geometry to be designed. A hypothetical hand is presented along with how input measurements might be taken for the algorithm. The inputs are entered into the algorithm, and the geometry of the bands for each finger are generated. Results are discussed, and future work is noted, providing a means for the design of a customized orthotic device.

The loss of a hand or arm is a devastating life event that results in many months of healing and challenging rehabilitation. Technology has allowed the development of an electronic replacement for a lost limb but similar advancements in therapy have not occurred. The situation is made more challenging because people with amputations often do not live near specialized rehabilitation centres. As a result, delays in therapy can worsen common complications like nerve pain and joint stiffness. For children born without a limb, poor compliance with the use of their prosthesis leads to delays in therapy and may affect their development. In many parts of the world, amputation rehabilitation does not exist. Fortunately, we live in an age where advances in technology and engineering can help solve these problems. Virtual reality creates a simulated world or environment through computer animation much like what is seen in modern video games. An experienced team of rehabilitation doctors, therapists, engineers and computer scientists are required to realize a system such as this. A person with an amputation will be taught to control objects in the virtual world by wearing a modified electronic prosthesis. Using computers, it will be possible to analyze his or her movements within the virtual world and improve the wearer's skills. The goals of this system include making the system portable and internet compatible so that people living in remote areas can also receive therapy. The novel approach of using virtual reality to rehabilitate people with upper limb amputations will help them return to normal activities by providing modern and appropriate rehabilitation, reducing medical complications, improving motivation (via gaming modules), advancing health care technology and reducing health care costs. The use of virtual reality technology in the field of amputee rehabilitation is in its earliest stages of development world wide. A virtual environment (VE) will facilitate the early rehabilitation of a patient before they are clinically ready to be fitted with an actual prosthesis. In order to create a successful virtual reality rehabilitation system such as this, an accurate method of tracking the arm in real-time is necessary. A linear displacement sensor and a microelectromechanical system (MEMS) inertial measurement unit (IMU) were used to create a device for capturing the motion of a user's movement with the intent that the data provided by the device be used along with a VE as a virtual rehabilitation tool for new upper extremity amputation patients. This thesis focuses on the design and testing of this motion capture device in order to determine the suitability of current commercially available sensing components as used in this system. Success will be defined by the delivery of accurate position and orientation data from the device so that that data can be used in a virtual environment. Test results show that with current MEMS sensors, the error introduced by double integrating acceleration data is too significant to make an IMU an acceptable choice for position tracking. However, the device designed here has proven to be an excellent cable emulator, and would be well suited if used as an orientation tracker.

博士
長庚大學
臨床醫學研究所
98
More than 6,800 lower-extremity amputations (LEA) are performed annually in Taiwan. Living with limb loss may cause a number of challenges in physical, psychological and social dimensions, as well as quality of life. Although it has been demonstrated that support groups can decrease individual’s stress and promote their adjustment, no study has examined the effectiveness of a support group program for people with LEA in Taiwan. The major purposes of this study were to (1) develop the amputee support group (ASG) program for patients with LEA specifically, and (2) evaluate the effectiveness of the ASG program. This study included 2 phases. In phase I, according to the findings of phenomenological approach and many other methods, the needs of amputees were assessed and an ASG program was developed with cultural consideration. The 6-session support group program ran for 2-hour twice a week for a period of 3 weeks. In phase II, a quasi-experimental trial with a time-series design was selected to identify the outcomes of the ASG program. The study subjects were recruited from three large prosthetic rehabilitation centers in northern part of Taiwan. Out of 85 eligible patients were assigned into the experimental group (attending 3-week ASG program) or the control group (CG, received routine care) according to their personal choice, 78 completed the study (ASG group = 34, CG = 44). Instruments included the Chinese version of Medical Outcomes Study Short-Form Health Survey (SF-36), Center for Epidemiological Studies Depression Scale (CES-D) and Multidimensional Scale of Perceived Social Support (MSPSS). Data were collected at pre-test, post-test, 3 months and 6 months following the intervention. The generalized estimating equation (GEE) was used to analyze the effectiveness of the ASG program on outcome measures over time. The 3-week ASG program effectively improved the perceived social support and 5 domains of HRQOL (physical function, social function, mental health, vitality and general health) of participants in the experimental group at 3-month follow-up, with maintaining at 6 months. For the depressive symptoms and domains of physical role limitations and bodily pain of HRQOL, significant effects were observed at 6-month follow-up. In addition, the scores of emotional role limitations had gradually improved in the experimental group but did not yield statistical significance during the research period. These results suggested that participation in the ASG program may generally improve health-related quality of life and perceived social support and decrease depressive symptoms for lower-extremity amputees. It is anticipated that the findings may provide information for health professionals to develop the discharge planning and provide continuity of care for persons with LEA in the future.

