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Evaluation of the Pectoralis Major Myocutaneous Flap
Oral Abstract Session 1
Lateral Alveolar Ridge Augmentation With Allogenic Block Grafts: Observations From a Multicenter Prospective Clinical Trial Michael Peleg, DMD, 3005 NE 207 Terrace, Aventura, FL 33180 (Garg A; Mazor Z) Statement of the Problem: The use of autogenous bone block grafts in guided bone regeneration procedures for alveolar ridge augmentation is limited by donor-site morbidity and the need for advanced bone-harvesting skills. The need for advanced bone-harvesting techniques was highlighted as a key factor. It became apparent that the success of these early techniques was dependent upon operator skill and training with flap designs, membranes and stabilization screws, as well as the ability to harvest sufficient intraoral autogenous bone. The necessary skill level and postoperative patient morbidity have limited the potential for most clinicians to incorporate horizontal and vertical ridge augmentation techniques into their clinical practices. To enable more dental clinicians to use lateral ridge augmentation as a treatment option in patients with inadequate bone volume prior to implant placement, this paper describes the use of an allogenic bone block graft as an alternative to conventional GBR and autogenous block-grafting techniques. In this study, allogenic block grafts were used for ridge augmentation prior to implant placement. Materials and Methods: Twenty seven patients with severe ridge width deficiency underwent augmentation using an allogenic corticocancellous iliac bone block graft. The mean bone block size was 11⫻13⫻5 mm. Two miniscrews were used for each block graft. In 15 patients the block graft was placed in the anterior maxilla. After rigid fixation of the graft with miniscrews, the graft site was covered with a type I collagen membrane and tension-free closure was performed. Patients received postoperative antibiotics. Implants were placed 6 months later and bone-core biopsies were taken for histological examination. Six months after implant placement, computed tomography scans and panoramic radiographs were taken. Further bone-core biopsies were taken from one patient. Method of Data Analysis: Cumulative data and histological examination of bone-core biopsies. Results: No clinical problems were encountered. The block graft became well integrated into the surrounding bone, and the augmented bone remained stable throughout the implant placement procedures. Six months after implantation, there was no bone resorption, and bonecore biopsies showed newly formed woven bone and new lamellar bone within the graft. Conclusion: Evidence demonstrates that allogenic bone block grafts in conjunction with resorbable membranes might be a viable alternative to autogenous grafts AAOMS • 2005
in patients with alveolar ridge deficiencies. Further study and data accumulation is required. References Misch CM: Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 12:767, 1997 Garg AK, Morales MJ, Navarro I, et al: Autogenous mandibular bone grafts in the treatment of the resorbed maxillary anterior alveolar ridge: Rationale and approach. Implant Dent 7:169, 1998 Lyford RH, Mills MP, Knapp CI, et al: Clinical evaluation of freezedried block allografts for alveolar ridge augmentation: A case series. Int J Periodont Restor Dent 23:417, 2003
Evaluation of the Pectoralis Major Myocutaneous Flap Eustorgio A. Lopez, DDS, MD, 1611 NW 12th Avenue, Northwing, Suite 101, Miami, FL 33136 (Peleg M) Statement of the Problem: Since 1979, the pectoralis major muscular and myocutaneous flap has been extensively used for head and neck reconstruction. Maxillofacial defects secondary to trauma, cancer extirpation, and osteoradionecrosis requiring soft tissue and later bone reconstruction, are the main indications for its use. The unique demands of the maxillofacial region dictate not only re-establishment of esthetic harmony but, more importantly, successful return to normal function comparable to predisease state. Despite its routine use in reconstructions encompassing oral structures, an analysis concerning the recovery of functional speech, swallowing, mastication, tongue mobility, oral competence, mouth opening, and flap adaptation, has not been reported in the literature. The purpose of this presentation is to describe the long-term functional results of oral cavity soft tissue reconstruction with 18 consecutive pectoralis major myocutaneous flaps. Special attention is given to the fate of the skin paddle. Materials and Methods: Twenty five consecutive patients undergoing soft tissue reconstruction with pectoralis major myocutaneous flaps throughout the period of 1993 to 1997 were prospectively included in this study. The patients were seen every 3 months during the first postoperative year and every 