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S225: Comprehensive Free Tissue Reconstruction of Composite Maxillofacial Defects
Surgical Clinics relevant to the issue of complications related to orthognathic surgery. Orthognathic surgery is extremely rewarding in terms of the functional and esthetic outcomes and is a significant part of oral and maxillofacial surgical procedures. It is only logical to be aware of the different potential complications that exist in order to avoid them. Complications can occur in the preoperative, intraoperative and postoperative phase. Complications can include hemorrhage, airway compromise, neurologic alteration, tooth injury, malocclusion, and unfavorable osteotomy with a resultant relapse, nonunion, malunion, infection, temporomandibular joint disorders, arteriovenous fistula, and vascular compromise of the segments including rare avascular necrosis. Surgical procedures discussed will include maxillary procedures including Le Fort I osteotomy and surgically assisted rapid palatal expansion and mandibular procedures including bilateral sagittal split osteotomy, vertical ramus osteotomy, subapical osteotomies and genioplasty. The literature is quite extensive in this regard. There have been several publications related to this topic ranging from the most common to very rare complications. This presentation will cover all the complications and a discussion on ways to avoid them. Management of the complications will also be addressed. References Bays RA. Complications of orthognathic surgery. In: Kaban LB, Pogrel MA, Perrott DH, eds. Complications in Oral and Maxillofacial Surgery. Philadelphia: WB Saunders Co:193-221, 1997 Kim Su-Gwen, Park Sun-Sik: Incidence of complications and problems related to orthognathic surgery. J Oral Maxillofac Surg; 65(12); 2438-44, 2007 Patel PK, Morris DE, Gassman A: Complications of Orthognathic Surgery J Craniomaxillofac Surg; 18(4); 975-984, 2007
S224 Computer-Aided Surgical Simulation for Complex Cranio-Maxillofacial Surgery Jaime Gateno, DDS, MD, Houston, TX James J. Xia, MD, PhD, MS, Houston, TX Background and Purpose: The success of cranio-maxillofacial (CMF) surgery depends not only on surgical techniques, but also upon an accurate surgical plan. Unfortunately, traditional planning methods are often inadequate for planning CMF deformities. To this end, we developed 3D computer-aided surgical simulation (CASS) technique. Using our CASS method, we are able to treat patients with significant asymmetries in a single operation which in the past was usually completed in two stages. The purpose of this lecture is to teach oral and maxillofacial surgeons and craniofacial surgeons us120
ing CASS planning protocol in the treatment of patients with complex cranio-maxillofacial deformities. Method: In our protocol, a CT scan is initially obtained. The first step is to create a composite skull model, which reproduces both the bony structures and the dentition with a high degree of accuracy. The second step is to quantify the deformity. The third step is to simulate the entire surgery in the computer. The shape and size of the bone grafts, if needed, is also simulated. The final step is to transfer the planned outcome from computer to the patient at the time of the surgery. This can be achieved by either surgical templates or surgical navigation, depending on the indication. Main Objectives of Presentation: This lecture will familiarize surgeons with the basic principles of CASS in the treatment of complex CMF deformities. It will present the advantages, disadvantages and indications and limitations of this technology. References Department of Oral and Maxillofacial Surgery, The Methodist Hospital Research Institute, Houston, TX; Department of Surgery (Oral and Maxillofacial Surgery), Weill Cornell Medical College, Cornell University, New York, NY
S225 Comprehensive Free Tissue Reconstruction of Composite Maxillofacial Defects Domenick Coletti, DDS, MD, Baltimore, MD Josh Lubek, DDS, MD, Baltimore, MD Sequencing reconstructive strategies for patients with ablative tumor defects and high-energy craniomaxillofacial injuries can be a monumental challenge. These wounds present extensive tissue loss and therefore require composite tissue replacement. Free tissue transfer offers a unique consortium of vascularized tissues in a single stage. The sequenced combination of free flaps with osseointegrated dental implants has refined the surgeon’s ability to provide state of the art cosmetic and functional restorations. However, comprehension of the true architectural tissue defect as well as composite flap selection and its limitations facilitate the surgeon with a strategic approach. Consequently, achieving complete oral rehabilitation demands that the reconstructive surgeon understand the impact of flap selection on the surgical and prosthetic phases of implant surgery. This presentation will outline a comprehensive approach to complex maxillofacial reconstruction which utilizes the combination of free tissue transfer and implant surgery. It will detail flap selection and their limitations, timing and sequence of the surgical and prosthetic rehabilitation. AAOMS • 2009
