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Obliteration of the frontal sinus with autogenous fat
448
British
Journal
of Oral
and Maxillofacial
Surgery
-
region. Such difficulties as visibility and exact anatomic alignment plague transoral plating of mandibular angle fractures with the highest postsurgical complication rate of all mandibular fractures. Oral and maxillofacial surgeons are familiar with endoscopic principles and techniques on account of their experience with temperomandibular joint arthroscopy, and arthroscopic skills are now being utilized in the evolving areas of endoscopic sinus surgery and endoscopic facial aesthetic surgery. A natural progression of interest is in the endoscopic management of facial fractures. In an effort to minimize the problems encountered with transoral fixation, 15 consecutive displaced mandibular angle fractures have now been rigidly fixated transorally, yet with percutaneous endostopic assistance. The standard 2.7-mm and 4.0-mm endoscopes have each been used, and have provided sufficient illumination and resolution at the inferior border of the mandibular angle. Rigid fixation is maintained with a 3-D l.O-mm bone plate (Leibinger, Dallas, Texas) and 2.0-mm screws. Preliminary experience has yielded excellent exposure to the inferior border at the mandibular angle, invaluable assistance with fracture alignment and plate adaption, decreased operating time and complication rate, and the avoidance of a large external incision and potential facial nerve damage.
Lag screws Jay Cagata
in rigid DMD,
fixation of mandibular parasympbysis MD, Louisville, Kentucky, USA.
fractures.
Presented by: Jay Cagata DMD, MD. Objective. The purpose of this study is to review a specific technique of placement of the lag screw, to review how principles of rigid fixation apply, and to review the results of our experience in treatment of mandibular parasymphysis fractures. Procedures. This is a five-year review of parasymphysis fractures from July 1991 to June 1996. The study includes patients who sustained fractures of the mandible anterior to the mental foramina with or without other facial fractures. A total of 135 patients was recorded. Comminuted fractures of the parsymphysis were not treated with lag screws. Two screws were used to compress, reduce and stabilize the fracture when using the lag screw technique. The technique is described in detail. Results. Of the 135 fractures, 51 were treated by closed reduction and intermaxillary fixation, and 84 were treated with open reduction and internal fixation, using lag screw technique in 36 patients. There were no complications requiring subsequent removal of hardware with the lag screw technique. Conclusion. In our experience, the lag screw technique for rigid fixation of mandibular parasymphysis fractures is a suitable and successful option.
Detection of child abuse. John F. Coyne DMD, Steven Garin DMD. Allen Fred Fielding DMD,
David
King
DMD,
Temple University,
Philadelphia, Pennsylvania, USA. Presented by: John F. Coyne DMD. The oral and maxillofacial surgeon is in a unique position to diagnose and help children who are being abused and neglected. As many as 65% of the cases of child abuse include injuries to the head, neck, or mouth, parts of the body in which oral and maxillofacial surgeons specialize. Additionally, studies show that more than 70% of the fatalities attributed to child abuse are also caused by injuries to the head and neck. Oral and maxillofacial surgeons are mandated reporters, and are required by law to report suspected cases of child abuse and neglect. However, the major barrier to reporting suspected cases is a lack of training in the areas of detection and reporting process of child abuse. This presentation discusses the role of the oral and maxillofacial surgeon in the detection and reporting of child abuse. Child abuse will be defined and demonstrated and the surgeon’s responsibilities will be discussed. Specific signs and symptoms of child abuse will be reviewed, along with the methodology of reporting suspected cases. Finally, resources for obtaining additional information on the detection and reporting of child abuse will be presented.
References
Schmitt B.D. Types of child abuse and neglect: an overview for dentists. Ped Dent 1986: 8 (Spec. Issue 1): 67-70. The Dental Coalition to Combat Child Abuse and Neglect (Massachusetts). Dental conditions to combat child abuse. Dental facts relating to child abuse, l-2. ADA Council on Dental Practice. The dentist’s responsibility in identifying and reporting child abuse, 1989 revision. Advanced extraction Gross DDS.
therapy
utilizing
bioplant
HTR-24.
