Management of infections of the oral and maxillofacial region

Surgical Roundtable Clinics

Correctionof Ptosis Correctionof “Clown Tear Deformity” PostoperativeCareandInstructions ComplicationsandTheir Management GeneralComplications EctropionManagement Relative Ectropion Excisional(Iatrogenic)Ectropion ScarContractureEctropion Flaccid Ectropion NasolacrimalApparatusInjury Xerophthalmiaand ChronicInflammation Brow andSuprabrowLifting Direct Approach MidforeheadLifts CoronalLifts Techniqueof Surgery Skin Marking and,Ezcision SuspensionProcedures Considerationof Symmetryand MuscleActivity Repair of SurgicalSites Adjunctive Treatment Modalities Correctionof HyperactiveGlabellarMusculature CollagenTherapyfor Rhytids Fibrel and Fat Transplantation PermanentEyeliner andBrow Highlighter Conclusions References Rees, T.D., Wood-Smith, D.: Cosmetic Facial Surgery. Philadelphia, PA, Saunders, 1983 Pastorek, N.J.: Facial Plastic Surgery, vol 3. Plastic Surgery of the Upper Face. Thieme, 1985 Homblass, A. (ed): Oculoplastic, Orbital and Reconstructive Surgery, vol I. Baltimore, MD, Williams & Wilkins. 1988

SRC140/240 Solving of Problem Areas in the Clinical Use of Implant Systems Philip J. Boyne,DMD, MS, DSc, Loma Linda, CA Paul H.J. Kwon, DDS, PhD, Minneapolis,MN The increasesin the useof intraosseousand subperiosteal implants with and without bone grafts hasbeen made possiblerehabilitation of many types of patients presentingwith deficient and compromisedbone. This clinic will targetproblem areasinvolvingclinical diagnosis, intraoperative treatment and postoperativecare. Recent surgical techniquesusing both endostealand subperiostealimplants enabling the surgeonto select the maximally effectiveprocedureto addressindividual patient needswill be discussed. Clinical application of innovative proceduresusing intraosseousimplants in the deficientmaxilla are based AAOMS

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1991

upon variations of anatomyof the max3lary sinus and nasalfloor and the appropriateuseof graftsof boneand bone substitutes. The location of intraosseousimplants in relation to the nasal and sinus floor and walls is extremely important. Clinical cases illustrating these pointswiI1be demonstrated. The useof endosseous implantsin bone-compromised sites such as irradiated and/or bone-graftedpatients having received rib and solid one-piece grafts and patients with PMCB grafts, and the placement and timing of graftingwill be discussed. New modifications of subperiostealimplants with posterior extensionand additional ridge coverageand HA coating will be discussed.Subperiostealimplants madeon a CT scangenerated-model,havenow brought this type of implant surgeryto a new health care level. The use of such implants in the mandible and maxilla will be discussed,with the indicationsfor their consideration asan alternativeto intraosseousimplants. The useof porousHA, bovineanimal bonemineral of the porousvariety,anddemineralizedfreeze-driedbone and other bone substituteswith intraosseousimplants will becovered,andthe applieationof recentresearchto areasof clinical concernwill be presented.Gsteointegration hasbeenshownto be possiblewith a relativelysmall percentageof calcified bone matrix adjacent to the titanium implant surface.Previouslyit hadbeenthought that implants required 100% bony integration to be effective. Since it is known now that it is possible to obtain osteointegrationwith only 50% to 60% bone to implant interface, the treatment of patients otherwise not consideredfeasrbleimplant-candidatesis nowpossible. Thus the applicationof the surgicaluseof implants has been extendedto a much larger pool of patients bringingaboutan enhancementin the qualityof surgical andprosthodonticreconstructivecare. References Boyne, P.J., James, R.A.: Research in Subperiosteal Implant Surgery. Clinical Dentistry. 51:1-g, Harper & Row Publishers, Philadelphia, 1987 Boyne, P.J.: Preprosthetic surgery for the older patient. Special care in dentistry. JADA, Jan-Feb, 1987 Boyne, P.J.: Preprosthetic adjunctive surgery in post cancer rehabilitation. Proceedings of the First International Congress on Oral Cancer and Jaw Tumors. Singapore, November 1987

SRCl41/241 it&amge~ntOfh&&ions oftheoralsnd Maxi&facialRegion ThomasR. Fly, DMD, Hartford, CT The changingmicrobiologyof odontogenicdeepspace infections has been a topic of considerableinterest in 27

