Surgical Clinics S101 The Clinical Treatment of Infection Is Both a Science and an Art Russel Lurie, BDS, HDip Dent, MDent, Johannesburg, South Africa Infections of the jaws know no boundaries. The greatest number of infections in and around the facial skeleton are odontogenic in origin, arising from periapical, periodontal, and pericoronal inflammation; odontogenic cysts and tumors as well as trauma are also contributing factors. The science of diagnosing and treating infections is dependent on an understanding of the presenting signs and symptoms as well as the appropriate use of imaging and laboratory investigations. The art in managing infections is the ability of the clinician to evaluate the infection in relation to the patient. Three variables must be considered: 1) the cause, be it bacterial, viral, or fungal; 2) the anatomic location, vis-a-vis spread within the fascial spaces and bone; and 3) host resistance, the ability of the patient to resist and combat infection. Though the incidence of life-threatening odontogenic infections has decreased greatly, particularly in developed countries, the oral and maxillofacial surgeon must constantly be alert to the existence of these problems.
by the bacterium Clostridium botulinum, blocks acetylcholine-mediated neuromuscular transmission at the motor end plate. This property of producing profound but reversible muscular relaxation has made it a unique tool that can be targeted to specific locations. Its most popular application is its off-label cosmetic uses. This drug is now the treatment of choice for hyperkinetic facial lines. Research with BTX is in phase 2 and phase 3 clinical trials for numerous more debilitating conditions seen in daily practice. Recent studies indicate that chronic TMD, whiplash-associated disorder, and chronic headache are responsive to therapeutic injections of this drug. Experimental work being done with uncommon conditions such as facial hyperhidrosis, Frey’s syndrome, cluster headache, and hypersalivation has also been met with success. References Brin M: European Journal of Neurology 4, 1997 (suppl 2) Freund B, Schwartz M, Symmington J: The use of botulinum toxin for the treatment of temporomandibular disorders: Preliminary findings. J Oral Maxillofac Surg 57, 1999 Dutton J: Botulinum-A toxin in the treatment of craniocervical muscle spasms: Short- and long-term local and systemic effects. Surv Ophthalmol 41:51, 1996
S103 S102 Clinical Applications of Botulinum Toxin in the Head and Neck Brian J. Freund, DDS, MD, Pickering, Ontario, Canada Marvin Schwartz, DDS, MSc, Pickering, Ontario, Canada Pain and dysfunction of the head and neck complex continues to have a significant impact on patients’ quality of life and poses clinical challenges to the profession. Recent innovative applications of Botulinum toxin (BTX) have yielded marked therapeutic advances in some difficult-to-treat head and neck conditions. There is no consensus on the pathophysiology of complex myofascial conditions such as temporomandibular disorder (TMD) and neck pain. However, a myogenous component appears to be a consistent feature of these conditions. There is evidence to support the contention that some forms of headache such as tension type and cervicogenic should also be included in the classification of head and neck myofascial pain. Diagnosis and treatment of myofascial conditions has been limited by the lack of specificity of available agents. Botulinum toxin (BTX), a potent neurotoxin produced 104
Comprehensive Management of the Irradiated Surgery Patient Steven R. Schimmele, DDS, Indianapolis, IN Ralph M. Eichstaedt, DDS, Dayton, OH Oral and maxillofacial surgeons are routinely called on to manage diseases secondary to or requiring radiation therapy. An intimate knowledge of the pathophysiology of radiation tissue damage and its appropriate management is imperative to patient management and successful surgical outcomes. Soft tissue radiation necrosis and osteoradionecrosis are both well-known entities that occur frequently and provide difficult treatment planning decisions for the surgeon. Normal healing is retarded, and simple surgical procedures can precipitate life-threatening complications. The biologic response of soft and hard tissues to radiation is well known and has been correlated to clinically identifiable symptoms that aid the clinician in evaluation of the patient and aid in selection of the most appropriate surgical procedure required to treat the disease process. Reconstruction of radiation-related defects of the head and neck is imperative to return a patient to good form AAOMS
Surgical Clinics and function. Soft tissue augmentation with a variety of local and regional pedicled flaps or microvascular transfer can provide a sufficient tissue bed to perform reconstructive procedures for both the mandible and the maxilla. Subsequently, dental implants further return a patient toward normal function. Hyperbaric oxygen (HBO) therapy has been credited both as preventing possible complications and with increasing successful outcomes in surgery performed on irradiated patients. There is some controversy surrounding the amount of radiation required before hyperbaric oxygen should be administered and for what procedures HBO can be disregarded. The documented effects of HBO and clinical experience would suggest its routine use in the management of these difficult patients.
References Marx RE, Johnson RP, Kline SN: Prevention of osteoradionecrosis and randomized prospective clinical trial of hyperbaric oxygen versus penicillin. J Am Dent Assoc 111:49, 1985 Tibbles PM, Edelsberg JS: Hyperbaric oxygen therapy. N Engl J Med 334:1642, 1996 National Institute of Health Consensus Development Conference Statement: Oral complications of cancer therapies: Diagnosis prevention and treatment. NIH, J Am Dent Assoc 119:179, 1989
S104 Outpatient Tibia, Jaw, and Iliac Bone Harvesting Techniques John D. Stover, DDS, MD, PhD, New Orleans, LA Harvesting of bone for preprosthetic and peri-implant grafting is increasingly being done on an outpatient basis to avoid the excessive costs of hospitalization and because of patient desires to avoid general anesthesia. This presentation will first include a historical perspective on outpatient bone harvesting procedures. An anatomic description of various harvest sites, including tibia, mandible, maxilla, cranium, anterior, and posterior iliac crest, will follow. The indications, risks, and benefits of bone harvest from each of the above sites will be presented. A detailed description of the various harvest techniques will be presented, including intraoperative video demonstrations. Management of postoperative complications will be addressed.
References Marchena JM, Stover JD, Lirette D, et al: Tibia bone harvesting under intravenous sedation: Morbidity and patient experiences. (In press) Thorne AC, Malbin KF, Jain M, et al: Autologous bone marrow harvesting in outpatients. J Clin Anesth 8, 1996 Kovacs MJ, Crump M, Keating A: Outpatient bone marrow harvesting: An update. Bone Marrow Transplant 15, 1995
S105 Strategies for Aesthetic Implants Kirk L. Fridrich, DDS, MS, Iowa City, IA Dental implantology has progressed dramatically in recent years, allowing a transition to the ‘‘restorationdriven implant.’’ Dental implants must satisfy the same aesthetic tenets as conventional restorations, or preferably, natural teeth. Although hard tissue grafting is reliable and predictable, soft tissue management remains a formidable challenge to the implant team. The following subjects will be addressed in the context of case presentations: socket preservation; natural tooth pontics; ovate pontics; tissue stimulation with temporaries; stage I impressions; tissue-sparing incisions; use of provisionals; healing abutments; submerged versus nonsubmerged systems; free gingival grafts; connective tissue grafts; timing of soft tissue grafting; and bone grafting techniques and their relationship to soft tissue aesthetics. Periodontal biotypes will be reviewed and their importance to treatment planning emphasized. Other important treatment planning tenets will be discussed, including proper implant placement, use of stents, and age and growth considerations. Special attention will be given to surgical technique and handling of soft tissues. This discussion will include details of armamentarium, and preoperative and postoperative care. Strategies and techniques for maintenance and restoration of soft tissues will be presented. A clear distinction will be drawn between maintenance and restoration of soft tissues, and how this affects treatment planning and ultimately the final aesthetic outcome. As interest by other dental surgical specialties intensifies, it is paramount that the oral and maxillofacial surgeon pay close attention to the ‘‘dental’’ aspects of implantology. References Vezeau PJ: Soft-tissue interactions with implant biomaterials. Oral Maxillofac Surg Clin North Am 8:321, 1996 Jansen CE: Presurgical treatment planning for the anterior singletooth implant restoration. Compendium 16:746, 1995
S106 Soft Tissue Flaps in Facial Reconstruction Joseph I. Helman, DMD, Ann Arbor, MI Stephen E. Feinberg, DDS, PhD, MS, Ann Arbor, MI 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. 105
Surgical Clinics However, the aspect of soft tissue reconstruction by the utilization 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
S107 Surgical Management of TMJ Ankylosis and Correction of Associated Facial Deformities Ashok Vishnu Dabir, MDS, Mumbai, Maharashtra, India Deepak Vishnu Kulkarni, MDS, Pune, Maharashtra, India Treatment of ankylosis of the temporomandibular joint (TMJ) is always surgical. This surgical clinic is designed to inform the participants about the management of TMJ ankylosis in the following manner: 1. Surgical and applied anatomy: Skin creases and how to conceal scars Identification of important structures such as 2 layers of temporalis faciae, facial nerve, maxillary artery, deep temporal artery, marginal mandibular branch, etc. 106
2. Various surgical approaches with their benefits and problems 3. A step-by-step surgical technique for approach to the TMJ and placement of costochondral graft from incision to closure 4. Correction of associated facial deformities such as asymmetry of the face, retrognathia, bird face deformity, etc. (Surgical procedures: costochondral grafting, mandibular osteotomy, maxillary osteotomy, or simultaneous mobilization of maxilla and mandible) 5. Suggested timing and staging of osteotomies and genioplasty to minimize relapse The purpose of this surgical clinic is to present an approach to make the patient not only eat better but look better too! References Poswillo DE: Surgery of temporomandibular joint. Oral Sci Rev 6:87, 1974 Rowe NL: Ankylosis of the temporomandibular joint. R Coll Surg Edinb 1983 Norman JE deB, Bramley P: A Textbook and Colour Atlas of the Temporomandibular Joint, Wolfe Med Publications, Ltd, 1990
S108 Reconstructive Options for the Implant Patient With Severe Atrophy Norman J. Betts, DDS, MS, Ann Arbor, MI Restoration of the implant patient with severe atrophy of the maxilla, mandible, or both is particularly challenging. Thankfully, the days of placing implants where bone is present and making the prosthesis fit (if possible) are gone. The patient and the restorative dentist demand and deserve better. For these difficult cases, a team approach involving the use of a systematic method of diagnosis and treatment planning is essential to the achievement of a successful restoration. Treatment planning must begin with the patient and restorative practitioner determining the desired prosthesis. Based on the type of prosthesis chosen, the ideal number, angulation, and location of implants can be determined. The residual bone is then analyzed to determine the location, shape, and volume of bone grafts necessary to support the planned restoration. This involves determination of the width, vertical height, and the anteroposterior and transverse relationships of the residual bone. Vertical height analysis is the most complex of these determinations and centers on the determination of the crown-to-root ratio of each implant. This comprises both interarch distance and the available vertical height of the residual jaw. In the anterior maxilla implant length is limited by the nasal floor, in the posterior maxilla the maxillary sinus is the limiting AAOMS
Surgical Clinics factor, and implant placement in the posterior mandible is often confounded by the location of the neurovascular bundle of the inferior alveolar nerve. Once the extent and location of the bony deficits are identified, appropriate treatment options can be easily selected. Solutions for inadequate ridge width, inadequate vertical bone height, inadequate ridge relationship, and combination deformities are extensive and varied. If specific criteria are followed during bony reconstruction, chances for success are greatly increased. Future techniques of bone regeneration include distraction osteogenesis, bone morphogenic proteins and other growth factors, and tissue engineering with bioactive structures. References Collins TA: Branemark: Basic and Beyond, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992, pp 1131-1229 Sailer HF: A new method of inserting endosseous implants in totally atrophic maxillae. J Craniomaxillofac Surg 17:299, 1989
S109 The 3 Bs of Upper Face Rejuvenation: Blepharoplasty, Browlifting, and Botulinum Steven A. Guttenberg, DDS, 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 dramatic improvement of the maturing visage. After one has evaluated the patient and arrived at a diagnosis, several office-based, outpatient procedures can be used 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, 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 carbon dioxide laser to perform the procedures results in virtually bloodless operations and minimizes postoperative complications. The laser also can be used for resurfacing the upper eyelids and the lower eyelid skin in conjunction with transconjunctival blepharoplasties, eliminating or diminishing wrinkles while mitigating the risks of postoperative scleral show or ectropion. In patients in whom there is lowering of the eyebrows AAOMS
below the superior orbital rim, brow/forehead lifting is a technique that has gained in 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 ‘‘ear to 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.
