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M636: Advanced Approaches to Odontogenic Cysts and Tumors
Surgical Mini-Lectures Maxillary Sinus Grafting: A Clinical, Radiologic, and Periotest Study. Clin Implant Dent Relat Res 2001;1:39-49 Bedrossian E. The Zygomatic implant; Preliminary Data on Treatment of Severely Resorbed Maxillae. A Clinical Report. Int J Oral Maxillofac implants 2002; 17:861-865 Bedrossian E. Immediate stabilization at stage II of Zygomatic implants: Rationale and technique. Int J Oral Maxillofac implants 2000; 15:10-14 Malevez C, Abarca M, Durdu F, Dalemans P. Clinical outcome of 103 consecutive Zygomatic implants: A 6-48 month follow-up study. Clin Oral Impl Res 2004;115:18-22
M634 Pre and Post Orthognathic and TMJ Surgery Patient Management Larry M. Wolford, DMD, Dallas, TX Pre and post surgical patient management is a critical factor for high quality patient treatment and predictable outcomes in orthognathic surgery. However, lack of understanding of proper patient management on the part of the surgeon and orthodontist can result in compromised or even disastrous results. This presentation will begin by discussing presurgical orthodontic preparation of orthognathic surgery patients so that the teeth are appropriately aligned to facilitate surgery and minimize post surgical orthodontic and surgical relapse potential. Surgical factors will be discussed that will enhance post surgical orthodontics including surgical technical considerations and the use of surgical splints to make the subsequent orthodontics easier. Post surgery, there are specific orthodontic mechanics and timing of implementation that can improve outcomes. The post surgical healing process and expectations will be discussed including the management of the airway, bleeding, nausea, fatigue, pain, sensory and neuromotor deficit, muscle and jaw function, TMJ function, as well as clenching and bruxism. Pre and post surgical management considerations and expectations will be presented for diet, medications, hygiene, physical activities, sleep, school, and work. The last area to be discussed will be identifying and managing post surgical complications including infection, early and late jaw and occlusal instability (relapse), non-union or mal-union, as well as TMJ related problems. Pre and post surgical patient management is a very important aspect of orthognathic surgical treatment for providing optimal patient outcomes. Understanding this information should improve the quality of post surgical patient management and thus improve treatment results as well as educate clinicians and patients in the post surgical management and other factors affecting this phase of treatment. References Wolford LM, Alexander CM, Stevao ELL, Goncalves J: Orthodontics for Orthognathic Surgery. In Miloro M (Ed) Peterson’s Principles of
108
Oral and Maxillofacial Surgery, BC Decker, Lewiston, NY, 2004, Chapter 55, pgs. 1111-34 Wolford LM: Concomitant Temporomandibular Joint and Orthognathic Surgery. J Oral Maxillofac Surg, 61:1198-1204, 2003 Goncalves JR, Cassano OS, Wolford LM, Santos-Pinto A, Marquez IM: Postsurgical Stability of Counter-Clockwise Maxillo-Mandibular Advancement Surgery: Affect of Articular Disc Repositioning. J Oral Maxillofacial Surgery, 66;724-738, 2008
M635 Implants in Compromised Sites Bach T. Le, DDS, MD, Whittier, CA The esthetic demand in implant dentistry is ever growing. Simply having an implant integrated and restored is no longer the only benchmark for success. Esthetic management of the hard and soft tissue is of paramount importance in a successful implant practice. Unfortunately, the extraction of teeth results in alveolar bone loss due to resorption of the edentulous ridge. Up to 40-60% of alveolar bone width and height can be lost within the first year after tooth extraction. This reduction in bone volume can negatively affect the edentulous site for future implant placement. Even a small amount of labial ridge contraction, although adequate for implant placement, can result in compromised esthetic. Numerous techniques, protocols, and materials in hard and soft tissue grafting have been described to manage compromised sites of varying severity. The protocols and techniques employed should be predictable, minimally invasive, esthetic, and lasting. This evidence-based discussion will include the latest techniques in esthetic site development of the compromised implant site. Topics to be covered include patient evaluation and selection, from atraumatic extraction