The next morning, Samantha thinks she is suffering from a bad hangover. She bickers with her mother, who struggles to accept her daughter's lesbianism and is worried that she might have relapsed into hard drug use. Alice tells Samantha that the police are searching for BJ, who Alice had never met. At the restaurant where she works, Samantha has trouble eating and is overly sensitive to noise. She can't hear her customers as they order their drinks. When she bleeds heavily from her vagina, she visits her doctor. Despite her protests that she is a lesbian who has not had sex with men for nearly a year, he is suspicious that she has contracted a sexually transmitted disease from heterosexual intercourse because of a rash that has developed in her groin. Samantha is also constantly vomiting a lot of blood and as well as urinating a lot of blood and eventually a maggot falls out of her vagina in the bathroom without her noticing.
Contracted service providers assist the Division of Family & Children Services in providing effective service intervention to better serve children and families in Georgia. For parties interested in applying to become a contracted service provider, please see the relevant documents below.
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Introduction: Contracted endodontic cavities (CECs) have developed from the concept of minimally invasive dentistry and provide an alternative to traditional endodontic cavities (TECs). They have been designed in an effort to preserve the mechanical stability of teeth. The contracted cavity design preserves more of the dentin but may influence the geometric shaping parameters. The aim of this micro-computed tomographic study was to evaluate the influence of contracted endodontic cavities on the preservation of the original root canal anatomy after shaping with nickel-titanium rotary instruments.
Introduction: The impact of minimally invasive endodontic procedures on root canal disinfection has not been determined. This ex vivo study compared root canal disinfection and shaping in teeth with contracted or conventional endodontic cavities.
Results: All initial samples were positive for E. faecalis. After preparation, the number of bacteria-positive samples was significantly higher in the contracted cavity group (25/29, 86%) than in the conventional cavity group (14/28, 50%) (P < .01). Intergroup quantitative comparison showed that the reduction in bacterial counts was also significantly higher in the group of conventional cavities (P < .01). Micro-CT data revealed no significant difference in the amount of unprepared areas between groups.
Conclusions: Our findings showed that although shaping using an adjustable instrument was similar between groups, disinfection was significantly compromised after root canal preparation of teeth with contracted endodontic cavities.
Objective: This systematic review was performed to answer the following question: do contracted endodontic cavities (CECs) increase resistance to fracture in extracted human teeth compared to traditional endodontic cavities (TECs)?
Introduction: Recently, we reported that in mandibular molars contracted endodontic cavities (CECs) improved fracture strength compared with traditional endodontic cavities (TECs) but compromised instrumentation efficacy in distal canals. This study assessed the impacts of CECs on instrumentation efficacy and axial strain responses in maxillary molars.
A contracted socket is a complication of an anophthalmic socket which results in the inability to support a prosthesis. It is an uncommon but significant problem for the ophthalmic plastic surgeon. A poorly fitting prosthesis results in subpar cosmesis, can be damaging to the psyches of patients[1], and can result in additional injury and infection. A contracted socket can occur weeks to years after enucleation or evisceration. While historically it was believed that the symblepharon and sulcus deformity associated with a contacted socket were incurable[2], advances in the use of grafting materials, alloplastic implants, and flaps have allowed contracted sockets to be reformed, therefore returning the function of the normal fornix.
The contracted socket should not be confused with Post Enucleation Socket Syndrome (PESS) which is characterized by a deep upper eyelid sulcus, lower lid laxity, and eyelid malpositions without shrinkage or shortening of the soft tissues.[3]
The goal of management is to reform the scarred fornix vertically and posteriorly to approximate the form and function of the normal fornix.[9] This involves excision of all symblepharon followed by the placement of a graft or flap that promotes re-epithelization and increased conjunctival surface area.[8] Since the presentation of a contracted socket can be extremely variable, management is always tailored to the specific needs of the patient. Management of the contracted socket is based on two important clinical findings. The first, severity and location of symblepharon, and the second, amount of residual orbital volume.