S110 Evaluation and Management of Trigeminal Nerve Injuries Mark J. Steinberg, DDS, MD, Maywood, IL Trigeminal nerve injuries are known risks after many oral and maxillofacial surgical procedures. Typically, the injured alveolar nerve or the lingual nerve is injured. Reports concerning the incidence of these injuries vary greatly. This is because of a lack of consistency in injury classification terms and variable testing methods used in different studies. Patients with nerve injury require a thorough evaluation. A detailed history of the injury, and questioning concerning actual perception and pain is the first step. Examination is then conducted on multiple levels. Level A tests direction and 2-point discrimination. Level B involves testing to contact stimuli. Level C evaluates pain sensitivity. After injury, nerves undergo reactions at the proximal end, distal end, and cell body. The neurophysiology of nerve repair is an important factor for making a decision to perform surgery. Known, observed injuries should be treated early. Patients with mild injuries usually show some positive improvement within the first month after injury. This usually indicates a neuropraxia injury. Patients having no improvement after 3 months are unlikely to have significant recovery and are candidates for surgical repair. Most nerve repairs usually involve primary neurorrhaphy. The injured ends are dissected from scar tissue. The stumps are resected back to normalappearing nerve and are coapted. An epineurid repair is then done with 8–0 or 9–0 nylon. This type of clinical course is indicative of a more serious injury, such as neurotomesis. Other surgical therapies include nerve decompression and nerve graft repair. Results of these treatments vary depending on the extent of injury and timing. In our study, early repair of lingual nerve injury has a 90% success rate. The cases studied did not require grafting procedures. Tension-free neurorrhaphies were achieved by extensive mobilization of the proximal and distal nerve segments. 107
Surgical Clinics References Meyer RA: Evaluation and management of neurologic complications, in Kaban LM, Pogrel MA, Perrott DM: Complications in Oral & Maxillofacial Surgery. Philadelphia, PA, Saunders, 1996, pp 69-88 LaBanc JP, Gregg JM: Trigeminal nerve injuries: Basic problems, historical perspectives early succession and remaining challenges. Oral Maxillofacial Clinic North Am 4:277, 1992 Zuniga JR, Essick GK: A contemporary approach to the clinical evaluation of trigeminal nerve injuries. Oral Maxillofacial Clinic North Am 4:353, 1992
S111 Tibial Bone Graft Technique in the OR and in the Office George M. Kushner, DMD, MD, Louisville, KY Brian Alpert, DDS, Louisville, KY The oral and maxillofacial surgeon faces many reconstructive challenges in contemporary practice. Reconstruction of the bony maxillofacial skeleton is frequently required for trauma, pathology, implant site preparation, and a host of other clinical scenarios. The ‘‘gold standard’’ in bony reconstruction is autogenous grafting. Several sites, including the calvarium, iliac crest, tibia, and the mandible itself, are popular in clinicians’ hands. Each site has its own advantage, and disadvantages or limitations must be evaluated for each patient. We believe the tibia bone graft site is very versatile, technically easy to perform, and has a low complication rate. The amount of bone that can be harvested is usually more than adequate. Additionally, this procedure can easily be adapted to use in the office. We will present the technical aspects of this surgical procedure and show its use in a variety of surgical cases. Last, we will discuss the University of Louisville experience and our complications with the tibia bone graft. References Catone GA, Reimer BL, McNeir D, et al: Tibial autogenous cancellous bone as an alternative donor site in maxillofacial surgery: A preliminary report. J Oral Maxillofac Surg 50:1258, 1992 Alt V, Nawab A, Seligson D: Bone grafting from the proximal tibia. J Trauma 47:555, 1999 Besly W, Ward Booth P: Technique for harvesting tibial cancellous bone modified for use in children. Br J Oral Maxillofac Surg 37:129, 1999
S112 Pharmacology Update for the Oral and Maxillofacial Surgeon David W. Todd, DMD, MD, Jamestown, NY David M. Feinerman, DMD, MD, Boynton Beach, FL Keeping abreast of advances in pharmacology can be difficult given the number of new agents brought onto 108
the market each year. In addition, with trends toward increasing outpatient care, an increasing number of medically compromised patients can be expected to be seen in a typical OMF office. Knowledge of drug mechanism of action and potential interactions are important to the clinician treating the medically compromised patient to provide optimal care. Our purpose will be to provide a review of pharmacology of agents that have become important in patient management over the past 5 years. For the medications covered, we will review indications, mechanism of action, examples, and notes of importance to the OMS. Where practical we will compare the newer agents with older-generation agents to improve understanding. We will not cover anesthesia agents or antimicrobials, because current reviews are available elsewhere in the OMS literature. We will expand on our discussion of the impact of these medications on patient management.
S113 Periodontal Plastic Surgery for the Implant Patient Anthony G. Sclar, DMD, Miami, FL Modern periodontal plastic surgery evolved from traditional resective periodontal surgery as a result of the development of various reconstructive and regenerative surgical techniques. The impetus for these surgical and biotechnological developments was an increased public awareness and demand for aesthetic dental services. Today periodontal plastic surgery techniques are used to manage vestibular insufficiency, aberrant frenum, marginal tissue recession, excessive gingival display, lost interdental papillae, deficient alveolar ridges, as well as in the preservation of alveolar hard and soft tissues after tooth removal. An anatomic basis exists for the successful application of these techniques to both periodontal and peri-implant hard and soft tissues. Most importantly, the clinician must understand that the peri-implant soft tissues lack a connective tissue attachment to the permucosal implant structures and do not enjoy the blood supply normally derived from the periodontal ligament around natural teeth. In addition, the peri-implant soft tissues do not enjoy the vascular anastomotic connections present in the periodontal soft tissues. These important anatomic differences render the peri-implant soft tissues more vulnerable than periodontal tissues to mechanical and bacterial challenges and can limit the soft tissue volume yielded from the various soft tissue reconstructive procedures used to reconstruct missing soft tissues at implant sites. Nevertheless, soft tissue preservation and reconstructive techniques can be used not only to enhance the AAOMS
Surgical Clinics aesthetic results obtained in the partially edentulous implant patient but also to improve the functional results obtained when implant therapy is used to treat the edentulous patient. Application of these techniques in implant therapy requires a meticulous surgical technique and strict adherence to the basic principles governing oral soft tissue grafting procedures. With an understanding of peri-implant soft tissue anatomy, and the principles of oral soft tissue grafting, the clinician can select, sequence, and successfully apply reconstructive periodontal plastic surgical techniques to enhance functional and aesthetic results in implant therapy. References Bauman GR, Rapley JW, Hallmon WW, et al: The peri-implant sulcus. Int J Oral Maxillofac Implants 8:273, 1993 Miller PD: Regenerative and reconstructive periodontal plastic surgery. Dent Clin North Am 32:287, 1988 Langer B, Langer L: Subepithelial connective tissue graft technique for root coverage. J Periodontol 56:175, 1983
S114 Laser-Assisted UPPP, Somnoplasty and Coblation: Which Works Best in Treating Snoring and Chronic Nasal Congestion? Mansoor Madani, DMD, Bala Cynwyd, PA In search of a surgical method to treat sleep apnea, snoring, and chronic nasal congestion, a variety of techniques have been advocated. In this presentation, a comparative analysis of different techniques is discussed. The routine physical examinations and basic principle of diagnosis will be reviewed. The use of CO2 and Nd YAG laser has been well established to be effective, safe, and simple. More recently, however, a variety of radiofrequency (RF) procedures have been introduced to the field of Oral and Maxillofacial Surgery and Otolaryngology. Somnoplastyt, a unipolar RF generator, has been cleared by FDA for treatment of snoring, chronic nasal congestion, and even sleep apnea. Coblationt is a bipolar generator, which has been used extensively in orthopedic surgery and now is being introduced to treat the same conditions. Many surgeons may rush to purchase these devices, assuming the simplicity of these procedures and unaware of their effectiveness. Our goal will be to review the techniques of performing these procedures and discuss the advantages, disadvantages, and problems with each procedure in detail. Over 3,500 cases have been treated for correction of snoring, chronic nasal congestion, and sleep apnea in the last 5 years. Since 1997, Somnoplastyt procedures have been performed on over 290 patients, and Coblationt treatment has been performed on over 400 patients. Comparative studies between Coblationt, Somnoplastyt, and laser surgery will be discussed. Radiofrequency AAOMS
procedures have several advantages, including ease of operation, reduced surgical time, and less postoperative pain and complications. Conversely, laser treatment for snoring has been the most effective method of reducing or even eliminating the snoring sound. Radiofrequency treatments were used in oral and nasal and tonsillar tissues, where shrinkage of tissues was required to correct and improve snoring and nasal congestion. Laserassisted UPPP was performed, mostly under IV sedation. The outcome of palatal laser surgery was far superior and stable than other techniques. The only drawback was severe pain associated with laser. As technology develops, we are bombarded with new devices and techniques to manage and treat common disorders in our practices. Some companies may approach surgeons not familiar with these developments and promise that their device will cure certain problems. One of these problems that attracted many surgeons’ attention is the treatment of snoring and chronic nasal congestion. In this presentation, we will discuss the advantages, disadvantages, risks, and benefits of the 3 most common devices in the market. We will explore the patient selection, clinical presentation, and success and failure rate of each technique. References Madani M: Radiofrequency Somnoplastyt: A new treatment for snoring and sleep apnea. Int J Oral Maxillofac Surg 1:108, 1999 Madani M: Effectiveness of UPPP assisted with laser for treatment of snoring and mild to moderate sleep Apnea. J Sleep Sleep Disorder Research 21:322 (1998) Nelson B, Powell MD, et al: Laboratory and animal investigations, Radiofrequency volumetric reduction of the tongue. Chest 111:1348, 1997
S115 Surgical Treatment of TMJ Internal Derangement and Osteoarthritis M. Franklin Dolwick, DMD, PhD, Gainesville, FL Surgery of the temporomandibular joint (TMJ) continues to have a small but nonetheless important role in the management of specific temporomandibular disorders (TMD). Appropriate case selection is the mandatory requirement for successful surgical intervention to achieve the desired outcomes of relief of symptoms and improved function. Surgery of the TMJ is best undertaken by surgeons who maintain the philosophy that surgery should aim to avoid further harm to the joint itself and err on the side of more conservative surgical procedures. The benefits and limitations of each of the surgical procedures are readily determined on an individual case basis. The goal is to determine the most appropriate technique that will yield the highest probability of success with the lowest morbidity. 109
Surgical Clinics This presentation will review diagnostic criteria for the common muscle and joint disorders. Nonsurgical treatment modalities will be briefly discussed. The major focus will present case selection for surgical intervention. Arthrocentesis, arthroscopic lavage and lysis, arthroplasty, and condylotomy will be discussed in detail. Discussion will include indications, outcomes, and complications associated with each procedure. Finally, autogenous reconstruction of the multiply operated patient will be reviewed. References Dolwick MF, Dimitroulis G: Is there a role for temporomandibular joint surgery? Br J Oral Maxillofac Surg 32:307, 1994 Dimitroulis G, Dolwick MF, Martinez A: Temporomandibular joint arthrocentesis and lavage for the treatment of closed lock: A follow-up study. Br J Oral Maxillofac Surg 33:23, 1995 Quinn PD: Color Atlas of Temporomandibular Joint Surgery. St Louis, MO, Mosby, 1998
S116 Advanced Temporomandibular Joint Surgery William C. Donlon, DMD, MA, Jacksonville, FL The last half of the 1990s saw tremendous shifts in the options for and popularity of temporomandibular joint reconstruction. This followed the failures of some materials advocated for jaw joint reconstruction in the 1980s. The new decade begins with some prosthetic options being removed from the marketplace and others coming into full clinical availability. Meanwhile, choices for biologic reconstruction are developing. All this creates a new dynamic field for comprehensive surgery of the temporomandibular joint. This course will review the rise and fall of the techniques of the last 20 years and present the current state of affairs vis `a vis commercial development of joint implants and surgical maneuvers using autogenous and allogeneic tissues. References Donlon WC (ed): Total temporomandibular joint reconstruction. Oral Maxillofac Surg Clin North Am 12:1, 2000 Quinn PD: Color Atlas of Temporomandibular Joint Surgery. St Louis, MO, Mosby, 1998, pp 3-245 Norman JE deB, Bramley P: Textbook and Color Atlas of the Temporomandibular Joint. Chicago, IL, YearBook, 1990, pp 1-255
S201 Pediatric Anesthesia and Sedation
S202 Early Dermabrasion and Revision of the Post-Traumatic Scar David A. Bitonti, DMD, 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 offers 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 is well established and has 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, in-office procedures 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 7:1992 Baker TJ, Gordon HL, Stuzin JM: Surgical Rejuvenation of the Face (ed 2). St Louis, MO, Mosby, 1996, p 135
S203 Endoscopic Forehead Rejuvenation for the Oral and Maxillofacial Surgeon John H. Watts, DDS, Biloxi, MS Vernon A. Sellers, DMD, Portsmouth, VA
Jeffrey D. Bennett, DMD, Farmington, CT (no abstract provided) 110
Ptotic brow position, upper lid skin redundancy, and forehead rhytids are among the most common comAAOMS
Surgical Clinics plaints 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 their 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.
accepted treatment protocols, the knowledge and experience of the surgeon is 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 to continue to advance in this rapidly growing field. References Woodson TB, et al: Operative Techniques in Otolaryngology—Head and Neck Surgery, vol 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
S205 Selected Cutaneous Neoplasms for the Oral and Maxillofacial Surgeon Mark H. Karakourtis, DDS, MD, Jacksonville, FL
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
S204 Comprehensive Reconstruction of the Upper Airway in the Treatment of Sleep-Related Breathing Disorders
Malignant cutaneous neoplasms are the most common forms of cancer in humans, and the sun-exposed skin of the head and neck is the most frequent site involved. The relative ease of early diagnosis and intervention provides an excellent opportunity for the oral and maxillofacial surgeon to decrease the significant morbidity and mortality associated with more advanced lesions. This surgical clinic will focus on the epidemiology, clinical presentation, histopathology, differential diagnosis, and treatment modalities for basal cell carcinoma, squamous cell carcinoma, malignant melanoma, as well as for other selected tumors of the oral and maxillofacial region.
