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Indications to Use Zygoma Implants in the Mandible
Oral Abstract Session 2 Conclusion: This is the largest cadaver study comparing autogenous intraoral donor sites. Our preliminary results indicate that the characteristics among different donor sites vary greatly in regard to thickness, volume, and cortical surface area. Additionally, we have found that the percentage of bone yield per site is relatively consistent between cadavers. With this more exact knowledge of the various yields derived from these grafts a surgeon will be more adequately equipped to confront the reconstructive challenges of the maxillofacial region. References: Gungormus M, et al. The Ascending Ramus of the Mandible as a Donor Site in Maxillofacial Bone Grafting. JOMS. 60: 1316-1318 (2002) Gellrich NC, et al. Alveolar Zygomatic Buttress: A New Donor Site for Limited Pre-implant Augmentation Procedures. JOMS: 65:275-280 (2007).
Bone Harvest from the Iliac Crest for Pre-Prosthetic Procedures in Denmark. Donor Site Morbidity of the Anterior and the Posterior Approach E. Swiatecka: Dept. of OMS, Southwest Hospital Esbjerg, Denmark, J. Thorn, J. Ingerslev Statement of the Problem: In 2009 62% of all iliac crest bone grafts in Denmark were taken by specialists in Oral and Maxillofacial Surgery (OMS) as compared to 10% in 19991. The specialty of OMS in Denmark is based on a dental degree exclusively. The harvesting of bone grafts from the iliac crest was first legalized for OMS in 2010 by the National Board of Health. The performance of the procedure by specialists in OMS in Denmark, however, has not yet been evaluated. Materials and Methods: We present a total of 74 cases of bone harvested from either the anterior or the posterior iliac crest at the Department of Oral and Maxillofacial Surgery, Hospital of Southwest Denmark Esbjerg, Region of Southern Denmark, in terms of purpose, procedure and donor site morbidity. The patients were operated on between 2001 and 2009 and data was obtained retrospectively from 2001 to 2004 and prospectively from then on. Observation time is thus at least one year. Transplants were harvested from the anterior crest in 20 cases and from the posterior crest in 54 cases. The purpose of the harvest was in some cases larger or minor jaw reconstructions but in most cases pre-prosthetic reconstruction of Cawood V- and VI-type maxillas as inlays combined with veneer grafts. The “anterior” group was considerably younger than the “posterior” group. Nevertheless, no differences in long term morbidity of the two groups were observed, except for a small area of cutaneous hyposensitivity around the site of the incision, which was found in 24% in the “posterior” group in contrast to 9% in the anterior. Although not statistically significant, the posterior approach e-18
caused less pain the first week, but after 4 months no differences were noted. No serious side effects occurred in any of the cases. Results: The results are in accordance with the literature and it is concluded that bone harvested from the iliac crest by specialists in OMS in Denmark is done according to best specialist standard. The choice between the anterior and the posterior iliac crest as a donor site for bone harvest is in our opinion dependant of the amount of bone needed for the reconstructive procedure. When in doubt of the amount of bone needed we prefer the posterior approach. References: Statistics of the National Board of Health, personal communication. Kessler et al. Harvesting of bone from the iliac crest - comparison of the anterior and posterior sites. Brit J Oral Maxillofac Surg 2005: 43: 51-56
Indications to Use Zygoma Implants in the Mandible C. Guerrero: Santa Rosa Maxillofacial Surgery Center, P. Lopez, M. Gonzalez, R. Rodriguez Statement of the Problem: This study evaluates the functional and cosmetic results of using zygoma implants with different angulations (15-45 degrees) after particular mandibular bony reconstructions with poor bone quality or quantity, but mandibular continuity and good bone support in the adjacent areas; also as provisional dental anchorage in mandibular reconstructions to partially rehabilitate the lower dentition, waiting for bone healing, definitive implant placement and osseointegration; finally, as lateral fixtures in the all-on-4 concept, to avoid dealing with complicated prosthetic abutments and connections. Materials and Methods: Fifteen patients (8 female, 7 male) ages between 22 and 66 years old (average 41.9) were treated with zygoma implants in the mandible, eight (8/15) individuals underwent mandibular reconstruction post-tumoral resection with adequate bone continuity, fibula or iliac crest bone grafts, but poor bone volume for implants insertion; adjacent bone to the reconstruction was sufficient to place zygoma implants and secure good anchorage for definitive rehabilitation. Two (2/15) patients with high cosmetics standard required dental rehabilitation to resume working activities before bone reconstruction, fixtures insertion and osseointegration could take place; zygoma implants that would not interfere with proper healing were inserted and temporary rehabilitation installed. Five (5/15) patients underwent the all-on-4 concept with short zygoma implants used in the lateral fixtures, to secure a faster healing and immediate rehabilitation, eliminating the need for multiple prosthodontics part connections. For reconstructive and atrophic mandibular patients, ZygoAAOMS • 2011
