Surgical Clinics

Surgical Clinics

Surgical Clinics S101 Complex Tumor Resections of the Oral and Maxillofacial Region Eric R. Carlson, DMD, MD, Miami, FL The oral and maxillofacial reg...

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Surgical Clinics S101 Complex Tumor Resections of the Oral and Maxillofacial Region Eric R. Carlson, DMD, MD, Miami, FL The oral and maxillofacial region is the source of a large number of benign and malignant tumors, many of which can develop to very large sizes. Such neoplasms become extensive due to cancer phobia, which delays diagnosis; the fear of surgery for a mass that is cosmetically detracting while not interferring with function; short tumor doubling times; and inaccessible health care as occurs in some Third World countries. Tumors become large by their ability to replicate in the cell cycle, a series of molecular biologic events culminating in cell division. A doubling time is simply defined as the time required for a single cell to become 2 cells. It is generally believed that 30 doublings are required for a tumor to become clinically apparent. Similarly, 1 g of tumor tissue is the minimum tumor burden to be clinically apparent, while 1 kg of tumor tissue is thought to be the lethal burden of tumor. Malignant tumors that double in short periods of time have been shown to be more sensitive to radiation therapy or chemotherapy compared to those that possess long doubling times. As malignant tumors become excessively large, they may enter the Go, or quiescent stage, whereby cell division ceases. As such, these large tumors lose their radio- and chemosensitivity. With this in mind, many large tumors of the oral and maxillofacial region should probably be approached with surgery as the primary form of therapy with the understanding that these surgeries likely are debulking in nature. A debulking malignant tumor resection should be approached as one that removes 100% of clinically obvious tumor with the likelihood that microscopic tumor remains in the tissue bed at the conclusion of these operations. Since debulking surgeries are known to induce the reentry of Go cells into the active cell cycle, postoperative radiation and/or chemotherapy becomes more effective once a tumor has been debulked. Once the patient and surgeon agree on surgery as the primary or sole approach to large benign or malignant tumors, proper exposure becomes the next key element in the management of these patients. Enhanced forms of access in the form of the Weber-Ferguson approach to the maxilla, lower lip splits for mandibular tumor extirpations, and mandibular osteotomies to access large parapharyngeal space tumors prove very useful in the approach to large tumor ablations. Most large tumor ablations share 2 additional common denominators: the need to provide immediate soft tissue reconstruction of these defects, and the production of 126

cosmetic and functional deformities, many of which can be difficult to correct with subsequent bony reconstruction and revisional surgeries. These potential problems must be discussed when obtaining informed consent from these patients. References Carlson ER: Pathologic facial asymmetries, in Lew D (ed): Management of facial asymmetries. Atlas Oral Maxillofac Surg Clin North Am 1997, pp 19-35 Carlson ER, Schimmele SR: Management of salivary gland tumors of the oral cavity, in Pogrel MA (ed): Surgical Management of Salivary Gland Disease. Philadelphia, PA, Saunders, 1998, pp 75-98

S102 Contemporary Management of Frontal Sinus Fractures Andre H. Montazem, DMD, MD, New York, NY Daniel Buchbinder, DMD, MD, New York, NY (no abstract provided)

S103 The 3 Bs of Upper Face Rejuvenation: Blepharoplasty, Browlifting, and Botulinum Steven A. Guttenberg, DDS, MD, Washington, DC Ptosis of the upper-face soft tissues can lead to the appearance of aging, which is easily noticed by our patients and their peers. Rejuvenation of this facial third is relatively straightforward and can lead to dramtic improvement of the maturing visage. After one has evaluated the patient and arrived at a diagnosis, there are several office-based, outpatient procedures that can be utilized to correct the defect(s). Injection of Clostridium botulinum toxin type A to weaken periorbital depressor muscle contractions can diminish wrinkles and frown lines and may even raise the brow superiorly. Use of this neurotoxin complex is a quick and facile method to renew the upper facial third. Chronologic aging, ultraviolet radiation, and genetic and environmental factors can lead to the descent of periorbital and intraorbital fat, which contributes to an unaesthetic appearance. Upper and lower blepharoplastic procedures to correct this baggy eyelid deformity can aid greatly in cosmetic improvement of this facial zone. Use of the carbon dioxide laser to perform the procedures results in virtually bloodless operations and minimizes postoperative complications. The laser can also be used for resurfacing the upper eyelids and the lower eyelid skin in conjunction with transconjunctival blephAAOMS • 2002

Surgical Clinics aroplasties, eliminating or diminishing wrinkles while mitigating the risks of postoperative scleral show or ectropion. In patients in whom there is lowering of the eyebrows below the superior orbital rim, brow/forehead lifting is a technique that has gained popularity. Much of the reluctance of patients to undergo this procedure has been diminished by virtue of an advancement in technology. Specifically, use of the endoscope with small, hidden incisions has all but replaced the previously used “earto-ear” hairline incisions. Patient acceptance has increased, results have improved, and morbidity has diminished. The use of these aforementioned procedures, alone or in combination, has significantly helped oral and maxillofacial surgeons to improve the facial cosmesis of their patients.

alveolar clefts has shown that in unilateral alveolar clefts, the aforementioned soft tissue problems can be adequately dealt with by using 2 specially designed mucoperiosteal advancement flaps. In bilateral clefts, the triple-flap technique with advancement and Y closure is the method of choice. These techniques achieve extensive scar release in the upper lip, lengthening of the labial vestibule, and closure of existing vestibular oronasal communications and provide healthy, nonscarred tissue and periosteum over the grafted cleft, while placing suture lines away from the grafted cleft sites. Palatal oronasal communications, in our hands, are managed before alveolar cleft repair using anteriorly based tongue flaps (single or fork flaps). Flap volume can be reduced by raising thin (3-mm) flaps or through laser debulking. References

S104 Diagnosis and Management of Pediatric Maxillofacial Infections Jeffrey S. Kingsbury, DDS, MD, Farmington, CT David M. Shafer, DMD, Farmington, CT

Skouteris CA, Sotereanos GC: Closure of the vestibular oronasal communications in cleft patients: A retrospective study. J Oral Maxillofac Surg 45:M9, 1987 Demas PN, Sotereanos GC: Closure of alveolar clefts with corticocancellous block grafts and marrow: A retrospective study. J Oral Maxillofac Surg 46:682, 1988 Kim MJ, Lee JH, Choi JY, et al: Two-stage reconstruction of bilateral alveolar cleft using Y-shaped anterior-based tongue flap and iliac bone graft. Cleft Palate Craniofac J 38:432, 2001

(no abstract provided)

S106 S105 Soft Tissue Closure Techniques in Alveolar Cleft Grafting Chris A. Skouteris, DMD, Dr DENT (Path), Athens, Greece Unilateral and bilateral alveolar clefts are associated with a variety of soft tissue problems that are usually the result of previous procedures for cleft lip and palate repair. These residual soft tissue deficiencies include extensive labial and palatal scarring, dense tissue bands that cause tethering of the upper lip with obliteration of the labial vestibule, and vestibular as well as palatal oronasal communications. Most of the existing soft tissue closure techniques in alveolar cleft grafting fail to address all of these soft tissue problems expeditiously. Moreover, they set the stage for the development of complications, namely wound dehiscence, that can adversely affect the overall outcome of the grafting procedure. Among the most common pitfalls of these techniques is the placement of suture lines directly over the grafted sites and the attempt to close wide palatal oronasal communications in a 1-stage procedure at the time of alveolar cleft grafting. Our experience with soft tissue closure techniques in AAOMS • 2002

Oral Appliances and Hypomandibular Surgery in the Treatment of Snoring and Obstructive Sleep Apnea Barry H. Hendler, DDS, MD, Philadelphia, PA Patients with primary snoring and/or obstructive sleep apnea frequently fail to respond to or are not appropriate candidates for behavior measures such as weight loss or change in sleep position. Frequently those individuals also cannot tolerate or refuse treatment with nasal CPAP. Therefore, many types of oral appliances have been used successfully to move the base of the tongue forward in order to enlarge the upper airway. Despite considerable variation of the design of these appliances, the positive clinical effects have been remarkably consistent. The American Sleep Disorders Association review in 1995 concluded that, in patients studied, the mean Apnea/Hypopnea Index (AHI) was reduced from 47 to 19, with approximately half of the patients treated achieving an AHI of less than 10. Overall compliance seemed significantly higher than that for nasal CPAP. As a result, they produced practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances. For those treating obstructive sleep apnea and upper airway resistance syndrome, oral appliances offer a reasonable nonsurgical approach and/or presurgical evalu127

Surgical Clinics ation tool for a variety of patients. Oral and maxillofacial surgeons working in conjunction with other sleep specialists are uniquely trained to offer this service. Since all conservative medical measures used to manage snoring and sleep disordered breathing, including CPAP, BiPAP, demand positive airway pressure, oral appliances, weight loss, etc, have limitations such as patient tolerance and patient compliance, combined surgical procedures offer encouraging results in the treatment of patients with moderate to severe obstructive sleep apnea. Although maxillomandibular osteotomy appears to offer impressive success rates, consent for such surgery is mediated by patient acceptance, the severity of symptoms, and the level of upper airway collapse. Since no single surgical procedure, except tracheostomy, consistently and completely opens the upper airway, we have developed a philosophy directed toward surgery that would not only achieve high acceptance rates but also offer significant success in a wide variety of patients. Multiple potential sites of airway occlusion include the soft palate, lateral pharyngeal walls, and base of the tongue; thus uvulopharyngopalatoplasty (UPPP) in conjunction with skeletal mobilization techniques to advance the anterior mandibular attachments of the tongue and suprahyoid musculature can improve both oral and hypopharyngeal cross-sectional anatomy. Genioglossus advancement via mortised genioplasty allows a large soft tissue pedicle to be significantly advanced and rigidly fixated in a way that minimizes the potential for mandibular fracture. This technique will be discussed in detail, including specific indications thereof. The outcome data of several hundred patients treated at the University of Pennsylvania Center for Sleep Disorders will be reviewed in detail.

which may be obliterated by localized fatty depositions. As part of the patient evaluation, it is imperative that the treating surgeon differentiate this fatty lipomatosis from other deformities such as mandibular hypoplasia or skin redundancy resulting from age-related changes. Submental liposuction works through the removal of fat close to the undersurface of the overlying skin, leading to contraction and permanent changes in contour. This is performed at a subcutaneous plane safely above the platysma muscle. As the technique evolved with the introduction of the tumescent technique, the procedure was able to be performed more rapidly and safely and with better postoperative results. Paramount to the final result is the proper patient selection and rigorous postoperative care, including pressure garments. This surgical clinic shall discuss the patient selection process and outline definitive guidelines for optimal results. Discussion will follow on the anatomy of the surgical region and basic armamentarium to begin performing these procedures. The incorporation of submental liposuction along with other concomitant surgeries such as orthognathic surgery or implant reconstruction will be presented since this is an avenue of entry for many surgeons in this area. Presentation of potential complications and their management with development of proper informed consent will be presented. Finally, case assessment and critical evaluation of results will be presented with participant discussion. References Goodstein WA: Superficial liposculpture of the face and neck. Plast Reconstr Surg 98:988, 1996 Kennedy B: Suction lipectomy of the youthful neck. Oral Maxillofac Surg Clin North Am 2:233, 1990 Epker BN, Stella JP: Systematic aesthetic evaluation of the neck for cosmetic surgery. Oral Maxillofac Surg Clin North Am 2:217, 1990

References Schmidt-Nowara, et al: Oral appliances for the treatment of snoring and obstructive sleep apnea: A review. Sleep 18:501, 1995 Clark, et al: A crossover study comparing the efficacy of CPAP with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest 109:1477, 1996 Fairbanks D, Fwita S (eds): Snoring and Obstructive Sleep Apnea (ed 2). New York, NY, Raven Press, 1994

S107 Basic Technique of Submental Liposuction Vincent B. Ziccardi, DDS, MD, Newark, NJ Neck aesthetics is important in overall facial beauty. Fat in the submental and lateral neck region is considered unattractive by many in our society. This critical aesthetic area of the face can be influenced by a variety of surgical procedures including submental liposuction. The cervicalmandibular contours create neck and facial definition 128

S108 Lip Augmentation John D. Stover, DDS, MD, PhD, Kamuela, HI William McMunn III, DDS, MD, Colorado Springs, CO Lip augmentation is a commonly performed procedure by cosmetic and reconstructive surgeons. Older patients with ptotic lips and patients of all ages with hypoplastic lips typically desire increased fullness with preserved contour and a greater show of mucosa. Patients with loss of lip mass and contour after trauma also often request augmentation. There are numerous methods currently used for lip augmentation, including implantation of alloplastic materials and grafting of autologous tissue. The materials most frequently placed today are autologous fat, autologous dermis, a cadaveric acellular dermis matrix manufactured and marketed as AlloDerm (Lifecore BiomediAAOMS • 2002