6 months thereafter. Six patients declined follow-up and one flap underwent total necrosis and was excluded. The final study group comprised 18 patients. Data recorded included: age, gender, diagnosis, surgical procedures, and adjuvant therapies. The skin paddle was assessed for its size intraoperatively and during the follow up period, as well as its contour, color, adaptation to the recipient site and hair bearing areas. Tongue mobility, speech (speech assessment was based on phone conversations with the patient), and mouth opening were evaluated preoperatively and during the follow up period. Speech was defined as intelligible, concentrate, and unintelligible. Tongue mobility was defined as good, acceptable, and poor. Immediate 29
Oral Abstract Session 1 and late postoperative complications were recorded and evaluated. All the flaps were developed as described by R. E. Marx in 1990 and the skin paddles were extended to the anterior rectus sheath for increased reach of 2-3 cm. The size of the skin paddle ranged from 5 x 3 cm to 11 x 5 cm. Long term follow up averaged 5.5 years. Method of Data Analysis: Fisher exact test. Results: Out of the 18 patients 15 were diagnosed with squamous cell carcinoma of the oral cavity, one patient had avascular necrosis of the mandible, and two patients had osteosarcoma of the mandible. The ages ranged from 33 to 79 years (mean 59). Gender distribution was 7 females and 11 males. All of the patients with squamous cell carcinoma underwent a therapeutic neck dissection in conjunction with extirpation of the primary tumor and five had postoperative radiation therapy. The donor sites in all of the patients healed without complications. Flap complications included: partial skin paddle necrosis in four patients, 50%, 25%, 15%, and 10% respectively, with no evident muscle damage or loss. Healing in these four patients was prolonged but soft tissue integrity was finally achieved without additional surgery. The other 14 flaps had no complications and healed without changes in skin color. In 5 male patients hair was present in the skin paddle intraorally during all of the follow up period without complaints. At 6 months follow up, all the skin paddles were leveled with the adjacent intraoral soft tissues and without any bulkiness. The initial excess volume resolved during the first three to six months. Most of the patients (15) had good tongue mobility (including the flap with 10% necrosis) while the other three patients with partial skin necrosis over 10% had acceptable tongue mobility only (p ⫽ 0.0049). The speech was intelligible in 15 patients and concentrate in 3 patients. None of the patients was judged as having unintelligible speech. Mouth opening was satisfactory in all patients and no significant difference was noted when compared to preoperative measurements at 6 months follow up. The first assessment of swallowing was performed one week postoperatively. All patients showed some dysfunction in swallowing 1-3 weeks after beginning of oral feeding. At 3-6 months functional swallowing was reestablished in all patients. The skin paddle contracted only by 37% and preserved a mean of 63% of its original surface area. Conclusion: The pectoralis major myocutaneous flap can be used predictably to reconstruct soft tissue defects of the oral cavity not only to address resurfacing but also volumetric needs and at the same time support and not interfere with reestablishment of oral function. The complication rate is low and is consistent with other reported publication. The presence of hair bearing skin intraorally does not affect functional outcome or patient acceptance of the reconstruction. The initial bulkiness of the flap and its impact in recovery of function remains only for a limited period of time. Good adaptation of the 30
flap margins to the oral epithelium is observed. Even when breast tissue in females is transferred with the flap, where larger amount of fat are present, good adaptation and matching of the skin paddle to the oral soft tissues occurs. Speech, regarded as one of the most important functions of the oral cavity, is intelligible in most of the patients. The good mobility of the tongue can be attributed to the presence of the skin paddle and prevention of contractions in the oral soft tissues. Mouth opening can be maintained by enabling healing of the oral mucosa with prevention of scar formation and contraction due to secondary healing. We can conclude that the pectoralis major myocutaneous flap still remains an excellent tool for intraoral soft tissue reconstruction. References Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: Experience with 437 cases at a single institution. The pectoralis major myofascial flap: clinical applications in head and neck reconstruction. An improved technique for development of the pectoralis major myocutaneous flap.