N. Ray Lee, DDS, Newport News, VA References
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 workup, including a detailed history and physical examination of the upper airway, is essential in making an accurate diagnosis. A multidisciplinary team approach, including participants’ 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 although there are no universally AAOMS
Karakourtis MH, Dierks EJ: Selected cutaneous tumors of the maxillofacial region. Oral Maxillofac Surg Clin North Am 9: 1997 Summers BK, Siegle RJ: Facial cutaneous reconstructive surgery: General aesthetic principles. J Am Acad Dermatol 29:699, 1993 Bennett RG: Fundamentals of Cutaneous Surgery. St Louis, MO, Mosby, 1988
S206 Predictable Implant Treatment Planning and Bone Grafting Techniques David A. Cottrell, DMD, Boston, MA Michael J. Hunter, DMD, North Andover, MA Implant treatment planning is a team approach that requires precision and predictability. No longer is it 111
Surgical Clinics acceptable to allow bone volume and position to dictate implant placement. The literature is replete with implant systems and various implant and bone graft techniques espousing high success. Unless a clinician has ‘‘tried it all,’’ it is difficult to know which approaches to implant placement and bone grafting are predictably successful without significant morbidity. Most of us are unwilling to experiment on our patients to find out. From a prosthetic point of view, it is important to understand which compromises in implant placement are acceptable and which are unacceptable. From a surgical point of view, it is important to understand which situations are amenable to surgical treatment when standard implant placement is not possible. Not all cases are best treated with implants, and not every extraction socket needs to be grafted. The science of implantology is in its infancy, and much of what we do is based on anecdotal information or case reports. Fortunately, a number of factors have been identified that can positively or negatively influence implant success. By following a standard evaluation and treatment protocol, we can significantly improve our outcomes and minimize complications. A lot is known about the physiology and mechanics of bone grafting. Unfortunately, not all techniques adhere to these basic tenants and can lead to poor results. There is no goose to lay a golden egg, and bone cannot be created from a bottle. The near future will bring advances to implantology that will surely revolutionize implant and bone generation techniques. Currently, there are many choices for the clinician, but few have proven success. We believe predictability is the key to success in implantology and patient satisfaction. The protocol we follow has proved successful. Autogenous bone graft techniques are most predictable, and our philosophy to bone replacement is straightforward, uncomplicated, and predictable. We believe that practitioners with basic or intermediate implant experience who wish to develop a more standardized approach to implant treatment planning or bone grafting will benefit from this approach. We invite clinicians to bring their own cases for discussion. References Clinical factors of importance to successful implant therapy. J Oral Maxillofac Surg 55:1997 (suppl 5) Collins TA, Collins TA: Surgical misadventures in implant placement. Oral Maxillofac Clin North Am 10:203, 1998
S207 The Surgical Airway: ‘‘Tracheotomy A-Z’’ Thomas J. Teenier, DDS, MD, New Orleans, LA Eric J. Dierks, DMD, MD, Portland, OR James Eyre, DMD, MD, Portland, OR (no abstract provided) 112
S208 Management of Acquired and Congenital Ear Deformities Barry Steinberg, DDS, MD, PhD, Jacksonville, FL Defects of the external ear can be caused by congenital and developmental disorders, trauma, and neoplasia. Although anatomic defects may vary widely, some common surgical principles can be used to guide the surgeon to obtain optimal functional and cosmetic results. Reconstruction should be based first and foremost on a clear understanding of development, physiology, and anatomy of the ear. The particular choice of surgical technique will hinge on the nature of the disorder and anatomic zone of the ear that is involved. Timing of reconstruction, particularly in children, is also part of the decision process. This presentation will discuss the anatomy of the normal ear as well as describing various total and subtotal defects of the ear. Treatment algorithms will be presented, as will representative cases. References Brent B: Reconstruction of the auricle, in McCarthy J (ed): Reconstructive Plastic Surgery. Philadelphia, PA, Saunders, 1995, pp 2094-2152 Talmi YP, Liokumovitch P, Wolf M, et al: Anatomy of the postauricular island ‘‘revolving door’’ flap (flip-flop flap). Ann Plast Surg 39:603, 1997 Wood-Smith D, Ascherman JA, Albom MJ: Reconstruction of acquired ear defects with transauricular flaps. Plast Reconstr Surg 95:73, 1995
S209 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 stepwise fashion, including preoperative appointments, the AAOMS
Surgical Clinics 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
S210 Surgical Aspects of Apicoectomies Stuart E. Lieblich, DMD, Avon, CT The oral and maxillofacial surgeon is often called on to provide surgical treatment of periapical lesions. The apicoectomy is often an effective way of treating persistent lesions that occur after conventional endodontic treatment. The literature regarding apicoectomy treatment shows that it is successful because sealing of apical leakage often can eliminate chronic periapical infections. Different materials have been used to seal the apex. Recently, mineral trioxide aggregate (MTA) has been described to have advantages over previously used materials. The recent advances in apical preparation have been brought about by the use of piezoelectric instruments (ultrasonics) to perform a microapical preparation. Through careful surgical technique and exposure of the periapical area, a more conservative preparation can be made, preserving more tooth structure and perhaps contributing to the success of the procedure. In addition, the use of ultrasonics allows more thorough debridement of organic materials at the apical area, which also may contribute to the success. Microapical preparation also permits a debridement of previously inaccessible areas, such as ribbon-shaped canals and the isthmus area frequently found on mesial roots of upper first molars.
ing on the site of origin and the causative organism. The ability of the oral and maxillofacial surgeon to predict the clinical behavior of deep space infections of the head and neck make this specialist the expert in the management of these conditions. That anatomic and surgical knowledge is summarized in this roundtable clinic. The surgical anatomy of the deep spaces of the head and neck is reviewed, including the borders, contents, relations, and likely causes of infections in the deep fascial spaces. The clinical presentation and diagnosis of infections of each of these spaces is illustrated with several cases, and the various surgical approaches for drainage of these spaces are discussed. The principles of the management of deep space head and neck infections are reviewed, including the primacy of surgical drainage in these cases. In addition, the use of drains, medical supportive care, and follow-up management of these infections are presented. Unusual and complicated infections are presented and illustrated with cases, including necrotizing fasciitis, brain abscess, mediastinitis, and cavernous sinus thrombosis. Anesthetic and airway considerations in the management of orofacial infections are then discussed. The diagnosis of airway compromise is reviewed, and currently available airway management techniques are compared. These considerations are supported by data resulting from a recently completed prospective study of 34 severe odontogenic infections recently completed at the Montefiore Medical Center, Bronx, NY. References Flynn TR: Surgical management of orofacial infections. Atlas of the Oral Maxillofac Clin North Am 8:77, 2000 Flynn TR: Anatomy and surgery of deep fascial space infections, in Kelly JJ (ed): Knowledge Update 1994, Rosemont, IL, American Association of Oral and Maxillofacial Surgeons, 1994 Flynn TR: Anesthetic and airway considerations in oral and maxillofacial infections, in Topazian RG, Goldberg MH (eds): Oral and Maxillofacial Infections (ed 3). Philadelphia, PA, Saunders, 1993
References Shaa N: Non-surgical management of periapical lesions: A prospective study. Oral Surg 66:365, 1988 Rud J, Andreason JO, Jensen JE: A follow-up study of 1,000 cases treated by endodontic surgery. Int J Oral Surg 1:215, 1972 Hirsch JM: Periapical surgery. J Oral Surg 8:173, 1979
S211 Anatomy and Surgical Therapy of Oral and Maxillofacial Infections Thomas R. Flynn, DMD, Boston, MA Orofacial infections usually spread in a predictable fashion from one anatomic space into another, dependAAOMS
S212 Aesthetic Principles in Head and Neck Reconstruction William C. Donlon, DMD, MA, Jacksonville, FL Mark H. Karakourtis, DDS, MD, Jacksonville, FL Reconstruction of the face and jaw after the ravages of trauma and neoplasia is a daunting task. The options are myriad, and the treatment plan developed will have a dramatic impact on the patient’s lifestyle and well-being. Methods used in planning facial cosmetic procedures can be adapted to decision making in reconstruction of head and neck ablative or traumatic defects. 113
Surgical Clinics Case examples will be presented. Participants are encouraged to bring cases for discussion. References Rose EH: Aesthetic Facial Reconstruction. Philadelphia, PA, LippincottRaven, 1998, pp 1-308 Naumann HH: Head and Neck Surgery, Vol I, Face, Nose and Facial Skull, Part 1. New York, NY, Theime, 1995, pp 41-360 Marx RE, Stevens MR: Reconstruction of avulsive maxillofacial injuries, in Fonseca RJ, et al (eds): Oral and Maxillofacial Trauma (ed 2). Philadelphia, PA, Saunders, 1997, pp 1101-1203
S213 Extraction Immediate Implant Placement
throsis have shown the effectiveness of modified condylotomy for relief of pain and dysfunction. The procedure has the highest documented rate of disk reduction of any surgical procedure for early-stage disease (reducing disk displacement). Incipient condylar bone lesions have been aborted with formation of new bone during the healing process. Data also suggest that the rate of progression of internal derangement and osteoarthrosis is substantially slowed by this procedure. The reoperation rate of failed procedures is low, and the outcomes generally are good, especially when compared with reoperation rates and outcomes for intra-articular procedures. Finally, even when the operation fails, the joint never seems to be worse than before operation, as can occur with intra-articular procedures.
Charles A. Babbush, DDS, MScD, Beachwood, OH 1. Review of 5 years retrospective (life-table) analysis of cases 2. Guidelines for extraction immediate implant placement 3. Treatment planning concepts a. Indications b. Contraindications c. CT scans with computer (SIM/Plant) analysis 4. Review of implant systems designs indicated for this technique 5. Review of biomaterials used in conjunction with these procedures 6. Review of 12 years of cases
References Upton LG: The case for mandibular condylotomy in the treatment of the painful deranged temporomandibular joint. J Oral Maxillofac Surg 54:64, 1997 Hall HD, Navarro EZ, Gibbs SJ: One and three-year prospective outcome study of modified condylotomy for treatment of reducing disc displacement. J Oral Maxillofac Surg 58:7, 2000 Hall HD, Navarro EZ, Gibbs SJ: Prospective outcome study of modified condylotomy for treatment of non-reducing disc displacement. Oral Surg Oral Med Oral Path Oral Radiol Endod 89:147, 2000
S215 Alloplastic Reconstruction of the Temporomandibular Joint Peter D. Quinn, DMD, MD, Philadelphia, PA
S214 Modified Condylotomy H. David Hall, DMD, MD, Nashville, TN Modified condylotomy is an improved version of the original condylotomy procedure. The procedure, a variation of the familiar intraoral vertical ramus osteotomy, was developed 16 years ago to provide greater surgical control and to minimize surgical complications. The rationale for this operation is that the joint is reconfigured to increase joint space and thus reduce load on the articular surfaces and soft tissues of the joint. A general orthopedic principle is that reduced joint loading relieves pain and allows repair and regeneration of damaged joint surfaces with reduction of inflammatory components. The increased joint space also relieves disk interference, even when the disk is not reduced by the procedure, and is a secondary reason for reduction of pain and inflammation. Condylotomy is unique among temporomandibular joint procedures in that there is no surgical damage or scarring of the joint. Prospective 1- and 3-year outcome studies of both early and late-stage internal derangements and osteoar114
Reconstruction of the multiply operated temporomandibular joint (TMJ) patient can be a difficult challenge for the oral and maxillofacial surgeon. Accepted indications for alloplastic joint reconstruction include • Failed autogenous grafts, especially in the multiply operated patient with a scarred, poorly vascularized tissue bed • Severe polyarticular inflammatory joint disease affecting the TMJ • Destruction of an autogenous bone graft by preexisting foreign body reactions to explanted alloplastic materials • Failed previous alloplastic reconstruction • Ankylosed, degenerated, or resorbed joints with severe anatomic discrepancies • Recurrent ankylosis with a history of excessive heterotopic bone formation There have been significant problems with failures of alloplasts in the past that are largely based on lack of attention to biomechanical principles, inappropriate design and material specifications, and ignorance of the experiential wisdom that has been gained in the orthopedic use of alloplastic joint replacements. We will review over 300 alloplastic joint replacements AAOMS
Surgical Clinics with five different systems. This overview will present ‘‘lessons learned’’ from experience with multiple systems, including Kent-Vitek, Timesh-Delrin, Synthes, Christensen, and TMJ Concepts. We will also present 5-year data on an alloplastic joint system developed by Lorenz that is currently under an FDA-approved investigational device clinical trial. In addition, pertinent anatomy for adequate surgical exposure for alloplastic joint replacement will be extensively discussed. References van Loon J et al: Evaluation of temporomandibular joint prostheses. J Oral Maxillofac Surg 53:984, 1995 Mercuri LG: Alloplastic temporomandibular joint reconstruction. Oral Surg Oral Med Oral Pathol 85:631, 1998 Quinn PD: Alloplastic reconstruction of the temporomandibular joint. Selected Readings in Oral and Maxillofacial Surgery, 7
S216 Utilization of Three-Dimensional Anatomic Models in Oral and Maxillofacial Surgery Jon P. Bradrick, DDS, Houston, TX Computed axial tomography (CT) has revolutionized the oral and maxillofacial surgeon’s management of complex facial trauma, pathology, and reconstruction cases. Three-dimensional reconstruction of CT data initially was limited to simple, object-surface-only renditions. Advances in computer capability resulted in 3D reconstruction that included internal object volume. Combination of CT volume reconstruction with computer-aided manufacturing (CAM) produced anatomic models of craniofacial osseous structures. Applicable CAM processes include milling, selective laser sintering, 3D printing, and stereolithography. Of these, stereolithography has the most capability. The surgeon’s understanding of, and involvement in, the entire process is essential for maximum model accuracy, surgical simulation, and error minimization. A variety of CT data acquisition protocols are available. Most CT-CAM anatomic model manufacturers recommend a specific CT protocol. However, protocol alterations may benefit certain cases, based on anatomic area of interest and surgical needs. Specifically, spiral scanning and coronal section scan protocols have improved model accuracy in select cases. Incorporation of radiopaque or radiolucent objects on, or in, the patient during the CT scan have predictable and beneficial results during model manufacture and presurgical manipulation. Surgeon communication with the CT-CAM anatomic model manufacturer is essential to case success. Disarticulation of joints, alteration of occlusion, type of model AAOMS
