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Second modification technique to stabilize dental prosthesis after resection of the maxilla and reconstruction
Poster Session Conclusion: The study suggests the cyclic biomechanical force could influence the osteoblast differentiation of periosteal derived stem cells under optimal stimulation condition and could applicable for tissue engineering.
POSTER 267 Optomising The Design Of Two Piece Peek Implants In Orbito-Zygomatic Reconstruction - The Jigsaw Technique R. J. Banks: Sunderland Royal Hospital, D. J. Keith Background: Polyetheretherketone (PEEK) is derived from the Polyaryletherketone family of linear aromatic polymers. The implantable grade of PEEK demonstrates a number of similarities to bone and has been available for some time as a patient specific implant in maxillofacial reconstruction. Method: Patient specific implants are created on a virtual stereo lithographic model produced following CT scan carried out using a prescribed protocol (SYNTHES, UK). The implant is designed via digital subtraction to match the opposite side and discussed and modified to match the clinical scenario via planning webinar. In this poster we demonstrate some of the defects, planning techniques and solutions using various designs of modified ‘ jigsaw piece’’ to facilitate insertion and fixation in the use of two piece PEEK implants to reconstruct the orbital rim, floor and zygomatic complex. We present the results of 10 sequential cases where the ‘‘jigsaw design’’ technique has been sucessfully used for large volume maxillary and orbital defects. Results: The relative ease of insertion and fixation, together with the precise anatomical fit and correction of the volume defect provide reduced operating time, improved patient acceptance and accuracy at the initial surgery. This has lead to increased patient satisfaction. Conclusion: We have demonstrated a novel approach to facilitate inserting relatively large PEEK implants to correct significant post-traumatic deformity through minimal and familiar approaches to the facial skeleton. References: 1. Kim MM, Kofi D, Boahene O, Byrne PJ. Use of Customized Polyetheretherketone (PEEK) Implants in the Reconstruction of Complex Maxillofacial Defects. Arch Facial Plast Surg 2009; 11: (1) 53-57 2. Schlegel J and Green S. Polyetheretherketones (PEEK)- A Biocompaticble high performance plastic. Medical Plastics 2000; 14: 12.1-12.10 3. Jarman-Smith M. Evolving uses for implantable PEEK and PEEK based compounds. Med Device Technol 2008 Oct;19 (6) 12-15
POSTER 268 Second modification technique to stabilize dental prosthesis after resection of the maxilla and reconstruction e-202
A. Abe: Nagoya Ekisai Hospital, K. Kurita, Y. Ito, K. Kohara, K. Kawahara Statement of the Problem: After the excision of the maxillary carcinoma, a functional improvement by means of skin-flap reconstruction and obturator denture can be conducted. However, quite a few cases show prosthesis stability difficulties due to the flap’s own weight. Therefore second modification technique is required to plan improvement of configuration. A purpose of second modification technique reduces flap, and to remove descent of flap. This reports on two new method of that took second modification technique. The first case is vestibuloplasty and defatting of the fibular osteoseptocutaneous flap from the palatal side. The second case is flap revision by skin flap lifting using mitek anchors was performed for extensive complete removal of the maxilla. Materials and Methods: Case 1: The patient was a 73- year-old woman at the time of maxillary reconstruction. She underwent resection of the maxilla and fibular osteoseptocutaneous flap in January, 2008. However, there was no oral vestibule because the flap had been sewed up onto the upper lip. Because the dental prosthesis was unstable, we decided on vestibuloplasty. The vestibuloplasty was performed under general anaesthesia in December, 2008. Case 2: The patient was a 56-year-old male, who underwent an extensive total maxillectomy and flap reconstruction using the rectus abdominus muscles in May 2005. Postoperatively, due to the difficulties of wearing a maxillary denture, he was transferred to our department with the chief complaint of no morphological improvement. The maxillary bone had already been removed from the midline with the rectus abdominus muscle flap sutured directly to the soft palate without oral vestibule, and the flap margin was moving together with the surrounding soft tissue. The flap size was 7050 mm, which was sagging due to its own weight and was in contact with mandibular molars, reducing the volume of the oral cavity without a denture being worn. In Dec 2008, reduction and lifting of the flap was conducted under general anesthesia. This operation used 3 mitek anchors implanted in the zygomatic bone, and the anchor suture placed through subcutaneous tissue to the skin flap for lifting. Three years to the day since the operation, no regression of sagging of the flap and no infection of the wound can be seen. Results: A purpose of second modification technique after maxillary cancer abscission is stability of prosthetic appliance. A main thing of second modification technique is vestibuloplasty. However, stability of dental prosthesis is insufficient in vestbuloplasty. Therefore, supporting methods to promote stability of dental prosthesis are required. In this case, a fibula was fixed with plates on the labial side. Then we elevated the flap from the posterior side and reduced fat tissue to make AAOMS 2014