Jefsyey
S.
Presented by: Jeffrey S. Gross DDS, FAGD. The goal of this study was to find a technique to manage and direct the healing of an extraction site. The protocol emphasized the creation of an environment that would promote faster healing and decrease the possibility of post-extraction osteitis, i.e. a dry socket. The ultimate goal was to preserve and maintain ridge height and width. The resultant architecture would facilitate the fabrication of future prosthesis. Four hundred and ninety-five (495) teeth were removed utilizing conventional techniques. The resultant wounds were treated with advanced extraction-therapy techniques, which involved filling the extraction sockets with an alloulast. Bioplant HTR-24. All sockets were closed with sutures using a modified double-horizontal mattress sutures. The patients were contacted the evening following treatment by telephone and seen 5-7 days later for suture removal. Only two patients demonstrated less than optimal results. The data should set a new ‘gold standard’ of care for tooth removal by the profession. The techniques are easy to learn and are not timeconsuming or cost-prohibitive for the practitioner. Above all, the confidence level and appreciation by the patient vis-a-vis the dentist, in particular, and towards dental care, in general, are raised to a new level. The tibia as a donor site for autogenous grafting. DOS, MD, University of Louisville, Louisville,
Lloyd
A. Hudson
Kentucky, USA.
Presented by: Lloyd A. Hudson DDS, MD. Autogenous bone grafting is a widely used technique in various reconstructive efforts. There is a relative paucity of information concerning the tibia as a donor site in the literature. This may be the result of a general opinion that there is an inadequate volume of cancellous bone available there. Nevertheless, the tibia is a viable alternative with fewer documented complications. Objectives. To describe the approach for obtaining autogenous marrow from the proximal tibia and discuss its low morbidity and advantages. Procedures/Techniques. 37 tibia1 grafts were performed in the last five years. The surgical technique is described in detail. Results. 35 of 37 patients were complication-free. The two complications were both infections, a superficial wound infection and a cellulitis that responded promptly to treatment without untoward sequelae. Conclusions. The disadvantage of this procedure are few. Although less bone is available than in the hip. 30-40 cc of bone are routinely obtained, which is an ample amount in many procedures. Our complication rate of 5.1% is higher than that in the literature, but is significantly lower than that reported for iliac crest grafts. The advantages appear to be many. There were no cases of sensory loss, fracture, hematoma or prolonged gait disturbance. The blood loss is essentially zero with the aid of a tourniquet. The anatomy, dissection, and bone procurement is relatively simple, even in obese patients. Postoperative pain is well controlled. Patients are ambulatory the next day with minimal assistance with crutch or cane. A mild limp rarely last past two weeks. Patient acceptance, including cosmesis, is high. Obliteration of the frontal DDS, Chester J. Chorazy
sinus with autogenous fat. Robert L. Jolly DOS, MDS, St Francis Medical Center,
Pittsburgh, Pennsylvania, USA. Presented by: Robert L. Jolly DDS. Surgical options for frontal sinus fractures vary depending on the type, location and severity of the fracture as well as the condition
Abstracts and patency of the nasofrontal ducts. Non-displaced anterior table fractures with functioning ducts have been successfully treated without surgery, whereas more severe anterior table fractures will require at minimum an open exploration, and in cases with significant nasofrontal duct damage, a sinus obliteration is indicated. Access to the frontal region can be accomplished in several ways. However, the bicoronal flap with its ability to camouflage the scar in the hairline and offer wide exposure is the preferred approach. After adequate access, the anterior table is removed. debrided of any contaminants and, if necessary, reassembled. It is then stored in normal saline until it is ready to be replaced. The nasofrontal ducts are then identified and inspected. Patency is verified by injecting methyline blue into the duct and then examining the middle meatus of the nasal cavity for the presence of the dye. If the ducts prove to be occluded and are damaged to an extent that prevents repair or cannulation, an obliteration will need to be performed. The initial step in this procedure is total removal of the sinus mucoperiosteum. Next, the nasofrontal ducts are packed to ensure that no communication exists between the frontal sinus and the nasal cavity. Obliteration of the sinus is accomplished with autogenous fat, which is easily harvested in sufficient quantity from the periumbilical region. The anterior table is replaced and fixated, and the coronal flap is then closed in the usual manner.