material, inclusion of internal model structural support, selective coloring of anatomic structures or foreign bodies, and fabrication of surgical splints and guides are sample items that, if controlled by prescription, contribute positively to outcome. Presurgical manipulation and alteration of the model by the surgeon has a major impact on case success. Construction of these models involves significant investment, so contingency indexing of areas intended for surgical alteration provides backup for return of model topography if the surgeon wishes to entertain alternative treatment plans. During planning, the surgeon must be constantly aware of soft tissue structures in approximation to intended surgical alteration. CT-generated anatomic models contribute significantly to mandibular reconstruction after benign and malignant neoplasm resection, reconstruction after malunion of facial fractures, fabrication of custom orbital and cranial implants, and custom total temporomandibular joint replacement. Dental training provides the necessary experience to manipulate materials and understand concepts of custom implant or prosthesis fabrication. Surgical training provides the necessary experience for tissue alteration, tissue manipulation, and alloplastic device insertion. The oral and maxillofacial surgeon’s background provides a unique marriage of these pathways, culminating in indigenous ability to capitalize on CT anatomic modeling for the benefit of our patients. References Kernan BT, Wimsatt JA III: Use of a stereolithography model for accurate, preoperative adaptation of a reconstruction plate. J Oral Maxillofac Surg 58:349, 2000 Sailer HF, Haers PE, Zollikofer CP, et al: The value of stereolithographic models for preoperative diagnosis of craniofacial deformities and planning of surgical corrections. Int J Oral Maxillofac Surg 27:327, 1998 Hoffmann J, Cornelius CP, Groten M, et al: Using individually designed ceramic implants for secondary reconstruction of the bony orbit (Article in German). Mund Kiefer Gesichtschir 2:S98, 1998 (suppl 1)
S217 Oral Sedation and Monitoring of the Pediatric Patient Stephen Wilson, DMD, PhD, Columbus, OH The use of pharmacologic management during the treatment of young, uncooperative patients has been popular for decades. Usually, pharmacologic management for restorative purposes has used the oral route. Despite a long history of the use of oral sedative agents, the clinical science of this modality of treatment is in its infancy and not well documented. 115
Surgical Clinics A specific area of concern for the practitioner is the selection of oral drugs and dosages that match the patient’s characteristics and dental needs. Factors to be considered are patient age and its related cognitive development, temperament and personality traits, coping mechanisms, and extent of dental needs. The literature has not addressed these factors to any significant degree, although recent publications have outlined the problem. Paralleling the recent interest in the clinical science associated with the use of oral sedatives in young, uncooperative children has been the recent study of patient monitoring, especially electronic monitoring. Children are significantly different than adults in terms of their behaviors, anatomy, and physiology. Because of these major differences, special attention has to be given to the process of approaching and monitoring the sedated child. In general, monitors may be nonelectronic, such as a precordial stethoscope, or electronic (eg, pulse oximeter). Evidence suggests that the deeper the level of sedation, the more reliable is the electronic monitor than clinical observation in detecting true episodes of ventilation and oxygenation problems. The pulse oximeter has become the most frequently used monitor used in pediatric dental sedation, despite its shortcomings in the dental setting. Since 20% or more of all behaviors in sedated patients during the dental appointment involve crying and struggling, there is a good likelihood of false alarms (ie, oxygen desaturations associated with movement). The pulse oximeter relates information concerning the patient’s oxygenation, albeit slightly delayed in time. The capnograph relates information about the patient’s ventilation and airway blockage. It may be the single most important monitor in children who appear to be sleeping during sedative procedures. A precordial stethoscope is also a valuable instrument under these circumstances, but the sound of the dental handpiece often masks that of the breath and heart sounds during auscultation. Other monitors such as bispectral monitoring of brain activities have not produced promising results during oral sedation of sedated children. These and other issues will be addressed during the presentation. References Wilson S: Patient monitoring in the conscious sedation of children for dental care. Curr Opin Dent 1:570, 1991 Wilson S: Review of monitors and monitoring during sedation with emphasis on clinical applications. Pediatr Dent 17:413, 1995 Aka W, Jedrychowski JR: Intraoperative and postoperative physiological monitoring practices by pediatric dentists. J Clin Pediatr Dent 19:91, 1995 Whitehead BG, Durr DP, Adair SM, et al: Monitoring of sedated pediatric dental patients. ASDC J Dent Child 55:329, 1988 Wilson S: Facial electromyography and chloral hydrate in the young dental patient. Pediatr Dent 15:343, 1993
Iwasaki J, Vann WF Jr, Dilley DC, et al: An investigation of capnography and pulse oximetry as monitors of pediatric patients sedated for dental treatment. Pediatr Dent 11:111, 1989 Wilson S: Conscious sedation and pulse oximetry: False alarms? Pediatr Dent 12:228, 1990 Croswell RJ, et al: A comparison of conventional versus electronic monitoring of sedated pediatric dental patients. Pediatr Dent 17:332, 1995
S218 Cervicofacial Rhytidectomy John E. Griffin, Jr, DMD, Columbus, MS Thomas Zakkak, DDS, Biloxi, MS The natural aging process, heredity, exposure to the sun, and other factors cause the skin to wrinkle and sag. Folds of skin become more prominent around the mouth, chin, jawline, and neck. A cervicofacial rhytidectomy is designed to remove the excess skin and fat deposits and allow the skin to tighten, allowing for a more youthful appearance. 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 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 used 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 Rees DT, La Trenta SG: Aesthetic Plastic Surgery. Philadelphia, PA, Saunders, 1994 Tardy ME, Thomas JR, Brown JR: Facial Aesthetic Surgery. St Louis, MO, Mosby, 1995 Giampapa CV, Di Bernardo EB: Neck recontouring with suture suspension and liposuction: An alternative for the early rhytidectomy candidate. Aesth Plast Surg 19:217, 1995
S219 Diagnosis and Management of Trigeminal Nerve Injuries Michael Miloro, DMD, MD, Baltimore, MD 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 most 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, 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, because it carries, in some branches, both general sensory information as well as special sensation (ie, 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 to most appropriately managed 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 employed 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 impacts on 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 ParCare 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 AAOMS
nerve stumps 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; 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 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
S220 Intraoral Distraction Osteogenesis: A New Frontier Ce´sar A. Guerrero, DDS, Caracas, Venezuela William H. Bell, DDS, Dallas, 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 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 distraction 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 latency period with no distraction to allow soft tissue healing over the osteotomy site and collagen fibers type I formation as a net between the intrabony walls where the osteotomy was performed for 7 days, 3) 117
Surgical Clinics 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. Two hundred ninety 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 sagittal 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, absence of sensory nerve disruption or injury to developing follicle, and good patient compliance. The greatest mandibular transverse expansion achieved was 17 mm, with an average of 8 mm. In this presentation, multidimensional movements of the maxilla using the law of tension-stress will be discussed as well. The technique for intraoral maxillary osteogenic distraction, using a Hyrax appliance, protraction facial mask Class III with heavy elastics to promote 3-dimensional bone expansion, is described. Maxillary movements were precisely predicted according to the patients’ needs to correct the maxillary deficiency. One hundred twenty-five patients, with ages ranging from 10 to 37 years, were treated with maxillary widening, with an average of 7 mm (range, 4 to 14 mm). Growth and proper dental alignment were achieved in all patients, without extraction, with excellent osseous union, a healthy periodontal response, without neurologic or developing dental follicle injury, and exceptional patient acceptance. The mandibular and maxillary distraction osteogenesis techniques provide reliable mandibular or maxillary lengthening or widening with minimal surgical intervention. The results demonstrate simultaneous correction of 3-dimensional dentofacial deformities. References Bell WH, Harper RP, Gonzalez M, et al: Distraction osteogenesis to widen the mandible. Br J Oral Maxillofac Surg 35:11, 1997 Guerrero C, Contasti G: Transverse (horizontal) mandibular deficiency, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery, vol 3. Philadelphia, PA, Saunders, 1992, pp 2383-2397
Guerrero C, Bell WH, Contasti GI, et al: Mandibular widening by intraoral distraction osteogenesis. Br J Oral Maxillofac Surg 35:383, 1997
S221 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 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 continuous positive airway pressure (CPAP). Therefore, many types of oral appliances have been used successfully to move the base of the tongue forward 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 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 or presurgical evaluation tool for a variety of patients. Oral and maxillofacial surgeons working in conjunction with other sleep specialists are uniquely trained to offer this service. Because all conservative medical measures used to manage snoring and sleep-disordered breathing, including CPAP, BiPAP, demand positive airway pressure, oral appliances, and 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. Because no single surgical procedure, except tracheostomy, consistently and completely opens the upper airway, we have developed a philosophy directed toward surgery that not only would achieve high acceptance rates but also offers 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 conAAOMS
Surgical Clinics junction 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 through mortised genioplasty allows a large soft tissue pedicle to be significantly advanced and ridgidly 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. References Schmidt-Nowara W, Lowe A, et al: Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea: A Review. American Sleep Disorders Association, Sleep, Vol 18, No. 6, July 1995, pp 501-513 Clark G, Blumenthal I, et al: A crossover study comparing the efficacy of CPAP with anterior mandibular positioning devices onpatients 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
tions, which accelerate bone regeneration and produce a more dense graft. Platelet-rich plasma has been shown to contain platelet-derived growth factor (PDGF), transforming growth factor-beta1, and beta2 (TGF-b1 and TGF-b2). Cancer-related defects and those defects associated with osteoradionecrosis often require significant soft tissue reconstruction first. It is common to place soft tissue flaps such as pectoralis major, trapezius, latissimus dorsi, or sternocleidomastoid myocutaneous flaps together with a titanium reconstruction plate in advance of bone grafting. In the maxilla, the temporalis muscle flap is the preferred flap. In addition, several free vascular soft tissue flaps are useful, such as the radial forearm flap, the circumflex scapular flap, and the rectus abdominis 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. References
S222 Reconstruction of Major Preprosthetic and Tumor Defects
Marx RE, Carlson ER, Eichstaedt RM, et al: Platelet rich plasma— Growth factor enhancement for bone grafts. Oral Surg 85:638, 1998 Marx RE: Mandibular reconstruction: Advances in oral and maxillofacial surgery, 1943-1993. J Oral Maxillofacial Surg 466, 1993 Gray JC, Phil M, Elves MW: Donor cells contribution to osteogenesis in cancellous bone grafts. Clin Orthop 163:261, 1982
Robert E. Marx, DDS, Miami, FL Successful reconstruction and rehabilitation of the jaws requires scientific knowledge and surgical skills 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. We manage severely resorbed mandibles with ‘‘tenting,’’ a concept whereby 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. Continuity defects of the mandible resultant from benign tumor surgeries mostly do not require specific soft tissue reconstruction. However, a contaminationfree and infection-free tissue bed is needed for a successful bony reconstruction. Bone grafting is therefore best accomplished from a transcutaneous approach that avoids oral communications. Cancellous cellular marrow grafts are the superior graft results today, particularly when enhanced with platelet-rich plasma growth factor addiAAOMS
S223 Temporomandibular Disorders and the Medicolegal Arena John H. Campbell, DDS, MS, Indianapolis, IN Heidi C. Crow, DMD, MS, Indianapolis, IN Diagnosis and management of temporomandibular disorders (TMD) have been controversial since the symptom complex was initially described by Costen in 1934. Current medicolegal controversies have made it imperative that clinicians realize what is currently understood about TMD and what information about diagnosis and treatment is supported by the scientific literature. Because oral and maxillofacial surgeons may be required to provide testimony about TMD in a deposition or court of law, conflicting information about etiology, diagnosis, and treatment modalities for TMD may make this task particularly onerous. Our lack of research-supported insight into TMD may make it difficult to adequately defend statements that will become part of the legal record. Although attorneys may demand specific definitive answers, many of the questions regarding TMD will not be amenable to simplistic responses. Rephrasing of testimony by an attorney may distort a fact, and the witness may not be comfortable with the potential misinterpretation inherent in reword119
Surgical Clinics ing. Although being subpoenaed to provide testimony is unlikely to become a function relished by the surgeon, familiarity with the current knowledge base may make testifying more accurate and less stressful for the clinician. The medical practitioner may interact with the legal system in two major areas related to TMD: 1) disabilities allegedly resulting from injury to the temporomandibular apparatus, and 2) professional liability secondary to misdiagnosis or nonstandard therapeutic interventions. This program will address each of these areas by focusing on 1) suggested protocols in record-keeping for cases involving litigation; 2) evaluation of literature support for causes of TMD, focusing primarily on trauma; 3) current standards of care in diagnosis (based on literature support); 4) current accepted treatment modalities and discussion of more controversial interventions; and 5) an approach to provision of accurate, literature-supported testimony.