Poster Session the flap thin. The oral vestibule was also formed well enough. The dental prosthesis was stable after the operation. We think this method is good in that the fibula is covered by the base of the flap and the following necrosis of the flap is reduced. Conclusions: Dental prosthesis was able to be stable by using vestibuloplasty and flap loss technique and supporting means. References: 1. Yu K, Kim AJ, Tadros M, Costantino PD. Mitek anchor-augmented static facial suspension., Arch Facial Plast Surg.;12(3):159-65. 2010 2. Hashemi HM, Parhiz A, Ghafari S. FVestibuloplasty: allograft versus mucosal graft.Int J Oral Maxillofac Surg. 41(4):527-30. 2012
POSTER 269 Non-invasive real-time monitoring of perfusion and vascularization of an engrafted soft tissue engineered oral mucosa R. Y. Kim: University of Michigan Health System, A. C. Fasi, K. Vishwanath, S. Kuo, R. Guriar, H. M. Kim, D. E. Wolf, S. E. Feinberg Statement of the Problem: Repair of soft tissue defects of the lips, as seen in complex maxillofacial injuries and post-ablative defects, requires pre-vascularized multitissue composite grafts. Protocols for fabrication of human exvivo produced oral mucosal equivalents (EVPOME) composed of epithelial cells and a dermal equivalent are now available to create prelaminated flaps for grafting in patients for lip reconstruction. However, invivo assessment of vascularization of the buried prelaminated flaps remains clinically challenging. Here, we use diffuse reflectance spectroscopy (DRS) and diffuse correlation spectroscopy (DCS) to non-invasively quantify longitudinal changes in the vascular saturation and blood-flow within EVPOME grafts, and explore the utility of these optical techniques for assessing vascularization of implanted grafts. Materials and Methods: Twenty SCID mice were implanted with an EVPOME graft subcutaneously in their backs. DRS and DCS measurements were obtained from each animal both atop the graft site and a distance from the graft site (off-site). Measurements were obtained from each implanted graft at four consecutive weeks post-implantation. Methods of Data Analysis: DRS measurements provided information derived from tissue reflectance, which is determined in turn by the concentration of oxy and deoxyhemoglobin. DCS monitors high-frequency fluctuations of the source laser speckle, which depends on the motion of red-blood cells in the blood vessels. DRS measurements were analyzed using a quantitative Monte Carlo based photon transport model to extract data, representAAOMS 2014
ing vascular saturation. The DCS data were analyzed using theoretical methods of diffuse optics to obtain the relative blood flow (RBF) index. Random-effect regression model was used to obtain differences in means at the graft site versus off-site at each week along with their 95% confidence intervals and P values. Results: There were significant differences in the mean optical parameters (averaged across all mice) at the graft site versus the off-site measurements. For week 1 and 2 measurements, DRS instrument was significant with vascular saturation differences of 9.03 (p= 0.003; 95% CI = 2.97, 15.09) and 13.49 (p=0.001; 95% CI = 5.38, 21.60), respectively. At week 3, DCS instrument was significant with RBF index difference of 0.075 (p = 0.02; 95% CI = 0.01, 0.14). At week 4, neither DRS nor DCS instrument measurements showed statistically significant difference. Conclusions: Both DRS and DCS measurements detected changes in vascularity occurring in (or around) the implanted EVPOME constructs. DRS data indicated increases in vascular saturation when measured atop the site of the grafts, significantly in the first two weeks post-implantation. DCS data showed that the relative blood flow was higher on-graft, statistically significant at 3 weeks post-operatively, though the measurements were reliably higher for all four weeks. Although it is difficult to control for factors such as inflammation leading to vasodilatation and transient hyper-vascularization during wound healing, DRS and DCS techniques were able to discern significantly between on and off-graft. Furthermore, these optical techniques were able to quantify perfusion and vascularization, characterizing the changes longitudinally. Therefore, our study shows the potential of these techniques for challenging clinical scenarios such as monitoring of buried flaps. References: 1. Holze F, Loeffelbein DJ, et. al. Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg. 2006 34, 25-33. 2. Mesquita RC, Schenkel SS, et. al. Influence of probe pressure on the diffuse correlation spectroscopy blood flow signal: extra-cerebral contributions. Biomed Opt Express. 2013. 4(7): 978-94
POSTER 270 Three case of ridge augmentation of alveolar ridge of maxilla and mandible using bioresorbable material HA/PLLA composites H. Yutori: Kakogawa East City Hospital, S. LI, Y. Tutumi, K. Matumoto, T. Komori Three cases of ridge augmentation using bioresorbable material HA/PLLA composites were presented. A patient of case 1, 60 year-year-old female, had missed five anterior teeth in maxilla and hoped reconstruction