Surgical Clinics cal, Chaska, MN), and expanded polytetrafluoroethylene (PTFE) (Gore-Tex; W.L. Gore & Associates, Inc, Flagstaff, AZ). None of these tissues or materials is ideal for lip augmentation. The ideal lip augmentation material should be biocompatible, safe, infection resistant, soft, and flexible so as to freely move with the lip and capable of being customized to each patient situation. The material should not extrude when tunnelled in a superficial plane, should not resorb, should not cause changes in lip sensation, and should feel even and natural to the patient. Not only is there a relative paucity of scientific literature related to lip augmentation, there are minimal published data comparing the various common augmentation modalities. None of the augmentation tissues or materials have been compared in a controlled manner over time. References Tobin HA, Karas ND: Lip augmentation using an Alloderm graft. J Oral Maxillofac Surg 56:6, 1998 Wilkinson TS: Lip enhancement. Plast Reconstr Surg 92:7, 1993

marily for lower facial/mandibular reconstruction. One responsible report, in fact, suggests a decrease in application of these techniques for maxillary reconstruction in recent years, and another deemphasizes the importance of postablative reconstruction in children, in general. This session emphasizes the importance of surgical improvement of the maxilla (even in those patients to be subsequently served prosthetically), the general preferability of staged reconstruction of the hard and soft tissues of the upper jaw, and the general preference of local soft tissue maneuvers over the more complex, albeit more popular, distant tissue transfers. References Garatea J, Buenechea R, Bescos C, et al: Intraoral reconstruction with the nasolabial island flap: A modified technique. J Craniomaxillo Fac Surg 19:119, 1991 Vaughn ED, Bainton R, Martin IC: Improvements in morbidity of mouth cancer using microvascular free flap reconstruction. J Craniomaxillofac Surg 20:132, 1992 Martin IC, Brown AE: Free vascularized fascial flap in oral cavity reconstruction. Head Neck 16:45, 1994 Tresserra L, Collares MV, Regas JS, et al: Maxillectomy in childhood. J Craniomaxillofac Surg 19:155, 1991

S109 Reconstruction of Postablative and Developmental Maxillary Defects Robert B. MacIntosh, DDS, Bingham Farms, MI Because it is more common and because its prosthetic rehabilitation is so complex and often impossible, anatomic reconstruction of the mandible carries much more emphasis in the literature than does that of the maxilla in discussions of postablative surgical compromise. This presentation takes the position, however, that rehabilitation of the compromised maxilla is as or even more important than is that of the mandible. Certainly, prosthetic rehabilitation of the deficient maxilla is generally easier and more effective than is that of the mandible, but patients with anatomic deficit of the upper jaw, whether severe or even more routine, still gain from improvement of anatomy before prosthetic restitution. Aesthetic compromises in the maxilla and midface are generally of greater social consequence than are those in even severe loss of the mandible. The primary repair of alveolar and palatal clefts has been an emphasized discipline for more than a century, but repair of earlier failed efforts, or of combinations of cleft and problematic orthognathic surgery, has not received as much attention. Further, soft tissue repair has gained much more consideration than has hard tissue reconstruction in the restitution of congenital or acquired maxillary deficiency; this is evident in review of both the American and international literature. A myriad of vascularized free flaps have been described for use in the maxillofacial area but, again, priAAOMS • 2002

S110 Temporalis Muscle Flap for Reconstruction of Oral Defects A. Omar Abubaker, DMD, PhD, Richmond, VA For defects in the oral and maxillofacial region, several varieties of flaps can be used. These include local, free, and regional flaps. Local flaps can be used successfully for small defects. They utilize local tissues adjacent to the defect and gain blood supply through small vessels in their base. They are usually described according to their geometry: rotation, transposition, and advancement flaps. However, for moderate to large defects, such as after tumor resection or after traumatic injury, free or regional flaps are often necessary to reconstruct such defects. While free flaps provide predictability and vascularity when the vascular supply to the recipient bed is deficient, the operative time, technical expertise, additional operative site, and occlusion of the pedicle are some of the potential problems associated with these flaps. On the other hand, regional flaps provide a viable alternative for reconstruction of defects in the oral and maxillofacial region with greater degree of predictability, adequate bulk, and minimal morbidity to the donor site. Of these flaps, the temporalis muscle provides one of the best options because of its reliability, vascularity, adequate bulk, and proximity to defects in the oral and maxillofacial region. The flap can be used as a myofascial, myo-osseous, or myo-osseocutaneous flap. It has been used for reconstruction of various defects in the 129

Surgical Clinics oral and maxillofacial region, including defects of the base of the skull. In a case-based format, we will review the different local and regional flaps used for reconstruction of oral defects with emphasis on the temporalis muscle flap. We will also review the surgical anatomy and the surgical technique of temporalis flap and its uses, advantages, and disadvantages in reconstruction of intraoral defects. References Del Hoyo JA, Sanroman JF, Gil-Diez JL, et al: The temporalis muscle flap: An evaluation and review of 38 cases. J Oral Maxillofac Surg 52:143, 1994 Antonyshyn O, Gruss JS, Birt BD: Versatility of temporal muscle flaps. Br J Oral Maxillofac Surg 41:118, 1988 Brusati R, Raffaimi M, Sesenna E, et al: The temporalis muscle flap in temporomandibular joint surgery. J Craniomaxillofac Surg 18:352, 1990 Colmenero C, Martorell V, Colmenero B, et al: Temporalis myofacial flap for maxillofacial reconstruction. J Oral Maxillofac Surg 49:1067, 1991 Demas PN, Sotereanos GC: Transmaxillary temporalis transfer for reconstruction of a large palatal defect: Report of a case. J Oral Maxillofac Surg 47:197, 1989

S111 The Team Approach: Surgical and Prosthetic Options to Enhance Implant Aesthetics Guillermo E. Chacon, DDS, Columbus, OH Miguel A. Alfaro, DDS, MS, San Jose, Costa Rica Classically, implant success was defined as a clinically immobile implant, capable of carrying a load, and without radiographic evidence of a soft tissue interface between the surface of the fixture and the bone. As this discipline continued to evolve and both clinicians and patients became more educated, the idea of a functional and aesthetic implant surfaced as the new standard for implant success. Many factors play significant roles in dictating the final appearance of a given restoration; to name a few, location in the arch, condition of neighboring teeth, axial inclination, depth of placement, quantity and quality of surrounding soft tissue, amount of bone, and timing of placement/restoration. From a surgical standpoint, different steps can be taken to maximize the position of the fixture: follow surgical stent, bone grafting, ridge splitting, connective tissue grafting, soft tissue transfer and sculpting, immediate placement, modification of flap design, and use of temporary implants. If postoperative cosmetic issues still remain or are foreseen before implant placement, there are several prosthetic options that could be considered: stent fabrication, restoration of neighboring teeth, use of all ce130

ramic components, use of anatomic abutments, indexing at the time of implant placement, immediate provisionalization, immediate loading, and immediate delivery of the final restoration. References Larsen PE: Surgical considerations to enhance implant esthetics. Oral Maxillofac Surg Clin 8:401, 1996 Oda T, Sawaki Y, Ueda M: Experimental alveolar ridge augmentation by distraction osteogenesis using a simple device that permits secondary implant placement. Int J Oral Maxillofac Implants 15:95, 2000 Blatz MB, Hu ¨ rzeler MB, Strub JR: Reconstruction of the lost interproximal papilla: Presentation of surgical and nonsurgical approaches. Int J Periodontics Restorative Dent 19:395, 1999 Chiche GJ: The evolution of prosthetic treatment. Pract Periodontics Aesthet Dent 12:94, 2000

S112 Total Alloplastic TMJ Reconstruction With a Patient-Fitted System Louis G. Mercuri, DDS, MS, Maywood, IL Total alloplastic reconstruction is considered a mechanical rather than a biological solution to the management of severe and debilitating anatomic temporomandibular joint (TMJ) disease. Although there may be indications for autogenous or allogeneic reconstruction, from reports in the recent literature it appears that alloplastic total TMJ reconstruction provides more predictable results in adults. Indications for total alloplastic TMJ reconstruction are disorders that anatomically mutilate the articular components of the joint such as inflammatory arthritis (ie, rheumatoid) where autogenous and/or allogeneic tissue reconstructions are unpredictable; functionless, multiply operated TMJ patients; joints damaged by failed alloplasts such as Proplast-Teflon (Vitek, Houston, TX), Silastic (Dow-Corning, Arlington, TX), polymethylmethacrylate and metal particulation, and other partial and/or total TMJ prosthetic failures; ankylosis and/or reankylosis where bone grafting is intuitively unreasonable; and loss of posterior vertical height of the mandible secondary to developmental, neoplastic, traumatic, or degenerative disorders affecting the TMJ. The criteria for successful alloplastic total TMJ reconstruction are that the osseointegration of any such device is directly related to its ability to be stabilized and fixed in position without micromotion at initial implantation; that the components be designed to withstand the forces to which they will be exposed during function; that the components be made from materials that are biocompatible with the surrounding tissues; and that they be aseptically implanted for the right indications after the accepted surgical protocol. Failures of past and some present TMJ alloplast devices result from inattention by the surgeon and/or manufacturer to these criteAAOMS • 2002

Surgical Clinics ria, which were developed for orthopedic devices over 4 decades of experience. The FDA-approved TMJ Concepts System (Camarillo, CA) was developed by marrying the concepts of computed tomography (CT) and stereo laser lithography (SL) for the development of an anatomic model of each patient’s clinical and functional TMJ condition. From this SL model, the fossa and ramus components are designed and manufactured from materials that have been considered the “gold standard” for alloplastic joint reconstruction for over 40 years in orthopedic surgery. Since the components are designed for the specific anatomic and functional situation found in each case, they will intimately conform to the available bone, ensuring maximum stability at implantation, and will withstand the loads placed on them over time with function. This system, which satisfies all of the criteria for successful alloplastic TMJ reconstruction, has been used successfully for over 10 years for the management of these complex cases. This is mirrored in the prospective studies that have been reported in the literature. References Mercuri LG, Sanders B, White RD, et al: Custom CAD/CAM total temporomandibular joint reconstruction system: Preliminary multicenter report. J Oral Maxillofac Surg 53:106, 1995 Mercuri LG: Subjective and objective outcomes for patients reconstructed with a patient fitted total temporomandibular joint prosthesis. J Oral Maxillofac Surg 57:1427, 1999 Mercuri LG: The TMJ Concepts patient fitted total temporomandibular joint reconstruction prosthesis. Oral Maxillofac Surg Clin North Am 12:73, 2000

S201 Diagnosis and Management of Trigeminal Nerve Disorders Michael Miloro, DMD, MD, Omaha, NE Injuries to the terminal branches of the trigeminal nerve may occur commonly after a variety of routine procedures performed by the oral and maxillofacial surgeon. Nerve damage constitutes a large proportion of the medicolegal matters facing surgeons today. Most commonly, third molar surgery is responsible for a majority of injuries to both the inferior alveolar and lingual nerves. The reported incidence of nerve injury varies depending on the literature cited, but generally, both temporary and permanent paresthesia must be considered. Nerve injury may occur after orthognathic surgery, and maxillofacial trauma, and with the current increasing trends in implant placement in the mandible, the inferior alveolar nerve is further subject to potential trauma. The anatomy of the trigeminal nerve system is unique, since it carries, in some branches, both general sensory information as well as special sensation (ie, AAOMS • 2002

taste). Injury to the nerve may result in neuroma formation, which can present in a variety of forms. Nerve injuries are classified by 2 popular classification schemes, which are based on the likelihood of an injured nerve to recover spontaneously. A basic understanding of normal nerve wound healing is essential in order to most appropriately manage clinical situations. The initial evaluation of patients with nerve injuries must proceed in an orderly fashion, with several levels of testing to determine most accurately the degree of individual nerve injury. A standard set of neurosensory tests may be used for most patients; however, some advanced testing is available for special circumstances. In considering the treatment options for the patient with nerve injury, a variety of pharmacologic and nonsurgical treatments are available. For patients with dysesthesia, several neuroablative techniques exist. Currently, the use of low-level laser therapy has shown significant potential for managing the patient with a nerve injury, especially after sagittal split osteotomy procedures. Once the decision is made to proceed with microneurosurgery, the success rates of the specific procedures must be evaluated. Various surgeons report different success rates, and the most important factor in determining this involves the length of time since injury, because this affects the degree of Wallerian degeneration. The AAOMS Clinical Interest Group on Maxillofacial Neurologic Disorders has made certain treatment time recommendations for the patient with a nerve injury, and these are reflected in the AAOMS ParPath 2000 Parameters. Specific surgical techniques depend on which nerve is involved, as well as the extent of injury. The specifics of the microneurosurgical repair of a trigeminal nerve injury involves neurolysis and preparation of the nerve stumps in order to perform neurorrhaphy. Several investigators have documented the deleterious effects of tension on a nerve repair site, so an inability to perform primary repair warrants the consideration for an autogenous nerve graft, and other options exist for management of the nerve gap (ie, entubulation). After surgery, postoperative sensory reeducation is an important component of the repair process. The field of microneurosurgery is in its infancy. As more surgeons become familiar with the diagnosis and management of nerve-injured patients, more laboratory and clinical research information will become available to guide therapy. Also, residency programs will become better able to teach the principles and practice of microneurosurgery to residents and foster access to care throughout the country. References Zuniga JR, Meyer RA, Gregg JM, et al: The accuracy of clinical neurosensory testing for nerve injury diagnosis. J Oral Maxillofac Surg 56:2, 1998