References National Institutes of Health Technology Assessment Conference on Management of Temporomandibular Disorders. Oral Surg Oral Med Oral Pathol 83:49, 1997 Ferrari R, Leonard MS: Whiplash and temporomandibular disorders: A critical review. J Am Dent Assoc 129:1739, 1998 Goldstein BH: Medical legal considerations in temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 88:395, 1999
S224 Total Joint Reconstruction for the Temporomandibular Joint David C. Hoffman, DDS, Staten Island, NY The purpose of this clinic will be to present a comprehensive discussion on total joint replacement for the temporomandibular joint (TMJ). It will combine both orthopedic and maxillofacial surgery perspectives and ultimately key in on clinical applications. It would be of benefit to anyone who has had TMJ surgical experience and is now interested in total joint reconstruction. In addition, it will specifically help understand the treatment of a patient who has had multiple surgical procedures and hopefully offer a good review of the fundamental knowledge to proceed with a total joint system. The lecture will use material from over 100 total joint replacement surgical patients as well as from experiences in developing a prosthesis under Food and Drug Administration (FDA) clinical trials. The topics will be divided into 6 major areas, which are as follows: 120
General Principles of Total Joint Reconstruction A temporomandibular joint prosthesis must combine knowledge from the orthopedic experiences with hips and knee replacement and features unique to the temporomandibular joint itself. The following general principles will be reviewed: • Choice of biomaterials • Methods of fixation • Custom versus noncustom fit joints • Choice of design of articulating surfaces • Ease of surgical insertion
Overview of Current Systems Available for the Temporomandibular Joint A brief description of the 4 total joint reconstructive systems on the market, Christensen, Biomet, TMJ Concepts, and Endotec will begin this section of the presentation. Computer-aided design, computer-aided manufacturing (CAD CAM) imaging and computer models for treatment planning with these systems will be presented. Indications, advantages, and disadvantages of each system will be reviewed.
Indications and Technical Considerations for Placement of Total Joint Reconstruction and Postoperative Management Indications for total joint replacement will be reviewed. There are several absolute indications as well as relative indications at this time. The most common indications are: • Failed alloplastic and autogenous implants • Progressive degenerative joint disease • Ankylosis in an adult • Multioperated patients • Reconstruction of old condylar fractures • Loss of condyle • Rheumatoid arthritis
Surgical Technique Replacement of a temporomandibular joint with a total joint replacement is a complex procedure. Surgery incorporates a minimum of 2 incisions and familiarity with the anatomy of the facial nerve and various arteries and veins of the face. This section will offer a stepwise approach to both the preauricular and submandibular or retromandibular incisions. Computer graphics and video will be used to explain the surgical sequence. AAOMS
Clinical Experience Complications and Postoperative Care • Intraoperative problems of bleeding, staging procedures, and complex or unexpected anatomy • Combined orthognathic surgery and total joint reconstruction • Management of postoperative infections • Management of facial nerve injury and dislocation • Follow-up radiographs • Postoperative use of continuous passive motion and physical therapy • Pain management
Outcomes • Review of published outcomes for total joint reconstruction • Overall experiences in over 100 patients • Future of total joint replacement References Falkenstrom CH: Biomechanical Design Of A Total Temporomandibular Joint Replacement, Enschede, The Netherlands, Offset-drukkerij FEBO, 1993 Goh JCH, Ho NC, Bose K: Principles and Applications of ComputerAided Design and Computer-Aided Manufacturing (CAD/CAM) Technology in Orthopedics. Ann Acad Med (Singapore) 19:706, 1990 Harris WH, Sledge CB: Total hip and total knee replacement, part 1. N Engl J Med 323:725, 1990 Harris WH, Sledge CB: Total hip and total knee replacement, part 2. N Engl J Med 323:801, 1990 Morrey B: Joint Replacement Arthroplasty. New York, NY, Churchill Livingstone, 1991 Murphy SB, Kijewski PK, Simon SR: Computer aided simulation, analysis and design in orthopedic surgery. Orthop Clin North Am 17:637, 1986 Murphy SB, Kijewski PK, Millis MB, et al: The planning of orthopedic reconstruction surgery using computer-aided simulation and design. Comput Med Imaging Graph 12:33, 1988
S301 Current Concepts in the Development of Facial Skin Flaps: Cosmetic Considerations Victor H. Escobar, DDS, PhD, Pearland, TX Skilled cutaneous reconstructive surgery requires an understanding and application of the key principles of anatomy, wound healing, and basic excisional surgery with primary closure, skin grafting, and local skin flaps. In most cases the surgeon refers these patients for treatment, missing a unique opportunity to provide a service to the patient and for introduction of the concepts of facial cosmetic reconstruction in his/her office. This presentation will introduce the oral surgeon to the principles of skin cancer management and the preparation of the surrounding tissues for subsequent reconstrucAAOMS
tion with local skin flaps, grafts, or primary closure. This presentation will review the important concepts that provide the framework for functional and aesthetic reconstruction of cutaneous surgical defects of the face. The emphasis will be on local skin flaps, their surgical development, their indications, and their use as alternatives for reconstruction of each of the major facial cosmetic units.
References Klingensmith MR, Millman B, Foster WP: Analysis or methods for nasal tip reconstruction. Head and Neck 16:347, 1994 Summers BK, Siegle RJ: Facial cutaneous reconstructive surgery: General aesthetic principles. J Am Acad Dermatol 29:669, 1993
S302 Laser-Assisted Endoscopic Forehead Lift John E. Griffin, Jr, DMD, Columbus, MS Donald P. Max, DDS, Lexington, KY Interest in facial rejuvenation has greatly increased in recent years. Some of this interest stems from advances in technology and improved surgical technique. 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. Two of the most recent innovations in cosmetic surgery are the use of the laser and the endoscope. 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 using 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 insure a good outcome. Oral and maxillofacial surgeons should become familiar with the surgical technique of laser-assisted endoscopic forehead lift. It is important to understand the indications and limitations of this procedure so the most desirable outcome is achieved. References Griffin J, Frey B, Max D, et al: Laser-assisted endoscopic forehead lift. J Oral Maxillofac Surg (Submitted for publication) Epker B: Esthetic Maxillofacial Surgery. Philadelphia, PA, Lea and Feibinger, 1994
S303 Current Management of Peripheral Trigeminal Nerve Injuries Roger A. Meyer, DDS, MD, MS, Marietta, GA Most oral and maxillofacial surgical procedures are performed in close proximity to peripheral branches of the trigeminal nerve. Nerve injuries can occur despite careful techniques and knowledge of anatomy and are accepted risks of surgical treatment. However, peripheral nerve injuries do not always heal spontaneously, and they may have lasting and unpleasant sequelae. Numbness, pain, or other abnormal sensations, spontaneous or stimulus-related, in the lips, cheeks, gingiva, tongue, jaws, teeth, or face may become permanent, bothersome, and interfere with normal functions such as washing, shaving, toothbrushing, kissing, applying makeup or lipstick, eating, drinking, speaking, or swallowing, if left untreated. Reports in the literature and the author’s experience in laboratory animals and in microsurgical operations on patients with nerve injuries have established the efficacy of properly applied microneurosurgical principles and techniques. Results are technique sensitive and time dependent. In complete nerve severance, for example, recovery of useful sensory function (defined by the Medical Research Council as 2-point discrimination of 15 mm or better and reduction or absence of pain) can be expected in 80% to 90% of patients operated on by an experienced surgeon within 6 months of injury. Improvement in lost sensation is more predictable than relief of pain. Although late surgical repair can be successful in selected patients, replacement of distal nerve tissue with scar may reach a critical mass, making repair impossible after 12 to 18 months. Basic microanatomy, neurophysiology, and surgical principles provide the foundation for successful microneurosurgery. Experience is gained in fellowship training, laboratory animal operations, and postgraduate courses. Methods for prevention of nerve injuries in everyday oral and maxillofacial surgery practice are emphasized. An efficacious method of evaluation and documentation of nerve injuries is used. Accepted guidelines determine indications, timing, and prognosis of microsurgical repair of nerve injuries. Documented results from microsurgical operations on over 470 injured nerves in the author’s practice are discussed and analyzed. Currently, microneurosurgery offers selected nerveinjured patients an effective method of treatment and is part of the standard of care for such injuries. Some patients, especially those with long-standing painful nerve injuries, may benefit from nonsurgical management. 122
References Dodson TB, Kaban LB: Recommendations for management of trigeminal nerve defects based on a critical appraisal of the literature. J Oral Maxillofac Surg 55:1380, 1997 Meyer RA: Evaluation and management of neurologic complications, in Kaban LB, Pogrel MA, Perrott DH (eds): Complications in Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 1997, pp 69-88 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
S304 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. Furthermore, 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, primarily 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. AAOMS
Surgical Clinics References
Garatea J, Buenechea R, Bescos C, et al: Intraoral reconstruction with the nasolabial island flap: a modified technique. J Craniomaxillofac 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
Urken ML, Moscoso JF, Lawson W, et al: A systematic approach to functional reconstruction of the oral cavity following partial and total glossectomy. Arch Otolaryngol Head Neck Surg 120:589, 1994 Urken ML, Buchbinder D, Costantino PD, et al: Oromandibular reconstruction using microvascular composite flaps, report of 210 cases. Arch Otolaryngol Head Neck Surg 124:46, 1998 Brown MR, McCullough TM, Funk GF, et al: Resource utilization and patient morbidity in head and neck reconstruction. Laryngoscope 107:1028, 1997
S306 S305 Free Tissue Transfer in Head and Neck Reconstruction: Flap Selection and Technique Remy H. Blanchaert, Jr, DDS, MD, Baltimore, MD Reconstruction of head and neck defects is complex and challenging. The surgeon must make use of many skills and techniques to restore acceptable levels of function and cosmesis to the patient. These cases can be extremely rewarding. Microvascular free tissue transfer offers the reconstructive surgeon increased flexibility in head and neck reconstruction. The variety of available flaps and the inherent differences within them are the most valuable differences between these techniques and traditional pedicled flaps. Free flaps allow the surgeon to specifically tailor the reconstruction to match the particular demands of each individual case. These procedures are associated with improved patient outcome and acceptable donor site morbidity. Success rates in established centers are excellent. This course is designed to introduce the clinician to the benefits of microsurgical reconstructive techniques and provide a basis of understanding in regard to the planning and conduct of these techniques in head and neck reconstruction. A systematic, clinically useful methodology for the application of these techniques is presented. Definition of the requirements of the reconstruction is based on the characteristics of the anticipated defect. The clinician is provided with parameters useful in the establishment of an appropriate set of goals for the reconstruction. An understanding of the characteristics of specific flaps, and their inherent advantages and disadvantages, is supplied to assist the surgeon in treatment planning. Specific case examples are presented that cover the spectrum of defects most commonly encountered in head and neck reconstruction and reinforce the clinician’s understanding of the role of free tissue transfer in head and neck reconstruction. The clinical cases emphasize the rationale for the selection of specific techniques in each particular circumstance to offer the best outcome with the least morbidity. AAOMS
Diagnosis and Treatment of Head and Neck Skin Malignancy Thomas J. Teenier, DDS, MD, New Orleans, LA James Eyre, DMD, MD, Portland, OR I. Clinical caveats in the clinical diagnosis of nonmelanotic skin malignancy II. Melanoma III. Biopsy technique a. Shave b. Punch c. Incisional d. Excisional IV. Ablative technique a. Electro desiccation and curettage (ED&C) b. Topical chemotherapy c. Radiation d. Laser e. Cryo f . Excision g. Mohs V. Reconstruction a. Primary closure b. Secondary intention/granulation c. Skin grafting d. Composite grafting e. Random flap f . Axial flap g. Free flap VI. Follow-up/surveillance protocol
S307 Craniomaxillary Trauma Management Stuart N. Kline, DDS, Miami, FL Mark R. Stevens, DDS, Miami, FL A. History of midfacial trauma 1. Dinosaurs 2. ‘‘What Is In?’’ B. Skull base craniomaxillary fractures 1. Principles 2. Access incisions 123
Surgical Clinics 3. 3 E’s—Expose, Explore, Evaluate 4. Spatial Relations 5. Soft Tissue Considerations 6. Dislocated Bone vs. Nondislocated Bone C. Clinical Treatment of Skull Base Craniomaxillary Fractures 1. Physical Evaluation 2. Review of CT Scans 3. Stable Points of the Cranial Base 4. Horizontal and Vertical Buttresses D. NOEF (Naso-Orbital-Ethmoidal-Frontal) 1. Anatomy of the Frontal Sinus 2. The Importance of the Frontal Bar 3. Zygomatic Arch Points the Way 4. Application of Spatial Relations E. Clinical cases
endoscopic brow lifting techniques will also be discussed. At the end of this presentation, the attendees should have a basic knowledge of the indications and techniques described and apply them to the initiation of these procedures in their practice. References Carruthers J, Carruthers A: Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 18:17, 1992 Niamtu J: The cosmetic use of botulinum toxin A in oral and maxillofacial surgery. Submitted for publication in the Journal of Oral and Maxillofacial Surgery, 2-98 Tobin AT, Karas ND: Lip augmentation using alloderm graft. J Oral Maxillofac Surg 56:722, 1998
S309 S308 Low-Risk/High-Yield Facial Rejuvenation Techniques Joseph Niamtu III, DDS, Richmond, VA All doctors have an obligation to their patients to provide the latest advances in their specialty. Oral and maxillofacial surgery has expanded exponentially in terms of scope of practice. Cosmetic facial surgery represents contemporary oral and maxillofacial surgery and is being taught in our residency programs, is part of our boards, and is covered by AAOMS National Insurance Company. Adding cosmetic facial surgery to one’s practice can be intimidating and is best pursued by the initial performance of predictable, low-risk/high-yield procedures. These surgical techniques offer significant improvement for the patient and a comfort level for the surgeon. The surgeon can expand on these techniques at his or her own pace and progress to more comprehensive procedures. Various minor modifications of existing anesthetic techniques and equipment is a primary step, followed by the initiation of a basic skin care program to educate patients in need of rejuvenation procedures. Marketing of these techniques will be discussed. Chemical peeling, CO2, and Erbuim laser resurfacing, Botox injections, Gore-Tex facial implants, fat transfer, liposuction, collagen injectables, acne treatment and surgery, diagnosis and ablation of facial lesions and teleangectasias, and earlobe repair will be discussed. These basic topics will be presented in a sequence of indication, technique, and complications. The advancement to and incorporation of basic blepharoplasty and 124