When there is minimal symblepharon, a z-plasty (which can lengthen a contracted scar or rotate the scar tension line) or local conjunctival flap can be sufficient to provide room for a prosthesis to fit.[4][9] Lower lid laxity is managed with horizontal tightening procedures. If there is prolapse of the forniceal conjunctiva due to anterior migration of the inferior intraorbital fat causing an inadequate inferior cul-de-sac, this can be managed via externalized sutures[10] or conjunctival fixation to the inferior orbital rim periosteum.[11][12] If the inferior fornix is primarily scarred and the posterior lamella requires lengthening, various grafts including nasal septum, auricular cartilage, sclera , hard palate, or fascia lata can be implanted.[4][8][13][14][15] On the other hand, the Weis procedure can be used if there is cicatricial entropion in the setting of normal forniceal depth.
The use of a dermis fat graft (DFG) can be appropriate when the contracted socket has associated volume loss. The usage of DFG was first popularized by Byron Smith in the late 1970s as a way to supplement volume at the time of enucleation and to preserve the fornices and conjunctiva.[19][20] They are frequently harvested from the abdominal, gluteal and thigh regions. The viability of dermis by itself was substantiated by Wojno and Tenzel.[21] They noted that the dermis is easily accessible and harvested. When the epidermis is properly removed, there is low incidence of cyst formation. The hair follicles and sebaceous glands within the dermis disappear within 1-3 month.[21] Multiple reports have demonstrated viability of DFGs long-term with complications occurring mainly in sockets that have significant vascular compromise to the donor bed and therefore increase the risk of fat atrophy and failure.[22] A recent report describes the use of composite hard palate-dermis fat grafts (HPDFG) to both expand volume and lengthen the posterior lamella.[23]
Severely contracted sockets with little to no residual conjunctival lining and those that have failed previous surgeries are extremely difficult to repair. They can potentially be managed with space occupying alloplastic materials (i.e. silicone, polyethylene) or conformers fixed to the orbital rim which push a graft against the posterior orbit recipient bed while counteracting the forces of contraction during scarring.[4][24][25] Additionally, rotational or microvascular free flaps from a variety of locations can be used to re-vascularize the damaged conjunctiva, most importantly in post-radiation[26] or repeat surgery patients, but are difficult to perform and frequently require the expertise of other non-ophthalmologic surgical sub-specialties. A few examples of flaps that have had success include retroauricular[27], superficial temporalis facia[26], radial skin[28], thoracodorsal artery perforator[29], and galea[30]. Detailed flap descriptions can be found in the general plastic surgery literature.[7]
Unlike many ophthalmological procedures, there is no standard surgical follow-up for contracted socket reconstruction. Each case will be slightly different with post operative care ranging from 6-8 weeks to 1-2 years. As expected, more severely contracted sockets will require more extensive surgery and longer follow-up periods. This is especially the case for rotational and microvascular flaps where a staged approach may be taken.
In severely contracted sockets that have undergone extensive reconstruction or patients that have had multiple prior procedures, it is common to leave the conformer in place for months or even up to a year or more. The end point is reached when a prosthesis can be easily fitted and the socket can maintain the prosthesis in place.
Complications vary based upon the surgery performed and the inherent complications unique to each procedure. Ultimately, each failure will decrease the ability of the contracted socket to accept an ocular prosthesis. This may necessitate the need for staged or multiple procedures to be performed until the socket can maintain a prosthesis. There is always a risk of bleeding or infection, but as with most oculoplastic procedures, these rates are very low, likely due to the high blood flow to the face. The infection rate will be higher in the presence of systemic immunosuppression or local orbital conditions such as prior radiation treatment. Amniotic membrane grafts (AMG) present fewer post-operative complications in comparison to autografts due to the absence of donor site morbidity. [17]
Arguably, the worst complication may be the failure of an axial or microvascular free-flap. Flap surgery when performed is an indicator of the severe nature of the contracted socket and the poor vascular supply to the orbit. Prior attempts to correct the socket have failed and there are few remaining options. The type of flap that is initially chosen usually offers the best chances for procedural success. If a flap fails then this may necessitate choosing another flap that does not offer the same benefits and the need for the patient to undergo another procedure with additional donor site morbidity. be457b7860
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