Surgical Clinics Miloro M, Halkias LE, Chakeres DW, et al: Assessment of the lingual nerve in the third molar region using magnetic resonance imaging. J Oral Maxillofac Surg 55:134, 1997 Miloro M, Repasky M: Low level laser effect on neurosensory recovery following sagittal ramus osteotomy. Oral Surg Oral Med Oral Pathol 89:12, 2000

The timing and techniques for the repair of the alveolar cleft will be reviewed. Finally, the evaluation of velopharyngeal function will be discussed, and the use of the superiority-based pharyngeal flap will be shown. References

S202 Aesthetic Zone Reconstruction: Synergy of Hard and Soft Tissue Augmentation for Optimal Implant Placement

Millard DR: Cleft Craft Volumes I & II. Boston, MA, Little, Brown, 1977 Bulow KW: Treatment of Facial Cleft Deformities: An Illustrated Guide. St Louis, MO, Ishiyaku EuroAmerica Publishers, 1995 Kapetansky DI: Techniques in Cleft Lip Nose and Palate Reconstruction. New York, NY, Gower Medical Publishing Ltd, 1987 Shprintzen R, Bardash J: Cleft Palate Speech Management: A Multidisciplinary Approach. New York, NY, Mosby, 1995

Michael A. Pikos, Palm Harbor, FL The loss of alveolar ridge contour in the aesthetic zone compromises both aesthetics and function. This unique clinical course will focus on the application of both hard and soft tissue grafting in the aesthetic zone for optimal implant reconstruction. Emphasis will be on indications, timing, and surgical protocol using mandibular block autografts in conjunction with connective tissue grafts, acellular dermis matrix, and related soft tissue procedures to avoid functional and aesthetic pitfalls. Both single and multiple tooth cases will be presented. References Pikos MA: Block autografts for localized ridge augmentation, part I: The posterior maxilla. Implant Dent 8:279, 1999 Pikos MA: Block autografts for localized ridge augmentation, part II: The posterior mandible. Implant Dent 9:67, 2000 Langer B, Calagna L: The subepithelial connective tissue graft: A new approach to the enhancement of anterior esthetics. Int J Periodontics Restorative Dent 2:23, 1982

S203 Surgical Management of the Cleft Lip/ Palate Deformity Daniel Buchbinder, DMD, MD, New York, NY Rafael Ruiz-Rodriguez, DDS, Mexico City, O.F. Mexico The goal of this surgical clinic is to “demystify” the surgical procedures most commonly used for the repair of cleft lip and palate (CL/P) deformities. The epidemiology, genetic basis, and embryology of CL/P will be reviewed. The work-up and multidisciplinary approach to the care of the CL/P patient will be discussed. Simple, step-by-step surgical techniques used for the primary repair of unilateral and bilateral cleft lip will be demonstrated. The different revision techniques for the repair of residual deformities such as whistle tip, collumella (in the bilateral cleft), and lower cartilaginous nasal skeleton will also be demonstrated. Similarly, the various palatoplasty techniques both for the primary repair as well as revisions for residual oronasal fistulas will be discussed. 132

S204 Laser-Assisted UPPP, Somnoplasty, or Coblation: Which Works Best in Treatment of Snoring and Chronic Nasal Congestion? Mansoor Madani, DMD, MD, Bala Cynwyd, PA Snoring affects over 70 million Americans and is one of the signs of sleep apnea. Oral and maxillofacial surgeons are positioned on the front line of diagnosis and treatment of this condition. There are more patients suffering from this illness than dental implant patients or orthognathic surgery cases. An up to 6-year follow-up review of over 4,000 cases treated with laser, somnoplasty, coblation, and orthognathic surgery will be discussed. Advantages, disadvantages, complications, and outcomes of each type of surgery will be reviewed in detail. Case selection, clinical examination, and surgical techniques will be analyzed. Somnoplasty and coblation are the latest surgical techniques, using radiofrequency to reduce tissue volume, with many new and easy applications for the treatment of snoring, chronic nasal congestion, and obstructive tonsils. The presenter of the course has extensive experience in using these devices in hundreds of cases and will review his findings in detail.

S205 Current Concepts in TMJ Surgery Larry M. Wolford, DDS, Dallas, TX Surgical techniques in TMJ surgery have and will continue to undergo modifications and change in an effort to improve the quality of patient care and outcome. This program will present diagnostics and newer treatment approaches and technical modifications as well as the clinical and research results substantiating the efficacy of these surgical methods. The following modifications will be discussed. AAOMS • 2002

Surgical Clinics I. Simultaneous TMJ and orthognathic surgery A. Diagnosis and treatment planning 1. Clinical examination 2. Imaging 3. Decision making B. Surgical sequencing C. Disc repositioning D. High condylectomy for disproportionate growth E. Autogenous tissue replacement F. Total joint prosthesis Implementation of these techniques by the experienced, skilled surgeon, coupled with accurate diagnosis and treatment planning, should provide optimal functional and aesthetic outcomes for our patients. References Wolford LM: Temporomandibular joint devices: Treatment factors and outcomes. Oral Surg Oral Med Oral Pathol 83:143, 1997 Wolford LM, Cottrell DA, Henry CH: Temporomandibular joint total joint prosthesis. J Oral Maxillofac Surg 52:2, 1994 Wolford LM, Cottrell DA, Henry CH: Sternoclavicular grafts for temporomandibular joint reconstruction. J Oral Maxillofac Surg 52:119, 1994

S206 Guided Tissue Regeneration in Jaw Reconstruction: Review and Application Pamela L. Alberto, DMD, Sparta, NJ In 1982, a group of researchers reported that tissues lost to periodontal disease could be regenerated by the use of a surgical technique known as guided tissue regeneration. Since then, tremendous progress has been made in adapting these techniques to jaw reconstruction. Along with the development of guided tissue regeneration procedures came the development of many first-generation and second-generation membrane barriers. The current first-generation barriers available are Gore-Tex and TefGen. Both are made from 100% medical-grade polytetrafluoroethylene (e-PTFE), but differ in that TefGen is full density and is impervious to bacteria. Gore-Tex is expanded e-PTFE with pores. The biodegradable second-generation membrane barriers available are Vicryl, BioMend, BioGide, OsseoQuest, and Capset. Vicryl Mesh is composed of woven polyglactin 910. The pore size allows passage of fluids. It is resorbed in 2 to 6 months. BioMend is fabricated from type I collagen derived from bovine deep flexor tendon. It is completely resorbed in 4 to 8 weeks. The material must be hydrated in sterile water or saline for approximately 15 minutes before final placements. BioGide is composed of collagen types I and II in a bilayer membrane. It resorbs in 4 months. OsseoQuest is a barrier made of polyglycolic acid and polylactic acid with trimethylene carbonate. It AAOMS • 2002

resorbs in 6 months. Capset is composed of calcium sulfate. It must be used in conjunction with bone grafting material. It remains in the tissues for up to 30 days. All have been used in clinical studies with varying success. A critical point for success of second-generation membranes is the rate of degradation. The longer the material maintains barrier function, the better the results. Thus, bioabsorbables may not perform as well as nonabsorbables. A study performed by Sandberg, Dahlin, and Linde found bioabsorbable membranes to be as efficient as e-PTFE and a valid alternative. Third-generation membrane barriers are being developed that are impregnated with polypeptide growth factors, including platelet growth factor, insulin-like growth factor, transforming growth factor-B, fibroblast growth factor, or bone morphogenic protein. Current research shows some of these materials to be promising. Both first- and second-generation membrane barriers can be used in the treatment of osseous defects with implants, augmentation of atrophic ridges, treatment of failing implants, and extraction sites. When treating osseous defects with implants using biodegradable secondgeneration membrane, the dilemma arises in not knowing the amount of regeneration you obtained. Thus, familiarity with these materials along with their applications will increase the success rate of guided tissue regeneration in jaw reconstruction. References Becker W, Becker B: Clinical applications of guided tissue regeneration: Surgical considerations. Periodontology 1:1993, 2000 O’Neal R, Wang H: Cells and materials involved in guided tissue regeneration. Curr Opin Periodontol 1994 Jovanovic SA: Bone rehabilitation to achieve optimal aesthetics. Pract Periodont Aesthet Dent vol. 9, 1997

S207 Cleft Lip and Palate: Comprehensive Reconstruction From Infancy Through Adolescence Bernard J. Costello, DMD, MD, Pittsburgh, PA Ramon L. Ruiz, DMD, MD, Chapel Hill, NC Surgeons caring for children with cleft lip and palate deformities must proceed with a firm cognitive understanding of 3-dimensional regional anatomy, the extent of the hard and soft tissue defects, and the complex interplay between surgery and subsequent maxillofacial growth. This allows the clinician to appropriately formulate and sequence the staged surgical treatment of patients with cleft lip and palate deformities from the initial consultation in infancy through adulthood. Thoughtful, interdisciplinary planning of the reconstruction saves the patient’s family unnecessary therapies and operative procedures. As such, appropriate 133

Surgical Clinics planning avoids needlessly burdening the patient and/or health care system with inefficacious or unproven modalities. This clinic will provide a comprehensive review of the treatment rationale, diagnostic approach, and operative techniques (primary lip repair, primary and secondary palatal reconstruction, orthognathic surgery, and rhinoplasty) involved in the staged management of orofacial clefts. References Strauss RP: Health policy and craniofacial care: Issues in resource allocation. Cleft Palate Craniofac J 31:78, 1994 American Cleft Palate-Craniofacial Association: Parameters for the evaluation and treatment of patients with cleft lip/palate or other craniofacial anomalies. Cleft Palate Craniofac J 30:4, 1993 (suppl 1) Koop CE: Surgeon General’s Report: Children With Special Health Care Needs. Washington, DC, Government Printing Office, June 1987

S208 Facelift and Endoscopic Forehead Lift: Step by Step John E. Griffin, DMD, Columbus, MS P.J. Schaner, DMD, Marietta, GA Interest in facial rejuvenation has greatly increased in recent years. Some of this interest stems from advances in technology and improved surgical techniques. These advances are making it possible for the facial cosmetic surgeon to reliably produce excellent results with fewer risks of complications. This translates into satisfied patients and greater patient acceptance of proposed treatment plans. The natural aging process, heredity, exposure to the sun, and other factors cause the skin to wrinkle and sag. Folds of the skin become more prominent around the mouth, chin, jaw line, and neck. The laser-assisted endoscopic forehead lift provides an alternative to traditional brow lifting techniques. Without question, the periorbital area is one of the most expressive areas of the face, and there are many techniques available that affect the position of the eyebrows. The brow lift technique utilizing the endoscope and the CO2 laser is proving to be readily accepted by patients and provides consistently excellent results with fewer complications than other methods. Before this technique is added to the armamentarium of the cosmetic surgeon, it is important to understand the indications for the procedure to ensure a good outcome. In the last decade there have been many advancements in the technique of the facelift operation. These have resulted from a better understanding of the anatomy of the face, neck, and how the process of aging affects these tissues and alters their position. Currently, the long flap rhytidectomy is the most 134

popular procedure. This includes wide detachment of skin over the face, neck, mastoid, and frontotemporal regions. The superficial musculoaponeurotic system (SMAS) is then suspended in a superior and posterior direction. The contour of the neck is very important in facial rejuvenation. A well-contoured mandibular border is one of the key signs of a youthful appearance. Liposuction of the submental and submandibular areas to remove fat is performed along with resection or plication of the platysmal muscle. A sling suture from the midline platysma muscle to the contralateral mastoid fascia is utilized to achieve the youthful appearing neck. Oral and maxillofacial surgeons should become familiar with the various rhytidectomy techniques along with a good understanding of the anatomy. Preoperative and postoperative care is also crucial to obtaining excellent results. References Griffin J, Frey B, Max D, et al: Laser-assisted endoscopic forehead lift. Oral Maxillofac Surg 56:1040, 1998 Epker B: Esthetic Maxillofacial Surgery. Philadelphia, PA, Lea and Feibinger, 1994 Rees TD, LaTrenta, GS: Aesthetic Plastic Surgery. Philadelphia, PA, Saunders, 1994 Tardy EM, Thomas JR, Brown RJ: Facial Aesthetic Surgery. St Louis, MO, Mosby, 1995 Giamppapa VC, Di Bernardo BE: Neck recontouring with suture suspension and liposuction: An alternative for the early rhytidectomy candidate. Aesthetic Plast Surg 19:217, 1995