Arachidonic Acid Metabolites and NSAIDs Affect Osteoblast Response to Titanium Surface Roughness Daron Praetzel, DMD, 8 Birchbrook, San Antonio, TX 78254 (Powers DB; McGhee RM; Dean DD; Schmitz JP; Sylvia VL; Dinh DB) Statement of the Problem: Commercially pure titanium (cpTi) is used in dental implant applications. Implant surfaces of increasing roughness inhibit osteoblast proliferation and stimulate differentiation. In addition, surface roughness regulates osteoblast response to systemic factors such as 1,25(OH)2D3 and 17beta-estradiol. These in vitro results, as well as preclinical and clinical studies, suggest that surface roughness directs the osteogenic response to cpTi implants. Prostaglandin E2 (PGE2) is a potent local factor with effects on bone. At low concentrations, PGE2 stimulates osteoblast differentiation and increases bone formation; at high concentrations, PGE2 inhibits osteoblast differentiation and stimulates osteoclast-mediated bone resorption. Although it is known that increasing surface roughness stimulates production of PGE2 by osteoblasts, it is unknown if PGE2 and its precursor, arachidonic acid (AA), modulate osteoblast response to surface roughness. Further, it is unknown what impact commonly prescribed non-steroidal anti-inflammatory drugs (NSAIDs) may have on osteoblast response. The goal of this study was to examine how PGE2, AA, and indomethacin influence osteoblast proliferation and differentiation on cpTi surfaces of varying roughness. Materials and Methods: Smooth cpTi disks (Ra 0.3 micrometers) were prepared using silicon carbide paAAOMS • 2005
Lateral Alveolar Ridge Augmentation With Allogenic Block Grafts: Observations From a Multicenter Prospective Clinical Trial Michael Peleg, DMD, 3005 NE 207 Terrace, Aventura, FL 33180 (Garg A; Mazor Z) Statement of the Problem: The use of autogenous bone block grafts in guided bone regeneration procedures for alveolar ridge augmentation is limited by donor-site morbidity and the need for advanced bone-harvesting skills. The need for advanced bone-harvesting techniques was highlighted as a key factor. It became apparent that the success of these early techniques was dependent upon operator skill and training with flap designs, membranes and stabilization screws, as well as the ability to harvest sufficient intraoral autogenous bone. The necessary skill level and postoperative patient morbidity have limited the potential for most clinicians to incorporate horizontal and vertical ridge augmentation techniques into their clinical practices. To enable more dental clinicians to use lateral ridge augmentation as a treatment option in patients with inadequate bone volume prior to implant placement, this paper describes the use of an allogenic bone block graft as an alternative to conventional GBR and autogenous block-grafting techniques. In this study, allogenic block grafts were used for ridge augmentation prior to implant placement. Materials and Methods: Twenty seven patients with severe ridge width deficiency underwent augmentation using an allogenic corticocancellous iliac bone block graft. The mean bone block size was 11⫻13⫻5 mm. Two miniscrews were used for each block graft. In 15 patients the block graft was placed in the anterior maxilla. After rigid fixation of the graft with miniscrews, the graft site was covered with a type I collagen membrane and tension-free closure was performed. Patients received postoperative antibiotics. Implants were placed 6 months later and bone-core biopsies were taken for histological examination. Six months after implant placement, computed tomography scans and panoramic radiographs were taken. Further bone-core biopsies were taken from one patient. Method of Data Analysis: Cumulative data and histological examination of bone-core biopsies. Results: No clinical problems were encountered. The block graft became well integrated into the surrounding bone, and the augmented bone remained stable throughout the implant placement procedures. Six months after implantation, there was no bone resorption, and bonecore biopsies showed newly formed woven bone and new lamellar bone within the graft. Conclusion: Evidence demonstrates that allogenic bone block grafts in conjunction with resorbable membranes might be a viable alternative to autogenous grafts AAOMS • 2005