The efficacy of dezocine vs Fentanyl in outpatient i.v. sedation and general anesthesia. Andrat) L. Kunter DMD, Awwrigo J. Fedeli DMD, Guy L. Lmri DMD, Jonuthun E. Burke DMD. Brim M. Smith DMD, Temple University Health Sciences Center. Philadelphia, Pennsylvania, USA. Presented by: Andrew L. Kanter DMD. A prospective randomized study was undertaken to evaluate the efficacy of Dalgan (Dezocine, Astra Pharmaceuticals). a narcotic agonist/antagonist, as a substitute for Fentanyl used in outpatient i.v. sedation and general anesthesia for dentoalveolar surgery. The two anesthetic regimens, administered alternately on odd and even days, included: (I ) Fentanyl 100 pg, Midazolam 4 mg. variable dose 1% sodium methohexital and (2) Dalgan 10 mg, Midazolam 4 mg, variable dose 1% sodium methohexital. Variables analyzed in the two groups were: ( 1) amount of sodium methohexital used: (2) incidence of singultus and laryngospasm; (3) mean time to recover utilizing the Triger Test; (4) mean oxygen desaturation; (5) nausea and vomiting; (6) blood pressure and heart rate changes; (7) patient compliance as rated by the surgeon on an analog visual scale. Preliminary data indicates that with Dalgan, significantly less sodium methohexital was necessary to achieve adequate levels of sedation, fewer incidences of oxygen desaturation, singultus, and laryngospasm occurred, and decreased recovery time was observed. Additional benefits include significantly better patient
from
the ACOMS
18th Annual
Conference
449
compliance, lower abuse potential, and no requirement for strict documentation of use that is normally necessary for schedule II narcotics. The clear advantages of Dalgan far outweigh its slightly increased cost ($6.26 per patient) over Fentanyl ($3.00 per patient) and make it an excellent addition to the armamentarium of the OMFS.
Traumatic cranial defects reconstructed with the HTR-PM1 cranioplastic implant. John B. Rohersorz DMD. Jimmie L. Harper DDS. Robert Horton DDS, Willium S. Rosu&q MD, University of Cincinnati Medical Center. Cincinnati, Ohio, LJSA. Presented by: John B. Roberson DMD. Cranial defects as a result of trauma, including motor vehicle accidents, motorcycle accidents, gunshot wounds, occupational accidents and altercations with blunt objects, can be cosmetically disfiguring. In the past, titanium mesh, polymethylmethacrylate application and autogenous bone grafting have been used to reconstruct these defects. These methods are time-consuming. requiring a second surgical site, and may not achieve a satisfactory cosmetic result. A more recent technique for reconstructing these defects has proven to be less time-consuming and provides an excellent esthetic result for the patient. This technique involves the production of a cranioplastic implant using 3-D computed tomography imaging (Hard Tissue Replacement-Patient Matched Implant. HTR-PM]). We present two cases using this technique to correct traumatic cranial defects.
A comparison of complications following bone grafting of unilateral and bilateral maxillary alveolar clefts in children. D. C. 7bng, D. G. Mo/cx M..4. E&w, R. cI/. T. Myu//, Children’s Hospital and Medical Center, Seattle, Washington. USA. Presented by: Darryl C. Tong BDS. The objective of this retrospective study was to compare complications between children who had unilateral and bilateral maxillary alveolar clefts grafted at Children’s Hospital and Medical Center. Seattle from 1992 to present. Complications are generally described in cleft lip and palate patients as a whole but do not reflect the differences between the two population groups. All surgeries were performed by the same two surgeons over a four-year period. The medical and dental records of 54 unilateral and 17 bilateral cleft lip and palate children were reviewed and complications tabulated. In the unilateral group, there were three complications out of 54 procedures (5.6%). while in the bilateral group there were three complications out of I7 procedures ( 17.6’%). The complications seen in the unilateral clefts tended to be major loss of the graft. The complication rates, however, were not statistically significant.