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POSTER 267 Optomising The Design Of Two Piece Peek Implants In Orbito-Zygomatic Reconstruction - The Jigsaw Technique R. J. Banks: Sunderland Royal Hospital, D. J. Keith Background: Polyetheretherketone (PEEK) is derived from the Polyaryletherketone family of linear aromatic polymers. The implantable grade of PEEK demonstrates a number of similarities to bone and has been available for some time as a patient specific implant in maxillofacial reconstruction. Method: Patient specific implants are created on a virtual stereo lithographic model produced following CT scan carried out using a prescribed protocol (SYNTHES, UK). The implant is designed via digital subtraction to match the opposite side and discussed and modified to match the clinical scenario via planning webinar. In this poster we demonstrate some of the defects, planning techniques and solutions using various designs of modified ‘ jigsaw piece’’ to facilitate insertion and fixation in the use of two piece PEEK implants to reconstruct the orbital rim, floor and zygomatic complex. We present the results of 10 sequential cases where the ‘‘jigsaw design’’ technique has been sucessfully used for large volume maxillary and orbital defects. Results: The relative ease of insertion and fixation, together with the precise anatomical fit and correction of the volume defect provide reduced operating time, improved patient acceptance and accuracy at the initial surgery. This has lead to increased patient satisfaction. Conclusion: We have demonstrated a novel approach to facilitate inserting relatively large PEEK implants to correct significant post-traumatic deformity through minimal and familiar approaches to the facial skeleton. References: 1. Kim MM, Kofi D, Boahene O, Byrne PJ. Use of Customized Polyetheretherketone (PEEK) Implants in the Reconstruction of Complex Maxillofacial Defects. Arch Facial Plast Surg 2009; 11: (1) 53-57 2. Schlegel J and Green S. Polyetheretherketones (PEEK)- A Biocompaticble high performance plastic. Medical Plastics 2000; 14: 12.1-12.10 3. Jarman-Smith M. Evolving uses for implantable PEEK and PEEK based compounds. Med Device Technol 2008 Oct;19 (6) 12-15
POSTER 268 Second modification technique to stabilize dental prosthesis after resection of the maxilla and reconstruction e-202
A. Abe: Nagoya Ekisai Hospital, K. Kurita, Y. Ito, K. Kohara, K. Kawahara Statement of the Problem: After the excision of the maxillary carcinoma, a functional improvement by means of skin-flap reconstruction and obturator denture can be conducted. However, quite a few cases show prosthesis stability difficulties due to the flap’s own weight. Therefore second modification technique is required to plan improvement of configuration. A purpose of second modification technique reduces flap, and to remove descent of flap. This reports on two new method of that took second modification technique. The first case is vestibuloplasty and defatting of the fibular osteoseptocutaneous flap from the palatal side. The second case is flap revision by skin flap lifting using mitek anchors was performed for extensive complete removal of the maxilla. Materials and Methods: Case 1: The patient was a 73- year-old woman at the time of maxillary reconstruction. She underwent resection of the maxilla and fibular osteoseptocutaneous flap in January, 2008. However, there was no oral vestibule because the flap had been sewed up onto the upper lip. Because the dental prosthesis was unstable, we decided on vestibuloplasty. The vestibuloplasty was performed under general anaesthesia in December, 2008. Case 2: The patient was a 56-year-old male, who underwent an extensive total maxillectomy and flap reconstruction using the rectus abdominus muscles in May 2005. Postoperatively, due to the difficulties of wearing a maxillary denture, he was transferred to our department with the chief complaint of no morphological improvement. The maxillary bone had already been removed from the midline with the rectus abdominus muscle flap sutured directly to the soft palate without oral vestibule, and the flap margin was moving together with the surrounding soft tissue. The flap size was 7050 mm, which was sagging due to its own weight and was in contact with mandibular molars, reducing the volume of the oral cavity without a denture being worn. In Dec 2008, reduction and lifting of the flap was conducted under general anesthesia. This operation used 3 mitek anchors implanted in the zygomatic bone, and the anchor suture placed through subcutaneous tissue to the skin flap for lifting. Three years to the day since the operation, no regression of sagging of the flap and no infection of the wound can be seen. Results: A purpose of second modification technique after maxillary cancer abscission is stability of prosthetic appliance. A main thing of second modification technique is vestibuloplasty. However, stability of dental prosthesis is insufficient in vestbuloplasty. Therefore, supporting methods to promote stability of dental prosthesis are required. In this case, a fibula was fixed with plates on the labial side. Then we elevated the flap from the posterior side and reduced fat tissue to make AAOMS 2014
