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S323: Advanced Techniques in Pediatric Craniofacial Surgery
Surgical Clinics Continuity defects of the mandible resultant from benign tumor surgeries, mostly do not require specific soft tissue reconstruction. However, a contamination free and infection free tissue bed is needed for a successful bony reconstruction. Bone grafting is, therefore, best accomplished from a transcutaneous approach that avoids oral communications. Cancellous cellular marrow grafts are the superior graft results today, particularly when enhanced with platelet rich plasma growth factor additions, which accelerate bone regeneration and produce a more dense graft. Platelet rich plasma has been shown to contain Platelet Derived Growth Factor (PDGF), transforming growth factor-beta1 and beta2 (TGF-b1 and TGF-b2), vascular endothelial growth factors, (VEGF), and epithelial growth factor (EGF). In addition, recombinant human bone morphogenetic protein-2 (rhBMP-2/ACS) has now also shown initial good bone regenerations in some continuity defects without the use of autogenous bone. Cancer related defects and those defects associated with osteoradionecrosis often require significant soft tissue reconstruction first. It is common to place soft tissue flaps such as pectoralis major, trapezius, latissimus dorsi, or sternocleidomastoid myocutaneous flaps together with a titanium reconstruction plate in advance of bone grafting. In the maxilla, the temporalis muscle flap is the preferred flap. In addition, several free vascular soft tissue flaps are useful, such as the radial forearm flap, the circumflex scapular flap, and the rectus abdominus flap. Osteoradionecrosis defects also require hyperbaric oxygen prior to any type of reconstruction. The hyperbaric oxygen protocol of 20 sessions at 2.4 ATA for 90 treatment minutes before elective reconstruction, followed by ten sessions afterward, is the standard of care today.
The goal of this presentation is to analyze the different kinds of secondary deformities and to review the surgical techniques used to correct these deformities. We will discuss the diagnosis and treatment of: • Nasal sequelae such as flat nose, short columella, deviation and misplaced alar cartilage, opened floor of the nose, asymmetric nostrils, etc. • Lip problems such as short vertical length, whistle defect, lack of vermillion border, bad scars, etc. • Most common complications occurred in the palate such as anterior fistulae, posterior dehiscences and velopharyngeal insufficiency or incompetence. Treatment including the tongue flap and both retropharyngeal and functional sphincter flaps will be also reviewed. • Treatment of skeletal deformities including nasoalveolar grafting, premaxillary repositioning, and orthognathic treatment based on the diagnosis of the speech. References Millard RD Jr. Cleft Craft. The Evolution of Its Surgery. Boston, Little, Brown & Co. 1980 American Cleft Palate-Craniofacial Association. Parameters for the evaluation of treatment of patients with cleft lip/palate or the craniofacial anomalies. Cleft Palate Craniofac J 1993;30 suppl:4 Cohen MM Jr, Bankier A. Syndrome delineation involving orofacial clefting. Cleft Palate Journal 1991;28
S322 Fractures of the Orbital Skeleton— Patterns, Current Management Strategies and Techniques Harry Papadopoulos, DDS, MD, Indianapolis, IN Deepak Krishnan, BDS, Cincinnati, OH
References Marx, R.E., Carlson, E.R., Eichstaedt, R.M., Schimmele, S.R. Strauss, J.E. and Georgeff, K.R.: Platelet Rich Plasma – Growth factor enhancement for bone grafts. Oral Surg, 85, 638-646, 1998 Marx, R.E.: Mandibular Reconstruction – Advances in Oral and Maxillofacial Surgery, 1943-1993. J Oral Maxillofacial Surg, 466-479, 1993 Gray, J.C., Phil, M. and Elves, M.W.: Donor cells contribution to osteogenesis in cancellous bone grafts. Clin Orthop, 163, 261-269, 1982
S321 Secondary Management of Cleft Lip/Cleft Palate Deformities in Both Soft and Hard Tissues Rafael Ruiz-Rodriguez, DDS, Mexico, DF, Mexico Juan Carlos Lopez-Noriega, DDS, Mexico, DF, Mexico The management of the primary cleft lip and palate deformities often may be followed by several secondary sequelae in different areas: nose, lip, alveolar ridge, hard and/or soft palate and also dentofacial discrepancies. AAOMS • 2009
Fractures involving the orbital skeleton in either isolation or in concomitance with other injuries present challenges in diagnosis, and management to the practicing oral maxillofacial surgeon. Fracture patterns vary significantly and current imaging technology helps in treatment planning more than ever. Criteria for immediate, early or delayed intervention have been re-thought over the course of time as have surgical approaches and materials available for skeletal reconstruction. The presentation will outline current management principles, and discuss strategies to incorporate treatment of orbital trauma in your busy practice. Handouts will be included.