S209 Advanced TMJ Arthroscopy Including Use of the Holmium:YAG Laser Allen W. Tarro, DMD, Lowell, MA TMJ arthroscopy is indicated for surgical treatment of symptomatic TMJ intracapsular disorders that have not been resolved by properly performed nonsurgical modalities. Arthroscopy is minimally invasive and has revolutionized surgery of the TMJ. Lysis and lavage arthroscopy are commonly performed in the TMJ today. However, significant advances in techniques and instrumentation have been made in TMJ arthroscopy. Among these are advanced surgical techniques and the use of appropriate laser instrumentation. Selection of a laser instrument for TMJ arthroscopy involves a knowledge of the available laser systems and consideration of both the surgical site and the types of surgical procedures to be performed. A number of currently available lasers have particular characteristics that are less than ideal for use in the TMJ. At the present time, there is 1 laser system that is appropriate and approved for arthroscopic surgery. This is the holmium:YAG laser system with a wavelength of AAOMS • 2002

Surgical Clinics 2,100 nm. It is a pulsed, free-beam laser that can transmit laser energy through available quartz fiberoptics, and it can function properly in a fluid environment. Standard arthroscopic irrigation solutions can be used with this instrument. The holmium:YAG laser has low tissue penetration with precise control and low heat generation. It can ablate, sculpt, incise, and coagulate tissue with minimal thermal damage to surrounding tissue. The small size of the laser tip allows excellent access to cramped areas in this small joint with minimal iatrogenic damage. TMJ arthroscopic surgical procedures that may be performed with the holmium:YAG laser include anterior muscle release procedures (superior lateral pterygoid myotomy), lysing and removing fibrous adhesions and pseudo-walls, treatment of chondromalacia (including removal of articular cartilage fibrillation), tissue debridement (as in the treatment of symptomatic degenerative joint disease), treatment of synovitis (laser synovectomy), cauterization of bleeding vessels for hemostasis, discoplasty, and the removal of bone spurs and osteophytes. A major advantage of arthroscopic laser surgery is that it is more precise and produces significantly less heat and less resultant tissue damage than electrocautery. The tissue necrosis that occurs with the use of electrocautery is in the range of 0.7 mm to 1.8 mm of tissue penetration. The necrosis from electrocautery increases with time and continues after the surgery. With the use of the holmium:YAG laser, the tissue necrosis is in the range of 0.4 mm to 0.6 mm, and the necrosis decreases in time. Therefore, no further necrosis occurs after the surgery. There are certain precautions that should be exercised with the use of laser instrumentation in TMJ arthroscopy. Adequate knowledge of laser principles and laboratory experience with lasers should be obtained before performing laser arthroscopic surgery on live patients. Second, it is important to keep the laser beam away from the arthroscope because if the laser beam strikes the optical end of the arthroscope, the fiberoptics of that instrument will be damaged. Third, metallic instruments in the surgical field can reflect the laser beam and cause undesired tissue damage. Finally, the surgeon must be familiar with and implement the principles of laser safety when using these instruments. Besides the techniques performed with laser instrumentation, advanced TMJ arthroscopic techniques should include disc repositioning and disc suturing. In this surgeon’s opinion, disc suturing is important, especially in the treatment of disc displacement and hypermobility with painful chronic dislocation. There are a variety of disc suturing techniques. These include blind, partially blind, and fully visualized procedures. Each of the techniques has its advantages and disadvantages. One blind suturing technique that is easy to perform and routinely used by the presenter will be presented in detail. AAOMS • 2002

The purpose of this surgical clinic is to stimulate interest in advanced TMJ arthroscopic surgical techniques so that more surgeons will perform these procedures for the benefit of their patients. This presentation is intended for surgeons with previous arthroscopic education and at least some basic surgical experience in TMJ arthroscopy. References Tarro A: TMJ Arthroscopy: A Diagnostic and Surgical Atlas. Philadelphia, PA, JB Lippincott, 1993 Tarro A: A fully visualized arthroscopic disc suturing technique. J Oral Maxillofac Surg 52:362, 1994 Tarro A: TMJ arthroscopic diagnosis and surgery: Clinical experience with 152 patients over a 2 year period. J Craniomandib Pract 9:107, 1991

S210 Tracheotomy A-Z Thomas J. Teenier, DDS, MD, Corpus Christi, TX Eric J. Dierks, DMD, MD, Portland, OR James Eyre, DMD, MD, Salem, OR (no abstract provided)

S211 Transport Distraction Osteogenesis of Mandibular Continuity Defects Daniel B. Spagnoli, DDS, PhD, Charlotte, NC Anatomically correct functional and aesthetic reconstruction of mandibular continuity defects remains a formidable challenge. Current trends suggest that immediate reconstruction or at least stabilization of the mandible after resection ultimately leads to improved outcomes. The methods and principles of distraction osteogenesis described by Gabriel A. Ilizarov have been adapted and applied to the treatment of a variety of cranial facial deformities. Experimental studies have proven the feasibility of transport distraction osteogenesis. Our work has set out to establish a practical and easily applied method of mandibular stabilization and transport distraction osteogenesis. The goal of the transport distraction osteogenesis for reconstruction of mandibular continuity defects is to establish a union with bone dimensions, spatial relationships, and soft tissues representative of the native mandible. The availability of stereolithographic models provides an opportunity to adapt reconstruction plates to the exact anatomy of the mandible before surgery, thus providing accuracy while reducing operative time. A submucosal transport distraction system has been developed that attaches the distracter to the reconstruction plate as well as native bone and an osseous transport segment. The transport segment follows the bone plate, thus reproducing the size and shape of the mandible 135

Surgical Clinics while also reconstituting attached tissue and vestibule. This system permits anterior-to-posterior or posterior-toanterior transport based on availability of a transport segment. Mandibles with continuity defects resulting from malignant tumors (status post radiation and hyperbaric oxygen therapy), odontogenic tumors, osteomyelitis, and trauma have been reconstructed using this system. The final union of the transport disc to native bone requires a limited bone graft, and we are studying the potential for use of bone morphogenic protein as an alternative. Regenerate bone is rich in cellular and vascular components and creates an excellent matrix for dental implant placement. After dental prosthetic restoration and reestablishment of mandibular anatomy, the reconstructive objectives are achieved as structural and functional attributes of the mandible are restored. References Ilizarov GA: The principles of the Ilizarov method. Bull Hosp J Dis Orthop Inst 48:1, 1988 Swennen G: Int J Oral Maxillofac Surg 30:89, 2001 McCarthy JG, Schreiber J, Karp N, et al: Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 89:1, 1992 Block MS, et al: J Oral Maxillofac Surg 54:1365, 1976 Costantino PD, Shybut G, Friedman CD, et al: Segmental mandibular regeneration by distraction osteogenesis and experimental study. Arch Otolaryngol Head Neck Surg 116, 1990 Baker A, McMahon J, Parmar S: The immediate reconstruction of continuity defects of the mandible after tumor surgery. J Oral Maxillofac Surg 59:1333, 2001

S212 Management of Facial Asymmetries Nestor D. Karas, DDS, MD, Walnut Creek, CA One of the most challenging skeletal-facial deformities the clinician is faced with are those involving asymmetries. The causes and correction of this deformity can have many possibilities and often depend on the nature and extent of the problem. A complete understanding of skeletal growth patterns and the timing of surgical corrections can be critical. Staging of the surgical procedures for both hard and soft tissue correction is mandatory for a satisfactory outcome. The oral and maxillofacial surgeon will be called on to evaluate and treat a variety of facial asymmetries ranging from the patient with asymmetric prognathism to more severe malformations that can result in occlusal cants, lateral open bites, and chin and soft tissue deficiencies. A rationale for treatment at the different growth-related ages that these patients present is important in the overall outcome of correction. The causes of facial asymmetries and their effects on the facial growth patterns will be reviewed, including condylar hyperplasia, hemimandibular hypertrophy, hemifacial microsomia, and condylar resorption. The 136

evaluation of these patients in terms of their continued growth patterns and timing of treatment will be emphasized. The types of correction, including joint surgery, osteotomies, distraction osteogenesis, and soft tissue augmentation, will be demonstrated and discussed in detail. The nuances of facial evaluation and treatment planning for skeletal correction will also be reviewed. References Obwegeser HL, Makek MS: Hemimandibular hyperplasia—Hemimandibular elongation. J Maxillofac Surg 14:183, 1986 Chen YR, Bendor-Samuel RL, Huang CS: Hemimandibular hyperplasia. Plast Reconstr Surg 97:730, 1996 Kaban LB, Moses ML, Mulliken JB: Surgical correction of hemifacial microsomia in the growing child. Plast Reconstr Surg 82:155, 1988

S213 Comprehensive Management of SleepRelated Breathing Disorders N. Ray Lee, DDS, Newport News, VA The interest in surgical treatment for sleep-related breathing disorders has increased over the past decade. Indicated surgical treatments are selected based on the diagnosis: simple snoring, upper airway resistance syndrome, or obstructive sleep apnea. A comprehensive diagnostic work-up including a detailed history and physical examination of the upper airway is essential in making an accurate diagnosis. A multidisciplinary team approach, including participants in sleep medicine, pulmonology, oral and maxillofacial surgery, otolaryngology, and general dentistry, will enhance the treatment outcome. Multiple surgical treatments have been reported in the literature for the treatment of snoring and obstructive sleep apnea. Treatment selection is dependent on multiple variables, and while there are no universally accepted treatment protocols, the knowledge and experience of the surgeon are of importance. The surgeon treating sleep-related breathing disorders must be knowledgeable about the available procedures and their efficacy. The literature supports surgical reconstruction of the airway in the treatment of sleep-related breathing disorders. Scientific analysis of surgical outcome data is vital as new techniques evolve in order to continue to advance in this rapidly growing field. References Woodson TB, et al: Operative Techniques in Otolaryngology-Head and Neck Surgery, Volume II, No 1, 2000 Powell NB, Riley RW, Troell RJ, et al: Radiofrequency volumetric reduction of the palate in subjects with sleep-disordered breathing. Chest 113:1163, 1998 Riley RW, Powell NB, Guilleminault C: Obstructive sleep apnea syndrome: A review of 306 consecutively treated surgical patients. Otolaryngol Head Neck Surg 108:117, 1998

AAOMS • 2002

Surgical Clinics

S214 Early Dermabrasion and Revision of the Post-Traumatic Scar David A. Bitonti, DMD, CDR, DC, USN, Bethesda, MD The practice of oral and maxillofacial surgery is an evolving and expanding specialty. Early programmed dermabrasion and treatment of the post-traumatic scar offer the oral and maxillofacial surgeon practice expansion through treatment of post-traumatic scars in a preestablished patient population. In addition, it provides a transition into facial aesthetic surgery in that same preestablished population. The treatment of traumatic scars and the use of dermabrasion are well established and have been noted to result in favorable aesthetics. Dermabrasion and scar revision is commonly performed 6 to 12 months after the original injury. The success of early programmed dermabrasion revolves around the ability of the treated tissue to regenerate itself from the residual adnexal structures and to heal in a more aesthetic fashion. Post-traumatic scar revision and dermabrasion are most often, if not always, an in-office procedure strongly lending themselves to the oral and maxillofacial surgery practice. Minimal instrumentation is required and, therefore, a relatively easy transition for the interested oral and maxillofacial surgeon. Participants will learn procedure techniques for early programmed dermabrasion and scar revision, patient evaluation, and instrumentation. Specifically discussed will be the basics of wound healing and scar formation. Indications, contraindications, risks, and alternative treatments along with preoperative and postoperative care, expectations, and results are presented. On completion of this presentation, the clinician should have a good understanding of the techniques for the potential treatment of post-traumatic scars and of early programmed dermabrasion. In addition, the scope of practice and potential practice expansion are briefly discussed. References Yarborough JM: Ablation of facial scars by programmed dermabrasion. J Dermatol Surg Oncol 14:3, 1988 Rohrich RJ, Robinson JB Jr: Wound healing and closure, abnormal scars, tattoos, envenomation, and extravasation injuries. Select Read Plast Surg Vol 7, No 1, 1992 Baker TJ, Gordon HL, Stuzin JM: Surgical Rejuvenation of the Face (ed 2). St Louis, MO, Mosby, 1996, p 135