Surgical Clinics References Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg. 2005 Jul 32(3):421-430 Futran ND, Farwell DG, Smith RB, Johnson PE, Funk GF. Definitive management of severe facial trauma utilizing free tissue transfer. Otolaryngol Head Neck Surg. 2005 Jan;132(1):75-85 Clark N, Birely B, Manson PN, Slezak S, Kolk CV, Robertson B, Crawley W. High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction. Plast Reconstr Surg. 1996 Sep;98(4):583-601
S226 Diagnosis and Management of Obstructive Sleep Apnea Syndrome (OSAS) Joseph I. Helman, DMD, Ann Arbor, MI Obstructive sleep apnea (OSA) has a significant effect on quality of life with tools and questionnaires available to evaluate outcomes. OSA has been associated with an increased risk for cardiovascular disease, hypertension, stroke, gastroesophageal reflux, impotence, motor vehicle accidents, depression, etc. While the incidence seems to be higher in adult overweight males, OSA affects females and children as well. The treatment should be customized to the patient and to the specific etiology. In the pediatric population the most common cause of OSA is hypertrophic tonsils and adenoids while syndromic patients may require a completely different management. Several treatment modalities have been advocated in the adult population. Uvulopalatopharyngoplasty, genial advancement, hyoid suspension with or without suprahyoid myotomy and bimaxillary Advancement have been popularized in recent years. While many surgical techniques are offered, a critical evaluation of their success rates shows suboptimal outcomes. A retrospective analysis of data by the presenter offers an algorithm for the management of OSA. The role of the oral and maxillofacial surgeon in the sleep apnea team has become indispensable due to the high success and predictability of bimaxillary advancement procedures with or without distraction osteogenesis. References C. Moyer, S. Sonnad, S. Garetz, J. Helman, R. Chervin. Quality of life in obstructive sleep apnea: a systematic review of the literature. Sleep Med, 2: 477-491, November 2001 S.S. Sonnad, C. Moyer, S. Patel, J.I. Helman, S. Garetz, R. Chervin. A model to facilitate outcome assessment of obstructive sleep apnea. International Journal of Technology Assessment in Health Care, 19:25360, Winter 2003 K. Magliocca, J.I. Helman. Obstructive Sleep Apnea: Diagnosis, Medical Management and Dental Implications. J. of the American Dental Association, 136(8):1121-1129, 2005 K. Cottrell, J.I. Helman. “Distraction osteogenesis in the management of Obstructive Sleep Apnea Syndrome.” In Distraction Osteogenesis of the Facial Skeleton. Editors C. Guerrero and W. Bell. B. C. Decker Publisher, 2007
AAOMS • 2009
S227 Anterior Skull Base Trauma: Management Considerations for HighVelocity Fronto-Naso-Orbital Injuries R. Bryan Bell, DDS, MD, Portland, OR High-velocity fronto-naso-orbital injuries frequently involve the anterior skull base and offer the oral and maxillofacial surgeon a number of challenges related to the complex skeletal, neurologic, and ophthalmologic regional anatomy. Preoperative computer modeling and intraoperative navigation provide a useful guide for accurate restoration of form and function in these difficult patients. This course will review the etiology, mechanism, diagnosis and treatment of craniofacial injuries that involve the anterior skull base, including: 1) treatment of severely disrupted orbital fractures occurring posterior to the equator of the globe and involving the superior orbital fissure and orbital apex; 2) treatment of complex fronto-nasal trauma; 3) management of frontal sinus fractures; and 4) management of post-traumatic cerebrospinal fluid leaks. In addition, the course participants will learn advanced techniques in preoperative computer modeling and intraoperative navigation-assisted surgery for the primary and secondary reconstruction of a variety of acquired craniofacial defects. References Bell RB, Dierks EJ, Brar P, Potter JD, Potter BE. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg 65:825-839, 2007 Pham AM, Rafii AA, Metzger MC, Jamali, Strong B. Computer modeling and intraoperative navigation in maxillofacial surgery. Otolaryngol Head Neck Surg 137:624-631, 2007 Gellrich NC, Schramm A, Hammer B, Rojas S, Cufi D, Lagreze W, Schmelzeisen R. Computer-assisted secondary reconstruction of unilateral posttraumatic orbital deformity. Plast Reconstr Surg 110:1417, 2002