S323 Advanced Techniques in Pediatric Craniofacial Surgery Ramon L. Ruiz, DMD, MD, Orlando, FL Bernard J. Costello, DMD, MD, Pittsburgh, PA 127
Surgical Clinics With over 400 syndromes identified in the head and neck, it is important for surgeons caring for patients with congenital anomalies to have a clear understanding of concepts important in treatment planning comprehensive interdisciplinary care. There are also a number of acquired conditions that require advanced craniofacial techniques for initial treatment and reconstruction. Understanding the complex functional and esthetic needs of the patient with these issues allows the astute and informed clinician to effectively treat complex craniofacial challenges in a standard fashion from the fetus through the adult years. As such, appropriate planning avoids needlessly burdening the patient and/or health care system with inefficacious or unproven modalities. Timing these interventions is of great importance and early surgical procedures may have biologic consequences that must be understood in order to minimally interfere with long-term growth. This clinic will provide a comprehensive review regarding the treatment rationale, diagnostic approach, and operative techniques involved in the management of the complex craniofacial problems including micrognathia, craniofacial microsomia, craniosynostosis, pediatric craniofacial trauma, craniofacial pathology, and other deformities. References Costello BJ, Edwards S, Clemens M. Fetal Diagnosis and Treatment of Craniomaxillofacial Anomalies. J Oral Maxillofac Surg. 2008;66(10): 1985-95 Koop CE: Surgeon General’s Report: Children with Special Health Care Needs. Washington, D.C. Government Printing Office, June 1987 Costello BJ, Ruiz RL and Mooney M. Craniofacial Growth and Surgery. In Fonseca’s Oral and Maxillofacial Surgery. Elsevier. 2009
S324 A Comprehensive Approach to Mandibular Reconstruction Stephen MacLeod, BDS, MBChB, FDSRCS, FRCS, Minneapolis, MN David Mitchell, BDS, MBChB, FDSRCS, FRCS, Wakefield, England Deepak Kademani, DMD, MD, Minneapolis, MN The oral and maxillofacial surgeon is frequently required to reconstruct mandibular defects. Appreciation of the extent of the defect and the functional deficits is central to choosing the optimal reconstructive techniques. This clinic will provide a systematic approach to the classification of mandibular defects, review the available techniques and demonstrate a comprehensive approach to reconstruction. Participants are encouraged to bring difficult cases for discussion. References Kademani D, Keller Iliac Crest Grafting for mandibular reconstruction Atlas Oral Maxillofac Surg Clin North Am. 2006; 14:160
128
Mitchell, D.A., MacLeod, S.P.R. Strategies for avoiding complications with vascularised bone flaps in head and neck microvascular reconstruction. Seminars in Plastic Surgery (in press) MacLeod, S.P.R Non Union of the Mandible and Irradiated Mandible Hom, D.B., Hebda, P.A., Gosain A.K, Friedman C.D. Essential Tissue Healing of the Face and Neck. Hamilton. BC Decker (In press)
S325 Indications for and Management of Implants in Children Janice S. Lee, DDS, MD, MS, San Francisco, CA Arun Sharma, BDS, San Francisco, CA Complete or partial edentulism in children is an uncommon occurrence. There are both congenital and acquired conditions that may result in edentulism in the growing patient. The dearth of literature on this topic provides little guidance to the surgical and prosthodontic team in treating and decision-making for this problem. There is no reason to doubt that implants will integrate when placed in the maxilla or mandible of the growing child. Unfortunately, an integrated implant behaves like an ankylosed tooth. The concerns around placing implants in the growing child are related to jaw growth. If an implant is placed before growth is completed, will the implant still be in a position to support a restoration when growth is complete? Will the normal growth pattern of the maxilla and mandible be interfered with if an implant is placed before growth is complete? These unanswered questions have been responsible for the limited use of implants in the growing child. The purpose of this surgical clinic is to outline the indications