and socket grafting and management of the post-extraction site, to strategies for dealing with the horizontally and vertically deficient ridge. This course will also focus on the most current strategies in minimally invasive bone grafting and tissue grafting, papilla reconstruction and tissue management to improve long-term clinical success with dental implants, specifically in the esthetic zone. References Kois JC. Predictable single tooth peri-implant esthetics: five diagnostic keys. Compen Contin Educ Dent. 2001; 22(3):199-206 Le BT, Burstein J. Esthetic Grafting For Small Volume Hard & Soft Tissue Defects for Implant Site Development. Implant Dent. 2008 Jun;17(2):136-141 Le BT, Burstein J. Cortical Tenting Grafting Technique in the Severely Atrophic Alveolar Ridge for Implant Site Preparation. Implant Dent. 2008; 17(2):140-4
M636 Advanced Approaches to Odontogenic Cysts and Tumors Robert E. Marx, DDS, Miami, FL AAOMS • 2009
Surgical Mini-Lectures The odontogenic keratocyst is a cyst of known recurrence potential. This is due to the potential of any one single cell left behind to clone into a new cyst. Approaches to remove the entire cyst including wide access transoral approaches and extra oral approaches reduce recurrence to less than 3%. Straightforward enucleation and curettage is all that is necessary if accomplished in a controlled direct vision access manner. The use of adjuncts such as Carnoy’s solution, phenol, and cryotherapy is unnecessary and only risks wound healing complications and compromises bone regeneration in the defect. Odontogenic tumors typified by the ameloblastoma are predictably cured by resective surgery with frozen section control. Today this resective surgery is combined with nerve preservation techniques, nerve re-anastomosis techniques, and more rarely nerve grafting to return or restore sensation. In addition, when the condyle requires resection titanium condylar replacements in adults allow for precise retention of occlusion and maximum function. In children, an allogeneic mandibular condylar/ramus support acts as a scaffold for spontaneous bone regenerations that will include the condyle and even the curettage later pterygoid attachment for protrusive and working functions of the mandible. These improvements in surgical approach and materials permit surgeons to realize a higher quality outcome and reduced recurrence rates. References Marx RE and Stern ed: Oral and Maxillofacial Pathology: A rationale for diagnosis and treatment. Quintessence Publishing, Hanover Park, IL, 2004 Carlson ER and Marx RE. The Ameloblastoma: Primary curative surgical management. J Oral Maxillofac Surg 64:484-494, 2006 Marx RE: Mandibular Reconstruction. J Oral Maxillofacial Surg 51: 466-482, 1993
M641 Technology and Methods for Treatment of the Perceived Difficult Case Michael S. Block, DMD, Metairie, LA Clinicians often are presented with clinical situations which may appear challenging. These cases may include the partially edentulous case with decisions concerning space, tooth retention, lack of bone, esthetic challenges, or the totally edentulous case with bone deficiency yet the patient’s goals include fixed restoration. A similar algorithm is used for all patients. This treatment algorithm creates a base of information which then is used to determine several treatment plan options for the patient. The plan starts with establishing the patient’s goals, including obtaining an accurate dental history from the restorative dentist. The surgeon will need to obtain an accurate medical history and note specific AAOMS • 2009
clinical findings related to an esthetic analysis, ridge form, and the status of the remaining teeth, which may include probing. The surgeon should obtain specific imaging that illustrates the presence of bone in relation to the teeth. The restorative dentist should provide a diagnostic plan from which a treatment plan can be made. Based on the planned restoration, the necessary plans can be made to include orthodontics and prosthetic plans for provisionalization. A seemingly challenging situation can thus be simplified to several stages and the patient’s final result mimics the planning. For the totally edentulous patient a similar algorithm is used. Often a new prosthesis is needed to finalize the plan which will include imaging to determine the location of bone to the planned teeth. The final prosthetic plan needs to be established in regard to fixed or removable prosthetics, which will alter the planned locations of implants.