Oral Abstract Session 2 matic implants were inserted in the healthy non-operated bone, extending the body of fixture into the poor bone quality area. The zygomatic implant was used to bypass the junction site between the well-vascularized bone and the grafting emerging 5 to 10 mm away from the bony union, into the grafting area. Regular dental implants were used to complete the anchorage in the mandibular body to allow proper distribution and adequate biomechanics utilizing hybrid screw retained prosthesis. The short zygoma implants were utilized as replacement of the inclined lateral fixtures in the all-on-4 concept. Method of Data Analysis: All patient⬘s records included clinical, radiographs and photographs analysis, pre- and postoperative; all patients were followed for a minimum of 12 months. Also, prosthodontist and surgeon clinical evaluations were obtained and charts filled with information on dental occlusion, range of mandibular motion, tissue health around fixtures, level of the implant related to soft tissue, rehabilitation stability, hygiene, nasal airway and patient satisfaction. Results: All patients were dentally rehabilitated immediately with functional and esthetic hybrid dentures based on either acrylic or porcelain on a metal structure, using 37 zygomatic implants and 40 standard fixtures. Immediate provisional prosthesis was installed intra-operatively using provisional abutments. Patients were instructed to maintain excellent hygiene and periodontal control every 3 months. Conclusions: All patients were adequately rehabilitated, avoiding the need of new major grafting or distraction osteogenesis. This group of patients represents a major challenge after the initial reconstruction, where there is bone continuity, but the quality was unacceptable for standard dental implants; secondary surgeries in the compromised hostage bone would compromise the final outcome and would require further unpredictable surgeries. The zygoma fixture is an excellent possibility in the immediate loading concept for mandibular dental rehabilitation. References: Brånemark P-I. The Osseointegration Book From Calvarium to Calcaneus. Berlin: Quintessence Books 2005. Guerrero C. Sabogal A. Zygoma Implants: atlas of surgery and prosthetics. Madrid: Ripano 2010.
Tongue Flaps for Closure of Large Palatal Fistulas in Cleft Lip and Palate Patients R. Marques da Silva: Department of Oral and Maxillofacial Surgery, University of Oslo, Norway and Department of Oral and Maxillofacial Surgery, Center for Integral Assistance of Cleft Lip and Palate Patients (CAIF), Curitiba, Brazil, C. Biron, K. Ulbricht Gomes, J. Carlini AAOMS • 2011
Statement of the Problem: Palatal fistulas may occur in patients who have undergone cleft palate surgery. Small palatal fistulas may not be symptomatic, but large palatal fistulas produce various symptoms, including regurgitation of fluids into the nasal cavity and interference with normal speech. Treatment of these large fistulas is usually complex and difficult to be achieved by traditional local flaps. In such cases, tongue flaps may be an alternative option for treatment. Materials and Methods: Between 2005 and 2010, 7 cleft lip and palate patients were treated with a tongue flap procedure for closure of large anterior palatal defects. All palatal fistulas were larger than 2 x 1.5 cm in diameter and all patients had a bilateral complete cleft lip and palate. The fistulas were treated with the same technique, using the anterior two-thirds of the tongue to close the fistula. The flap pedicle remained connected to the tongue for 3 weeks, in order to maintain enough vascularization and to avoid flap necrosis. After this period, the patients were submitted to a new surgical procedure to free the flap from the tongue, and to close the remaining posterior fistula. Results of Investigation: All 7 flaps (100%) survived, and complete closure was obtained in all patients. No donor site complications were encountered. Conclusion: Our results demonstrate that the tongue flap is a safe and reliable technique for closure of large anterior palatal fistulas, particularly when repair is not achieved using other methods. References: Guerrero-Santos J, Altamarino JT. The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg 1986;38:123-128. Kim MJ, Lee JH, Choi JY, Kang N, Lee JH, Choi WJ. Two-stage reconstruction of bilateral alveolar cleft using Y-shaped anterior-based tongue flap and iliac bone graft. Cleft Palate Craniofac J 2001;38:432437.