in patients with alveolar ridge deficiencies. Further study and data accumulation is required. References Misch CM: Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 12:767, 1997 Garg AK, Morales MJ, Navarro I, et al: Autogenous mandibular bone grafts in the treatment of the resorbed maxillary anterior alveolar ridge: Rationale and approach. Implant Dent 7:169, 1998 Lyford RH, Mills MP, Knapp CI, et al: Clinical evaluation of freezedried block allografts for alveolar ridge augmentation: A case series. Int J Periodont Restor Dent 23:417, 2003
Evaluation of the Pectoralis Major Myocutaneous Flap Eustorgio A. Lopez, DDS, MD, 1611 NW 12th Avenue, Northwing, Suite 101, Miami, FL 33136 (Peleg M) Statement of the Problem: Since 1979, the pectoralis major muscular and myocutaneous flap has been extensively used for head and neck reconstruction. Maxillofacial defects secondary to trauma, cancer extirpation, and osteoradionecrosis requiring soft tissue and later bone reconstruction, are the main indications for its use. The unique demands of the maxillofacial region dictate not only re-establishment of esthetic harmony but, more importantly, successful return to normal function comparable to predisease state. Despite its routine use in reconstructions encompassing oral structures, an analysis concerning the recovery of functional speech, swallowing, mastication, tongue mobility, oral competence, mouth opening, and flap adaptation, has not been reported in the literature. The purpose of this presentation is to describe the long-term functional results of oral cavity soft tissue reconstruction with 18 consecutive pectoralis major myocutaneous flaps. Special attention is given to the fate of the skin paddle. Materials and Methods: Twenty five consecutive patients undergoing soft tissue reconstruction with pectoralis major myocutaneous flaps throughout the period of 1993 to 1997 were prospectively included in this study. The patients were seen every 3 months during the first postoperative year and every 6 months thereafter. Six patients declined follow-up and one flap underwent total necrosis and was excluded. The final study group comprised 18 patients. Data recorded included: age, gender, diagnosis, surgical procedures, and adjuvant therapies. The skin paddle was assessed for its size intraoperatively and during the follow up period, as well as its contour, color, adaptation to the recipient site and hair bearing areas. Tongue mobility, speech (speech assessment was based on phone conversations with the patient), and mouth opening were evaluated preoperatively and during the follow up period. Speech was defined as intelligible, concentrate, and unintelligible. Tongue mobility was defined as good, acceptable, and poor. Immediate 29
Oral Abstract Session 1 and late postoperative complications were recorded and evaluated. All the flaps were developed as described by R. E. Marx in 1990 and the skin paddles were extended to the anterior rectus sheath for increased reach of 2-3 cm. The size of the skin paddle ranged from 5 x 3 cm to 11 x 5 cm. Long term follow up averaged 5.5 years. Method of Data Analysis: Fisher exact test. Results: Out of the 18 patients 15 were diagnosed with squamous cell carcinoma of the oral cavity, one patient had avascular necrosis of the mandible, and two patients had osteosarcoma of the mandible. The ages ranged from 33 to 79 years (mean 59). Gender distribution was 7 females and 11 males. All of the patients with squamous cell carcinoma underwent a therapeutic neck dissection in conjunction with extirpation of the primary tumor and five had postoperative radiation therapy. The donor sites in all of the patients healed without complications. Flap complications included: partial skin paddle necrosis in four patients, 50%, 25%, 15%, and 10% respectively, with no evident muscle damage or loss. Healing in these four patients was prolonged but soft tissue integrity was finally achieved without additional surgery. The other 14 flaps had no complications and healed without changes in skin color. In 5 male patients hair was present in the skin paddle intraorally during all of the follow up period without complaints. At 6 months follow up, all the skin