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Practical guidelines for the reconstruction of the mandible and maxilla
Surgical Clinics tently and completely opens the upper airway, we have developed a philosophy directed toward surgery, which not only would achieve high acceptance rates but also offer significant success in a wide variety of patients. Multiple potential sites of airway occlusion include the soft palate, lateral pharyngeal walls, and base of the tongue; thus uvulopharyngopalatoplasty (UPPP) in conjunction with skeletal mobilization techniques to advance the anterior mandibular attachments of the tongue and suprahyoid musculature can improve both oral and hypopharyngeal cross-sectional anatomy. Genioglossus advancement via mortised genioplasty allows a large soft tissue pedicle to be significantly advanced and rigidly fixated in a way that minimizes the potential for mandibular fracture. This technique will be discussed in detail, including specific indications thereof. The outcome data of several hundred patients treated at the University of Pennsylvania Center for Sleep Disorders will be reviewed in detail.
This surgical clinic shall discuss the patient selection process and outline definitive guidelines for optimal results. Discussion will follow on the anatomy of the surgical region and basic armamentarium to begin performing these procedures. The incorporation of submental liposuction along with other concomitant surgeries such as orthognathic surgery or implant reconstruction will be presented since this is an avenue of entry for many surgeons in this area. Presentation of potential complications and their management with development of proper informed consent will be presented. Finally, case assessment and critical evaluation of results will be presented with participant discussion. References Goodstein WA: Superficial liposculpture of the face and neck. Plast Reconstr Surg 98:988, 1996 Kennedy B: Suction lipectomy of the youthful neck. Oral Maxillofac Surg Clin North Am 2:233, 1990 Epker BN, Stella JP: Systematic aesthetic evaluation of the neck for cosmetic surgery. Oral Maxillofac Surg Clin North Am 2:217, 1990
References Schmidt-Nowara W, Lowe A, et al: Oral appliances for the treatment of snoring and obstructive sleep apnea: A review. Sleep 18:501, 1995 Clark G, Blumenthal I, et al: A crossover study comparing the efficacy of CPAP with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest 109:l477, 1996 Fairbanks D, Fwita S (eds): Snoring and Obstructive Sleep Apnea (ed 2). New York, NY, Raven, 1994
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With the wide range of treatment options now available, surgeons are challenged to select the optimal method, material, and timing for a particular reconstruction. Four areas of the maxillofacial complex frequently require reconstruction: the mandible, maxilla, orbit, and zygoma. Part I of this clinic will cover reconstruction of the mandible and maxilla, and Part II will cover the orbit and zygoma. Mandibular defects can be divided into marginal defects, continuity defects, and continuity defects that include the mandibular condyle. Treatment varies among these 3 types of defects and also depends a great deal on the quantity and quality of the surrounding soft tissue. Mandibular defects with well-vascularized surrounding soft tissue of good volume can be treated by a variety of techniques using free autogenous bone grafts. When the soft tissue is deficient in quantity and/or quality, it must be improved or replaced before free autogenous bone grafting or free vascularized flaps may be used. The choice of reconstructive system is based on the experience of the surgeon and on the specific characteristics of the defect and the overall health of the patient. Our preferred technique in the nonirradiated patient with healthy surrounding soft tissue is a combination of a reconstruction plate and block corticocancellous graft from the posterior ilium. These grafts have demonstrated excellent retention over time and are compatible with osseointegrated implants.