S231 Comprehensive Overview of the Diagnosis, Evaluation and Management of Velopharyngeal Dysfunction in the Cleft Population Sean Edwards, DDS, MD, Ann Arbor, MI Mary Berger, MS, CCC, Ann Arbor, MI Speech disorders in the cleft population are as common as they are frustrating. The workup requires close collaboration with many practitioners including audiologists and speech language pathologists. While most surgeons will have received exposure to the various techniques employed in the surgical management of velopharyngeal dysfunction we often do not receive significant exposure to the different phases of evalua121
S224 Computer-Aided Surgical Simulation for Complex Cranio-Maxillofacial Surgery Jaime Gateno, DDS, MD, Houston, TX James J. Xia, MD, PhD, MS, Houston, TX Background and Purpose: The success of cranio-maxillofacial (CMF) surgery depends not only on surgical techniques, but also upon an accurate surgical plan. Unfortunately, traditional planning methods are often inadequate for planning CMF deformities. To this end, we developed 3D computer-aided surgical simulation (CASS) technique. Using our CASS method, we are able to treat patients with significant asymmetries in a single operation which in the past was usually completed in two stages. The purpose of this lecture is to teach oral and maxillofacial surgeons and craniofacial surgeons us120
ing CASS planning protocol in the treatment of patients with complex cranio-maxillofacial deformities. Method: In our protocol, a CT scan is initially obtained. The first step is to create a composite skull model, which reproduces both the bony structures and the dentition with a high degree of accuracy. The second step is to quantify the deformity. The third step is to simulate the entire surgery in the computer. The shape and size of the bone grafts, if needed, is also simulated. The final step is to transfer the planned outcome from computer to the patient at the time of the surgery. This can be achieved by either surgical templates or surgical navigation, depending on the indication. Main Objectives of Presentation: This lecture will familiarize surgeons with the basic principles of CASS in the treatment of complex CMF deformities. It will present the advantages, disadvantages and indications and limitations of this technology. References Department of Oral and Maxillofacial Surgery, The Methodist Hospital Research Institute, Houston, TX; Department of Surgery (Oral and Maxillofacial Surgery), Weill Cornell Medical College, Cornell University, New York, NY
S225 Comprehensive Free Tissue Reconstruction of Composite Maxillofacial Defects Domenick Coletti, DDS, MD, Baltimore, MD Josh Lubek, DDS, MD, Baltimore, MD Sequencing reconstructive strategies for patients with ablative tumor defects and high-energy craniomaxillofacial injuries can be a monumental challenge. These wounds present extensive tissue loss and therefore require composite tissue replacement. Free tissue transfer offers a unique consortium of vascularized tissues in a single stage. The sequenced combination of free flaps with osseointegrated dental implants has refined the surgeon’s ability to provide state of the art cosmetic and functional restorations. However, comprehension of the true architectural tissue defect as well as composite flap selection and its limitations facilitate the surgeon with a strategic approach. Consequently, achieving complete oral rehabilitation demands that the reconstructive surgeon understand the impact of flap selection on the surgical and prosthetic phases of implant surgery. This presentation will outline a comprehensive approach to complex maxillofacial reconstruction which utilizes the combination of free tissue transfer and implant surgery. It will detail flap selection and their limitations, timing and sequence of the surgical and prosthetic rehabilitation. AAOMS • 2009
Surgical Clinics References Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg. 2005 Jul 32(3):421-430 Futran ND, Farwell DG, Smith RB, Johnson PE, Funk GF. Definitive management of severe facial trauma utilizing free tissue transfer. Otolaryngol Head Neck Surg. 2005 Jan;132(1):75-85 Clark N, Birely B, Manson PN, Slezak S, Kolk CV, Robertson B, Crawley W. High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction. Plast Reconstr Surg. 1996 Sep;98(4):583-601
