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Premaxillary Osteotomy and Bone Grafting for Secondary BCLP Repair - Long-Term Evaluation of Growth
Oral Abstract Session 2 cells than Group II (6,208 RFU) (P ⫽ .02) and Group III (9,992 RFU) (P ⫽ .02). Group III had greater cell viability than Group II (P ⫽ .005). Conclusion: Storing bone graft on ice rather than at room temperature preserves cellular viability. Clinically, iliac crest bone graft should be kept on ice until placement in the alveolar cleft to maximize osteocyte survival. References: Guillaume B, Gaudin C, Georgeault S, Mallet R, Basle´ MF, Chappard D. Viability of osteocytes in bone autografts harvested for dental implantology. Biomed Mater. 2009 Feb;4:015012 Wong SY, Dunstan CR, Evans RA, Hills E. The determination of bone viability: a histochemical method for identification of lactate dehydrogenase activity in osteocytes in fresh calcified and decalcified sections of human bone. Pathology. 1982 14:439-42
Immediate Bone Grafting in the Presence of Infected Mandibular Fractures: An Update M. Madsen: University of Louisville, Resident, Oral and Maxillofacial Surgery, G. Kushner, B. Alpert Introduction: The use of immediate bone grafting in reconstruction of clinically infected mandibular fractures has been traditionally viewed as controversial treatment. Historically, a treatment algorithm of treating open maxillomandibular fractures has included stabilization appliances while controlling the occlusion, establishing drainage, sequestrectomy, and removal of teeth. Bone grafting follows 2-6 months after the cessation of drainage. With the emergence of rigid internal fixation, immobilization of infected mandibular fractures has led to a shortened course of treatment. Debridement, internal fixation, bone grafting and placement of healing adjuncts can be accomplished in one surgery. In a previous study, it was found that single stage treatment offers the advantages of allowing function during convalescence as well as shortening the course. It was also found that the success rate is superior to traditional forms of management for infected fractures and comparable to that for non-infected fractures. Although previous studies have provided convincing evidence for this treatment, it still remains controversial. Previous reports have been restricted by relatively limited patient numbers as well as a lack of treatment standardization. We present an update of single stage treatment of mandibular fractures using immediate bone grafting in the presence of infection. Materials and Methods: A retrospective review was carried out at the University of Louisville from 2004 to 2010 identifying patients who had undergone open reduction and internal fixation, debridement, and primary autogenous bone grafting of infected mandibular fractures. Diagnosis of infection was made based on purulent drainage from the fracture site. 15 fractures were e-16
identified. 11 of the fractures identified were failed fracture treatment, while 4 were infected at initial presentation. Age ranged from 18-67. There were no exclusions made on age, gender, race, or medical history. Surgical approach included both intraoral (N⫽6) and extraoral (N⫽9) approaches. Treatment included: open reduction and internal fixation, placement of a minimum of one 2.4 mm locking reconstruction plate (Synthes, West Chester, PA) anchored by a minimum of 3 screws on each end of the fracture, debridement, placement of autologous particulate bone graft, postoperative release from maxillo-mandibular fixation and immediate function. Results: Of the 15 fractures treated, 86% (N⫽13) achieved union after a single surgery without complication. The remaining 2 failed with loss of fixation and graft failure and required additional procedures to eventually achieve union. Both nonunions involved the extraoral approach and were deemed hardware failure. In addition, the nonunion group had confounding medical histories believed to contribute to poor healing. Neither age of the patient nor location of the fracture affected the outcome. There was no difference comparing the failed treatment group versus primary treatment. Conclusion: These findings are consistent with our previous study demonstrating high success rates with single stage surgery of infected mandibular fractures following principles of rigid fixation in conjunction with debridement and particulate bone grafting. Although the concept of rigid fixation of infected fractures is not new, we feel that concurrent reconstruction with autologous bone grafting offers patients the advantage of avoiding multiple surgeries, more hospital stays, and prolonged disability. It is a viable surgical option with a reliable result. References: Benson PD, Marshall MK, Engelstad ME, Alpert B. The Use of Immediate Bone Grafting in Reconstruction of Clinically Infected Mandibular Fractures: Bone Grafts in the Presence of Pus. J Oral Maxillofac Surg 64:122-126, Jan 2006 Lindqvist C, Kontio R, Pihakari A, et al: Rigid internal fixation of mandibular fractures. An analysis of 45 patients treated according to the ASIF method. Int J Oral Maxillofac Surg 15: 657, 1986