Basic Technique of Submental Liposuction Vincent Ziccardi, DDS, MD, Newark, NJ Neck aesthetics is important in overall facial beauty. Fat in the submental and lateral neck region is considered unattractive by many in our society. This critical aesthetic area of the face can be influenced by a variety of surgical procedures including submental liposuction. The cervicalmandibular contours create neck and facial definition that may be obliterated by localized fatty depositions. As part of the patient evaluation, it is imperative that the treating surgeon differentiate this fatty lipomatosis from other deformities such as mandibular hypoplasia or skin redundancy resulting from age-related changes. Submental liposuction works through the removal of fat close to the undersurface of the overlying skin leading to contraction and permanent changes in contour. This is performed at a subcutaneous plane safely above the platysma muscle. As the technique evolved with the introduction of the tumescent technique, the procedure was able to be performed more rapidly, safely and with better postoperative results. Paramount to the final result is the proper patient selection and rigorous postoperative care including pressure garments. AAOMS • 2003
Practical Guidelines for the Reconstruction of the Mandible and Maxilla Mark Wong, DDS, Houston, TX Brian Smith, DDS, Shreveport, LA
113
Surgical Clinics Maxillary defects can be divided into those defects that have loss of hard and soft tissue and those with loss of hard tissue only. Defects with loss of hard tissue only are less difficult to treat and are frequently treated by placement of free autogenous bone grafts, in many cases with subsequent or simultaneous implant placement. For the hemimaxillectomy defect in which there is loss of both hard and soft tissue, 3 general approaches can be used. The first is use of the traditional prosthetic obturator. A second is use of a pedicled flap such as the temporalis muscle flap, which separates the oral cavity from the nasal cavity and maxillary sinus region. A third would be use of free vascularized tissue transfer of soft tissue or soft tissue and bone. Although the obturator approach may be difficult for younger patients to accept, it has the advantage of avoiding another donor site and may give the most stable and predictable results long term. References Macintosh RB: Current spectrum of costochondral and dermal grafting, in Bell WH (ed): Modern Practice of Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, p 873 Keller EE: Mandibular discontinuity reconstruction with composite grafts: Free autogenous iliac bone, titanium mesh trays and titanium endosseous implants. Oral Maxillofac Surg Clin North Am 3:877, 1991 Bach DE, Burgess LPA, Zislis T, et al: Cranial, iliac and demineralized freeze-dried bone grafts of the mandible in dogs. Arch Otolaryngol Head Neck Surg 117:390, 1991
S210 Myocutaneous and Myo-Osseous Flaps for Oral and Maxillofacial Reconstruction Timothy Turvey, DDS, Chapel Hill, NC Defects of the oral and maxillofacial region resulting from trauma, tumor ablation, radiation, infection, etc, often involve bone and soft tissues. The importance of well-vascularized soft tissues in the successful management of these extensive defects is well recognized. Local muscle and bone donor sources exist adjacent to the maxillofacial region, which permits transfer of these tissues and may obviate the need for more distant pedicled flaps or free vascularized tissue transfer. The major advantages of local transfer are technical ease, less morbidity, and compliance with the surgical principle of using proximal donor sources for reconstruction. The platysma muscle with or without a skin paddle can be used to reline defects of the oral cavity and facial area. The temporalis muscle alone can be used similarly to resurface defects of the oral cavity but also can be used as a myo-osseous flap when bone is required. These local flaps are not suitable for every maxillofacial defect, but they are readily accessible and reliable for many oral and maxillofacial surgical defects. The anatomy with emphasis on vascular supply, sur114
gical technique, and the principles of tissue transfer will be highlighted with representative cases.
S211 Primary Surgical Management of Cleft Lip and Palate Deformities Rafael Ruiz-Rodriguez, DDS, Mexico City, O.F. Mexico Daniel Buchbinder, DMD, MD, New York, NY The goal of this surgical clinic is to “demystify” the surgical procedures most commonly used for the repair of cleft lip and palate (CL/P) deformities. The epidemiology, genetic basis, and embryology of CL/P will be reviewed. The work-up and multidisciplinary approach to the care of the CL/P patient will be discussed. Simple, step-by-step surgical techniques used for the primary repair of unilateral and bilateral cleft lip will be demonstrated. The different revision techniques for the repair of residual deformities such as whistle tip, collumella (in the bilateral cleft), and lower cartilaginous nasal skeleton will also be demonstrated. Similarly, the various palatoplasty techniques both for the primary repair as well as revisions for residual oronasal fistulas will be discussed. The timing and techniques for the repair of the alveolar cleft will be reviewed. Finally, the evaluation of velopharyngeal function will be discussed, and the use of the superiority-based pharyngeal flap will be shown. References Millard DR: Cleft Craft, vols I and II. Boston, MA, Little, Brown, 1977 Bulow KW: Treatment of Facial Cleft Deformities: An Illustrated Guide. St Louis, MO, Ishiyaku EuroAmerica Publishers, 1995 Kapetansky DI: Techniques in Cleft Lip Nose and Palate Reconstruction. New York, NY, Gower Medical Publishing Ltd, 1987 Shprintzen R, Bardash J: Cleft Palate Speech Management: A Multidisciplinary Approach. New York, NY, Mosby, 1995