Laser-Assisted Skin Resurfacing and Blepharoplasties Steven A. Guttenberg, DDS, Washington, DC Ever since carbon dioxide (CO2) laser use began in dentistry in the 1960s, there has been a continual evolution of the technology. Scientific advances in laser science have allowed the production of higher energy levels and pulse widths of less than the thermal relaxation time of skin. This has allowed the CO2 laser to be used in the treatment of facial skin without concomitant buildup of unnecessary heat, which could damage tissue and cause unwanted scarring. In the early 1990s, reports in the scientific community began emerging that touted the use of this laser modality to perform skin resurfacing procedures in much the same way that we had been in the past using chemical peeling agents and rotary instrument dermabrasion. In addition, practitioners began to use the laser as a tool to more effectively perform blepharoplasties. The high-power, rapidly pulsed CO2 laser has been found to produce results superior to those previously attained with dermabrasion and chemical peeling for skin resurfacing. With this treatment, facial rhytids produced by changes in the skin secondary to ultraviolet radiation and the normal aging process, can be eliminated. Histologically these alterations are noted as thickened, basket-woven stratum corneum, thinner, more atrophic epidermis, epidermal atypia, irregular melanin dispersion throughout epidermis, decreased glycosaminoglycans in the dermis, and abnormal-appearing elastic fibers in the dermis. This wrinkle-ablating therapy is accomplished in 2 ways: Water is the chromophore for CO2 laser energy. Epidermis contains approximately 70% water. Therefore, when skin is lased, the epidermis and the superficial dermis are ablated. Significantly, this is accomplished in a AAOMS
Surgical Clinics manner that is more precise and less injurious to the adjacent tissues than other techniques. In the normal healing process, new epidermis, without wrinkles, is produced. The second action of the laser to bring about smooth skin arises from the stimulation of the dermis, producing new collagen production, bonding of adjacent collagen strands, and shrinking of existent collagen fibers, all of which produce skin that is smooth and younger appearing. Because the goal of laser abrasion is to produce new, healthy skin, certain concepts related to healing should be appreciated so that we may perform our clinical procedures to enhance the biologic process based on science and not anecdotal observations. After injury, epithelial healing begins within 12 hours. Keratin formation stops, and horizontal migration and proliferation of epithelial cells begin. To facilitate skin repair without scarring, transected adnexal appendages provide a source for vertical migration of additional epithelial cells. The initial attachment of this new epidermis to the underlying dermis is weak and must be treated gently. The speed of healing and to some measure the quality of skin regeneration is proportional to the pilosebaceus density and not the size of wound. Hence, wounds on the face heal much more quickly and aesthetically than those on the chest and extremities. The most important concept to assist reepitheliazation is providing the proper substrate for epidermal migration. Epidermis will only migrate over type I, IV, or V collagen, fibronectin, or laminin. It will not migrate over dry crust, desiccated collagen, neutrophils, or wound debris. In addition, healing is slowed by dryness, crust, caustics, hemostatic agents, some antiseptics (0.5% chlorhexidine, 1% povidone-iodine, 3% H2O2, gentian violet), radiation within 24 hours, lower than normal temperatures, infection, steroids (topical 1% hydrocortisone is OK), and significant vitamin deficiencies. Clearly, these conditions must be avoided. Schemes can be followed that will diminish healing time. Topical retinoic acid, applied for 10 days before the resurfacing procedure, may speed epitheliazation, but if applied to a fresh wound may inhibit. Healing also may be enhanced by oil and water creams, antibiotic ointments, 10% and 20% benzoyl peroxide solution, and an ointment composed of a nonsteroidal bovine-derived, collagen/acid mucopolysaccharide complex. In conclusion, high-energy, rapidly pulsed lasers have been shown to be an excellent modality for the safe removal of facial rhytids and for precise and nearly bloodless blepharoplastic surgery. This occurs by action of the laser to: remove the epidermis and some dermis; stimulate collagen formation; shorten collagen strands by one third; weld collagen fragments; and to coagulate small diameter blood vessels. The result is rejuvenated tightened skin, improved appearance, and possibly enhanced vision. AAOMS
S310 Experience With an Intraoral, Preprogrammed, Tooth-Borne Distractor for Orthognathic Procedures Stuart Dessner, DDS, Arlington Heights, IL Yan Razdolsky, DDS, Buffalo Grove, IL Orthopedic surgeons have long known that morphology and dimension of long bones can be changed by using distraction osteogenesis techniques. Gavriel Ilizarov, MD, of Kurgan, Russia, presented his famous research illustrating bone-lengthening devices in New York in 1988. Since that time, efforts have been made to develop devices to facilitate distraction osteogenesis of facial bones. Many efforts with respect to distraction osteogenesis have focused on treatment of major facial anomalies such as hemifacial hypertrophy and mandibular deficiency syndromes. Most of these devices comprise transcutaneous pins and extraoral distractors. Technology for development of miniaturized distractors has arrived and now stimulates new efforts using intraoral and tooth-borne appliances. Preprogrammed intraoral tooth-borne devices have been used to correct mandibular retrognathia along planned vectors parallel to the sagittal plane. Investigations are under way to demonstrate whether forces applied by distraction devices move teeth or promote osteogenesis. This study investigates the efficacy of using various custom distraction devices. Several surgical approaches and distractor modifications were used. Bone markers were placed adjacent to the corticotomy to measure and distinguish skeletal from dental movement as a result of distraction. Distraction was accomplished within the dental arch and behind the dental arch. Distraction osteogenesis performed within the dental arches both increases arch length and creates space for orthodontic alignment and provides for skeletal correction. The results of this study and others will show that distraction osteogenesis should be considered part of the oral surgeon’s armamentaria in the treatment of major anomalies of the facial skeleton. Indeed, orthognathic corrections using distraction osteogenesis procedures will be performed as an office procedure.
References Ilizarov GA: The principles of the Ilizarov method. Bull Hosp Joint Dis 48:1, 1988 Molina F, Ortiz-Monasterio F: Mandibular elongation and remodeling by distraction: A farewell to major osteotomies. Plast Reconstr Surg 96:825, 1995 Guerro C, Costasti G: Transverse mandibular deficiency, in Bell (ed): Modern Practice in Orthognathic and Reconstructive Surgery (ed 3). Philadelphia, PA, Saunders, 1992, p 2383
S311 Evaluation and Management of Facial Asymmetries Nestor D. Karas, DDS, MD, San Francisco, 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, 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 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
S312 Mandibular Block Autografts: Avoiding Functional and Aesthetic Pitfalls Michael A. Pikos, DDS, Palm Harbor, FL Autogenous block grafting must be integrated into treatment planning by today’s implant surgeon to effectively treat patients with compromised implant sites. This clinically oriented lecture will draw from the author’s experience with more than 200 block autografts over an 8-year time frame and will include results of a 5-year retrospective study of 98 patients, 115 grafts, and 126
206 implants. The indications, contraindications, surgical protocol, histology, complications, and 5-year retrospective study data will be analyzed to feature the art and science of autogenous block grafting. Both symphysis and ramus buccal shelf donor sites will be compared and contrasted. In addition, both anterior and posterior maxillary and mandibular recipient sites will be featured in detail. Comprehensive case studies will highlight the advantages and predictability of this surgical grafting technique. References Pikos MA: Lateral ridge augmentation using monocortical autografts: a five-year retrospective study of 98 patients (submitted for publication) Sindet-Pedersen S, Enemark H: Reconstruction of alveolar clefts with mandibular or iliac crest bone grafts: A comparative study. J Oral Maxillofac Surg 48:554, 1990 Misch CM: Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implant 12:767, 1997
S313 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 use 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. Although 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. Conversely, 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 all maxillofacial regional flaps, the temporalis muscle is the most commonly used because of its reliability, vascularity, adequate bulk, and its proximity to defects in the oral and maxillofacial region. The flap can be used as a myofascial, myo-osseous, or as myo-osseocutaneous flap. The versatility of this flap permits its use in reconstruction of congenital and acquired defects of the orbit, maxilla, retromolar area, palate, the mandible, floor of the mouth, the oropharynx, and the base of the skull. The muscle can provide an abundant mobile tissue for AAOMS
Surgical Clinics reconstruction of these defects while lacking the functional morbidity or aesthetic deformity of the donor site. Finally, with adequate knowledge of the surgical anatomy of the temporal region, the surgical technique for harvesting and transferring the muscle is generally straightforward. The aim of this clinic is to review the surgical anatomy, and discuss the surgical technique, indications, advantages, and disadvantages of the temporalis flap in reconstruction of oral and maxillofacial defects. A number of cases will be used for illustrative purposes.
step-by-step approach to surgical correction of posttraumatic nasal deformities. Prevention, avoidance, and management of common complications will be reviewed. An extensive handout, including ICD-9/CPT codes, rhinoplasty worksheets, and classic articles, will be provided.
Alonso del Hoyo J, 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 B: Versatility of temporal muscle flaps. Br J Oral Maxillofac Surg 41:118, 1988 Bradley P, Brockbank J: The temporalis muscle flap in oral reconstruction: A cadaveric, animal and clinical study. J Maxillofac Surg 9:139, 1981
Tardy ME, Schwartz M, Parras G: Saddle nose deformity. Facial Plast Surg 6:121, 1989 Posnick JC, Seagle MB, Armstrong D: Nasal reconstruction will full-thickness cranial bone grafts and rigid internal-skeletal fixation through a coronal incision. Plast Reconstr Surg 86:894, 1990 Constantian MB, Clardy MB: The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinolplasty. Plast Reconstr Surg 98:38, 1996 Werther JR: External rhinoplasty approach for repair of posttraumatic nasal deformities. J Craniomaxillofac Trauma 2:12, 1996 Werther JR, Freeman JP: Changes in nasal tip projection and rotation after septo-rhinoplasty. A cephalometric analysis. J Oral Maxillofac Surg 56:728, 1998
Principles and Practice of Radiofrequency Volumetric Tissue Reduction for Treatment of Obstructive Upper Airway Pathology
John R. Werther, DMD, MD, Nashville, TN The nose is the most frequently injured facial bone. It has been estimated that up to 40% of primary repair of nasal injuries are suboptimal from a functional and aesthetic standpoint. Not surprisingly, the main reasons patients seek subsequent nasal surgery are to relieve nasal airway obstruction and to improve external appearance. Careful evaluation and documentation of the internal and external nasal anatomy, evaluation of the airway, and review of radiographs are necessary to generate a comprehensive treatment plan. Photographic analysis and computer video imaging are helpful in planning procedures and allow for visual communication with the patient as to what can and cannot be achieved by surgery. The goal of surgical planning is to design a functional and cosmetic repair, ideally in a single operation. Typically, complex nasal reconstruction is delayed 6 to 12 months from the time of the original injury to allow for resolution of edema and scar maturation. Although open or closed approaches to the nasal skeleton can be used, the external rhinoplasty approach is recommended for maximum visualization of complex deformities. Saddle nose deformity, septal deviation, crooked nose deformity, nasal tip asymmetry, and nasal airway obstruction are the most common posttraumatic nasal deformities. Each of these areas will be reviewed in detail, with emphasis on rational selection of procedures and reconstructive materials to be used for repair. Case examples will be presented for discussion and will illustrate a AAOMS
Kent E. Moore, DDS, MD, Charlotte, NC Radiofrequency volumetric tissue reduction (RVTR) is an emerging new surgical method that uses radiofrequency heating to create targeted tissue ablation, resulting in volumetric tissue reduction. RVTR uses very low levels of radiofrequency energy to create small, finely controlled necrotic lesions in soft tissue structures. After the general pattern of wound healing, the necrosis leads to scar formation and retraction of tissue, resulting in an overall reduction of tissue volume in the treated area. Over time, the scar tissue is partially resorbed by the body, causing further volumetric reduction. Like other treatment methods using radiofrequency energy, RVTR works by making the patient part of an electrical circuit and requires that a return electrode be placed on the patient. Operating at low power (2 to 10 watts) and low voltage (⬃80 volts), RVTR differs fundamentally from electrocautery, which is typically applied at very high power levels (in excess of 100 watts) and high voltage (up to 800 volts). RVTR only raises tissue temperature to the 60° to 90°C range, limiting heat dissipation and damage to adjacent tissue. In contrast, tissue temperatures generated by electrocautery, diathermy, and laser energy are significantly higher (750° to 900°C) and can result in heat propagation in excess of therapeutic need that may injure surrounding tissue. 127
Surgical Clinics RVTR has been studied extensively by specialists in cardiology, neurosurgery, and urology during the past two decades. It has demonstrated acceptable efficacy, safety, and reproducibility of treatment results. New applications of radiofrequency energy in the treatment of upper airway obstructive pathologies have recently become available. Traditional techniques for treating these disorders are often invasive, inconvenient (associated with low compliance), and may involve significant morbidity. Although long-term data surrounding efficacy and treatment results are pending, RVTR therapy offers a minimally invasive and convenient new treatment alternative for patients suffering from these disorders. References Powell NB, Riley RW, Troell RJ, et al: Radiofrequency volumetric tissue reduction of the tongue. Chest 111:1348, 1997 Powell NB, Riley RW, Troell RJ, et al: Radiofrequency volumetric tissue reduction of the palate in subjects with sleep-disordered breathing. Chest 113:1163, 1998 Organ LW: Electrophysiologic principals of radiofrequency lesion making. Appl Neurophysiol 39:69, 1976/77
A patient-fitted alloplastic total TMJ reconstruction prosthesis has been developed that is designed to fit the specific anatomy found in these difficult cases without the need for altering the components or adding potentially nonbiocompatible substances to make them fit. This has been achieved by marrying the concepts of computed tomography (CT) and stereolaser lithography in the development of an anatomical model for each case on which a patient-fitted total TMJ reconstruction prosthesis can be designed, developed, and manufactured. The device is therefore made specifically for the anatomic situation presented to the surgeon. This means it will fit the available bone, be able to achieve maximum stability, and, because it is designed specifically for the anatomic situation found in each specific case, it will withstand the loads placed on it over time. The components of the TMJ Concepts Patient-fitted Total Temporomandibular Joint Reconstruction Prosthesis are those that have been used successfully for decades in orthopedic surgery to reconstruct knees, hips, and shoulders.