Pharmacological Manipulation of Prostaglandins in Third Molar Surgery P. Mehra: Boston University, U. Reebye, D. Cottrell, M. Nadershah Statement of the Problem: Double-blind randomized clinical trial to assess the effect of four pharmacological regimens on the levels of prostaglandin E2 (PGE2) in urine and saliva and correlate the findings to the clinical postoperative course after removal of impacted lower third molars. Materials and Methods: ASA 1 patients requiring surgical removal of bilateral full-bony impacted lower third molars were included in the study and underwent surgery by a single surgeon under intravenous ambulatory general anesthesia using a standard technique. Patients were randomly divided into the following four groups (20 patients per group): Group 1: received ime-19
Bone Harvest from the Iliac Crest for Pre-Prosthetic Procedures in Denmark. Donor Site Morbidity of the Anterior and the Posterior Approach E. Swiatecka: Dept. of OMS, Southwest Hospital Esbjerg, Denmark, J. Thorn, J. Ingerslev Statement of the Problem: In 2009 62% of all iliac crest bone grafts in Denmark were taken by specialists in Oral and Maxillofacial Surgery (OMS) as compared to 10% in 19991. The specialty of OMS in Denmark is based on a dental degree exclusively. The harvesting of bone grafts from the iliac crest was first legalized for OMS in 2010 by the National Board of Health. The performance of the procedure by specialists in OMS in Denmark, however, has not yet been evaluated. Materials and Methods: We present a total of 74 cases of bone harvested from either the anterior or the posterior iliac crest at the Department of Oral and Maxillofacial Surgery, Hospital of Southwest Denmark Esbjerg, Region of Southern Denmark, in terms of purpose, procedure and donor site morbidity. The patients were operated on between 2001 and 2009 and data was obtained retrospectively from 2001 to 2004 and prospectively from then on. Observation time is thus at least one year. Transplants were harvested from the anterior crest in 20 cases and from the posterior crest in 54 cases. The purpose of the harvest was in some cases larger or minor jaw reconstructions but in most cases pre-prosthetic reconstruction of Cawood V- and VI-type maxillas as inlays combined with veneer grafts. The “anterior” group was considerably younger than the “posterior” group. Nevertheless, no differences in long term morbidity of the two groups were observed, except for a small area of cutaneous hyposensitivity around the site of the incision, which was found in 24% in the “posterior” group in contrast to 9% in the anterior. Although not statistically significant, the posterior approach e-18
caused less pain the first week, but after 4 months no differences were noted. No serious side effects occurred in any of the cases. Results: The results are in accordance with the literature and it is concluded that bone harvested from the iliac crest by specialists in OMS in Denmark is done according to best specialist standard. The choice between the anterior and the posterior iliac crest as a donor site for bone harvest is in our opinion dependant of the amount of bone needed for the reconstructive procedure. When in doubt of the amount of bone needed we prefer the posterior approach. References: Statistics of the National Board of Health, personal communication. Kessler et al. Harvesting of bone from the iliac crest - comparison of the anterior and posterior sites. Brit J Oral Maxillofac Surg 2005: 43: 51-56
Indications to Use Zygoma Implants in the Mandible C. Guerrero: Santa Rosa Maxillofacial Surgery Center, P. Lopez, M. Gonzalez, R. Rodriguez Statement of the Problem: This study evaluates the functional and cosmetic results of using zygoma implants with different angulations (15-45 degrees) after particular mandibular bony reconstructions with poor bone quality or quantity, but mandibular continuity and good bone support in the adjacent areas; also as provisional dental anchorage in mandibular reconstructions to partially rehabilitate the lower dentition, waiting for bone healing, definitive implant placement and osseointegration; finally, as lateral fixtures in the all-on-4 concept, to avoid dealing with complicated prosthetic abutments and connections. Materials and Methods: Fifteen patients (8 female, 7 male) ages between 22 and 66 years old (average 41.9) were treated with zygoma implants in the mandible, eight (8/15) individuals underwent mandibular reconstruction post-tumoral resection with adequate bone continuity, fibula or iliac crest bone grafts, but poor bone volume for implants insertion; adjacent bone to the reconstruction was sufficient to place zygoma implants and secure good anchorage for definitive rehabilitation. Two (2/15) patients with high cosmetics standard required dental rehabilitation to resume working activities before bone reconstruction, fixtures insertion and osseointegration could take place; zygoma implants that would not interfere with proper healing were inserted and temporary rehabilitation installed. Five (5/15) patients underwent the all-on-4 concept with short zygoma implants used in the lateral fixtures, to secure a faster healing and immediate rehabilitation, eliminating the need for multiple prosthodontics part connections. For reconstructive and atrophic mandibular patients, ZygoAAOMS • 2011