SurgicalRoundtableClinics recentyears.Improvedculturingtechniqueshavehelped to identify the synergistic roles that anaerobesand streptococciplay in theseinfections.It appearsthat the initial colonizationof the infectedsiteby oral facultative streptococciprovidesnutrients and a favorablereduced oxygenenvironmentfor later growth of obligateanaerobes, mainly Bacteroides species, Fusobacteria,and peptostreptococci.The implications of this new understandingof oral microbiologyin culturing and antibiotic therapyare discussed. Recent data on the antibiotic sensitivityof the commonly isolated pathogensof odontogenic infections indicatethat penicillin is still the empiric drugof choice. Erythromycin may no longer be appropriate for lifethreateninginfections,andClindamycinretainsits effectivenessin seriousand chronic cases.One can estimate also from these data the usefulnessof some newer antibiotics in odontogenicinfections, and that certain older antibiotics are now obsolete.A cost-effectiveness comparisonis made amongthe variousavailableantibiotics and their combinationsboth by the oral and the intravenousroute. The managementof seriousdeepspaceodontogenic infections is reviewed,with severalcasereports. Anatomic considerations,the clinical behaviorof infections in selecteddeep spaces,the importanceand timing of incision and drainageare emphasized.The diagnosisof airwaycompromiseis reviewed,and currently available airway managementtechniquesare compared.The recent literature on pulmonary aspiration of infected material indicatesthat the oral flora are the pathogens in aspiration pneumonitis, and recommendationsfor therapyaremade. References Flynn, T.R., Topazian, R.G.: Infections of the oral cavity, in Waite DE (ed): Textbook of Practical Oral and Maxillofacial Surgery. Philadelphia, PA, Lea & Febiger, 1987 Flynn, T.R.: Anesthetic and airway considerations in oral and maxillofacial infections, in Topazian, R.G., Goldberg, M.H. (eds): Oral andMaxillofacial Infections, Philadelphia, Saunders, 1987 Flynn, T.R.: Odontogenic infections. Oral Maxillofac Surg Clin North Am May 1991

SRC 142 Comprehensive Managementof Pan Facial FracturesIn&ding Rigid Fixation Richard A. Finn, DDS, Dallas, TX The impact of trauma to our societyandto individuals will be reviewedwith respectto etiology,costs,rehabilitation, andprevention.Historical highlightsin the evolution of managementof facial trauma will be reviewed. 23

ATL.S will be briefly discussedas it pertains to the OMFS role in this process. Mandibular fracture managementwill be examined from both an institutional and privatepracticeperspective. Complex midfacial-mandibularfractures are usually resultantfrom highspeedMVAs which appearto be decreasingin frequency.Nonethe less,detaileddiagnostic considerationssuch as imaging as well as realistic treatment options will be discussedin a caseby case format. The complexities and problems surrounding NasoOrbital Ethmoid fractures and other periorbital fractures will be reviewed in some detail. Surgical ap proachesto this area,including bicoronalflaps, aswell asperioperativecomplicationswill be evaluated. The open vs. closed managementof condylar fractureswith concomittantmidfacial fractureswill be dealt with in a participatoryfashion.Finally, the management of late cosmeticdeformities,jaw rehabilitationfollowing trauma, and the role of dental implants in the trauma patient will be discussed. References Fonseca, R.J., Walker, R.V.: Oral and Maxillofacial Trauma. Philadelphia, PA, Saunders, 1990 Pollock, R.A., Gruss, J.S.: Craniofacial and Panfacial Fractures, in Foster, C.A., Sherman, J.E. (eds): Surgery of Facial Bone Fractures. New York, Churchill Livingstone, 1987 (chap 12) Kawamoto, HR., Jr.: Late Posttraumatic Enophthalmos: A Correctable Deformity? Plast Reconstr Surg 69:423,1982

SRC 143 CalvariulBoneGrqftingfor Facial Reconsbuction N. Robert Markowitz, DMD, OklahomaCity, OK Literature Review Donor Site Anatomy Modified HarvestingTechnique RecipientSite Grafting Techniques SupraorbitalRegion NasalRegion ZygomaticArch Zygoma Infraorbital Rim Orbital Floor Maxilla Lateral Atrophic Alveolus Alveolar Clefts Mandible Atrophic Alveolus Symphysis AAOMS

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1991