The oral and maxillofacial surgeon has been, traditionally, the leading professional in the area of treatment of facial trauma, especially in reconstruction of the facial skeleton and the rehabilitation of the resulting functional disabilities. However, the aspect of soft tissue reconstruction by the use of pedicled local and regional flaps has been relatively neglected in the overall scope of our specialty. Considering the experience and understanding by the oral and maxillofacial surgeons of the functional characteristics of the different tissues in the facial area, a comprehensive approach to soft tissue reconstruction was considered by the presenters as a needed addition to the operative armamentarium of our colleagues. Until the late 1960s, most of the flaps were tubed or delayed, and since the early 1970s there has been a significant development of pedicled vascularized tissues, either advanced, rotated, or transpositioned into a deficient recipient site. The literature is rich in this field, with numerous flaps published as technical notes, case reports, and anecdotal comments. The scientific support by research in the areas of vascularization and tissue healing expanded the knowledge and therefore increased the predictability of the use of flaps. The objective of the presentation is to address the concepts of the design of local flaps with a “problemsolving” approach based on the anatomic and physiologic basis of each flap, the clinical data accumulated through the literature, and the clinical experience of the presenters. The indications for the use of different flaps as well as the short- and long-term results will be discussed. References Baker SR, Swanson NA: Local Flaps in Facial Reconstruction. St Louis, MO, Mosby, 1995 Jackson IT: Local Flaps in Head and Neck Reconstruction. St Louis, MO, Mosby, 1985 Urken ML, Cheney ML, Sullivan MJ, et al: Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York, NY, Raven Press, 1995

S216 S215 Soft Tissue Flaps in Facial Reconstruction Joseph I. Helman, DMD, Ann Arbor, MI Stephen E. Feinberg, DDS, MS, PhD, Ann Arbor, MI AAOMS • 2002

Scientific Basis and Clinical Application of Myocutaneous Island Flaps in Head and Neck Reconstruction Uwe K.G. Frohberg, DMD, MD, Dallas, TX (no abstract provided) 137

Surgical Clinics

S217 Lesson Learned in Surgical OMF Pathology—Monday Morning Quarterbacking: OMF Surgeon and OMF Pathologist as a Team Talib A. Najjar, DMS, MDS, PhD, Newark, NJ Surgical OMF pathology is a significant component of OMF-surgery practice. The aim is to present multiple oral and systemic pathology cases. These cases require comprehensive investigation, differential diagnosis, and medical and surgical management. References Gold L: Surgical pathology: Consideration in diagnosis and management. Oral Maxillofac Surg Clin North Am, 1994 Williams TP, Stewart JCS: Surgical pathology, in Fonseco RJ (ed): Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 2000 Najjar TA: General and Systemic Pathology. New Jersey Medical School, UMDNJ publication, 2002

easy device orientation intraoperatively, and intraoral placement, while maintaining proper horizontal and sagittal vector device trajectory. Intraoperatively, a mandibular occlusal splint is inserted to help guide the mandible into the ideal, planned occlusion. The mandibular splint is removed at the end of distraction, before the consolidation phase. Callus manipulation is facilitated during the active distraction phase with the use of orthodontic elastics, including Class II elastics to unload the TMJ. For asymmetric cases, “callus dancing” is performed on the less retrusive, “waiting-side” of the mandible. The distraction devices are removed after 8 to 12 weeks of osseous consolidation. The distraction technique can also be applied for procedures on the edentulous or atrophic, preprosthetic maxilla or for the reconstruction of post-tumor patients. Gentle sagittal distraction movements can allow bone fill and stable results without condylar rotation and also provide enhanced CN V3 protection from traditional transverse osteotomy technique. Basis and rationale with research studies will be shown as well as in-depth case technique presentation.

S218 Rationale and Technique of Distraction Osteogenesis for Orthognathic and TMD Patients Jeffrey J. Moses, DDS, Encinitas, CA Suzanne U. Stucki-McCormick, DDS, MS, Encinitas, CA Intraoral distraction osteohistiogenesis has become increasingly popular with the advent of microplate design and the proven versatility of the surgical technique. Additionally, distraction osteohistiogenesis provides a partial solution for the preservation of condyle function by minimizing condylar torque by vectored distraction after orthognathic principles. This coupled with the use of callus manipulation has allowed our center to successfully treat over 25 patients, assessed as at-risk temporomandibular dysfunction, Class II or asymmetric orthognathic patients with mandibular advancement surgery using distraction osteohistiogenesis. The surgical approach is similar to that of the classic BSSO, yet key modifications are required for clinical success. The modified sagittal osteotomy incorporates a shortened sagittal bone cut with removal of a portion of the lingual cortex, at the level of the horizontal bone cut. This decreases impedance and allows free rotation and advancement of the segments during the distraction process. An intraoral distraction device with microplate/ mesh footplate design (KLS Martin, Jacksonville, FL) is used for the mandibular advancement after a modification of the Ilizarov principles: 2.0 mm per day advancement (1.0 mm BID, to accommodate the increased bony contact from the modified BSSO and prevent premature consolidation). The mesh footplate design allows for 138

References Guerrero CA, Bell WH, Contasti GI, et al: Intraoral mandibular distraction osteogenesis. Semin Orthod 5:35, 1999 Markov MR, Harper RP, Cope JB, et al: Evaluation of inferior alveolar nerve function during distraction osteogenesis in the dog. J Oral Maxillofac Surg 56:1417, 1998 Block MS, Daire J, Stover J, et al: Changes in the inferior alveolar nerve following mandibular lengthening in the dog using osteogenesis. J Oral Maxillofac Surg 51:652, 1993

S301 Hair Transplantation and Micrografting for the Oral and Maxillofacial Surgeon Barry H. Hendler, DDS, MD, Philadelphia, PA Hair transplantation is the most commonly performed cosmetic procedure for facial enhancement. Its efficacy is based on over 40 years of study that began with Dr Norman Orentreich’s original paper on the theory of “Donor Dominance.” In this paper, he noted that grafts taken from hair-bearing areas on the back and sides of the scalp would become “donor dominant” and grow at recipient sites on the front and top of the scalp. These grafts, if properly selected and taken, could then continue to grow hair for the rest of the patient’s life. A complete understanding of male pattern baldness is needed to have a basic overview of which patients are candidates for hair transplantation. There are over 7 categories of male pattern baldness in which hair loss is both genetically and hormonally (androgens) controlled. Similarly, areas of the scalp (back and sides) on the same individuals who have male pattern baldness have the genetic predisposition to continue growing for life. AAOMS • 2002

Surgical Clinics However, in assessing candidates for transplantation, potential donor areas that exist must be sufficient to cover the balding or thinning areas completely and certainly should be evaluated for hair density in order to achieve the most favorable cosmetic results. The procedure used in this discussion will be punch grafting, and critical to its success is careful staging of transplantation so that all grafts receive optimum blood supply. Equally important is hairline placement, which is drawn in relationship to the concept of facial thirds. Studies of punch grafting techniques have supported the fact that donor grafts must be taken along the hair shafts to optimize the number of growing hairs in each graft. Hair direction as well as the selection of proper punch diameter size are also critical in achieving optimum cosmetic results. Over the past several years, the most refined method of hair transplantation involved the placement of microand minigrafts, which can be used to completely correct areas of alopecia and/or further enhance the frontal hairline. Micrografts contain from 1 to 3 hairs, minigrafts from 4 to 8 hairs, which produce a more delicate result, more closely resembling hair growth prior to balding. These grafts are usually taken from a donor strip. Through meticulous microsurgical technique, single hair follicles may also be used. Additional grafts can be placed throughout the transplanted area in order to blend hair and achieve the fullest appearance. This virtually eliminates the “tufted” look often created by individuals unfamiliar with the true art of hair transplant surgery. Lastly, the postoperative use of medication, proper bandaging, and careful cleansing of each graft in the immediate postoperative phase ensure 100% graft survival. References Unger WP: Hair Transplantation. New York, NY, Marcel Dekker, 1979 Norwood OT: Hair Transplantation Surgery. Springfield, IL, Charles C Thomas, 1984 Hendler BH: Hair restoration surgery, hair transplantation and micrografting. Atlas Oral Maxillofac Clin North Am 6, 1998 American Association of Oral and Maxillofacial Surgeons: OMS Knowledge Update, Volume One, Part II, Hair Transplantation and Micrografting, 1995

S302 The Clinical Management of Infection Is Both a Science and an Art Russel Lurie, BDS, Hdip, Mdent, FCMFOS, Johannesburg, South Africa The greatest number of infections in and around the facial skeleton are odontogenic in origin. Bacterial infections are the most common in the orofacial region that AAOMS • 2002

are managed on a daily basis; there must also be a constant awareness of the existence of infections of viral and fungal origin, head and neck manifestations of infections of systemic origin, and, most important, infections from contiguous anatomic regions. Playing a significant role in the presentation and behavior of infections is the escalating effects of HIV/AIDS and AIDS-related conditions. Management involves accurate diagnosis, correct medical therapy and when necessary, prompt surgical interventions. The presentation will give an overview of the immune system of the body, principles of antibiotic usage, as well as illustrative clinical examples of fascial space involvement by infection, including Ludwig’s angina and necrotizing fasciitis. Extension of infection in bone giving rise to the various forms of osteomyelitis will also be illustrated. The science of diagnosing and treating orofacial infections is an understanding of the signs and symptoms as well as the appropriate use of special investigations. The art is the ability to evaluate and manage the problem with regard to the involvement of fascial spaces and bone by infection. References Peterson LJ, Ellis E, Hupp JR, et al: Contemporary Oral and Maxillofacial Surgery (ed 2). St Louis, MO, Mosby, 1993 Killey HC, Seward GR, Kay LW: An Outline of Oral Surgery: Part I. Bristol, UK, John Wright and Sons, Ltd, 1971 Grant JCB: A Method of Anatomy (ed 6). Baltimore, MD, Williams Wilkins, 1958

S303 Rotation of the Maxillomandibular Complex: Indications, Treatment Planning, and Treatment Outcomes Johan P. Reyneke, MChD, FCMFOS(SA), Rivonia, South Africa Rotation of the maxillomandibular complex and the consequent alteration of the occlusal plane angulation offer the surgeon an alternative in orthognathic treatment planning. The concept of clockwise and anticlockwise rotation of the lower third of the face and the geometry of the surgical treatment design will be discussed. References Reyneke JP, Evans WG: Surgical manipulation of the occlusal plane. Int J Adult Orthod Orthognath Surg 5:99, 1990 Reyneke JP: Surgical manipulation of the occlusal plane: New concepts in geometry. Int J Adult Orthod Orthognath Surg 13:307, 1998 Reyneke JP: Surgical cephalometric prediction tracing for the alteration of the occlusal plane by means of rotation of the maxillomandibular complex. Int J Adult Orthod Orthognath Surg 14:55, 1999


Surgical Clinics

S304 Upper Facial Rejuvenation: Endoscopic Brow Lift, Blepharoplasty, and Botulinum

McKinney P, Mossie R, Zukowski M: Criteria for the forehead lift. Aesthetic Plast Surg 15:141, 1991 Oslin B, Core G, Vasconez L: The biplanar endoscopically assisted forehead lift. Clin Plast Surg 22:633, 1995 Ramirez O: Endoscopic subperiosteal browlift and facelift. Clin Plast Surg 22:639, 1995

Joseph Niamtu III, DDS, Richmond, VA Enhancement of the brow and forehead has always been the cornerstone of upper facial rejuvenation; however, renewed interest in this area has come to light with the technological advance of endoscopic assisted surgery. This procedure has popularized brow and forehead lifting, which in the past was a more difficult and morbid procedure. Contemporary cosmetic surgeons realize that brow position is integral to successful blepharoplasty. Some of the most experienced blepharoplasty surgeons still do not offer endoscopic brow and forehead lifting as a blepharoplasty option. Due to this, many patients undergo blepharoplasty and, although improved, are not truly aesthetically treated. Compounding this problem is the fact that a blepharoplasty patient who is aggressively treated may be deprived of a future brow lift option due to the fact that insufficient eyelid skin exists and lifting the brow would cause lagophthalmos. This procedure can enhance the upper face and, when combined with laser resurfacing, may in many cases eliminate the need for actual blepharoplasty. Although endoscopic brow and forehead lifting requires some specialized equipment and training, it is a technique that is readily learned, provides good results with minimal complications, and can be performed in the outpatient office setting. It is a technique well within the scope and ability of those surgeons with blepharoplasty experience. This presentation will outline the basic techniques of endoscopic brow and forehead lift anatomy, diagnosis, treatment planning, armamentarium, intraoperative technique, fixation options, postoperative care, and complications and pearls. This presentation will be multimedia in nature and include digital video of actual endoscopic procedures. This presentation will also focus on basic upper blepharoplasty, lower transconjunctival blepharoplasty with periorbital resurfacing, and upper facial use of Botox. At the conclusion of this presentation, attendees should have a basic familiarity with the anatomy, indications, applications, and complications of upper facial rejuvenation. References Niamtu J: Endoscopic Brow and Forehead Lifting: An Evolving Paradigm, Plastic Surgery Products, September 2000. Novicom Publications, November 2000 Niamtu J: A simple device for incision protection and retraction in endoscopic brow and forehead lifting. Dermatol Surg 27:779, 2000