Premaxillary Osteotomy and Bone Grafting for Secondary BCLP Repair Long-Term Evaluation of Growth J. Jensen: Dep OMFS, Aarhus University Hospital, A. Ku ¨ seler, T. Klit Pedersen, S. Norholt Statement of the Problem: Treatment of patients with bilateral cleft lip palate (BCLP) is a challenging discipline. At the age of 8-10 years BCLP patients often present with a premaxilla that is protruded and overerupted with hanging and retroclined upper incisors. Despite proper orthodontic treatment and secondAAOMS • 2011
Oral Abstract Session 2 ary bone grafting, facial growth in BCLP patients is often severely disturbed and later corrective orthognatic surgery is indicated. The aim of this study was to determine the long-term effect on facial growth of 2 treatment strategies for secondary BCLP repair. Patients in the study group had secondary bone grafting in combination with a premaxillary osteotomy, whereas the control group were treated by bone grafting and orthodontics only. Materials and Methods: The study group consisting of 27 BCLP patients (mean age of 11.9 years at surgery) with a malpositioned premaxilla were followed up to 9 years after surgery. Before surgery the mean inclination of the upper incisors was 82.8 degrees to the palatal plane (NL) and the vertical overerupted premaxilla resulted in a mean upper zone (OLs to NL) of 12.8 degrees. Moderate transversal expansion with Quad Helix was performed before patients had surgery. The surgery consisted of a corrective osteotomy of the premaxilla, with simultaneous bone grafting to the cleft defect using bone resected from the hypertrophic bony vomeric spur together with bone harvested from either the symphyseal region of the mandible (22 patients) or at the inner table of the anterior iliac crest (5 patients). A fixed surgical acrylic splint stabilized the premaxilla for 6 weeks postoperatively. Together with the study group a matching control group of 27 BCLP patients with malpositioned premaxilla treated by conventional procedures, orthodontics and bone grafting, was recalled for evaluation of growth and clinical outcome. In both groups lateral cephalograms were taken before bone grafting, after bone grafting and at the end of growth at 16 years of age. At that time the need for orthognatic surgery in order to establish an acceptable profile and occlusion was evaluated in 16 of 27 patients in the study group (the remaining 11 patients were still too young for final evaluation). Results of Investigation: In the study group mean upper incisor inclination was significantly increased to 111.0 degrees and the upper zone was significantly decreased to 3.9 degrees whereas the corresponding figures in the control group were 98.0 degrees and 8.0 degrees. Postoperative complications were registered in two patients in the study group. This was due to loosening of the splint postoperatively and resulted in a relapsed position of the premaxilla. At the age of 16 years it was evaluated that there was a need for orthognathic surgery in 1 of 16 patients in the study group (6%) and 10 of 27 patients in the control group (37%). Furthermore, there was a significantly shorter total treatment time among patients in the study group. Conclusion: Combined premaxillary osteotomy and bone grafting for BCLP repair proved to be a safe procedure without disturbing the maxillofacial growth. On the contrary, a smaller proportion of patients needed orthognatic surgical correction due to skeletal discrepancies. AAOMS • 2011
Furthermore there is a shorter total treatment time and patients received the immediate cosmetic (psychosocial) benefit by repositioning of the vertically displaced premaxilla. References: Scott JK, Webb RM Flood TR. Premaxillary osteotomy and guided tissue regeneration in secondary bone grafting in children with bilateral cleft lip and palate. Cleft Palate Craniofac J. 2007; 44: 469-75 Geraedts CT, Borstlap WA, Groenewoud JM, Borstlap-Engels VM, Stoelinga PJ. Long-term evaluation of bilateral cleft lip and palate patients after early secondary closure and premaxilla repositioning. Int J Oral Maxillofac Surg. 2007;36:788-96
Comparison of Intraoral Harvest Sites for Corticocancellous Bone Grafts D. Yates: University of Texas Southwestern Medical Center/Parkland Hospital, H. Brockhoff, R. Finn Purpose: A commonly used method for the repair of maxillofacial bony defects is the utilization of autogenous bone grafts from intraoral donor sites. There are many advantages associated with intraoral sites: easy accessibility, low rate of morbidity, and decreased cost. Multiple cadaver studies have looked at individual donor sites and have quantified the amount of bone available, however, the numbers studied were small and they failed to compare multiple donor sites within the same cohort and specimen. The aim of this study is to quantify the amount of bone that can reliably be harvested in the mandibular symphysis, ascending ramus/body, coronoid process, and the maxillary zygomatic buttress. The goal is to compare the differences within the same specimen, as well as within the cohort of cadavers. Methods: The maxillae and mandibles of 57 cadavers were harvested for our study. There were 27 females and 30 males with the average age being 72.5 years old (range 22-92). Osteotomies were performed with a 703 surgical bur according to previously described parameters in the existing literature. The sites harvested included the mandibular symphysis, coronoid process, ascending ramus/body, and the maxillary zygomatic arch. The dimensions of each corticocancellous block were measured with a ruler and boley gauge. The surface area was approximated by using standard geometric formulas. The volume of each specimen was then assessed using water displacement. Results: Donor Site Zygomatic buttress Symphysis Body/ramus Coronoid