Although dynamic prosthetic alignment is an important process for the rehabilitation of transtibial amputees, such alignment technique is subjective and inconsistent. Using biomechanical variables and questionnaire assessments, this study compared an instrument-assisted dynamic alignment technique using the Compas™ system and conventional alignment techniques on nine adults with unilateral transtibial amputation. A focus group discussion was conducted with six prosthetists to understand clinical practice of dynamic alignment and their perception of the Compas™ system. Results found that Compas™ produced more anterior weight line displacement and greater varus moment on the prosthesis than conventional alignment techniques. Alignment changes did not affect pelvic acceleration, and the instrument-assisted alignment technique produced certain biomechanical changes but not necessarily better alignments. Although the current version of the Compas™ system is not clinically feasible, it can be used as a teaching/justification tool. Further investigation with larger sample size and ankle alignment or moment measures is needed.

碩士
高雄醫學大學
牙醫學研究所碩士在職專班
94
Abstract Periodontal prosthodontics is interdisciplinary and integrates dental perspective treatment. The main objective is not only in research and treatment of periodontal diseases, but also involving endodontic, orthodontic, prosthodontic, implantology, restorative and occlusal rehabilitation - ect. A perio-prosthodontic treatment is needed for patient with advanced periodontal disease that has problems including missing/ mobile/ pathological migration teeth, collapse of occlusion and other complications. Treatment goals are not only to stabilize teeth and periodontal tissue but also to fulfill the long-term satisfaction of function and esthetic demands of periodontal patients. This thesis includes 11 representative periodontal prosthetic cases. 10 females and 1 male. Treatment endeavors patients'' chief complaints and needs for prosthetic reconstruction according to the principles of evidence-based medicine. Orthodontic treatment, implant surgery and occlusal rehabilitation were incorporated in the treatment depending on patient''s need. In all, 6 patients had full mouth rehabilitation, 2 patients had full arch prosthetic reconstruction and the rest of 3 had partial surgical treatment and reconstruction. The average treatment time was 16 months. Key words：periodontal prosthesis, full mouth rehabilitation, periodontal therapy, implant surgery.