S305 Microbiology and Antibiotic Therapy of Oral and Maxillofacial Infections Thomas R. Flynn, DMD, Boston, MA The changing microbiology of odontogenic deep space infections has been a topic of considerable interest in recent years. Improved culturing techniques have helped to identify the synergistic roles that anaerobes and streptococci play in these infections. It appears that the initial colonization of the infected site by oral facultative streptococci provides nutrients and a favorable reduced oxygen environment for later growth of obligate anaerobes, mainly Prevotella and Porphyromonas species, Fusobacteria, and Peptostreptococcusi. Immunocompromised patients may, however, harbor unusual pathogens. The implications of this new understanding of oral microbiology in culturing and antibiotic therapy are discussed. Antibiotic resistance is a growing problem in the head and neck region. The effect of antibiotic therapy on antibiotic resistance within individuals and communities is explored, along with the mechanisms of antibiotic resistance. Strategies for treatment of highly resistant organisms are also described. Recent data on the antibiotic sensitivity of the commonly isolated pathogens of odontogenic infections indicate that penicillin is still the empiric drug of choice, at least for outpatients. The effectiveness of erythromycin and the new macrolides is weak against the oral streptococci and anaerobes, making them obsolete. Clindamycin retains its effectiveness in serious (hospitalized) and chronic cases. One can estimate also from these data the usefulness of some newer antibiotics, including new fluoroquinolones and cephalosporins, in odontogenic infections, and that certain older antibiotics are now obsolete. A cost-effectiveness comparison is made among the various available antibiotics and their combinations by both the oral and intravenous routes. Salient pharmacology and antibiotic drug interactions are discussed. References Sakamoto H, Kato H, Sato T, et al: Semiquantitative bacteriology of closed odontogenic abscesses. Bull Tokyo Dent Coll 39:103, 1998 Flynn TR: Odontogenic infections. Oral Maxillofac Surg Clin North Am 3:311, 1991 Flynn TR, Wiltz M, Adamo AK, et al: Predicting length of hospital stay and penicillin failure in severe odontogenic infections. Int J Oral Maxillofac Surg 28:48, 1999 (abstr) (suppl 1)

AAOMS • 2002

Surgical Clinics

S306 Transconjunctival Lower Lid Blepharoplasty With Simultaneous Chemical Peel: Predictable Results With Minimal Complications John H. Watts, DDS, Biloxi, MS Vernon A. Sellers, DMD, Portsmouth, VA The most common complication associated with lower lid blepharoplasty is lid malposition/retraction. Clinical postoperative presentation may range from increased scleral show to lateral canthal rounding or ectropion. Any of these complications can exacerbate other ocular problems, such as dry eye syndrome, requiring more extensive oculoplastic correction. Transconjunctival lower lid blepharoplasty has been proved to produce a lower incidence of postoperative lid malposition versus open excision techniques. Coupled with surgical lid tightening and skin resurfacing, transconjuctival blepharoplasty is a safe and effective method for improving lower lid contour and reducing rhytids while producing minimal complications. Keys to predictable clinical success are understanding normal lower lid anatomy and its relation to structure/ support of the lid complex, recognizing changes associated with the aging eyelid complex, assessment and planning for surgery to restore structure, and avoiding operative techniques with a high probability of complications in patients with preexisting eyelid or ocular problems.

ity of composite tissue transfer and the patient benefits from decreased hospitalization time by avoiding multistaged surgery. This surgical clinic provides the participant with a full scope appreciation for the role of free flaps in maxillofacial reconstruction. The presentation is based around the basic principles of reconstruction and uses a sitespecific method to present the full spectrum of head and neck deformities encountered. Analysis of the outcomes after application of free tissue transfer techniques to these complex problems is included. Critical analysis includes an assessment of the decreased time to definitive reconstruction, and the impact this has on the patient supports the methods described in the presentation. The participant will take from the presentation a greater appreciation for the role of microvascular reconstruction in maxillofacial surgery and an honest opinion as to the impact this should have on patients in their clinical practice. Each clinician will understand which clinical cases benefit from these techniques and how they can participate in their application. References Brown MR, McCullough TM, Funk GF, et al: Resource utilization and patient morbidity in head and neck reconstruction. Laryngoscope 107:1028, 1997 Kroll SS, Schusterman MA, Reece GP: Costs and complications in mandibular reconstruction. Ann Plast Surg 29:341, 1992 Hidalgo DA, Disa JJ, Cordeiro PG, et al: A review of 716 consecutive free flaps for oncologic surgical defects: Refinement in donor-site selection and technique. Plast Reconstr Surg 102:722, 1998 Grime PD, Wei FC: Pattern assembly: An aid to flap design during oral microsurgical reconstruction. Microsurgery 15:344, 1994

References Popp JC: Complications of blepharoplasty and their management. Dermatol Surg Oncol 992:1122, 1992 Shorr N, Enzer YR: Considerations in aesthetic eyelid surgery. Dermatol Surg Oncol 992:1081, 1992 Zarem HA, Resnick JI: Operative technique for transconjunctival lower blepharoplasty. Clin Plast Surg 19:351, 1992

S307 Free Tissue Transfer in Head and Neck Reconstruction: Flap Selection and Technique Remy H. Blanchaert, Jr, DDS, MD, Baltimore, MD The reconstruction of form and function of the maxillofacial structures after ablative resection or massive tissue loss secondary to trauma remains a difficult clinical problem. The development, refinement, and popularization of microvascular free tissue transfer provide the reconstructive surgeon with numerous advantages over previously used multistaged pedicled flap– based reconstructions. The surgeon benefits from the reliabilAAOMS • 2002

S308 Muscle-Based Flaps for Oral and Maxillofacial Reconstruction Timothy A. Turvey, DDS, Chapel Hill, NC Defects of the oral and maxillofacial region resulting from trauma, tumor ablation, radiation, infection, etc often involve bone and soft tissues. The importance of well-vascularized soft tissues in the successful management of these extensive defects is well recognized. Local muscle and bone donor sources exist adjacent to the maxillofacial region, which permits transfer of these tissues and may obviate the need for more distant pedicled flaps or free vascularized tissue transfer. The major advantages of local transfer are technical ease, less morbidity, and compliance with the surgical principle of using proximal donor sources for reconstruction. The platysma muscle with or without a skin paddle can be used to reline defects of the oral cavity and facial area. The temporalis muscle alone can be used similarly to resurface defects of the oral cavity but also can be 141

Surgical Clinics used as a myo-osseous flap when bone is required. These local flaps are not suitable for every maxillofacial defect, but they are readily accessible and reliable for many oral and maxillofacial surgical defects. The anatomy with emphasis on vascular supply, surgical technique, and the principles of tissue transfer will be highlighted with representative cases.

S309 Soft Tissue Challenges With the Edentulous Mandible Hans Bosker, DDS, PhD, Haren, Netherlands Michael P. Powers, DDS, MS, Cleveland, OH Patients suffering with severe mandibular atrophy are typically deeply concerned with their inability to masticate comfortably without pain, significant changes in their facial appearance, and alterations in speech. Frequently, they have developed a profound depression associated with a loss of self-esteem expressed commonly with their hand in front of their mouth when they talk. Many of these patients have lost the social aspect of eating and do not feel comfortable eating at restaurants or other public events such as weddings, bar mitzvahs, funerals, etc. Practitioners who care for patients with severe mandibular atrophy are typically focused on the improvement of denture base stability and retention. Conventional preprosthetic procedures performed with bone grafts and endosseous implants include excision or further stripping of the muscular attachments to the mandible and lead to an increased deterioration of speech and facial appearance. Patients with residual mandibular bone of less than 20 mm in the symphyseal area have a typical edentulous face with the lower lip curled into the oral cavity, reduction of the vermillion border, exaggeration of the Langer lines about the lips and lower third of the face, and a sagging or double chin. The function of the facial muscles is altered and pronunciation deteriorated due to loss of the insertion of these muscles on the atrophic mandible. Through a submental incision, the muscles in the lower third of the face and neck are repositioned to strengthen the lips, restore the vermillion border, and support phonation. Through the same incision, the jowls and sagging chin can be removed and the jaw and neck lines enhanced with removal of excess dermis and redundant fat and repair of tears or bands in the platysma muscle. This 1-stage submental procedure in conjunction with the placement of implants is indicated to restore the patient’s masticatory function with a functional reconstruction of the facial muscles to deepen the vestibule, improve speech, avoid gingival hyperplasia along the implants, and rehabilitate the facial aesthetics and selfesteem for the patient. 142

References Powers MP, Bosker H: Functional and cosmetic reconstruction of the facial lower third with placement of the transmandibular implant. J Oral Maxillofac Surg 54:934, 1996 Bosker H, Wardle ML: Muscular reconstruction to improve the deterioration of facial appearance and speech caused by mandibular atrophy: Technique and case reports. Br J Oral Maxillofac Surg 37:277, 1999 Powers MP, Bosker H: The transmandibular implant reconstruction system, in Fonseca RJ (ed): Oral and Maxillofacial Surgery, Vol 7, Reconstructive and Implant Surgery. Philadelphia, PA, Saunders, 2000

S310 Submental Liposuction: A Great Place to Start John E. Fidler, Jr, DDS, Rockville, MD The practice of oral and maxillofacial surgery is an ever-expanding field. With this expansion, many surgeons are becoming more and more interested in facial cosmetic surgery. The submental region is one in which minimally invasive surgery can greatly enhance the appearance of one’s face. Liposuction surgery has been around for quite some time. Over the years, there have been many changes in the philosophy, instrumentation, and techniques of this procedure. It has gone from a major undertaking in the operating room to an in-office procedure. Changes in instrumentation and techniques have made submental liposuction a wonderful adjunct to our practice. The surgeon interested in submental liposuction will learn of the changes throughout the history of this procedure. The procedure will be discussed in a step-wise fashion, including preoperative appointments, the technique of the procedure, and the postoperative course. In addition, the indications, contraindications, risks, and complications will be discussed. On completion of the course, the clinician should have a good understanding of this procedure, and a great start to incorporating submental liposuction into the practice. References Ota BG: Cervicomental lipectomy as an adjunct to orthognathic surgery. Oral Maxillofac Surg Clin North Am 8:1996 Kennedy B: Suction lipectomy of the youthful neck. Oral Maxillofac Surg Clin North Am 2:1990

S311 Reconstruction of Major Preprosthetic and Tumor Defects Robert E. Marx, DDS, Miami, FL Today, successful reconstruction and rehabilitation of the jaws requires scientific knowledge and surgical skills AAOMS • 2002

Surgical Clinics of bone and soft tissue transplantation. The common major preprosthetic defects, such as severely resorbed mandibles (less than 6 mm of bone) and maxillas, as well as the common tumor-related continuity defects after benign tumor surgery, cancer surgery, and osteoradionecrosis, share the findings of missing soft tissue, as well as bone. Currently, we manage severely resorbed mandibles with “tenting,” a concept in which the soft tissue matrix is expanded surgically and then maintained by dental implants, so as to prevent resorption of a bone graft that is placed together with the implants. Severely resorbed maxillas are managed with Le Fort I osteotomies with bone graft rigid fixation, which advance and vertically reposition the maxilla to compensate for the upward and backward resorption vector. The majority of continuity defects of the mandible resulting from benign tumor surgeries 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 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, TGF-␤1, and TGF-␤2. Cancer-related defects and 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 before any type of reconstruction. The hyperbaric oxygen protocol of 20 sessions at 2.4 ATA for 90 treatment minutes before elective reconstruction, followed by 10 sessions afterward, is the standard of care today.