Oral Abstract Session 2 matic implants were inserted in the healthy non-operated bone, extending the body of fixture into the poor bone quality area. The zygomatic implant was used to bypass the junction site between the well-vascularized bone and the grafting emerging 5 to 10 mm away from the bony union, into the grafting area. Regular dental implants were used to complete the anchorage in the mandibular body to allow proper distribution and adequate biomechanics utilizing hybrid screw retained prosthesis. The short zygoma implants were utilized as replacement of the inclined lateral fixtures in the all-on-4 concept. Method of Data Analysis: All patient⬘s records included clinical, radiographs and photographs analysis, pre- and postoperative; all patients were followed for a minimum of 12 months. Also, prosthodontist and surgeon clinical evaluations were obtained and charts filled with information on dental occlusion, range of mandibular motion, tissue health around fixtures, level of the implant related to soft tissue, rehabilitation stability, hygiene, nasal airway and patient satisfaction. Results: All patients were dentally rehabilitated immediately with functional and esthetic hybrid dentures based on either acrylic or porcelain on a metal structure, using 37 zygomatic implants and 40 standard fixtures. Immediate provisional prosthesis was installed intra-operatively using provisional abutments. Patients were instructed to maintain excellent hygiene and periodontal control every 3 months. Conclusions: All patients were adequately rehabilitated, avoiding the need of new major grafting or distraction osteogenesis. This group of patients represents a major challenge after the initial reconstruction, where there is bone continuity, but the quality was unacceptable for standard dental implants; secondary surgeries in the compromised hostage bone would compromise the final outcome and would require further unpredictable surgeries. The zygoma fixture is an excellent possibility in the immediate loading concept for mandibular dental rehabilitation. References: Brånemark P-I. The Osseointegration Book From Calvarium to Calcaneus. Berlin: Quintessence Books 2005. Guerrero C. Sabogal A. Zygoma Implants: atlas of surgery and prosthetics. Madrid: Ripano 2010.
Tongue Flaps for Closure of Large Palatal Fistulas in Cleft Lip and Palate Patients R. Marques da Silva: Department of Oral and Maxillofacial Surgery, University of Oslo, Norway and Department of Oral and Maxillofacial Surgery, Center for Integral Assistance of Cleft Lip and Palate Patients (CAIF), Curitiba, Brazil, C. Biron, K. Ulbricht Gomes, J. Carlini AAOMS • 2011
Statement of the Problem: Palatal fistulas may occur in patients who have undergone cleft palate surgery. Small palatal fistulas may not be symptomatic, but large palatal fistulas produce various symptoms, including regurgitation of fluids into the nasal cavity and interference with normal speech. Treatment of these large fistulas is usually complex and difficult to be achieved by traditional local flaps. In such cases, tongue flaps may be an alternative option for treatment. Materials and Methods: Between 2005 and 2010, 7 cleft lip and palate patients were treated with a tongue flap procedure for closure of large anterior palatal defects. All palatal fistulas were larger than 2 x 1.5 cm in diameter and all patients had a bilateral complete cleft lip and palate. The fistulas were treated with the same technique, using the anterior two-thirds of the tongue to close the fistula. The flap pedicle remained connected to the tongue for 3 weeks, in order to maintain enough vascularization and to avoid flap necrosis. After this period, the patients were submitted to a new surgical procedure to free the flap from the tongue, and to close the remaining posterior fistula. Results of Investigation: All 7 flaps (100%) survived, and complete closure was obtained in all patients. No donor site complications were encountered. Conclusion: Our results demonstrate that the tongue flap is a safe and reliable technique for closure of large anterior palatal fistulas, particularly when repair is not achieved using other methods. References: Guerrero-Santos J, Altamarino JT. The use of lingual flaps in repair of fistulas of the hard palate. Plast Reconstr Surg 1986;38:123-128. Kim MJ, Lee JH, Choi JY, Kang N, Lee JH, Choi WJ. Two-stage reconstruction of bilateral alveolar cleft using Y-shaped anterior-based tongue flap and iliac bone graft. Cleft Palate Craniofac J 2001;38:432437.
Pharmacological Manipulation of Prostaglandins in Third Molar Surgery P. Mehra: Boston University, U. Reebye, D. Cottrell, M. Nadershah Statement of the Problem: Double-blind randomized clinical trial to assess the effect of four pharmacological regimens on the levels of prostaglandin E2 (PGE2) in urine and saliva and correlate the findings to the clinical postoperative course after removal of impacted lower third molars. Materials and Methods: ASA 1 patients requiring surgical removal of bilateral full-bony impacted lower third molars were included in the study and underwent surgery by a single surgeon under intravenous ambulatory general anesthesia using a standard technique. Patients were randomly divided into the following four groups (20 patients per group): Group 1: received ime-19