Surface Max Thickness Volume Area (mm2) (mm) (mm3) 163.4 345.4 1125.0 161.6
4 9.5 4 3.25
0.18 1.87 2.8 0.43 e-17
Immediate Bone Grafting in the Presence of Infected Mandibular Fractures: An Update M. Madsen: University of Louisville, Resident, Oral and Maxillofacial Surgery, G. Kushner, B. Alpert Introduction: The use of immediate bone grafting in reconstruction of clinically infected mandibular fractures has been traditionally viewed as controversial treatment. Historically, a treatment algorithm of treating open maxillomandibular fractures has included stabilization appliances while controlling the occlusion, establishing drainage, sequestrectomy, and removal of teeth. Bone grafting follows 2-6 months after the cessation of drainage. With the emergence of rigid internal fixation, immobilization of infected mandibular fractures has led to a shortened course of treatment. Debridement, internal fixation, bone grafting and placement of healing adjuncts can be accomplished in one surgery. In a previous study, it was found that single stage treatment offers the advantages of allowing function during convalescence as well as shortening the course. It was also found that the success rate is superior to traditional forms of management for infected fractures and comparable to that for non-infected fractures. Although previous studies have provided convincing evidence for this treatment, it still remains controversial. Previous reports have been restricted by relatively limited patient numbers as well as a lack of treatment standardization. We present an update of single stage treatment of mandibular fractures using immediate bone grafting in the presence of infection. Materials and Methods: A retrospective review was carried out at the University of Louisville from 2004 to 2010 identifying patients who had undergone open reduction and internal fixation, debridement, and primary autogenous bone grafting of infected mandibular fractures. Diagnosis of infection was made based on purulent drainage from the fracture site. 15 fractures were e-16
identified. 11 of the fractures identified were failed fracture treatment, while 4 were infected at initial presentation. Age ranged from 18-67. There were no exclusions made on age, gender, race, or medical history. Surgical approach included both intraoral (N⫽6) and extraoral (N⫽9) approaches. Treatment included: open reduction and internal fixation, placement of a minimum of one 2.4 mm locking reconstruction plate (Synthes, West Chester, PA) anchored by a minimum of 3 screws on each end of the fracture, debridement, placement of autologous particulate bone graft, postoperative release from maxillo-mandibular fixation and immediate function. Results: Of the 15 fractures treated, 86% (N⫽13) achieved union after a single surgery without complication. The remaining 2 failed with loss of fixation and graft failure and required additional procedures to eventually achieve union. Both nonunions involved the extraoral approach and were deemed hardware failure. In addition, the nonunion group had confounding medical histories believed to contribute to poor healing. Neither age of the patient nor location of the fracture affected the outcome. There was no difference comparing the failed treatment group versus primary treatment. Conclusion: These findings are consistent with our previous study demonstrating high success rates with single stage surgery of infected mandibular fractures following principles of rigid fixation in conjunction with debridement and particulate bone grafting. Although the concept of rigid fixation of infected fractures is not new, we feel that concurrent reconstruction with autologous bone grafting offers patients the advantage of avoiding multiple surgeries, more hospital stays, and prolonged disability. It is a viable surgical option with a reliable result. References: Benson PD, Marshall MK, Engelstad ME, Alpert B. The Use of Immediate Bone Grafting in Reconstruction of Clinically Infected Mandibular Fractures: Bone Grafts in the Presence of Pus. J Oral Maxillofac Surg 64:122-126, Jan 2006 Lindqvist C, Kontio R, Pihakari A, et al: Rigid internal fixation of mandibular fractures. An analysis of 45 patients treated according to the ASIF method. Int J Oral Maxillofac Surg 15: 657, 1986
Premaxillary Osteotomy and Bone Grafting for Secondary BCLP Repair Long-Term Evaluation of Growth J. Jensen: Dep OMFS, Aarhus University Hospital, A. Ku ¨ seler, T. Klit Pedersen, S. Norholt Statement of the Problem: Treatment of patients with bilateral cleft lip palate (BCLP) is a challenging discipline. At the age of 8-10 years BCLP patients often present with a premaxilla that is protruded and overerupted with hanging and retroclined upper incisors. Despite proper orthodontic treatment and secondAAOMS • 2011