M642 Orthognathic Surgery: Treatment Planning and Surgical Techniques Larry M. Wolford, DMD, Dallas, TX Surgical techniques in orthognathic surgery have and will continue to undergo modifications and change in an effort to improve the quality of patient care and outcome. This program will present state-of-the-art surgical techniques and research results substantiating the efficacy of these surgical methods. The following modifications will be discussed: 1. Genioplasty A. Augmentation B. Tenon and mortise osseous genioplasty 2. Anterior mandibular subapical osteotomy 3. Mandibular body osteotomy 4. Mandibular ramus sagittal split osteotomy modifications A. Ramus and inferior border osteotomy C. Rigid fixation 5. Maxillary osteotomy modification A. Maxillary step osteotomy and rigid fixation B. Porous block HA grafting 6. Double jaw surgery A. Selective alteration of the occlusal plane B. Surgical Sequencing of the maxilla and mandible C. Model surgery modifications 7. TMJ factors affecting orthognathic surgery outcomes Implementation of these techniques by the experienced, skilled surgeon, coupled with accurate diagnosis and treatment planning, should provide optimal functional and esthetic outcomes for our patients. 109
M634 Pre and Post Orthognathic and TMJ Surgery Patient Management Larry M. Wolford, DMD, Dallas, TX Pre and post surgical patient management is a critical factor for high quality patient treatment and predictable outcomes in orthognathic surgery. However, lack of understanding of proper patient management on the part of the surgeon and orthodontist can result in compromised or even disastrous results. This presentation will begin by discussing presurgical orthodontic preparation of orthognathic surgery patients so that the teeth are appropriately aligned to facilitate surgery and minimize post surgical orthodontic and surgical relapse potential. Surgical factors will be discussed that will enhance post surgical orthodontics including surgical technical considerations and the use of surgical splints to make the subsequent orthodontics easier. Post surgery, there are specific orthodontic mechanics and timing of implementation that can improve outcomes. The post surgical healing process and expectations will be discussed including the management of the airway, bleeding, nausea, fatigue, pain, sensory and neuromotor deficit, muscle and jaw function, TMJ function, as well as clenching and bruxism. Pre and post surgical management considerations and expectations will be presented for diet, medications, hygiene, physical activities, sleep, school, and work. The last area to be discussed will be identifying and managing post surgical complications including infection, early and late jaw and occlusal instability (relapse), non-union or mal-union, as well as TMJ related problems. Pre and post surgical patient management is a very important aspect of orthognathic surgical treatment for providing optimal patient outcomes. Understanding this information should improve the quality of post surgical patient management and thus improve treatment results as well as educate clinicians and patients in the post surgical management and other factors affecting this phase of treatment. References Wolford LM, Alexander CM, Stevao ELL, Goncalves J: Orthodontics for Orthognathic Surgery. In Miloro M (Ed) Peterson’s Principles of
108
Oral and Maxillofacial Surgery, BC Decker, Lewiston, NY, 2004, Chapter 55, pgs. 1111-34 Wolford LM: Concomitant Temporomandibular Joint and Orthognathic Surgery. J Oral Maxillofac Surg, 61:1198-1204, 2003 Goncalves JR, Cassano OS, Wolford LM, Santos-Pinto A, Marquez IM: Postsurgical Stability of Counter-Clockwise Maxillo-Mandibular Advancement Surgery: Affect of Articular Disc Repositioning. J Oral Maxillofacial Surgery, 66;724-738, 2008
M635 Implants in Compromised Sites Bach T. Le, DDS, MD, Whittier, CA The esthetic demand in implant dentistry is ever growing. Simply having an implant integrated and restored is no longer the only benchmark for success. Esthetic management of the hard and soft tissue is of paramount importance in a successful implant practice. Unfortunately, the extraction of teeth results in alveolar bone loss due to resorption of the edentulous ridge. Up to 40-60% of alveolar bone width and height can be lost within the first year after tooth extraction. This reduction in bone volume can negatively affect the edentulous site for future implant placement. Even a small amount of labial ridge contraction, although adequate for implant placement, can result in compromised esthetic. Numerous techniques, protocols, and materials in hard and soft tissue grafting have been described to manage compromised sites of varying severity. The protocols and techniques employed should be predictable, minimally invasive, esthetic, and lasting. This evidence-based discussion will include the latest techniques in esthetic site development of the compromised implant site. Topics to be covered include patient evaluation and selection, from atraumatic extraction and socket grafting and management of the post-extraction site, to strategies for dealing with the horizontally and vertically deficient ridge. This course will also focus on the most current strategies in minimally invasive bone grafting and tissue grafting, papilla reconstruction and tissue management to improve long-term clinical success with dental implants, specifically in the esthetic zone. References Kois JC. Predictable single tooth peri-implant esthetics: five diagnostic keys. Compen Contin Educ Dent. 2001; 22(3):199-206 Le BT, Burstein J. Esthetic Grafting For Small Volume Hard & Soft Tissue Defects for Implant Site Development. Implant Dent. 2008 Jun;17(2):136-141 Le BT, Burstein J. Cortical Tenting Grafting Technique in the Severely Atrophic Alveolar Ridge for Implant Site Preparation. Implant Dent. 2008; 17(2):140-4