British
Journal
of Oral
and Maxillofacial
Surgery
-
region. Such difficulties as visibility and exact anatomic alignment plague transoral plating of mandibular angle fractures with the highest postsurgical complication rate of all mandibular fractures. Oral and maxillofacial surgeons are familiar with endoscopic principles and techniques on account of their experience with temperomandibular joint arthroscopy, and arthroscopic skills are now being utilized in the evolving areas of endoscopic sinus surgery and endoscopic facial aesthetic surgery. A natural progression of interest is in the endoscopic management of facial fractures. In an effort to minimize the problems encountered with transoral fixation, 15 consecutive displaced mandibular angle fractures have now been rigidly fixated transorally, yet with percutaneous endostopic assistance. The standard 2.7-mm and 4.0-mm endoscopes have each been used, and have provided sufficient illumination and resolution at the inferior border of the mandibular angle. Rigid fixation is maintained with a 3-D l.O-mm bone plate (Leibinger, Dallas, Texas) and 2.0-mm screws. Preliminary experience has yielded excellent exposure to the inferior border at the mandibular angle, invaluable assistance with fracture alignment and plate adaption, decreased operating time and complication rate, and the avoidance of a large external incision and potential facial nerve damage.
Lag screws Jay Cagata
in rigid DMD,
fixation of mandibular parasympbysis MD, Louisville, Kentucky, USA.
fractures.
Presented by: Jay Cagata DMD, MD. Objective. The purpose of this study is to review a specific technique of placement of the lag screw, to review how principles of rigid fixation apply, and to review the results of our experience in treatment of mandibular parasymphysis fractures. Procedures. This is a five-year review of parasymphysis fractures from July 1991 to June 1996. The study includes patients who sustained fractures of the mandible anterior to the mental foramina with or without other facial fractures. A total of 135 patients was recorded. Comminuted fractures of the parsymphysis were not treated with lag screws. Two screws were used to compress, reduce and stabilize the fracture when using the lag screw technique. The technique is described in detail. Results. Of the 135 fractures, 51 were treated by closed reduction and intermaxillary fixation, and 84 were treated with open reduction and internal fixation, using lag screw technique in 36 patients. There were no complications requiring subsequent removal of hardware with the lag screw technique. Conclusion. In our experience, the lag screw technique for rigid fixation of mandibular parasymphysis fractures is a suitable and successful option.
Detection of child abuse. John F. Coyne DMD, Steven Garin DMD. Allen Fred Fielding DMD,
David
King
DMD,
Temple University,
Philadelphia, Pennsylvania, USA. Presented by: John F. Coyne DMD. The oral and maxillofacial surgeon is in a unique position to diagnose and help children who are being abused and neglected. As many as 65% of the cases of child abuse include injuries to the head, neck, or mouth, parts of the body in which oral and maxillofacial surgeons specialize. Additionally, studies show that more than 70% of the fatalities attributed to child abuse are also caused by injuries to the head and neck. Oral and maxillofacial surgeons are mandated reporters, and are required by law to report suspected cases of child abuse and neglect. However, the major barrier to reporting suspected cases is a lack of training in the areas of detection and reporting process of child abuse. This presentation discusses the role of the oral and maxillofacial surgeon in the detection and reporting of child abuse. Child abuse will be defined and demonstrated and the surgeon’s responsibilities will be discussed. Specific signs and symptoms of child abuse will be reviewed, along with the methodology of reporting suspected cases. Finally, resources for obtaining additional information on the detection and reporting of child abuse will be presented.
References
Schmitt B.D. Types of child abuse and neglect: an overview for dentists. Ped Dent 1986: 8 (Spec. Issue 1): 67-70. The Dental Coalition to Combat Child Abuse and Neglect (Massachusetts). Dental conditions to combat child abuse. Dental facts relating to child abuse, l-2. ADA Council on Dental Practice. The dentist’s responsibility in identifying and reporting child abuse, 1989 revision. Advanced extraction Gross DDS.
therapy
utilizing
bioplant
HTR-24.
Jefsyey
S.