paddles were leveled with the adjacent intraoral soft tissues and without any bulkiness. The initial excess volume resolved during the first three to six months. Most of the patients (15) had good tongue mobility (including the flap with 10% necrosis) while the other three patients with partial skin necrosis over 10% had acceptable tongue mobility only (p ⫽ 0.0049). The speech was intelligible in 15 patients and concentrate in 3 patients. None of the patients was judged as having unintelligible speech. Mouth opening was satisfactory in all patients and no significant difference was noted when compared to preoperative measurements at 6 months follow up. The first assessment of swallowing was performed one week postoperatively. All patients showed some dysfunction in swallowing 1-3 weeks after beginning of oral feeding. At 3-6 months functional swallowing was reestablished in all patients. The skin paddle contracted only by 37% and preserved a mean of 63% of its original surface area. Conclusion: The pectoralis major myocutaneous flap can be used predictably to reconstruct soft tissue defects of the oral cavity not only to address resurfacing but also volumetric needs and at the same time support and not interfere with reestablishment of oral function. The complication rate is low and is consistent with other reported publication. The presence of hair bearing skin intraorally does not affect functional outcome or patient acceptance of the reconstruction. The initial bulkiness of the flap and its impact in recovery of function remains only for a limited period of time. Good adaptation of the 30
flap margins to the oral epithelium is observed. Even when breast tissue in females is transferred with the flap, where larger amount of fat are present, good adaptation and matching of the skin paddle to the oral soft tissues occurs. Speech, regarded as one of the most important functions of the oral cavity, is intelligible in most of the patients. The good mobility of the tongue can be attributed to the presence of the skin paddle and prevention of contractions in the oral soft tissues. Mouth opening can be maintained by enabling healing of the oral mucosa with prevention of scar formation and contraction due to secondary healing. We can conclude that the pectoralis major myocutaneous flap still remains an excellent tool for intraoral soft tissue reconstruction. References Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: Experience with 437 cases at a single institution. The pectoralis major myofascial flap: clinical applications in head and neck reconstruction. An improved technique for development of the pectoralis major myocutaneous flap.
Arachidonic Acid Metabolites and NSAIDs Affect Osteoblast Response to Titanium Surface Roughness Daron Praetzel, DMD, 8 Birchbrook, San Antonio, TX 78254 (Powers DB; McGhee RM; Dean DD; Schmitz JP; Sylvia VL; Dinh DB) Statement of the Problem: Commercially pure titanium (cpTi) is used in dental implant applications. Implant surfaces of increasing roughness inhibit osteoblast proliferation and stimulate differentiation. In addition, surface roughness regulates osteoblast response to systemic factors such as 1,25(OH)2D3 and 17beta-estradiol. These in vitro results, as well as preclinical and clinical studies, suggest that surface roughness directs the osteogenic response to cpTi implants. Prostaglandin E2 (PGE2) is a potent local factor with effects on bone. At low concentrations, PGE2 stimulates osteoblast differentiation and increases bone formation; at high concentrations, PGE2 inhibits osteoblast differentiation and stimulates osteoclast-mediated bone resorption. Although it is known that increasing surface roughness stimulates production of PGE2 by osteoblasts, it is unknown if PGE2 and its precursor, arachidonic acid (AA), modulate osteoblast response to surface roughness. Further, it is unknown what impact commonly prescribed non-steroidal anti-inflammatory drugs (NSAIDs) may have on osteoblast response. The goal of this study was to examine how PGE2, AA, and indomethacin influence osteoblast proliferation and differentiation on cpTi surfaces of varying roughness. Materials and Methods: Smooth cpTi disks (Ra 0.3 micrometers) were prepared using silicon carbide paAAOMS • 2005