and timing for the use of implants in growing children. At the University of California, San Francisco (UCSF), we have been conducting clinical trials using implants in children ranging in age from 6 to 18 years. These studies have included an evaluation of implants placed in grafted alveolar clefts of patients with unilateral or bilateral cleft lip and palate and the use of implants in patients with ectodermal dysplasia. We have also placed implants in children who have had maxillary or mandibular resections for tumors and subsequent reconstruction. Long term follow up of these patients has allowed us to develop a protocol for implant placement in the growing child. This systematic protocol is based on three categories of hypodontia or anodontia. We will review the indications and protocol for implant placement in children based on the clinical findings. References Kearns, G., D. H. Perrott, et al. (1997). Placement of endosseous implants in grafted alveolar clefts. Cleft Palate Craniofac J 34(6): 520-5 Kearns, G., A. Sharma, et al. (1999). Placement of endosseous implants in children and adolescents with hereditary ectodermal dysplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88(1): 5-10
AAOMS • 2009
The goal of this presentation is to analyze the different kinds of secondary deformities and to review the surgical techniques used to correct these deformities. We will discuss the diagnosis and treatment of: • Nasal sequelae such as flat nose, short columella, deviation and misplaced alar cartilage, opened floor of the nose, asymmetric nostrils, etc. • Lip problems such as short vertical length, whistle defect, lack of vermillion border, bad scars, etc. • Most common complications occurred in the palate such as anterior fistulae, posterior dehiscences and velopharyngeal insufficiency or incompetence. Treatment including the tongue flap and both retropharyngeal and functional sphincter flaps will be also reviewed. • Treatment of skeletal deformities including nasoalveolar grafting, premaxillary repositioning, and orthognathic treatment based on the diagnosis of the speech. References Millard RD Jr. Cleft Craft. The Evolution of Its Surgery. Boston, Little, Brown & Co. 1980 American Cleft Palate-Craniofacial Association. Parameters for the evaluation of treatment of patients with cleft lip/palate or the craniofacial anomalies. Cleft Palate Craniofac J 1993;30 suppl:4 Cohen MM Jr, Bankier A. Syndrome delineation involving orofacial clefting. Cleft Palate Journal 1991;28
S322 Fractures of the Orbital Skeleton— Patterns, Current Management Strategies and Techniques Harry Papadopoulos, DDS, MD, Indianapolis, IN Deepak Krishnan, BDS, Cincinnati, OH
References Marx, R.E., Carlson, E.R., Eichstaedt, R.M., Schimmele, S.R. Strauss, J.E. and Georgeff, K.R.: Platelet Rich Plasma – Growth factor enhancement for bone grafts. Oral Surg, 85, 638-646, 1998 Marx, R.E.: Mandibular Reconstruction – Advances in Oral and Maxillofacial Surgery, 1943-1993. J Oral Maxillofacial Surg, 466-479, 1993 Gray, J.C., Phil, M. and Elves, M.W.: Donor cells contribution to osteogenesis in cancellous bone grafts. Clin Orthop, 163, 261-269, 1982
S321 Secondary Management of Cleft Lip/Cleft Palate Deformities in Both Soft and Hard Tissues Rafael Ruiz-Rodriguez, DDS, Mexico, DF, Mexico Juan Carlos Lopez-Noriega, DDS, Mexico, DF, Mexico The management of the primary cleft lip and palate deformities often may be followed by several secondary sequelae in different areas: nose, lip, alveolar ridge, hard and/or soft palate and also dentofacial discrepancies. AAOMS • 2009
Fractures involving the orbital skeleton in either isolation or in concomitance with other injuries present challenges in diagnosis, and management to the practicing oral maxillofacial surgeon. Fracture patterns vary significantly and current imaging technology helps in treatment planning more than ever. Criteria for immediate, early or delayed intervention have been re-thought over the course of time as have surgical approaches and materials available for skeletal reconstruction. The presentation will outline current management principles, and discuss strategies to incorporate treatment of orbital trauma in your busy practice. Handouts will be included.