Presented by: Jeffrey S. Gross DDS, FAGD. The goal of this study was to find a technique to manage and direct the healing of an extraction site. The protocol emphasized the creation of an environment that would promote faster healing and decrease the possibility of post-extraction osteitis, i.e. a dry socket. The ultimate goal was to preserve and maintain ridge height and width. The resultant architecture would facilitate the fabrication of future prosthesis. Four hundred and ninety-five (495) teeth were removed utilizing conventional techniques. The resultant wounds were treated with advanced extraction-therapy techniques, which involved filling the extraction sockets with an alloulast. Bioplant HTR-24. All sockets were closed with sutures using a modified double-horizontal mattress sutures. The patients were contacted the evening following treatment by telephone and seen 5-7 days later for suture removal. Only two patients demonstrated less than optimal results. The data should set a new ‘gold standard’ of care for tooth removal by the profession. The techniques are easy to learn and are not timeconsuming or cost-prohibitive for the practitioner. Above all, the confidence level and appreciation by the patient vis-a-vis the dentist, in particular, and towards dental care, in general, are raised to a new level. The tibia as a donor site for autogenous grafting. DOS, MD, University of Louisville, Louisville,
Lloyd
A. Hudson
Kentucky, USA.
Presented by: Lloyd A. Hudson DDS, MD. Autogenous bone grafting is a widely used technique in various reconstructive efforts. There is a relative paucity of information concerning the tibia as a donor site in the literature. This may be the result of a general opinion that there is an inadequate volume of cancellous bone available there. Nevertheless, the tibia is a viable alternative with fewer documented complications. Objectives. To describe the approach for obtaining autogenous marrow from the proximal tibia and discuss its low morbidity and advantages. Procedures/Techniques. 37 tibia1 grafts were performed in the last five years. The surgical technique is described in detail. Results. 35 of 37 patients were complication-free. The two complications were both infections, a superficial wound infection and a cellulitis that responded promptly to treatment without untoward sequelae. Conclusions. The disadvantage of this procedure are few. Although less bone is available than in the hip. 30-40 cc of bone are routinely obtained, which is an ample amount in many procedures. Our complication rate of 5.1% is higher than that in the literature, but is significantly lower than that reported for iliac crest grafts. The advantages appear to be many. There were no cases of sensory loss, fracture, hematoma or prolonged gait disturbance. The blood loss is essentially zero with the aid of a tourniquet. The anatomy, dissection, and bone procurement is relatively simple, even in obese patients. Postoperative pain is well controlled. Patients are ambulatory the next day with minimal assistance with crutch or cane. A mild limp rarely last past two weeks. Patient acceptance, including cosmesis, is high. Obliteration of the frontal DDS, Chester J. Chorazy
sinus with autogenous fat. Robert L. Jolly DOS, MDS, St Francis Medical Center,
Pittsburgh, Pennsylvania, USA. Presented by: Robert L. Jolly DDS. Surgical options for frontal sinus fractures vary depending on the type, location and severity of the fracture as well as the condition
Abstracts and patency of the nasofrontal ducts. Non-displaced anterior table fractures with functioning ducts have been successfully treated without surgery, whereas more severe anterior table fractures will require at minimum an open exploration, and in cases with significant nasofrontal duct damage, a sinus obliteration is indicated. Access to the frontal region can be accomplished in several ways. However, the bicoronal flap with its ability to camouflage the scar in the hairline and offer wide exposure is the preferred approach. After adequate access, the anterior table is removed. debrided of any contaminants and, if necessary, reassembled. It is then stored in normal saline until it is ready to be replaced. The nasofrontal ducts are then identified and inspected. Patency is verified by injecting methyline blue into the duct and then examining the middle meatus of the nasal cavity for the presence of the dye. If the ducts prove to be occluded and are damaged to an extent that prevents repair or cannulation, an obliteration will need to be performed. The initial step in this procedure is total removal of the sinus mucoperiosteum. Next, the nasofrontal ducts are packed to ensure that no communication exists between the frontal sinus and the nasal cavity. Obliteration of the sinus is accomplished with autogenous fat, which is easily harvested in sufficient quantity from the periumbilical region. The anterior table is replaced and fixated, and the coronal flap is then closed in the usual manner.