S212 Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea Peter Waite, DDS, MD, Birmingham, AL (no abstract provided)
S213 Lip Augmentation John Stover, DDS, MD, PhD, Hilo, HI Lip augmentation is a commonly performed procedure by cosmetic and reconstructive surgeons. Older patients with ptotic lips and patients of all ages with hypoplastic lips typically desire increased fullness with AAOMS • 2003
This surgical clinic shall discuss the patient selection process and outline definitive guidelines for optimal results. Discussion will follow on the anatomy of the surgical region and basic armamentarium to begin performing these procedures. The incorporation of submental liposuction along with other concomitant surgeries such as orthognathic surgery or implant reconstruction will be presented since this is an avenue of entry for many surgeons in this area. Presentation of potential complications and their management with development of proper informed consent will be presented. Finally, case assessment and critical evaluation of results will be presented with participant discussion. References Goodstein WA: Superficial liposculpture of the face and neck. Plast Reconstr Surg 98:988, 1996 Kennedy B: Suction lipectomy of the youthful neck. Oral Maxillofac Surg Clin North Am 2:233, 1990 Epker BN, Stella JP: Systematic aesthetic evaluation of the neck for cosmetic surgery. Oral Maxillofac Surg Clin North Am 2:217, 1990
References Schmidt-Nowara W, Lowe A, et al: Oral appliances for the treatment of snoring and obstructive sleep apnea: A review. Sleep 18:501, 1995 Clark G, Blumenthal I, et al: A crossover study comparing the efficacy of CPAP with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest 109:l477, 1996 Fairbanks D, Fwita S (eds): Snoring and Obstructive Sleep Apnea (ed 2). New York, NY, Raven, 1994
S209
S208
With the wide range of treatment options now available, surgeons are challenged to select the optimal method, material, and timing for a particular reconstruction. Four areas of the maxillofacial complex frequently require reconstruction: the mandible, maxilla, orbit, and zygoma. Part I of this clinic will cover reconstruction of the mandible and maxilla, and Part II will cover the orbit and zygoma. Mandibular defects can be divided into marginal defects, continuity defects, and continuity defects that include the mandibular condyle. Treatment varies among these 3 types of defects and also depends a great deal on the quantity and quality of the surrounding soft tissue. Mandibular defects with well-vascularized surrounding soft tissue of good volume can be treated by a variety of techniques using free autogenous bone grafts. When the soft tissue is deficient in quantity and/or quality, it must be improved or replaced before free autogenous bone grafting or free vascularized flaps may be used. The choice of reconstructive system is based on the experience of the surgeon and on the specific characteristics of the defect and the overall health of the patient. Our preferred technique in the nonirradiated patient with healthy surrounding soft tissue is a combination of a reconstruction plate and block corticocancellous graft from the posterior ilium. These grafts have demonstrated excellent retention over time and are compatible with osseointegrated implants.
Basic Technique of Submental Liposuction Vincent Ziccardi, DDS, MD, Newark, NJ Neck aesthetics is important in overall facial beauty. Fat in the submental and lateral neck region is considered unattractive by many in our society. This critical aesthetic area of the face can be influenced by a variety of surgical procedures including submental liposuction. The cervicalmandibular contours create neck and facial definition that may be obliterated by localized fatty depositions. As part of the patient evaluation, it is imperative that the treating surgeon differentiate this fatty lipomatosis from other deformities such as mandibular hypoplasia or skin redundancy resulting from age-related changes. Submental liposuction works through the removal of fat close to the undersurface of the overlying skin leading to contraction and permanent changes in contour. This is performed at a subcutaneous plane safely above the platysma muscle. As the technique evolved with the introduction of the tumescent technique, the procedure was able to be performed more rapidly, safely and with better postoperative results. Paramount to the final result is the proper patient selection and rigorous postoperative care including pressure garments. AAOMS • 2003
