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Condylectomy and Costochondral Graft Reconstruction for Treatment of Active Idiopathic Condylar Resorption
Oral Abstract Session 1 Results: Follow up has been from six to thirty-eight months. Successful distraction osteogenesis took place in all cases. There were no complications. Solid regenerate bone, noted on interval x-rays, was confirmed clinically on distractor removal. All cases have had excellent range of motion, stable occlusion, and radiographic remodeling of the reconstructed condyle. Pain control has not been a problem in this series of patients. Conclusion: Distraction osteogenesis is a promising treatment for reconstruction of the RCU. It shares all of the advantages of autogenous bone grafting without the disadvantages of a donor site. It has none of the drawbacks of prosthetic joint reconstruction. Further evaluation of the technique is clearly warranted. References Ilizarov GA: The principles of the Ilizarov method. Bull Hosp Joint Dis 48:1, 1988 Stucki-McCormick SU: Reconstruction of the mandibular condyle using transport distraction osteogenesis. J Craniofac Surg 18:48, 1997
Power Doppler Harmonic Imaging in the Monitoring of Free Flap Tissue Perfusion: A Pilot Study Sanjay Sharma, BDS, MBBS, FDSRCS, MRCSI, MRCS, 5 Cadgwith Place, Port Solent PO6 4TD, UK (Anand R; Brennan P; Greaves K; Senior R; Ilankovan V) Statement of the Problem: Many methods have been described to monitor the blood flow in microvascular free tissue transfer. The commonest methods are clinical and subjective. None visualize the entire microcirculation of the free flap. Our aim was to examine a technique to objectively measure blood flow kinetics through the micro-circulation of free tissue transfers in head and neck reconstruction. Materials and Methods: We used power Doppler harmonic imaging using an infusion of microbubbles into the peripheral circulation. This was carried out pre-, intra-, and postoperatively. We examined blood flow dynamics, practical issues relating to transducer settings, and infusion rates for microbubbles. Method of Data Analysis: Images were acquired in real-time and analysed using customised software. This generated information on replenishment kinetics (mean transit time blood velocity) and flow dynamics (blood volume). Practical constraints and optimization of technical indices were analysed critically. Logistical difficulties, time delays, and drug safety issues are described. Results: We found that power Doppler harmonic imaging of the micro-circulation in free flaps is a viable technique in quantifying blood flow dynamics in head and neck microvascular free tissue transfer. Conclusion: Our technique was able to visualize the micro-circulation blood flow in real-time. Although further studies will be required to assess its usefulness in 32
the clinical setting we feel this technique shows great promise. References Lindner JR: Microbubbles in medical imaging: Current applications and future directions. Nat Rev Drug Discov 3:527, 2004 Senior R, Kaul S, Soman P, et al: Power Doppler harmonic imaging: A feasibility study of a new technique for the assessment of myocardial perfusion. Am Heart J 139(2 Pt 1):245, 2000 Christiansen JP, Leong-Poi H, Amiss LR, et al: Skin perfusion assessed by contrast ultrasound predicts tissue survival in a free flap model. Ultrasound Med Biol 28:315, 2002
Condylectomy and Costochondral Graft Reconstruction for Treatment of Active Idiopathic Condylar Resorption Fardad T. Tayebaty, BS, MGH, 55 Fruit St, Warren 1201, Boston, MA 02114 (Troulis MJ; Tayebaty FT; Papadaki M; Williams WB; Kaban LB) Statement of the Problem: Huang et al (1997) published a report indicating that condylectomy and costochondral graft (CCG) reconstruction provided the most stable outcome in patients treated for idiopathic condylar resorption. The purpose of this study was to evaluate outcomes in a case series of patients with active bilateral idiopathic condylar resorption treated by a similar protocol. Materials and Methods: This was a retrospective evaluation of 10 consecutive patients who had 1) active bilateral idiopathic condylar resorption confirmed by clinical examination, plain x-rays, and technetium-99 bone scans, 2) adequate documentation, 3) minimum of 12 months follow-up. Patients who had condylar resorption due to trauma or steroid use, less than 12 months follow-up, or inadequate documentation were excluded. All patients in this series underwent condylectomy and placement of the CCG by using the endoscopic technique. Preoperative (T0), postoperative (T1), 6-month (T2), one year (T3), and latest follow up (T4) clinical examinations, lateral cephalograms, and panoramic radiographs were used to evaluate the outcomes. Pain, facial symmetry, inferior alveolar and lingual nerve function, jaw motion, and occlusion were evaluated by history and physical examination. Cephalometric measurements included overbite, overjet, SNB and mandibular plane angles. Ramus/condyle unit (RCU) height was measured on panoramic radiographs. Method of Data Analysis: This was a retrospective evaluation of 10 consecutive patients who had 1) active bilateral idiopathic condylar resorption confirmed by clinical examination, plain x-rays, and technetium-99 bone scans, 2) adequate documentation, 3) minimum of 12 months follow-up. Patients who had condylar resorption due to trauma or steroid use, less than 12 months follow-up, or inadequate documentation were excluded. All patients in AAOMS • 2005