The efficacy of dezocine vs Fentanyl in outpatient i.v. sedation and general anesthesia. Andrat) L. Kunter DMD, Awwrigo J. Fedeli DMD, Guy L. Lmri DMD, Jonuthun E. Burke DMD. Brim M. Smith DMD, Temple University Health Sciences Center. Philadelphia, Pennsylvania, USA. Presented by: Andrew L. Kanter DMD. A prospective randomized study was undertaken to evaluate the efficacy of Dalgan (Dezocine, Astra Pharmaceuticals). a narcotic agonist/antagonist, as a substitute for Fentanyl used in outpatient i.v. sedation and general anesthesia for dentoalveolar surgery. The two anesthetic regimens, administered alternately on odd and even days, included: (I ) Fentanyl 100 pg, Midazolam 4 mg. variable dose 1% sodium methohexital and (2) Dalgan 10 mg, Midazolam 4 mg, variable dose 1% sodium methohexital. Variables analyzed in the two groups were: ( 1) amount of sodium methohexital used: (2) incidence of singultus and laryngospasm; (3) mean time to recover utilizing the Triger Test; (4) mean oxygen desaturation; (5) nausea and vomiting; (6) blood pressure and heart rate changes; (7) patient compliance as rated by the surgeon on an analog visual scale. Preliminary data indicates that with Dalgan, significantly less sodium methohexital was necessary to achieve adequate levels of sedation, fewer incidences of oxygen desaturation, singultus, and laryngospasm occurred, and decreased recovery time was observed. Additional benefits include significantly better patient
from
the ACOMS
18th Annual
Conference
449
compliance, lower abuse potential, and no requirement for strict documentation of use that is normally necessary for schedule II narcotics. The clear advantages of Dalgan far outweigh its slightly increased cost ($6.26 per patient) over Fentanyl ($3.00 per patient) and make it an excellent addition to the armamentarium of the OMFS.
Traumatic cranial defects reconstructed with the HTR-PM1 cranioplastic implant. John B. Rohersorz DMD. Jimmie L. Harper DDS. Robert Horton DDS, Willium S. Rosu&q MD, University of Cincinnati Medical Center. Cincinnati, Ohio, LJSA. Presented by: John B. Roberson DMD. Cranial defects as a result of trauma, including motor vehicle accidents, motorcycle accidents, gunshot wounds, occupational accidents and altercations with blunt objects, can be cosmetically disfiguring. In the past, titanium mesh, polymethylmethacrylate application and autogenous bone grafting have been used to reconstruct these defects. These methods are time-consuming. requiring a second surgical site, and may not achieve a satisfactory cosmetic result. A more recent technique for reconstructing these defects has proven to be less time-consuming and provides an excellent esthetic result for the patient. This technique involves the production of a cranioplastic implant using 3-D computed tomography imaging (Hard Tissue Replacement-Patient Matched Implant. HTR-PM]). We present two cases using this technique to correct traumatic cranial defects.
A comparison of complications following bone grafting of unilateral and bilateral maxillary alveolar clefts in children. D. C. 7bng, D. G. Mo/cx M..4. E&w, R. cI/. T. Myu//, Children’s Hospital and Medical Center, Seattle, Washington. USA. Presented by: Darryl C. Tong BDS. The objective of this retrospective study was to compare complications between children who had unilateral and bilateral maxillary alveolar clefts grafted at Children’s Hospital and Medical Center. Seattle from 1992 to present. Complications are generally described in cleft lip and palate patients as a whole but do not reflect the differences between the two population groups. All surgeries were performed by the same two surgeons over a four-year period. The medical and dental records of 54 unilateral and 17 bilateral cleft lip and palate children were reviewed and complications tabulated. In the unilateral group, there were three complications out of 54 procedures (5.6%). while in the bilateral group there were three complications out of I7 procedures ( 17.6’%). The complications seen in the unilateral clefts tended to be major loss of the graft. The complication rates, however, were not statistically significant.