Practical Guidelines for the Reconstruction of the Mandible and Maxilla Mark Wong, DDS, Houston, TX Brian Smith, DDS, Shreveport, LA
113
Surgical Clinics Maxillary defects can be divided into those defects that have loss of hard and soft tissue and those with loss of hard tissue only. Defects with loss of hard tissue only are less difficult to treat and are frequently treated by placement of free autogenous bone grafts, in many cases with subsequent or simultaneous implant placement. For the hemimaxillectomy defect in which there is loss of both hard and soft tissue, 3 general approaches can be used. The first is use of the traditional prosthetic obturator. A second is use of a pedicled flap such as the temporalis muscle flap, which separates the oral cavity from the nasal cavity and maxillary sinus region. A third would be use of free vascularized tissue transfer of soft tissue or soft tissue and bone. Although the obturator approach may be difficult for younger patients to accept, it has the advantage of avoiding another donor site and may give the most stable and predictable results long term. References Macintosh RB: Current spectrum of costochondral and dermal grafting, in Bell WH (ed): Modern Practice of Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, p 873 Keller EE: Mandibular discontinuity reconstruction with composite grafts: Free autogenous iliac bone, titanium mesh trays and titanium endosseous implants. Oral Maxillofac Surg Clin North Am 3:877, 1991 Bach DE, Burgess LPA, Zislis T, et al: Cranial, iliac and demineralized freeze-dried bone grafts of the mandible in dogs. Arch Otolaryngol Head Neck Surg 117:390, 1991
S210 Myocutaneous and Myo-Osseous Flaps for Oral and Maxillofacial Reconstruction Timothy Turvey, DDS, Chapel Hill, NC Defects of the oral and maxillofacial region resulting from trauma, tumor ablation, radiation, infection, etc, often involve bone and soft tissues. The importance of well-vascularized soft tissues in the successful management of these extensive defects is well recognized. Local muscle and bone donor sources exist adjacent to the maxillofacial region, which permits transfer of these tissues and may obviate the need for more distant pedicled flaps or free vascularized tissue transfer. The major advantages of local transfer are technical ease, less morbidity, and compliance with the surgical principle of using proximal donor sources for reconstruction. The platysma muscle with or without a skin paddle can be used to reline defects of the oral cavity and facial area. The temporalis muscle alone can be used similarly to resurface defects of the oral cavity but also can be used as a myo-osseous flap when bone is required. These local flaps are not suitable for every maxillofacial defect, but they are readily accessible and reliable for many oral and maxillofacial surgical defects. The anatomy with emphasis on vascular supply, sur114
gical technique, and the principles of tissue transfer will be highlighted with representative cases.
S211 Primary Surgical Management of Cleft Lip and Palate Deformities Rafael Ruiz-Rodriguez, DDS, Mexico City, O.F. Mexico Daniel Buchbinder, DMD, MD, New York, NY The goal of this surgical clinic is to “demystify” the surgical procedures most commonly used for the repair of cleft lip and palate (CL/P) deformities. The epidemiology, genetic basis, and embryology of CL/P will be reviewed. The work-up and multidisciplinary approach to the care of the CL/P patient will be discussed. Simple, step-by-step surgical techniques used for the primary repair of unilateral and bilateral cleft lip will be demonstrated. The different revision techniques for the repair of residual deformities such as whistle tip, collumella (in the bilateral cleft), and lower cartilaginous nasal skeleton will also be demonstrated. Similarly, the various palatoplasty techniques both for the primary repair as well as revisions for residual oronasal fistulas will be discussed. The timing and techniques for the repair of the alveolar cleft will be reviewed. Finally, the evaluation of velopharyngeal function will be discussed, and the use of the superiority-based pharyngeal flap will be shown. References Millard DR: Cleft Craft, vols I and II. Boston, MA, Little, Brown, 1977 Bulow KW: Treatment of Facial Cleft Deformities: An Illustrated Guide. St Louis, MO, Ishiyaku EuroAmerica Publishers, 1995 Kapetansky DI: Techniques in Cleft Lip Nose and Palate Reconstruction. New York, NY, Gower Medical Publishing Ltd, 1987 Shprintzen R, Bardash J: Cleft Palate Speech Management: A Multidisciplinary Approach. New York, NY, Mosby, 1995
S212 Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea Peter Waite, DDS, MD, Birmingham, AL (no abstract provided)
S213 Lip Augmentation John Stover, DDS, MD, PhD, Hilo, HI Lip augmentation is a commonly performed procedure by cosmetic and reconstructive surgeons. Older patients with ptotic lips and patients of all ages with hypoplastic lips typically desire increased fullness with AAOMS • 2003