Nos pacientes com defeitos ósseos palatinos congénitos ou adquiridos, quando a possibilidade de reconstrução cirúrgica não existe, poderá ter de se utilizar uma prótese obturadora palatina, com vista ao restabelecimento das funções do sistema estomatognático, tais como, a fonética, deglutição e mastigação. Contudo, esta necessidade não é só funcional mas também estética e psicológica, com vista a melhorar a qualidade de vida dos pacientes. As próteses obturadoras palatinas têm vindo a desenvolver há alguns séculos, com o aprimoramento das técnicas de confecção e materiais dentários que auxiliam na elaboração, cada vez mais eficientes, principalmente no que se refere a sua adaptação. Neste trabalho realizou-se uma revisão narrativa da literatura sobre próteses obturas palatinas utilizando as palavras-chave: maxillary birth bony defects; maxillary acquired bony defects; obturator prosthesis; prosthetic rehabilitation in maxillary defects; inflatable hollow obturator; prosthodontic rehabilitation of maxillary defects. Os objectivos deste trabalho foi o de conhecer os diferentes tipos de próteses obturadoras palatinas utilizadas na reabilitação de pacientes com defeitos ósseos palatinos, bem como, as suas indicações, contra-indicações, os cuidados de utilização e o protocolo clínico e laboratorial de confecção. As próteses obturadoras palatinas são assim uma solução possível na reabilitação funcional de um número grande de pacientes com defeitos ósseos palatinos, no entanto, o seu sucesso está dependente do correcto planeamento e da execução clínica e laboratorial cuidadosa.
In patients with congenital palatal bone defects or acquired, when the possibility of surgical reconstruction does not exist, you may have to use a palatal obturator prosthesis with a view to restoration of the stomatognathic system functions, such as phonetics, swallowing and chewing. However, this need is not only aesthetic but also functional and psychological, to improve the quality of life of patients. The palatine obturator prostheses have been developing for several centuries, with the improvement of production techniques and dental materials that assist in the preparation, more efficient, especially as regards its adaptation. In this work is a narrative review of the literature on prosthetic palatal obturator using the keywords: maxillary birth bony defects; maxillary acquired bony defects; obturator prosthesis; prosthetic rehabilitation in maxillary defects; inflatable hollow obturator; prosthodontic rehabilitation of maxillary defects. The objectives of this study was to know the different types of palatal obturator prosthesis used in the rehabilitation of patients with palatal bone defects, as well as its indications, contraindications, use care and clinical and laboratory protocol execution. The prosthetic palatine obturator are thus a possible solution in the functional restoration of a large number of patients with palatine bone defects, however, its success is dependent on careful planning and proper clinical and laboratory performance.

碩士
高雄醫學大學
牙醫學研究所碩士在職專班
92
The severely destroyed alveolar bone of the chronic severe periodontal teeth will atrophy even more quickly after the extraction of the teeth.This phenomenon often causes the difficulty of later prosthetics.Even if bone grafting and tissue grafting have been conducted many times at the same area,it is also hard to increase even half of the original height of alveolar bone .In order not to let patients suffer the pain from the operations and to improve the effectiveness of the operation,immediate implant placement into the socket after the extraction of the teeth to gain the height of alveolar bone is very important. The objective of the case report was to evaluate the preservation of the height of the alveolar bone after the extraction of the teeth with the chronic severe periodontal disease.The results of this report support the conclusion that periodontal infected site may be not a contraindication for immediate implant and even for severe peridontal teeth if appropriate administration of periodontal infection has performed before implant placement,as describe by Novaes Jr. and Novaes coworkers,such as antibiotic administration,meticulous cleaning,and alveolar debridement before surgery.In addition,primary flap closure is also desirable when placing immediate implants,and avoid exposure of the implant must be considered.

O presente documento, Relatório de Atividade Clínica, trata de toda a actividade realizada por mim, na Clínica Universitária no presente ano lectivo 2014/15. Este trabalho é realizado com o intuito de relatar todas as atividades clínicas, tendo como objetivo resumir todo o percurso deste ano lectivo, podendo, quando terminado, ter um conjunto de informação com interesse académico e pessoal, de evolução e integração de conhecimentos. Juntamente a isto pretende-se também estudar a população que se apresenta à consulta da Clínica Universitária, avaliando o Índice de CPO, dentes perdidos, reabilitações protéticas e doença periodontal. Assim sendo, este relatório elabora um plano de trabalho, seguindo uma linha de pensamento, de forma a apresentar possíveis conclusões com sentido e lógica. O tema a ser abordado é o envelhecimento e degradação da saúde oral da população, sendo este um assunto, na minha opinião, com interesse para a Medicina Dentária, tendo repercussões directas na nossa prática clinica diária. Acompanhado com um relato, quantitativo e qualitativo, do cumprimento do programa proposto pelas diferentes áreas disciplinares. O Médico Dentista tem de estar preparado para o aumento da população idosa e das suas necessidades e espectativas em relação ao tratamento dentário. É essencial investir na prevenção e gestão da doença, ao invés de apenas tratar o paciente.
This document, Clinical Activity Report, deals with all the activity carried out by me, at the University Clinic during the present school year, 2014/15. This work is elaborated in order to report all academic activities, both clinical and research work. Aiming to summarize all the work from this present year, may, when completed, have a set of information with academic and personal interest, showing development and integration of knowledge. Along to this there will be a study about the population that is presented to the consultation in University Clinic, assessing the DMF Index, lost teeth, prosthetic rehabilitation and periodontal disease. Therefore, this report shall prepare a work plan, following a line of thought, in order to present possible conclusions with sense and logic. The issue to be addressed is the aging of population and degradation of oral health, which is a subject that in my opinion, is relevant to dentistry since it has direct implications on our daily clinical practice. Attached there will be a report, quantitatively and qualitatively, that will resume the fulfilment of the proposed program by the different disciplines. The Dentist must be prepared for the increasing of elderly population which has needs and expectations in relation to dental treatment. It is essential to invest in prevention and management of disease, rather than just treating the patient.