Oral Abstract Session 1 this series underwent condylectomy and placement of the CCG by using the endoscopic technique. Preoperative (T0), postoperative (T1), 6-month (T2), one year (T3), and latest follow up (T4) clinical examinations, lateral cephalograms and panoramic radiographs were used to evaluate the outcomes. Pain, facial symmetry, inferior alveolar and lingual nerve function, jaw motion, and occlusion were evaluated by history and physical examination. Cephalometric measurements included overbite, overjet, SNB and mandibular plane angles. Ramus/condyle unit (RCU) height was measured on panoramic radiographs. Results: Condylectomy and CCG reconstruction were successfully performed using the endoscopic approach (n ⫽ 10). Mean follow up was 20 months (range 12 to 53 months). At T0 all ten patients presented with a class II malocclusion, mean RCU height was 5.2 cm, mean open bite was 2.7 mm, mean overjet was 6.25, mean mandibular plane angle was 44.5 degrees, and mean SNB was 70.6 degree. At T1 all patients demonstrated class I occlusion, a mean RCU height of 6.2 cm; over bite of 1.5 mm; overjet of 2.4 mm; mandibular plane angle of 34.5 degrees; and SNB angle of 74.5 degrees. All patients maintained a clinically acceptable, stable, and reproducible occlusion at the latest follow up and showed good range of motion with no evidence of temporomandibular joint dysfunction. Long-term cephalometric data will be presented. Conclusion: Results of this study indicate that a stable outcome is achievable in patients with active idiopathic condylar resorption by condylectomy and CCG reconstruction. The results were consistent with previous reports. References Huang YL, Pogrel AM, Kaban LB: Diagnosis and management of condylar resorption. J Oral Maxillofac Surg 55:114, 1997 Troulis MJ, Williams WB, Kaban LB: Endoscopic mandibular condylectomy and reconstruction: Early clinical results. J Oral Maxillofac Surg 62:460, 2004
Risk Assessment of Long Term PostOperative Bleeding Following Tooth Extraction(s) in the Pre-Transplant Liver Failure Patient E. Marc Weideman, DMD, 2086 Bent Trail Court, Ann Arbor, MI 48108 (Ward BB) Statement of the Problem: Liver failure patients are at high risk for postoperative complications including bleeding. At present there is no defined protocol for clinicians to follow regarding tooth extraction in the pre-transplant liver failure patient population. This study investigates and defines the preoperative risk factors that predict treatment failure leading to bleeding requiring hospital admission. Materials and Methods: Since August of 2001, twentyfive liver failure patients requiring extraction of one or AAOMS • 2005
more teeth prior to being placed on the transplant list were treated in the Department of Oral and Maxillofacial Surgery and Hospital Dentistry at the University of Michigan Hospital. These patients were stratified preoperatively into 3 different “risk” groups based on the total number of teeth to be extracted and the number of full/partial bony impacted teeth to be extracted. Risk was determined only by the planned surgical procedure and defined as “the potential for postoperative bleeding requiring post-op care or follow up.” The three groups were defined as: “Minimal Risk”—less than or equal to five non-impacted teeth requiring extraction; “Moderate Risk”— greater than or equal to six, but less than or equal to 9 non-impacted teeth requiring extraction; “High Risk”— greater than or equal to one impacted tooth or greater than or equal to ten teeth (impacted or not) requiring extraction. All patients received local measures for hemostasis at the time of surgery. In addition, based upon their preoperative group assignment, patients received pre-operative FFP, platelets, both, or nothing depending upon their presenting lab values. The aggressiveness of treatment with platelets and/or FFP was increased with each progressive category. The outcomes measured included long-term postoperative bleeding, the need for hospital admission for bleeding management, and the requirement of blood products in the management of complications. Additional factors considered as possible predictors of failure in this study included: age, pre-op PT, and pre-op PTT. Method of Data Analysis: A two-tailed Pearson correlation and regression analysis was conducted. Results: A total of twenty-five patients were treated in twenty-eight separate procedures. A two-tailed Pearson correlation and regression analysis was conducted. A statistically significant correlation (p ⬍ 0.05) was found between preoperative “risk,” and both the occurrence of long term postoperative bleeding and the need for hospital admission. Pre-op PT, pre-op PTT, pre-op INR, and pre-op platelet count were not statistically significant in predicting outcomes. In addition, despite more aggressive preoperative management of “high risk” category patients (including preoperative platelet counts of greater than 80,000 and INR less than 2) 80% experienced prolonged postoperative bleeding, with 75% requiring admission. Conclusion: Even with aggressive management, liver transplant patients requiring extraction of greater than or equal to one impacted tooth or greater than or equal to ten teeth (impacted or not) prior to placement on the liver transplant list are at significant risk of long term postoperative bleeding and hospital admission for its management. In our study, only preoperative “risk” (guided by the number and severity of extractions) had a statistically significant correlation with outcomes. Preoperative labs were not statistically significant in predicting postoperative outcomes. The current study is limited 33