S323 Advanced Techniques in Pediatric Craniofacial Surgery Ramon L. Ruiz, DMD, MD, Orlando, FL Bernard J. Costello, DMD, MD, Pittsburgh, PA 127
Surgical Clinics With over 400 syndromes identified in the head and neck, it is important for surgeons caring for patients with congenital anomalies to have a clear understanding of concepts important in treatment planning comprehensive interdisciplinary care. There are also a number of acquired conditions that require advanced craniofacial techniques for initial treatment and reconstruction. Understanding the complex functional and esthetic needs of the patient with these issues allows the astute and informed clinician to effectively treat complex craniofacial challenges in a standard fashion from the fetus through the adult years. As such, appropriate planning avoids needlessly burdening the patient and/or health care system with inefficacious or unproven modalities. Timing these interventions is of great importance and early surgical procedures may have biologic consequences that must be understood in order to minimally interfere with long-term growth. This clinic will provide a comprehensive review regarding the treatment rationale, diagnostic approach, and operative techniques involved in the management of the complex craniofacial problems including micrognathia, craniofacial microsomia, craniosynostosis, pediatric craniofacial trauma, craniofacial pathology, and other deformities. References Costello BJ, Edwards S, Clemens M. Fetal Diagnosis and Treatment of Craniomaxillofacial Anomalies. J Oral Maxillofac Surg. 2008;66(10): 1985-95 Koop CE: Surgeon General’s Report: Children with Special Health Care Needs. Washington, D.C. Government Printing Office, June 1987 Costello BJ, Ruiz RL and Mooney M. Craniofacial Growth and Surgery. In Fonseca’s Oral and Maxillofacial Surgery. Elsevier. 2009
S324 A Comprehensive Approach to Mandibular Reconstruction Stephen MacLeod, BDS, MBChB, FDSRCS, FRCS, Minneapolis, MN David Mitchell, BDS, MBChB, FDSRCS, FRCS, Wakefield, England Deepak Kademani, DMD, MD, Minneapolis, MN The oral and maxillofacial surgeon is frequently required to reconstruct mandibular defects. Appreciation of the extent of the defect and the functional deficits is central to choosing the optimal reconstructive techniques. This clinic will provide a systematic approach to the classification of mandibular defects, review the available techniques and demonstrate a comprehensive approach to reconstruction. Participants are encouraged to bring difficult cases for discussion. References Kademani D, Keller Iliac Crest Grafting for mandibular reconstruction Atlas Oral Maxillofac Surg Clin North Am. 2006; 14:160
128
Mitchell, D.A., MacLeod, S.P.R. Strategies for avoiding complications with vascularised bone flaps in head and neck microvascular reconstruction. Seminars in Plastic Surgery (in press) MacLeod, S.P.R Non Union of the Mandible and Irradiated Mandible Hom, D.B., Hebda, P.A., Gosain A.K, Friedman C.D. Essential Tissue Healing of the Face and Neck. Hamilton. BC Decker (In press)
S325 Indications for and Management of Implants in Children Janice S. Lee, DDS, MD, MS, San Francisco, CA Arun Sharma, BDS, San Francisco, CA Complete or partial edentulism in children is an uncommon occurrence. There are both congenital and acquired conditions that may result in edentulism in the growing patient. The dearth of literature on this topic provides little guidance to the surgical and prosthodontic team in treating and decision-making for this problem. There is no reason to doubt that implants will integrate when placed in the maxilla or mandible of the growing child. Unfortunately, an integrated implant behaves like an ankylosed tooth. The concerns around placing implants in the growing child are related to jaw growth. If an implant is placed before growth is completed, will the implant still be in a position to support a restoration when growth is complete? Will the normal growth pattern of the maxilla and mandible be interfered with if an implant is placed before growth is complete? These unanswered questions have been responsible for the limited use of implants in the growing child. The purpose of this surgical clinic is to outline the indications and timing for the use of implants in growing children. At the University of California, San Francisco (UCSF), we have been conducting clinical trials using implants in children ranging in age from 6 to 18 years. These studies have included an evaluation of implants placed in grafted alveolar clefts of patients with unilateral or bilateral cleft lip and palate and the use of implants in patients with ectodermal dysplasia. We have also placed implants in children who have had maxillary or mandibular resections for tumors and subsequent reconstruction. Long term follow up of these patients has allowed us to develop a protocol for implant placement in the growing child. This systematic protocol is based on three categories of hypodontia or anodontia. We will review the indications and protocol for implant placement in children based on the clinical findings. References Kearns, G., D. H. Perrott, et al. (1997). Placement of endosseous implants in grafted alveolar clefts. Cleft Palate Craniofac J 34(6): 520-5 Kearns, G., A. Sharma, et al. (1999). Placement of endosseous implants in children and adolescents with hereditary ectodermal dysplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88(1): 5-10
AAOMS • 2009