Poster Session the flap thin. The oral vestibule was also formed well enough. The dental prosthesis was stable after the operation. We think this method is good in that the fibula is covered by the base of the flap and the following necrosis of the flap is reduced. Conclusions: Dental prosthesis was able to be stable by using vestibuloplasty and flap loss technique and supporting means. References: 1. Yu K, Kim AJ, Tadros M, Costantino PD. Mitek anchor-augmented static facial suspension., Arch Facial Plast Surg.;12(3):159-65. 2010 2. Hashemi HM, Parhiz A, Ghafari S. FVestibuloplasty: allograft versus mucosal graft.Int J Oral Maxillofac Surg. 41(4):527-30. 2012
POSTER 269 Non-invasive real-time monitoring of perfusion and vascularization of an engrafted soft tissue engineered oral mucosa R. Y. Kim: University of Michigan Health System, A. C. Fasi, K. Vishwanath, S. Kuo, R. Guriar, H. M. Kim, D. E. Wolf, S. E. Feinberg Statement of the Problem: Repair of soft tissue defects of the lips, as seen in complex maxillofacial injuries and post-ablative defects, requires pre-vascularized multitissue composite grafts. Protocols for fabrication of human exvivo produced oral mucosal equivalents (EVPOME) composed of epithelial cells and a dermal equivalent are now available to create prelaminated flaps for grafting in patients for lip reconstruction. However, invivo assessment of vascularization of the buried prelaminated flaps remains clinically challenging. Here, we use diffuse reflectance spectroscopy (DRS) and diffuse correlation spectroscopy (DCS) to non-invasively quantify longitudinal changes in the vascular saturation and blood-flow within EVPOME grafts, and explore the utility of these optical techniques for assessing vascularization of implanted grafts. Materials and Methods: Twenty SCID mice were implanted with an EVPOME graft subcutaneously in their backs. DRS and DCS measurements were obtained from each animal both atop the graft site and a distance from the graft site (off-site). Measurements were obtained from each implanted graft at four consecutive weeks post-implantation. Methods of Data Analysis: DRS measurements provided information derived from tissue reflectance, which is determined in turn by the concentration of oxy and deoxyhemoglobin. DCS monitors high-frequency fluctuations of the source laser speckle, which depends on the motion of red-blood cells in the blood vessels. DRS measurements were analyzed using a quantitative Monte Carlo based photon transport model to extract data, representAAOMS 2014
ing vascular saturation. The DCS data were analyzed using theoretical methods of diffuse optics to obtain the relative blood flow (RBF) index. Random-effect regression model was used to obtain differences in means at the graft site versus off-site at each week along with their 95% confidence intervals and P values. Results: There were significant differences in the mean optical parameters (averaged across all mice) at the graft site versus the off-site measurements. For week 1 and 2 measurements, DRS instrument was significant with vascular saturation differences of 9.03 (p= 0.003; 95% CI = 2.97, 15.09) and 13.49 (p=0.001; 95% CI = 5.38, 21.60), respectively. At week 3, DCS instrument was significant with RBF index difference of 0.075 (p = 0.02; 95% CI = 0.01, 0.14). At week 4, neither DRS nor DCS instrument measurements showed statistically significant difference. Conclusions: Both DRS and DCS measurements detected changes in vascularity occurring in (or around) the implanted EVPOME constructs. DRS data indicated increases in vascular saturation when measured atop the site of the grafts, significantly in the first two weeks post-implantation. DCS data showed that the relative blood flow was higher on-graft, statistically significant at 3 weeks post-operatively, though the measurements were reliably higher for all four weeks. Although it is difficult to control for factors such as inflammation leading to vasodilatation and transient hyper-vascularization during wound healing, DRS and DCS techniques were able to discern significantly between on and off-graft. Furthermore, these optical techniques were able to quantify perfusion and vascularization, characterizing the changes longitudinally. Therefore, our study shows the potential of these techniques for challenging clinical scenarios such as monitoring of buried flaps. References: 1. Holze F, Loeffelbein DJ, et. al. Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg. 2006 34, 25-33. 2. Mesquita RC, Schenkel SS, et. al. Influence of probe pressure on the diffuse correlation spectroscopy blood flow signal: extra-cerebral contributions. Biomed Opt Express. 2013. 4(7): 978-94
POSTER 270 Three case of ridge augmentation of alveolar ridge of maxilla and mandible using bioresorbable material HA/PLLA composites H. Yutori: Kakogawa East City Hospital, S. LI, Y. Tutumi, K. Matumoto, T. Komori Three cases of ridge augmentation using bioresorbable material HA/PLLA composites were presented. A patient of case 1, 60 year-year-old female, had missed five anterior teeth in maxilla and hoped reconstruction
e-203