S312 Endoscopy for Mandibular Reconstruction Maria Troulis, DDS, BSc, Boston, MA During the last 25 years there has been great interest in the development of minimally invasive techniques for gynecologic, urologic, general, cardiovascular, and facial aesthetic surgery. It is only recently that oral and maxilAAOMS • 2002

lofacial surgeons have begun to develop an interest in endoscopic techniques for the correction of facial soft tissue and skeletal deformities. The benefits of endoscopy include small and remotely placed incisions, acceptable scars, and direct visualization of a magnified and illuminated operative field. Minimal dissection and tissue manipulation result in decreased pain and swelling, less overall morbidity, and faster recovery, which have a significant impact on cost and availability of treatment. For these reasons, minimally invasive surgery has gained enthusiastic public acceptance. The endoscopic procedure for placement of a distraction device for mandibular advancement and endoscopic vertical ramus osteotomy for mandibular setback have been reported by us in an animal model. More recently, we have described our early clinical experience in a case series. The purpose of this clinic is to describe the endoscopic technique for the performance of condylectomy, open reduction and internal rigid fixation of subcondylar fracture, vertical ramus osteotomy, and costochondral graft reconstruction. References Troulis MJ, Kaban LB: Endoscopic approach to the ramus/condyle unit: Clinical applications. J Oral Maxillofac Surg 59:503, 2001 Troulis MJ, Perrott DH, Kaban LB: Endoscopic mandibular osteotomy, placement and activation of a semi-buried distractor. J Oral Maxillofac Surg 57:1110, 1999 Troulis MJ, Nahlieli O, Castano F, et al: Minimally invasive orthognathic surgery: Endoscopic vertical ramus osteotomy. Int J Oral Maxillofac Surg 29:239, 2000

S401 Craniosynostosis and Craniofacial Dysostosis: Diagnosis and Surgical Management Ramon L. Ruiz, DMD, MD, Chapel Hill, NC Bernard J. Costello, DMD, MD, Pittsburgh, PA Craniosynostosis is defined as the premature fusion or absence of 1 or more of the cranial vault sutures and is associated with clinically significant neurologic and morphologic consequences. Growth is arrested perpendicular to the fused suture and a compensatory overgrowth occurs across the sutures that remain open. The result is a characteristic craniofacial dysmorphology and lack of cranial vault growth that restricts the growing brain. Management of craniosynostosis requires release of the involved suture(s) combined with the dismantling and reconstruction of the dysmorphic skeletal components. Plagiocephaly resulting from postnatal external deformational forces (benign positional skull molding) is generally not associated with any functional neurologic problems and is not a surgical problem. 143

Surgical Clinics The craniofacial dysostosis syndromes (Crouzon, Apert, Carpenter, Saethre-Chotzen, Pfieffer) are familial forms of craniosynostosis in which there is involvement of the midfacial sutures. Successful correction of the facial anomalies seen in these syndromic conditions requires multiple, carefully sequenced stages of surgical reconstruction. Initially, release of the synostosis with reshaping of the cranial vault is undertaken. A second stage of reconstruction centers around the management of the total orbital/midfacial deficiency during childhood. The decision regarding what type of osteotomy (subcranial Le Fort III versus monobloc advancement) is carried out must be based on the specific skeletal dysmorphology and the anteroposterior position and contour of the fronto-orbital region. As the child approaches skeletal maturity, definitive orthognathic surgical procedures are often required in order to finalize occlusal relationships. This surgical clinic will provide course participants with exposure to the evaluation and management (surgical and nonsurgical) of infants with plagiocephaly. Specific clinical findings, radiographic studies, and current operative techniques will be covered with detailed case-based examples. In addition, the rationale and specific surgical procedures involved in a staged reconstructive approach to the craniofacial dysostosis syndromes will be discussed. References Posnick JC: Craniofacial and Maxillofacial Surgery in Children and Young Adults. Philadelphia, PA, Saunders, 2000 Turvey TA, Ruiz RL: Craniosynostosis and craniofacial dysostosis, in Fonseca RJ (ed): Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 2001 Posnick JC, Ruiz RL: The craniofacial dysostosis syndromes: Current surgical thinking and future directions. Cleft Palate Craniofac J 37:434, 2000

S402 Surgical Aspects of Apicoectomies With “Hands-On” Demonstration of Microapical Preparation Stuart E. Lieblich, DMD, Avon, CT Conventional endodontic therapy is successful approximately 80% to 85% of the time. Many of these failures will occur after 1 year. The presence of continued pain, drainage, mobility, or an increasing size of a radiolucent area are some of the indications to treat the case surgically. Since many of these cases may have had final restorations placed by the dentist, the salvage of these cases is of importance to the patient. The oral and maxillofacial surgeon is often called on to provide periapical surgical procedures due to his or her expertise in working around the maxillary sinus, posterior mandible, and the aesthetic zone of the anterior maxilla. 144

Advances in periapical surgery have included the use of ultrasonic root end preparation. With the use of these piezoelectric devices, a more controlled apical preparation can be achieved. Additionally, isthmus areas between canals can be appropriately prepared and sealed. The precision afforded with these devices reduces the chances for a malpositioned fill. The apex of the tooth does not need to be prepared with as long of a bevel, thereby creating less leakage via the dentinal tubules. Controversy also surrounds the use of various root end–filling materials. Most authors feel the creation of a hermetic seal at the apex is critical for the long-term success of the case. Amalgam has previously been the most well described material, but its use is of concern to some patients. The use of a modified IRM material, Super-EBA, has been reported to provide a more precise apical seal without the concerns of implanting a mercury-containing compound. A newer material, mineral trioxide aggregate (MTA), may show promise at providing an excellent seal as well as promoting reformation of bone at the apical region. However, the long-term success of this material, as well as independent verification of its use, is still pending. References Johnson BR: Considerations in the selection of a root-end filling material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:398, 1999 Troabinejad M, Chivian N: Clinical applications of mineral trioxide aggregate. J Endo 25:197, 1999 Trope M, Lost C, Schmitz H-J: Healing of apical periodontitis in dogs after apicoectomy and retrofilling with various filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 81:221, 1996

S403 Practical Guidelines for the Reconstruction of the Mandible and Maxilla Brian R. Smith, DDS, MS, Shreveport, LA Mark E.K. Wong, DDS, Houston, TX With the wide range of treatment options now available, surgeons are challenged to select the optimal method, material, and timing for a particular reconstruction. Four areas of the maxillofacial complex frequently require reconstruction: the mandible, maxilla, orbit, and zygoma. Part I of this clinic will cover reconstruction of the mandible and maxilla while Part II will cover the orbit and zygoma. Mandibular defects can be divided into marginal defects, continuity defects, and continuity defects that include the mandibular condyle. Treatment varies among these 3 types of defects and also depends a great deal on the quantity and quality of the surrounding soft tissue. Mandibular defects with well-vascularAAOMS • 2002

Surgical Clinics ized surrounding soft tissue of good volume can be treated by a variety of techniques using free autogenous bone grafts. When the soft tissue is deficient in quantity and/or quality, it must be improved or replaced before free autogenous bone grafting or free vascularized flaps may be used. The choice of reconstructive system is based on the experience of the surgeon and on the specific characteristics of the defect and the overall health of the patient. Our preferred technique in the nonirradiated patient with healthy surrounding soft tissue is a combination of a reconstruction plate and block corticocancellous graft from the posterior ilium. These grafts have demonstrated excellent retention over time and are compatible with osseointegrated implants. Maxillary defects can be divided into those defects that have loss of hard and soft tissue and those with loss of hard tissue only. Defects with loss of hard tissue only are less difficult to treat and are frequently treated by placement of free autogenous bone grafts, in many cases with subsequent or simultaneous implant placement. For the hemimaxillectomy defect in which there is loss of both hard and soft tissue, 3 general approaches can be used. The first is use of the traditional prosthetic obturator. A second is use of a pedicled flap such as the temporalis muscle flap, which separates the oral cavity from the nasal cavity and maxillary sinus region. A third would be use of free vascularized tissue transfer of soft tissue or soft tissue and bone. Although the obturator approach may be difficult for younger patients to accept, it has the advantage of avoiding another donor site and may give the most stable and predictable results long term. References Macintosh RB: Current spectrum of costochondral and dermal grafting, in Bell WH (ed): Modern Practice of Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, p 873 Keller EE: Mandibular discontinuity reconstruction with composite grafts: Free autogenous iliac bone, titanium mesh trays and titanium endosseous implants. Oral Maxillofac Surg Clin North Am 3:877, 1991 Bach DE, Burgess LPA, Zislis T, et al: Cranial, iliac and demineralized freeze-dried bone grafts of the mandible in dogs. Arch Otolaryngol Head Neck Surg 117:390, 1991

S404 Intraoral Distraction Osteogenesis: A New Frontier Cesar A. Guerrero, DDS, Miami, FL William H. Bell, DDS, Plano, TX Patients with severe anteroposterior, transverse, and vertical deficiencies present a challenge in both surgery and orthodontics. In the past, these patients have undergone a variety of surgical modalities to correct their AAOMS • 2002

deformities. Surgical correction has been limited by the need for bone grafting, prolonged periods of maxillomandibular fixation, expensive rigid fixation armamentarium, and extractions. Distraction osteogenesis is a technique of bone lengthening by gradual movement and subsequent remodeling. The idea behind this concept is the law of tension-stress, stating that gradual traction on living tissues creates stresses that stimulate and maintain the regeneration and active growth of certain tissue structures. Gavril Ilizarov demonstrated this principle in the canine long bone. The quality and quantity of the newly formed bone depended on a number of factors: 1) optimal preservation of periosteal tissue and blood supply at the time of osteotomy, 2) a 7-day latency period with no distraction to allow soft tissue healing over the osteotomy site and collagen fiber type I formation as a net between the intrabony walls where the osteotomy was performed, 3) an expansion rhythm of 1 mm once per day, and 4) a stabilization period of 60 or more days. We applied these concepts of distraction osteogenesis to the mandible intraorally, using a universal distractor appliance. Three hundred twenty patients, with ages ranging from 2 to 38 years, underwent this procedure. Where a bilateral transverse deficiency was present, a symphyseal distraction was accomplished. If a unilateral transverse discrepancy was evident, a unilateral parasymphyseal distraction was performed. In cases of severe anteroposterior hypoplasia not correctable with sagital split osteotomy, the goal was to gain length in the body. Mandibular distraction osteogenesis was also simultaneously performed in combination with a number of other maxillofacial surgical procedures based on individual needs of the patient, such as genioplasty, sagittal split osteotomy, Le Fort I osteotomy, rapid palatal expansion, maxillary posterior segmental osteotomy, and rib grafting. Significant mandibular lengthening (average, 12 mm) was obtained as well as proper dental alignment without the need for extraction, with excellent bone formation, healthy gingival response, no temporomandibular joint dysfunction, absense of sensory nerve disruption or injury to developing follicle, and good patient compliance. The greatest mandibular transverse expansion achieved was 20 mm, with an average of 9 mm. In this presentation, multidimensional movements of the maxilla using the law of tension-stress will be discussed as well. Maxillary movements were precisely predicted according to the patient’s needs to correct the maxillary deficiency. One hundred fifty-six patients were treated by distraction osteogenesis in the maxilla using either intraoral devices to advance the maxilla at different levels or a Hyrax appliance, protraction facial mask Class III with heavy elastics to promote 3-dimensional bone expansion. 145

Surgical Clinics The mandibular and maxillary distraction osteogenesis techniques provide reliable mandibular or maxillary lengthening or widening with minimal surgical intervention. The results demonstrate correction of 3-dimensional dentofacial deformities. References Bell WH, Epker BN: Surgical orthodontic expansion of the maxilla. Am J Orthod 70:517, 1976 Guerrero C, Bell WH, Contasti GI, et al: Mandibular widening by intraoral distraction osteogenesis. Br J Oral Maxillofac Surg 35:383, 1997 Guerrero C, Bell W, Gonzales M, et al: Intraoral distraction osteogenesis, in Fonseca RJ (ed): Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 2000, pp 343-402

S405 Diagnosing and Managing the Oral Cancer Patient Randall M. Wilk, DDS, MD, PhD, Newark, NJ (no abstract provided)

S406 Diagnosis and Treatment of Head and Neck Skin Malignancy Thomas J. Teenier, DDS, MD, Corpus Christi, TX James Eyre, DMD, MD, Salem, OR (no abstract provided)

S407 Incisor Position: A Key to Orthognathic Treatment Planning Johan P. Reyneke, MChD, FCMFOS(SA), Rivonia, South Africa The surgical repositioning of the jaws and the eventual aesthetic and functional results are dictated by the preoperative orthodontic positioning of the teeth. Principles of treatment planning for preoperative orthodontic positioning of the incisor teeth will be discussed. Treated cases will be used to demonstrate the principles and importance of this aspect of treatment planning. References Shanker S, Vig KWL: Orthodontic prediction for orthognathic surgery, in Fonseca RJ (ed): Oral and Maxillofacial Surgery, vol 2. Philadelphia, PA, Saunders, 2000, pp 82-97 Epker BN, Stella JP, Fish LC: Dentofacial Deformities: Integrated Orthodontic and Surgical Correction, vol 1 (ed 2). St Louis, MO, Mosby, 1996, pp 80-139 Proffit WR, White RP: Surgical Orthodontic Treatment. St Louis, MO, Mosby, 1991, pp 93-224