M636 Advanced Approaches to Odontogenic Cysts and Tumors Robert E. Marx, DDS, Miami, FL AAOMS • 2009
Surgical Mini-Lectures The odontogenic keratocyst is a cyst of known recurrence potential. This is due to the potential of any one single cell left behind to clone into a new cyst. Approaches to remove the entire cyst including wide access transoral approaches and extra oral approaches reduce recurrence to less than 3%. Straightforward enucleation and curettage is all that is necessary if accomplished in a controlled direct vision access manner. The use of adjuncts such as Carnoy’s solution, phenol, and cryotherapy is unnecessary and only risks wound healing complications and compromises bone regeneration in the defect. Odontogenic tumors typified by the ameloblastoma are predictably cured by resective surgery with frozen section control. Today this resective surgery is combined with nerve preservation techniques, nerve re-anastomosis techniques, and more rarely nerve grafting to return or restore sensation. In addition, when the condyle requires resection titanium condylar replacements in adults allow for precise retention of occlusion and maximum function. In children, an allogeneic mandibular condylar/ramus support acts as a scaffold for spontaneous bone regenerations that will include the condyle and even the curettage later pterygoid attachment for protrusive and working functions of the mandible. These improvements in surgical approach and materials permit surgeons to realize a higher quality outcome and reduced recurrence rates. References Marx RE and Stern ed: Oral and Maxillofacial Pathology: A rationale for diagnosis and treatment. Quintessence Publishing, Hanover Park, IL, 2004 Carlson ER and Marx RE. The Ameloblastoma: Primary curative surgical management. J Oral Maxillofac Surg 64:484-494, 2006 Marx RE: Mandibular Reconstruction. J Oral Maxillofacial Surg 51: 466-482, 1993
M641 Technology and Methods for Treatment of the Perceived Difficult Case Michael S. Block, DMD, Metairie, LA Clinicians often are presented with clinical situations which may appear challenging. These cases may include the partially edentulous case with decisions concerning space, tooth retention, lack of bone, esthetic challenges, or the totally edentulous case with bone deficiency yet the patient’s goals include fixed restoration. A similar algorithm is used for all patients. This treatment algorithm creates a base of information which then is used to determine several treatment plan options for the patient. The plan starts with establishing the patient’s goals, including obtaining an accurate dental history from the restorative dentist. The surgeon will need to obtain an accurate medical history and note specific AAOMS • 2009
clinical findings related to an esthetic analysis, ridge form, and the status of the remaining teeth, which may include probing. The surgeon should obtain specific imaging that illustrates the presence of bone in relation to the teeth. The restorative dentist should provide a diagnostic plan from which a treatment plan can be made. Based on the planned restoration, the necessary plans can be made to include orthodontics and prosthetic plans for provisionalization. A seemingly challenging situation can thus be simplified to several stages and the patient’s final result mimics the planning. For the totally edentulous patient a similar algorithm is used. Often a new prosthesis is needed to finalize the plan which will include imaging to determine the location of bone to the planned teeth. The final prosthetic plan needs to be established in regard to fixed or removable prosthetics, which will alter the planned locations of implants.
M642 Orthognathic Surgery: Treatment Planning and Surgical Techniques Larry M. Wolford, DMD, Dallas, TX Surgical techniques in orthognathic surgery have and will continue to undergo modifications and change in an effort to improve the quality of patient care and outcome. This program will present state-of-the-art surgical techniques and research results substantiating the efficacy of these surgical methods. The following modifications will be discussed: 1. Genioplasty A. Augmentation B. Tenon and mortise osseous genioplasty 2. Anterior mandibular subapical osteotomy 3. Mandibular body osteotomy 4. Mandibular ramus sagittal split osteotomy modifications A. Ramus and inferior border osteotomy C. Rigid fixation 5. Maxillary osteotomy modification A. Maxillary step osteotomy and rigid fixation B. Porous block HA grafting 6. Double jaw surgery A. Selective alteration of the occlusal plane B. Surgical Sequencing of the maxilla and mandible C. Model surgery modifications 7. TMJ factors affecting orthognathic surgery outcomes Implementation of these techniques by the experienced, skilled surgeon, coupled with accurate diagnosis and treatment planning, should provide optimal functional and esthetic outcomes for our patients. 109