S226 Diagnosis and Management of Obstructive Sleep Apnea Syndrome (OSAS) Joseph I. Helman, DMD, Ann Arbor, MI Obstructive sleep apnea (OSA) has a significant effect on quality of life with tools and questionnaires available to evaluate outcomes. OSA has been associated with an increased risk for cardiovascular disease, hypertension, stroke, gastroesophageal reflux, impotence, motor vehicle accidents, depression, etc. While the incidence seems to be higher in adult overweight males, OSA affects females and children as well. The treatment should be customized to the patient and to the specific etiology. In the pediatric population the most common cause of OSA is hypertrophic tonsils and adenoids while syndromic patients may require a completely different management. Several treatment modalities have been advocated in the adult population. Uvulopalatopharyngoplasty, genial advancement, hyoid suspension with or without suprahyoid myotomy and bimaxillary Advancement have been popularized in recent years. While many surgical techniques are offered, a critical evaluation of their success rates shows suboptimal outcomes. A retrospective analysis of data by the presenter offers an algorithm for the management of OSA. The role of the oral and maxillofacial surgeon in the sleep apnea team has become indispensable due to the high success and predictability of bimaxillary advancement procedures with or without distraction osteogenesis. References C. Moyer, S. Sonnad, S. Garetz, J. Helman, R. Chervin. Quality of life in obstructive sleep apnea: a systematic review of the literature. Sleep Med, 2: 477-491, November 2001 S.S. Sonnad, C. Moyer, S. Patel, J.I. Helman, S. Garetz, R. Chervin. A model to facilitate outcome assessment of obstructive sleep apnea. International Journal of Technology Assessment in Health Care, 19:25360, Winter 2003 K. Magliocca, J.I. Helman. Obstructive Sleep Apnea: Diagnosis, Medical Management and Dental Implications. J. of the American Dental Association, 136(8):1121-1129, 2005 K. Cottrell, J.I. Helman. “Distraction osteogenesis in the management of Obstructive Sleep Apnea Syndrome.” In Distraction Osteogenesis of the Facial Skeleton. Editors C. Guerrero and W. Bell. B. C. Decker Publisher, 2007
AAOMS • 2009
S227 Anterior Skull Base Trauma: Management Considerations for HighVelocity Fronto-Naso-Orbital Injuries R. Bryan Bell, DDS, MD, Portland, OR High-velocity fronto-naso-orbital injuries frequently involve the anterior skull base and offer the oral and maxillofacial surgeon a number of challenges related to the complex skeletal, neurologic, and ophthalmologic regional anatomy. Preoperative computer modeling and intraoperative navigation provide a useful guide for accurate restoration of form and function in these difficult patients. This course will review the etiology, mechanism, diagnosis and treatment of craniofacial injuries that involve the anterior skull base, including: 1) treatment of severely disrupted orbital fractures occurring posterior to the equator of the globe and involving the superior orbital fissure and orbital apex; 2) treatment of complex fronto-nasal trauma; 3) management of frontal sinus fractures; and 4) management of post-traumatic cerebrospinal fluid leaks. In addition, the course participants will learn advanced techniques in preoperative computer modeling and intraoperative navigation-assisted surgery for the primary and secondary reconstruction of a variety of acquired craniofacial defects. References Bell RB, Dierks EJ, Brar P, Potter JD, Potter BE. A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg 65:825-839, 2007 Pham AM, Rafii AA, Metzger MC, Jamali, Strong B. Computer modeling and intraoperative navigation in maxillofacial surgery. Otolaryngol Head Neck Surg 137:624-631, 2007 Gellrich NC, Schramm A, Hammer B, Rojas S, Cufi D, Lagreze W, Schmelzeisen R. Computer-assisted secondary reconstruction of unilateral posttraumatic orbital deformity. Plast Reconstr Surg 110:1417, 2002
S231 Comprehensive Overview of the Diagnosis, Evaluation and Management of Velopharyngeal Dysfunction in the Cleft Population Sean Edwards, DDS, MD, Ann Arbor, MI Mary Berger, MS, CCC, Ann Arbor, MI Speech disorders in the cleft population are as common as they are frustrating. The workup requires close collaboration with many practitioners including audiologists and speech language pathologists. While most surgeons will have received exposure to the various techniques employed in the surgical management of velopharyngeal dysfunction we often do not receive significant exposure to the different phases of evalua121