S408 Delayed Reconstruction of Skin Cancer Defects Michael F. Zide, DMD, Fort Worth, TX Most surgeons who treat patients with facial skin malignancies advocate an operating room setting for excision of the tumor. Intraoperatively, frozen sections are examined microscopically to ascertain adequate surgical margins. After excision of the tumor, the surgeon closes the defect in an attempt to minimize infection and maximize cosmesis. For the inexperienced surgeon, this desire to maximize cosmesis can conflict with adequate tumor removal, because large defects require more complex closure patterns. Several reports have addressed the potential problems of excision and immediate reconstruction. Examples are the accuracy of the frozen section and certainty of tumor removal. Although some advocate excision of the tumor with delayed primary reconstruction, others suggest immediate reconstruction, or excision of the tumor with healing by secondary intention. Excision of skin tumors without immediate closure is a simple, quick, in-office procedure performed under local anesthesia with or without light sedation. It has the advantage that the excised tissue may be evaluated carefully by routine histologic methods. Margin width can be assessed and further excisions made in subsequent visits, if necessary. Reluctance among surgeons to delay closure of skin defects is related to 1) fear that open facial wounds will heal with undesirable scarring, pain, bleeding, or infection and 2) that patient comfort will be compromised by caring for an open wound. The advantages and disadvantages of open wound therapy with delayed primary reconstruction are discussed. Advantages 1. Reduces cost of histologic assessment (ie, no frozen section fees) 2. Limits complications associated with graft survival (eg, bleeding) 3. Secondary intention healing option available 4. Severity of surgical procedure may be limited by changing treatment options 5. Surgeon has time to research and design 6. Patient appreciates size of defect and participates in treatment options 7. Patient understands position of scars and residual defects before reconstruction 8. Reduces or eliminates some or all hospital costs Disadvantages 1. Patient involvement difficult for elderly or infirm; may necessitate home health care 2. Wound care may be uncomfortable or difficult 3. Cartilage/bone desiccation possible 4. May increase number of office visits AAOMS • 2002

Surgical Clinics References Thomas JR, Frost TW: Immediate versus delayed repair of skin defects following resection of carcinoma. Otolaryngol Clin North Am 26:203, 1993 Barton FE, Cottel WI, Walker B: The principle of chemosurgery and delayed primary reconstruction in the management of difficult basal cell carcinomas. J Plast Reconst Surg 68:746, 1981 Escobar V, Zide M: Delayed repair of skin cancer defects. J Oral Maxillofac Surg 57:271, 1999

S409 TMJ Surgery: Arthroscopy, Arthroplasty, and Total Joint Reconstruction David C. Hoffman, DDS, Staten Island, NY Temporomandibular joint (TMJ) surgery is one of the few surgical procedures that belongs specifically to the oral and maxillofacial surgeon. This lecture will share the presenter’s experiences in over 2,000 surgical procedures of the TMJ. The surgery has been divided into arthroscopy, arthroplasty, and total joint reconstruction. Arthroscopy: Basic understanding of arthroscopic surgery will be demonstrated. Clinical skills, indications, and the use of arthroscopic procedures will be discussed. The use of arthroscopic equipment, in-office arthroscopy, and surgical arthroscopic procedures will be demonstrated. Surgical suturing and partial discectomy will be demonstrated. Pre- and postoperative care, as well as indications and long-term results, will be reviewed. Arthroplasty: Although there are a variety of surgical techniques that can be considered useful in treatment of TMJ disorders, they all have in common that the surgeon must feel comfortable dissecting and accessing the TM joint. This part of the program, through the use of slides and videotapes, will discuss the surgical techniques used to dissect and enter a TMJ safely. A variety of surgical procedures will then be demonstrated, including discectomy, placement of Mitek bone anchors, and placement of ear cartilage grafts. Indications for surgical procedures, as well as pre- and postoperative care and long-term results, will be illustrated. Total joint reconstruction: Total joint reconstruction represents the most drastic of all procedures of the TMJ. Unfortunately, patients who have had multiple surgical procedures of the TMJ often require joint replacements. This part of the program will review the use of custommade joints using CT scans and CAD-CAM technology. Additionally, the surgical technique will be demonstrated through the use of slides and videos for the successful placement of a total joint prosthesis. IndicaAAOMS • 2002

tions, pre- and postoperative care and long-term results will be reviewed. All 3 of the above procedures will be discussed in terms of their overall indications while directing the participants toward using each of these procedures appropriately and treating patients requiring surgical procedures of the TMJ.

S410 Endoscopic Forehead Rejuvenation for the Oral and Maxillofacial Surgeon John H. Watts, DDS, Biloxi, MS Vernon A. Sellers, DMD, Portsmouth, VA Ptotic brow position, upper lid skin redundancy, and forehead rhytids are among the most common complaints verbalized by patients seeking cosmetic rejuvenation of the upper face. Upper lid blepharoplasty, combined with numerous open forehead lifting techniques, has been used for years to obtain predictable surgical results. Unfortunately, many patients are hesitant to undergo extensive open lifting procedures. Failure to identify or treat the full range of problems associated with the aging upper face leads to less than optimal results and patient dissatisfaction. During the past decade, endoscopic forehead lifting has dramatically changed the surgical treatment of patients seeking cosmetic rejuvenation. The advantages are decreased postoperative morbidity, virtual elimination of visible scarring, and increased patient acceptance with comparable clinical results to open techniques. The oral and maxillofacial surgeon, using anatomic knowledge based on the coronal flap approach to NOE trauma and expertise in temporomandibular joint arthroscopic surgery, can rapidly incorporate endoscopic forehead lifting into his or her cosmetic practice. As with most new techniques, diagnostic knowledge, patient selection criteria, use of straightforward reliable surgical techniques, and prompt recognition and management of complications lead to predictable surgical success. References Daniel RK, Tirkanits B: Endoscopic forehead lift: An operative technique. Plast Reconstr Surg 98:1148, 1996 Daniel RK: Endoforehead lift, in Endoscopic Aesthetic Surgery. New York, NY, Springer-Verlag, 1995, p 7 Aston SJ, Thorne CH: The forehead and brow, in Aesthetic Plastic Surgery, Vol 2 (ed 2). Philadelphia, PA, Saunders, 1994, p 732


Surgical Clinics



Distraction Osteogenesis for Pediatric Airway Obstruction

Comprehensive Management of Lip Cancers

Daniel Sampson, DDS, MD, St Louis Park, MN James Sidman, MD, Minneapolis, MN

G.E. Ghali, DDS, MD, Shreveport, LA James W. Sikes, Jr, DMD, MD, Shreveport, LA

Management of obstructive apnea in pediatric airways is a problematic issue. Treatment methods ranging from infant positioning and nasal airways to invasive surgical procedures such as tongue-lip adhesion and tracheotomy are routinely used in pediatric tertiary care centers. Patients present with multifactorial causes for airway obstruction, which must be evaluated thoroughly to aid the clinician in deciding on an appropriate treatment course. Base of tongue obstruction may be caused by structural abnormalities of the skeleton or soft tissue abnormalities including macroglossia or other forms of redundant soft tissue and neurological impairment resulting in hypotonia. Syndromes associated with micrognathia and attendant airway obstruction may include Pierre Robin sequence, Treach-Collins syndrome, Nager syndrome, Pfeiffer syndrome, and velocardiofacial syndrome. While some syndromic patients may achieve normal mandibular projection within 6 months of age, not all will. By virtue of the anatomy of the tongue base and its attachment to the mandible, advancement of the mandible results in anterior positioning of the tongue base, relieving obstruction. Conventional osteotomies with rigid fixation are impractical in infants and small children. Distraction osteogenesis is a technique that we have applied to over 30 cases of pediatric airway obstruction with marked success. Patients are evaluated with multiple modalities to determine the appropriateness of this technique. A multidisciplinary surgical team is involved in all phases of the patient’s care. This approach has led to successful decannulation or extubation of all except 1 child, who died from other causes. This clinic will review the indication for, techniques of, and problems encountered during mandibular advancement using distraction osteogenesis. Emphasis is placed on a team approach.

Lip cancer is one of the most common cancers of the head and neck region. While most have an excellent prognosis, those that present late are biologically aggressive and may demonstrate local recurrence, metastasis, or mortality in up to 15% of patients. Squamous cell carcinoma is the most common form of lip cancer; while other malignancies of the lip do occur, they are quite rare. In the United States the incidence of lip cancer is 1.8 per 100,000 population. In general the behavior of lip cancer is more like that of skin cancer than that of mucosa-based lesions of the oral cavity. The lower lip is most commonly affected, comprising 88% to 98% of lip cancers. Lip cancers have a definitive predilection for males. Cervical metastasis from lip cancer occurs in less than 10% of lower lip cancers and in up to 20% of upper lip cancers or lip cancers involving the commissure. Surgery and radiation are the preferred treatment modalities at this time. Excellent results using local flaps are possible with relatively low morbidity. With overall cure rates of 80% to 90%, lip cancers have a more favorable prognosis than most other head and neck cancers. Management of lip cancers may be achieved, in most cases, on an ambulatory basis or in an oral and maxillofacial surgeon’s outpatient facility.

References Sidman JD, Sampson D, Templeton B: Distraction osteogenesis of the mandible for airway obstruction in children. Laryngoscope 111:1137, 2001 Moore MH, Guzman-Stein G, Proodman TW, et al: Mandibular lengthening by distraction for airway obstruction in Treacher-Collins syndrome. J Craniofac Surg 5:22, 1994 Cohen SR, Ross DA, Burstein FD, et al: Mandibular distraction osteogenesis in the treatment of upper airway obstruction in children with craniofacial deformities. Plast Reconstr Surg 101:312, 1998


References Zitsch RP, Park CW, Renner GJ, et al: Outcome analysis for lip carcinoma. Otolaryngol Head Neck Surg 113:589, 1995 Ghali GE, Ll BD: Management of cancer of the lip. Selected Readings Oral Maxillofac Surg 8:4, 2000 Shah JP, Candela FC, Poddar AK: The patterns of cervical lymph node metastasis from squamous cell carcinoma of the oral cavity. Cancer 66:109, 1990

S413 Methods of Reconstructing Alveolar Ridges Prior to Implant Placement Alan S. Herford, DDS, MD, Loma Linda, CA Common causes of alveolar defects include bone resorption due to loss of teeth, infection, trauma, or congenital origin. There may be insufficient height or width of residual bone to permit the placement of dental implants and bone grafting may be required prior to implant placement. AAOMS • 2002

Surgical Clinics Various bone grafting techniques are available for reconstruction of small alveolar deficiencies to more complex, extensive bony defects. Without grafting, the implants may have to be placed in anatomically unfavorable positions or have adverse angulations. These position/ angulation compromises can lead to aesthetic dissatisfaction, mechanical overload, and possibly, implant loss. There are minimum dimensions that the remaining alveolar process must possess for implants to be placed. When these dimensions are not present it will be necessary to augment the size of the ridge prior to implant placement via a grafting procedure, or place implants so they are not completely contained within bone and place a semipermeable membrane over the bone and exposed part of the implant so as to permit bone growth to occur over the exposed area. Alveolar defects can be restored by autologous grafting techniques including corticocancellous blocks, compressed particulate cancellous bone and marrow, and cortical grafts. All 3 of these types of grafts can be obtained from the mandible, maxilla, tibia and iliac crest, and cranium. Bone obtained from these sites varies in volume, hardness, and contour characteristics. Either local or distant sites may be considered for donor sits. An advantage of local grafts includes the proximity of the donor and recipient sites and convenient surgical access. This proximity decreases the operative and anesthesia time. General anesthesia is

AAOMS • 2002

avoided and the procedure is associated with decreased costs and morbidity. Another advantage is that there is no visible external scar. A disadvantage is that there is less bone available than from extraoral sites. Meticulous techniques and rigid fixation of block grafts are important to improve success rates. It is important with any alveolar defect to follow basic surgical principles. The mucoperiosteal flap should be designed to adequately expose the underlying ridge, maintain a broad base for vascular supply, and allow tension-free primary closure. Midcrestal incisions maximized the vascularity to the margins of the flaps. The decision to graft is prosthetically driven. Aesthetic and functional compromise can be prevented by ridge augmentation procedures and enhanced emergence profiles of the implants can be obtained. The importance of primary stability cannot be overemphasized for longterm success. Autogenous bone grafts are recommended because of their osteogenic potential. References Boyne PJ, Herford AS: An algorithm for reconstruction of alveolar defects before implant placement. Oral Maxillofac Surg Clin North Am 13, 2001 Buser D, Bragger U, Lang NP, et al: Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Implant Res 1:22, 1990 Misch CM: Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants 12:767, 1997