S316 Total Alloplastic TMJ Reconstruction With a Patient-Fitted System Louis G. Mercuri, DDS, MS, Maywood, IL Alloplastic total temporomandibular joint reconstruction is a mechanical rather than a biologic solution to severe joint disease. Although autogenous temporomandibular joint (TMJ) reconstruction is still considered the ‘‘gold standard’’ for the initial reconstruction of the temporomandibular joint, there are situations in which alloplastic reconstruction offers more predictable results. Such situations are rheumatoid and other systemic arthritic conditions in which autogenous and allogeneic tissues have been unpredictable; functionless, anatomically mutilated, multiply operated temporomandibular joints; joints degenerated by Proplast-Teflon, silicone rubber, or other failed alloplasts; severe bony ankylosis or degenerative joint diseases; and other severe joint pathology. The ability of an alloplastic joint replacement to withstand the forces placed on it over time is directly related to how well it is adapted and fixated to the available bone to which it is attached. In cases described above, it is often very difficult to make stock or off-theshelf alloplastic devices fit and function properly. For them to be fitted to available bone, these devices either have to be bent, weakening the metal, or shimmed or grouted with methylmethacrylate, creating potential for failure and foreign body reaction. 128
Mercuri LG, Wolford LM, Sanders B, et al: Custom CAD/CAM total temporomandibular joint reconstruction system: Preliminary multicenter report. J Oral Maxillofac Surg 53:106, 1995 Wolford LM, Cottrell DA, Henry CH: Temporomandibular joint reconstruction of the complex patient with the Techmedica custommade total joint prosthesis. J Oral Maxillofac Surg 52:2, 1994 Henry CH, Wolford LM: Treatment outcomes for temporomandibular joint reconstruction after Proplast-Teflon implant failure. J Oral Maxillofac Surg 51:352, 1993
S317 Basic Technique of Submental Liposuction Vincent B. Ziccardi, DDS, MD, Newark, NJ Norman J. Betts, DDS, MS, Ann Arbor, MI 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 cervical-mandibular contours create neck and facial definition, 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 agerelated changes. Submental liposuction works through the removal of fat close to the undersurface of the overlying skin, leading to contraction and permanent changes in conAAOMS
Surgical Clinics tour. 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, 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 or implant reconstruction will be presented because 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
S318 Rhytidectomy: A Practical Outpatient Approach G.E. Ghali, DDS, MD, Shreveport, LA As oral and maxillofacial surgeons, we are in a unique position to evaluate and definitively manage patients seeking facial rejuvenation. Maxillofacial aesthetic reconstruction represents a natural extension of and complement to our orthognathic skills. With few exceptions, most decisions regarding the selection of a specific orthognathic surgical procedure are predicated on existing facial aesthetics in conjunction with occlusal and cephalometric analyses. Furthermore, the oral and maxillofacial surgeon is able to provide aesthetic services on a routine basis in an outpatient setting. Because most offices are equipped for intravenous and deep sedation, very little additional on-site preparation is necessary to provide this service in a safe and cost-effective manner. In recent years, a multitude of techniques have been introduced to improve the long-term results of rhytidectomy. Oftentimes, these techniques are more time consuming, more technically difficult to perform, and potentially associated with increased morbidity. With this in mind, we will focus on the superficial plane rhytidecAAOMS
tomy procedure. We believe that this technique is readily adaptable to many outpatient oral and maxillofacial surgery practices. We will discuss patient selection, anesthetic technique, operative technique, postoperative management, and complications associated with facelifting procedures.
S319 New Concepts in Orthognathic Surgery Larry M. Wolford, DDS, Dallas, TX Surgical techniques in orthognathic 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 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: I. Genioplasty A. Porous block HA and HTR augmentations B. Tenon and mortise osseous genioplasty II. Anterior mandibular subapical osteotomy III. Mandibular body osteotomy A. Anterior B. Posterior IV. Mandibular ramus sagittal split modifications A. Ramus and inferior border osteotomy B. Rigid fixation V. Maxillary osteotomy modification A. Maxillary step osteotomy and rigid fixation B. Porous block HA grafting VI. Double-jaw surgery A. Selective alteration of the occlusal plane B. Surgical sequencing of the maxilla and mandible C. Model surgery modifications VII. Simultaneous orthognathic surgery and rhinoplasty A. Surgical sequencing B. Rhinoplasty techniques 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: The use of porous block hydroxyapatite, chap 28, Part II, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, 1992 Wolford LM, Chemello PD, Hilliard FW: Occlusal plane in orthognathic surgery. J Oral Maxillofac Surg 51:730, 1993 Cottrell DA, Wolford LM: Altered orthognathic surgical sequencing and a modified approach to model surgery. J Oral Maxillofac Surg 52:1010, 1994
S320 Guided Tissue Regeneration in Jaw Reconstruction: Review and Applications
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.
Pamela L. Alberto, DMD, Sparta, NJ References
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 were the development of many first-generation and second-generation membrane barriers. The current first-generation barriers available are GoreTex and TefGen. Both are made from 100% medicalgrade polytetrafluoroethylene, but they differ in that TefGen is full density and is impervious to bacteria. Gore-Tex is expanded polytetrafluoroethylene (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 to saline for approximately 15 minutes before final placement. 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 resorbes 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 membranes barriers are being developed that are impregnated with polypeptide growth factors, including platelet growth factor, insulin-like growth factor, transforming growth factor-␤, 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 by using biodegradable second-generation membrane, the dilemma arises in not 130
Becker W, Becker B: Clinical applications of guided tissue regeneration: Surgical considerations. Periodontology 2000 1:46, 1993 O’Neal R, Wang H, MacNeal RL, et al: Cells and materials involved in guided tissue regeneration. Current Opin Periodontol 141, 1994 Jovanovic SA: Bone rehabilitation to achieve optimal aesthetics. Pract Periodontics Aesthet Dent 9:41, 1997
S321 Skin Graft Vestibuloplasty: A Simplified Stentless Technique Hillel D. Ephros, DMD, MD, Paterson, NJ Meredith Blitz, DDS, Paterson, NJ The split-thickness graft (STSG) vestibuloplasty with lowering of the floor of the mouth has been downplayed in recent years. This may be attributable in part to the emergence of implant dentistry as a safe and reliable modality for many patients. Moreover, the traditional STSG vestibuloplasty is a difficult and lengthy procedure that requires fabrication of a surgical stent. It is associated with significant morbidity and postoperative discomfort. The modified procedure does not rely on a stent, is relatively simple, and generally can be completed in under one and one half hours. Patients consistently experience only minimal postoperative discomfort and significant improvements in vestibular morphology are achieved and maintained in nearly every case. Complications related to the use of a stent are eliminated. A cumulative experience of more than 850 cases over 20 years has evolved a technique that is adaptable to a variety of clinical conditions. Patients with unfavorable soft tissue attachments, alveolar bone resorption, or difficulty functioning with existing prostheses may be candidates for treatment. The mandibular labial vestibule may be treated alone or in combination with lowering of the floor of the mouth. The procedure is also easily adaptable for use in the maxillary vestibule. There are few medical or surgical contraindications to the procedure. Complications are infrequent and are almost always eminently manageable or resolve without intervention. These include graft loss, unwanted hair growth, submental abscess, transient sensory deficit, exposed lingual bone, and granulations. At the donor site, superficial infection and keloid formation have been noted. There are many patients for whom implant-borne prostheses are not a feasible prosthetic goal. In others, when implants are used, there may still be a need to AAOMS
Surgical Clinics modify vestibular morphology. The stentless technique described above yields reliable long-term improvements with minimal morbidity and excellent patient acceptance. There is also evidence to suggest that alveolar bone resorption may be slowed in patients who have undergone this procedure. Early results using allogeneic dermis in place of autogenous skin are being compiled and will be reported. References Starshak TJ, Sanders B: Preprosthetic Oral and Maxillofacial Surgery. St. Louis, MO, Mosby, 1980, pp 165-213 Samit AM, Popowich L: Mandibular vestibuloplasty: A clinical update. Oral Surg 51:141, 1982 Samit AM, Kent K: Complications associated with skin graft vestibuloplasty: Experiences with 100 cases. Oral Surg 56:586, 1983
the loss of self-confidence and self-esteem of these patients by improving their quality of life. References 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: Functional and cosmetic reconstruction of the facial lower third associated with placement of the transmandibular implant system. J Oral Maxillofac Surg 54:934, 1996 Powers MP, Maxson BB, Scott RF, et al: The transmandibular implant: A 2-year prospective study. J Oral Maxillofac Surg 47:679, 1990
S323 TMJ Arthroscopic Surgery: Rationale, Treatment, and Management
Jeffrey J. Moses, DDS, Encinitas, CA
Soft Tissue Challenges With the Edentulous Mandible Hans Bosker, DDS, PhD, Haren, The Netherlands Michael P. Powers, DDS, MS, Cleveland, OH One of the consequences of mandibular atrophy is the loss of attachment of the facial muscles that originate from the alveolar process and basal bone. With the loss of the origins of the mentalis and incisivus labii inferioris muscles, the medial part of the lip turns inward, the vermilion is reduced, the patient is unable to pout, and the chin drops. The partial loss of the origin of the buccinator muscle causes a reduction in the width of the mouth, an inability to open the mouth properly when laughing or crying, and it would make playing a wind instrument difficult. The loss of the origin of the depressor labii inferioris muscles weakens the mouth and causes the lips to sink inward, resulting in reduction in the width of vermilion laterally and the development of rhagades. Another consequence is a loss of vestibular depth and reduction in the width of the attached gingiva. The result is reduced ability to chew, a changed and aged appearance, difficulties with pronunciation, and a reduced range of expressions. The traditional goal of treatment has been to improve the ability to chew. Using a submental incision, a technique was developed by which all these functions can be improved by a combination of functional reconstruction of the facial muscles and position of the lips and insertion of implants. When the muscles are repositioned, the buccal vestibule is deepened, and the incidence of gingival hyperplasia and infrabony pockets along the implants is eliminated. This treatment, which also rejuvenates the face and improves the ability to speak, should help to overcome AAOMS
Surgical considerations of anatomic structures will be discussed from a morphologic development viewpoint, as well as relationships to pathologic indications for surgery and potential complications. TMJ dysfunction will be discussed, relating current concepts in pathophysiology and the differential diagnosis for disease progression states. Specific therapeutic modalities for each pathologic condition discussed will be correlated. All aspects of preoperative management will be covered, along with surgical techniques of diagnostic and surgical TMJ arthroscopy. Included will be some advanced techniques of triple puncture, eminoplasty, and percutaneous transillumination technique, as well as endaural visualization and puncture technique. The use of Holmium-Yag laser in the treatment of TMD and disc-related disorders will be reviewed and emphasized as well as discussion of the obstructive disc phenomenon (ODP) and the functional laser-assisted discectomy technique. Research correlation of MRI, arthrograms, and arthroscopic findings illustrating the diagnostic value of arthroscopic surgery along with long-term follow-up and tomographic evaluation will be presented. Timing of TMJ surgery in conjunction with patients requiring orthognathic surgery will be discussed as well as when simultaneous procedures may be used. References Moses JJ, Poker ID: Temporomandibular joint arthroscopy: The endaural approach. Int J Oral Maxillofac Surg 18:347, 1989 Moses JJ, Sartoris D, Glass R, et al: The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ disc position and mobility. J Oral Maxillofac Surg 47:674, 1989 Moses JJ, Topper DC: A functional approach to temporomandibular joint internal joint derangement. J Craniomandib Disord 5:19, 1991
S324 How To Apply an External Fixator: Indications and Uses
Haug R, Schwimmer A: Fibrous union of the mandible: A review of 27 patients. J Oral Maxillofac Surg 52:832, 1994 Morris JH: Biphase connector, external skeletal splint for reduction and fixation of mandibular fractures. Oral Surg 2:1382, 1949
Gregory W. Hueler, DDS, Minneapolis, MN Karl H. Andreasen, DDS, Minneapolis, MN With the advent and general acceptance of internal rigid fixation for the treatment of mandible fractures, discontinuity defects, mandibular infections related to open reduction and internal fixation (ORIF), etc, the use of the external fixator has greatly declined. There are cases, however, in which this device is useful for stabilization of the mandible. It offers an alternative treatment modality that can be quite useful in certain instances. The external fixator avoids periosteal stripping and yet accomplishes the same primary goal as internal fixation; it allows fixation and stabilization of bony fragments, as well as bridging of continuity defects. It is a closed technique and hence preserves or minimally disrupts the blood supply to the host bone. It also offers several other advantages over internal fixation. Placement of the device takes a short amount of time, the alignment of the bony segments can be altered during treatment if needed, and the fixator is easy to remove at the completion of treatment. Numerous indications for external fixation have been advocated. These include infected open comminuted fractures, fractures with extensive bone loss, gunshot fractures, edentulous fractures, pathologic fractures, open fractures in multiply injured patients, temporomandibular joint (TMJ) resections, osteomyelitis with failing internal fixation, and initial fixation after mandibular resection. There are several components to the external fixation device. These include bone screws that screw into the bone through a transcutaneous incision, connectors that connect the screws to the external bar, and the external bar, which is the first phase in the application of the device. Once this has been placed and adjusted, a less cumbersome bar is fabricated from acrylic, and the first phase bar is removed. Several general guidelines exist. The first is to place at least 2 screws in each bony fragment. Second, these 2 screws should be placed a maximum distance apart in each bone fragment. The external connecting bar should be placed as close to the bone as is clinically possible. Setting up the first phase fixator before screw placement is advantageous. As with all mandibular reductions, proper occlusion needs to be confirmed before final acrylic bar placement. References Finn R: Treatment of comminuted mandibular fractures by closed reduction. J Oral Maxillofac Surg 54:320, 1996
S401 Perioperative Anesthetic Management of the Geriatric Patient Martin R. Boorin, DMD, New Hyde Park, NY (no abstract provided)
S402 Transconjunctival Lower Lid Blepharoplasty Using the Four-Step Method: 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, transconjunctival 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.