Oral Abstract Session 2 ary bone grafting, facial growth in BCLP patients is often severely disturbed and later corrective orthognatic surgery is indicated. The aim of this study was to determine the long-term effect on facial growth of 2 treatment strategies for secondary BCLP repair. Patients in the study group had secondary bone grafting in combination with a premaxillary osteotomy, whereas the control group were treated by bone grafting and orthodontics only. Materials and Methods: The study group consisting of 27 BCLP patients (mean age of 11.9 years at surgery) with a malpositioned premaxilla were followed up to 9 years after surgery. Before surgery the mean inclination of the upper incisors was 82.8 degrees to the palatal plane (NL) and the vertical overerupted premaxilla resulted in a mean upper zone (OLs to NL) of 12.8 degrees. Moderate transversal expansion with Quad Helix was performed before patients had surgery. The surgery consisted of a corrective osteotomy of the premaxilla, with simultaneous bone grafting to the cleft defect using bone resected from the hypertrophic bony vomeric spur together with bone harvested from either the symphyseal region of the mandible (22 patients) or at the inner table of the anterior iliac crest (5 patients). A fixed surgical acrylic splint stabilized the premaxilla for 6 weeks postoperatively. Together with the study group a matching control group of 27 BCLP patients with malpositioned premaxilla treated by conventional procedures, orthodontics and bone grafting, was recalled for evaluation of growth and clinical outcome. In both groups lateral cephalograms were taken before bone grafting, after bone grafting and at the end of growth at 16 years of age. At that time the need for orthognatic surgery in order to establish an acceptable profile and occlusion was evaluated in 16 of 27 patients in the study group (the remaining 11 patients were still too young for final evaluation). Results of Investigation: In the study group mean upper incisor inclination was significantly increased to 111.0 degrees and the upper zone was significantly decreased to 3.9 degrees whereas the corresponding figures in the control group were 98.0 degrees and 8.0 degrees. Postoperative complications were registered in two patients in the study group. This was due to loosening of the splint postoperatively and resulted in a relapsed position of the premaxilla. At the age of 16 years it was evaluated that there was a need for orthognathic surgery in 1 of 16 patients in the study group (6%) and 10 of 27 patients in the control group (37%). Furthermore, there was a significantly shorter total treatment time among patients in the study group. Conclusion: Combined premaxillary osteotomy and bone grafting for BCLP repair proved to be a safe procedure without disturbing the maxillofacial growth. On the contrary, a smaller proportion of patients needed orthognatic surgical correction due to skeletal discrepancies. AAOMS • 2011
Furthermore there is a shorter total treatment time and patients received the immediate cosmetic (psychosocial) benefit by repositioning of the vertically displaced premaxilla. References: Scott JK, Webb RM Flood TR. Premaxillary osteotomy and guided tissue regeneration in secondary bone grafting in children with bilateral cleft lip and palate. Cleft Palate Craniofac J. 2007; 44: 469-75 Geraedts CT, Borstlap WA, Groenewoud JM, Borstlap-Engels VM, Stoelinga PJ. Long-term evaluation of bilateral cleft lip and palate patients after early secondary closure and premaxilla repositioning. Int J Oral Maxillofac Surg. 2007;36:788-96
Comparison of Intraoral Harvest Sites for Corticocancellous Bone Grafts D. Yates: University of Texas Southwestern Medical Center/Parkland Hospital, H. Brockhoff, R. Finn Purpose: A commonly used method for the repair of maxillofacial bony defects is the utilization of autogenous bone grafts from intraoral donor sites. There are many advantages associated with intraoral sites: easy accessibility, low rate of morbidity, and decreased cost. Multiple cadaver studies have looked at individual donor sites and have quantified the amount of bone available, however, the numbers studied were small and they failed to compare multiple donor sites within the same cohort and specimen. The aim of this study is to quantify the amount of bone that can reliably be harvested in the mandibular symphysis, ascending ramus/body, coronoid process, and the maxillary zygomatic buttress. The goal is to compare the differences within the same specimen, as well as within the cohort of cadavers. Methods: The maxillae and mandibles of 57 cadavers were harvested for our study. There were 27 females and 30 males with the average age being 72.5 years old (range 22-92). Osteotomies were performed with a 703 surgical bur according to previously described parameters in the existing literature. The sites harvested included the mandibular symphysis, coronoid process, ascending ramus/body, and the maxillary zygomatic arch. The dimensions of each corticocancellous block were measured with a ruler and boley gauge. The surface area was approximated by using standard geometric formulas. The volume of each specimen was then assessed using water displacement. Results: Donor Site Zygomatic buttress Symphysis Body/ramus Coronoid
Surface Max Thickness Volume Area (mm2) (mm) (mm3) 163.4 345.4 1125.0 161.6
4 9.5 4 3.25
0.18 1.87 2.8 0.43 e-17