Ao longo das últimas décadas tem-se verificado um crescente envelhecimento populacional e com este, um aumento na preocupação com a saúde oral dos idosos, maioritariamente os institucionalizados. Esta apreensão advém do facto desta amostra vulnerável apresentar um estado de saúde mais precário. Objetivos: Este estudo visa caracterizar a saúde oral e a reabilitação protética dos idosos institucionalizados, assim como a sua capacidade mastigatória e a sua auto-perceção sobre a sua saúde oral. Materiais e Métodos: Trata-se de um estudo epidemiológico observacional analítico transversal com uma amostra constituída por 63 participantes residentes em instituições da cidade de Viseu. A recolha de dados foi efetuada através da aplicação oral de um questionário, seguido de uma observação intra-oral. Resultados: Os idosos institucionalizados apresentaram um valor de CPOD de 27,27±7,126, com uma maior prevalência de dentes perdidos (26,14±8,293). Estes dados devem-se aos reduzidos índices de saúde oral verificados nesta amostra, resultantes dos escassos cuidados de higiene oral presentes nos pacientes institucionalizados. Quanto à capacidade mastigatória aferiu-se que os pacientes portadores de prótese dentária apresentam uma maior eficácia mastigatória (p=0,007 e p=0,21). Adicionalmente, os idosos reabilitados proteticamente apresentam uma melhor auto-perceção da sua saúde oral, segundo o Índice GOHAI (p=0,037). Conclusões: O conhecimento das principais necessidades de tratamento Médico-Dentário dos idosos institucionalizados é fundamental de modo a elaborar medidas de promoção de saúde oral e consciencializar tanto os idosos como os seus familiares e cuidadores para a sua importância. É fulcral que os Médicos-Dentistas se tornem numa parte integrante, ativa e dinâmica da Medicina Dentária Geriátrica.
Introduction: Over the last few decades there has been progressive aging of the populations and with it, an increase in the concern with the oral health of the elderly, particularly the institutionalized ones. This apprehension arises from the fact that this vulnerable sample is in a poorer state of health. Objectives: This study aims to characterize the oral health and prosthetic rehabilitation of institutionalized elderly, as well as their masticatory ability and self-perception of oral health Materials and Methods: The present study is an observational epidemiological cross-sectional study with a sample of 63 participants living in institutions in Viseu. The data was collected through an oral application of a questionnaire, followed by an intra-oral observation. Results: Institutionalized elderly patients presented a DMFT value of 27.27±7.126, with a higher prevalence of missing teeth (26.14±8.293). These data are due to the low oral health indexes verified in this sample, that are a result of the scarce care of oral hygiene present in the institutionalized patients. As to masticatory capacity, it was verified that patients with dental prosthesis had a greater masticatory efficacy (p=0.007 and p=0.21). In addition, the elderly who are prosthetically rehabilitated have a better self-perception of their oral health, according to the GOHAI Index (p=0.037). Conclusions: The knowledge of the main treatment needs of the institutionalized elderly is fundamental in order to elaborate oral health promotion measures and to raise awareness among the elderly, their families and caregivers about the importance of this matter. It is essential that Medical-Dentists become an integral, active and dynamic part in Geriatric Dental Medicine.