Power Doppler Harmonic Imaging in the Monitoring of Free Flap Tissue Perfusion: A Pilot Study Sanjay Sharma, BDS, MBBS, FDSRCS, MRCSI, MRCS, 5 Cadgwith Place, Port Solent PO6 4TD, UK (Anand R; Brennan P; Greaves K; Senior R; Ilankovan V) Statement of the Problem: Many methods have been described to monitor the blood flow in microvascular free tissue transfer. The commonest methods are clinical and subjective. None visualize the entire microcirculation of the free flap. Our aim was to examine a technique to objectively measure blood flow kinetics through the micro-circulation of free tissue transfers in head and neck reconstruction. Materials and Methods: We used power Doppler harmonic imaging using an infusion of microbubbles into the peripheral circulation. This was carried out pre-, intra-, and postoperatively. We examined blood flow dynamics, practical issues relating to transducer settings, and infusion rates for microbubbles. Method of Data Analysis: Images were acquired in real-time and analysed using customised software. This generated information on replenishment kinetics (mean transit time blood velocity) and flow dynamics (blood volume). Practical constraints and optimization of technical indices were analysed critically. Logistical difficulties, time delays, and drug safety issues are described. Results: We found that power Doppler harmonic imaging of the micro-circulation in free flaps is a viable technique in quantifying blood flow dynamics in head and neck microvascular free tissue transfer. Conclusion: Our technique was able to visualize the micro-circulation blood flow in real-time. Although further studies will be required to assess its usefulness in 32
the clinical setting we feel this technique shows great promise. References Lindner JR: Microbubbles in medical imaging: Current applications and future directions. Nat Rev Drug Discov 3:527, 2004 Senior R, Kaul S, Soman P, et al: Power Doppler harmonic imaging: A feasibility study of a new technique for the assessment of myocardial perfusion. Am Heart J 139(2 Pt 1):245, 2000 Christiansen JP, Leong-Poi H, Amiss LR, et al: Skin perfusion assessed by contrast ultrasound predicts tissue survival in a free flap model. Ultrasound Med Biol 28:315, 2002
Condylectomy and Costochondral Graft Reconstruction for Treatment of Active Idiopathic Condylar Resorption Fardad T. Tayebaty, BS, MGH, 55 Fruit St, Warren 1201, Boston, MA 02114 (Troulis MJ; Tayebaty FT; Papadaki M; Williams WB; Kaban LB) Statement of the Problem: Huang et al (1997) published a report indicating that condylectomy and costochondral graft (CCG) reconstruction provided the most stable outcome in patients treated for idiopathic condylar resorption. The purpose of this study was to evaluate outcomes in a case series of patients with active bilateral idiopathic condylar resorption treated by a similar protocol. Materials and Methods: This was a retrospective evaluation of 10 consecutive patients who had 1) active bilateral idiopathic condylar resorption confirmed by clinical examination, plain x-rays, and technetium-99 bone scans, 2) adequate documentation, 3) minimum of 12 months follow-up. Patients who had condylar resorption due to trauma or steroid use, less than 12 months follow-up, or inadequate documentation were excluded. All patients in this series underwent condylectomy and placement of the CCG by using the endoscopic technique. Preoperative (T0), postoperative (T1), 6-month (T2), one year (T3), and latest follow up (T4) clinical examinations, lateral cephalograms, and panoramic radiographs were used to evaluate the outcomes. Pain, facial symmetry, inferior alveolar and lingual nerve function, jaw motion, and occlusion were evaluated by history and physical examination. Cephalometric measurements included overbite, overjet, SNB and mandibular plane angles. Ramus/condyle unit (RCU) height was measured on panoramic radiographs. Method of Data Analysis: This was a retrospective evaluation of 10 consecutive patients who had 1) active bilateral idiopathic condylar resorption confirmed by clinical examination, plain x-rays, and technetium-99 bone scans, 2) adequate documentation, 3) minimum of 12 months follow-up. Patients who had condylar resorption due to trauma or steroid use, less than 12 months follow-up, or inadequate documentation were excluded. All patients in AAOMS • 2005
Oral Abstract Session 1 this series underwent condylectomy and placement of the CCG by using the endoscopic technique. Preoperative (T0), postoperative (T1), 6-month (T2), one year (T3), and latest follow up (T4) clinical examinations, lateral cephalograms and panoramic radiographs were used to evaluate the outcomes. Pain, facial symmetry, inferior alveolar and lingual nerve function, jaw motion, and occlusion were evaluated by history and physical examination. Cephalometric measurements included overbite, overjet, SNB and mandibular plane angles. Ramus/condyle unit (RCU) height was measured on panoramic radiographs. Results: Condylectomy and CCG reconstruction were successfully performed using the endoscopic approach (n ⫽ 10). Mean follow up was 20 months (range 12 to 53 months). At T0 all ten patients presented with a class II malocclusion, mean RCU height was 5.2 cm, mean open bite was 2.7 mm, mean overjet was 6.25, mean mandibular plane angle was 44.5 degrees, and mean SNB was 70.6 degree. At T1 all patients demonstrated class I occlusion, a mean RCU height of 6.2 cm; over bite of 1.5 mm; overjet of 2.4 mm; mandibular plane angle of 34.5 degrees; and SNB angle of 74.5 degrees. All patients maintained a clinically acceptable, stable, and reproducible occlusion at the latest follow up and showed good range of motion with no evidence of temporomandibular joint dysfunction. Long-term cephalometric data will be presented. Conclusion: Results of this study indicate that a stable outcome is achievable in patients with active idiopathic condylar resorption by condylectomy and CCG reconstruction. The results were consistent with previous reports. References Huang YL, Pogrel AM, Kaban LB: Diagnosis and management of condylar resorption. J Oral Maxillofac Surg 55:114, 1997 Troulis MJ, Williams WB, Kaban LB: Endoscopic mandibular condylectomy and reconstruction: Early clinical results. J Oral Maxillofac Surg 62:460, 2004
Risk Assessment of Long Term PostOperative Bleeding Following Tooth Extraction(s) in the Pre-Transplant Liver Failure Patient E. Marc Weideman, DMD, 2086 Bent Trail Court, Ann Arbor, MI 48108 (Ward BB) Statement of the Problem: Liver failure patients are at high risk for postoperative complications including bleeding. At present there is no defined protocol for clinicians to follow regarding tooth extraction in the pre-transplant liver failure patient population. This study investigates and defines the preoperative risk factors that predict treatment failure leading to bleeding requiring hospital admission. Materials and Methods: Since August of 2001, twentyfive liver failure patients requiring extraction of one or AAOMS • 2005
more teeth prior to being placed on the transplant list were treated in the Department of Oral and Maxillofacial Surgery and Hospital Dentistry at the University of Michigan Hospital. These patients were stratified preoperatively into 3 different “risk” groups based on the total number of teeth to be extracted and the number of full/partial bony impacted teeth to be extracted. Risk was determined only by the planned surgical procedure and defined as “the potential for postoperative bleeding requiring post-op care or follow up.” The three groups were defined as: “Minimal Risk”—less than or equal to five non-impacted teeth requiring extraction; “Moderate Risk”— greater than or equal to six, but less than or equal to 9 non-impacted teeth requiring extraction; “High Risk”— greater than or equal to one impacted tooth or greater than or equal to ten teeth (impacted or not) requiring extraction. All patients received local measures for hemostasis at the time of surgery. In addition, based upon their preoperative group assignment, patients received pre-operative FFP, platelets, both, or nothing depending upon their presenting lab values. The aggressiveness of treatment with platelets and/or FFP was increased with each progressive category. The outcomes measured included long-term postoperative bleeding, the need for hospital admission for bleeding management, and the requirement of blood products in the management of complications. Additional factors considered as possible predictors of failure in this study included: age, pre-op PT, and pre-op PTT. Method of Data Analysis: A two-tailed Pearson correlation and regression analysis was conducted. Results: A total of twenty-five patients were treated in twenty-eight separate procedures. A two-tailed Pearson correlation and regression analysis was conducted. A statistically significant correlation (p ⬍ 0.05) was found between preoperative “risk,” and both the occurrence of long term postoperative bleeding and the need for hospital admission. Pre-op PT, pre-op PTT, pre-op INR, and pre-op platelet count were not statistically significant in predicting outcomes. In addition, despite more aggressive preoperative management of “high risk” category patients (including preoperative platelet counts of greater than 80,000 and INR less than 2) 80% experienced prolonged postoperative bleeding, with 75% requiring admission. Conclusion: Even with aggressive management, liver transplant patients requiring extraction of greater than or equal to one impacted tooth or greater than or equal to ten teeth (impacted or not) prior to placement on the liver transplant list are at significant risk of long term postoperative bleeding and hospital admission for its management. In our study, only preoperative “risk” (guided by the number and severity of extractions) had a statistically significant correlation with outcomes. Preoperative labs were not statistically significant in predicting postoperative outcomes. The current study is limited 33