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
S403 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 Peptostreptococci. 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 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 oral and intravenous routes. 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, May 1991 Gilmore WC, Jacobus NV, Gorbach SL, et al: A prospective doubleblind evaluation of penicillin versus clindamycin in the treatment of odontogenic infections. J Oral Maxillofac Surg 46:1065, 1988
S404 Management of the Difficult Alveolar Cleft Hillel D. Ephros, DMD, MD, Paterson, NJ Robert J. DeFalco, DDS, Paterson, NJ First described in 1972 by Boyne and Sands, alveolar bone grafting has become part of the standard of care in AAOMS
the habilitation of patients with cleft lip and palate. Much debate has been generated about the timing of this procedure. The embryologic origin of the donor bone and the site of its harvest are also issues that continue to receive a great deal of attention. On many cleft palate/craniofacial teams, surgicalorthodontic management of the alveolar cleft has become quite routine. A good number of cases follow closely the standard descriptions found in various texts and journal articles. However, many cases pose significant challenges, and these patients may benefit from treatment modifications. It is very important to recognize these potential problems during the presurgical evaluation so that they can be addressed properly at the time of surgery. Several factors may contribute to loss of part or all of an alveolar bone graft. Among these are inadequate soft tissue closure, movement across the cleft site(s), occlusal trauma, food impaction, and closure line exploration by the patient’s tongue. There are cases in which traditional techniques for providing nasal and oral mucosal closure will prove inadequate. Unusually wide clefts, certain bilateral clefts, and cases of premaxillary amputation may require alternative solutions to achieve adequate soft tissue coverage. The position and the mobility of the premaxillary segment may complicate the management of some bilateral cases. It may be beneficial to employ techniques for stabilization and unloading of the premaxilla in these cases. Interference with soft tissue healing by food debris or an active tongue may complicate the postoperative period even on seemingly straightforward cases. The use of a protective wound covering may help to prevent these complications and to preserve the surgical result. The management of difficult clefts begins with a thorough team evaluation and good presurgical preparation. Once a potential problem is identified, treatment modifications designed to improve the likelihood of success can be implemented. Early results with several of these techniques are quite encouraging. References Boyne PJ, Sands NR: Secondary bone grafting of residual alveolar and palatal clefts. J Oral Surg 30:87, 1972 Hall HD, Werther JR: Conventional alveolar cleft bone grafting. Oral Maxillofac Surg Clin North Am 3:609, 1991 DeFalco R, Ephros H, Hall C: The tongue flap in alveolar bone grafting. Br J Oral Maxillofac Surg 5:1997 (abstr)
S405 Current Concepts in the Management of Obstructive Sleep Apnea B.D. Tiner, DDS, MD, San Antonio, TX John K. Jones, DMD, MD, Austin, TX Obstructive sleep apnea syndrome (OSAS) is a potentially disabling disorder with multiple metabolic and physiologic consequences. Afflicting as much as 4% of 133
Surgical Clinics the male population, the cost in terms of health care resources and lost productivity is staggering. Enhanced awareness and advances in diagnostic testing have resulted in improved ability to diagnose this entity as well as quantify severity. Polysomnography has emerged as the gold standard for diagnosis and evaluating the success of treatment in these patients. However, definitive determination of the level of obstruction (nasopharyngeal, oropharyngeal, hypopharyngeal) has proved elusive. Because of the inability to determine the level(s) of obstruction, treatment has been largely empirical. Despite this significant limitation, advances in diagnosis of OSAS have fostered advances in nonsurgical and surgical therapy. The mainstay of nonsurgical therapy has been continuous positive airway pressure (CPAP). Although yielding good results, compliance is poor secondary to the cumbersome nature of the equipment. Because of poor compliance, surgical therapy has assumed a more prominent role in the management of these patients. Traditional surgical therapies have included relief of nasal airway obstruction through septoplasty or turbinectomy, uvulopalatopharyngoplasty, or in extreme cases, tracheostomy. Correction of nasal airway obstruction and UPPP have yielded disappointing outcomes on follow-up polysomnography. Tracheostomy bypasses all possible sites of obstruction but has a poor acceptance rate. Because of these findings and an improving ability to evaluate these patients, orthognathic surgery has been applied to the patient population in an attempt to improve outcomes. Using a team approach to this problem and state-of-theart diagnostic methods, we have evaluated and treated 20 patients with orthognathic surgery as part of their treatment plan. Current diagnostic methods, treatment planning, surgical technique, and results will be discussed, with emphasis on the increasing role of the oral and maxillofacial surgeon in the management of patients afflicted with obstructive sleep apnea syndrome. References Riley RW, Powell NB, Guilleminault C: Obstructive sleep apnea syndrome: A surgical protocol for dynamic upper airway reconstruction. J Oral Maxillofac Surg 51:742, 1993 Waite PD, Wooten MD, Lachner J, et al: Maxillomandibular advancement surgery in 23 patients with obstructive sleep apnea syndrome. J Oral Maxillofac Surg 47:1256, 1989 Tiner BD, Waite PD: Surgical and nonsurgical management of obstructive sleep apnea, in Peterson LJ, Indresano AT, Marciani RD, et al (eds): Principles of Oral and Maxillofacial Surgery. Philadelphia, Lippincott, 1992, p 1531
S406 New Concepts in TMJ Surgery Larry M. Wolford, DDS, Dallas, TX Surgical techniques in temporomandibular joint (TMJ) surgery have and will continue to undergo modifications 134
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: 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
S407 Craniofacial Trauma Mark A. Egbert, DDS, Seattle, WA Joseph F. Piecuch, DMD, MD, Avon, CT Optimal surgical management of craniofacial trauma begins with a thorough understanding of the associated anatomy and issues specific to this region. The frequent association of significant brain injury with these fractures necessitates tempering facial fracture management decisions in deference to the best interests of the neurosurgical outcome. An understanding of brain injuries and the neurosurgical implications of orbital roof, cribiform plate, and other communicating facial fractures is therefore required. Frontal sinus management options must be understood and a rational approach to decision making applied. Coordinating efforts with the neurosurgery colleague is critical, because the optimal result for each specialty concern will frequently require a combined surgical procedure. The sequencing and timing of each specialist’s portions of the reconstruction must be planned and understood, and it may be necessary to combine as a team for certain components. We will AAOMS
Surgical Clinics discuss the team approach that works well in our institutions, and its rationale. The oral and maxillofacial surgeon who will manage these fractures must have many and varied skills with incision and flap design, bone grafting, and internal fixation techniques. We find that our neurosurgery colleagues have little interest in the aesthetic implications of their coronal flap designs or placement. It is our practice therefore, in combined cases, to design and raise the coronal flaps ourselves. Our incision and flap designs address the issues not only of adequate exposure and access for facial fracture management, but also for the neurosurgical concerns such as the maintenance of a pericranial flap to allow placement into anterior cranial fossa. The oral and maxillofacial surgeon’s attention to taking down temporalis muscles in as atraumatic a fashion as possible when required for the craniotomy access will save ourselves and our patients numerous unnecessary procedures for the release of associated postcraniotomy restriction of mouth opening. We present the rationales and the techniques of managing these fractures that work well in our hands. A series of cases will provide the background for our discussion. References Gruss J, Bubak P, Egbert M: Craniofacial fractures: An algorithm to optimize results. Clin Plast Surg 19:195, 1992 Stanley RB, Becker TS: Injuries of the nasofrontal orifices in frontal sinus fractures. Laryngoscope 97:728, 1987 Gonty AA, Marciani RD, Adornato DC: Management of frontal sinus fractures: A review of 33 cases. J Oral Maxillofac Surg 57:372, 1999 Stanley RB: J Oral Maxillofac Surg 57:380, 1999
S408 Recognition and Management of Anesthetic Adverse Events and Complications Jeffrey D. Bennett, DMD, Farmington, CT (no abstract provided)
S409 Practical Application for Flap Reconstruction of the Maxillofacial Region Andrew W. Baker, BDS, MBChB, FRCS, Derbyshire, United Kingdom G.E. Ghali, DDS, MD, Shreveport, LA I. Introduction A. Indications AAOMS
1. Tumor 2. Trauma 3. Congenital B. Classification 1. Local 2. Regional 3. Distant a. Pedicled b. Free Local Flaps A. Specific types B. Defect analysis C. Case selection/examples Regional A. Specific types B. Defect analysis C. Case selection/examples Distant A. Pedicled B. Free Summary A. Postop considerations B. Complications
S410 Intraoperative Diagnosis of Condylar Sag Johan P. Reyneke, BChD, MChD, Rivonia, South Africa A cardinal goal of orthognathic surgery is to establish maximal interdigitation of the teeth while both condyles are in a functional and stable relation to the articulating disc and glenoid fossa. A malocclusion is often apparent shortly after intraoperative removal of intermaxillary fixation. The most probable causes of an incorrect occlusion at this stage are: 1. Condylar sag 2. Mobility at the osteotomy site 3. A shift of the occlusion during the placement of rigid fixation Two types of condylar sag may occur, unilaterally or bilaterally: 1. Central condylar sag 2. Peripheral condylar sag: (i) Type I—fossa contact (ii) Type II—fossa contact with torquing force on the mandibular ramus Each of the above complications will lead to a specific malocclusion. It is essential not only to recognize the problem during surgery, but also to differentiate between the various complications. This will enable the surgeon to take the indicated corrective measures at the time of surgery and by doing so prevent a possible second surgical procedure. 135
Surgical Clinics References Arnett GW, Tomborello JA, Rathbone JA: Temporomandibular joint ramifications of orthognathic surgery, in Bell WH (ed): Modern Practice in Orthognathic and Reconstructive Surgery. Philadelphia, PA, Saunders, I:523, 1992 Will LA, Joondeph DR, Hohl TH, et al: Condylar position following mandibular advancement: Its relationship to relaps. J Oral Maxillofac Surg 42:578, 1984 Stroster TG, Pangrazio-Kulbersh V: Assessment of condylar position following bilateral sagittal split ramus osteotomy with wire fixation or rigid fixation. Int J Adult Orthod Orthognath Surg 1:55, 1994
S411 Sinus Elevation/Augmentation: A Comprehensive Overview Michael A. Pikos, DDS, Palm Harbor, FL This presentation will draw from the speaker’s experience of more than 340 sinus grafts over a 10-year time frame. The surgical technique of sinus augmentation is covered in detail, including flap design, access window, membrane elevation, perforation management, and graft placement. Discussion of graft materials will also be covered as well as immediate versus delayed implant placement, selection of proper implant design and surface, progressive bone loading, healing time, and histologic evaluation. Multiple case studies will be presented to effectively demonstrate examples of comprehensive treatment planning for fixed and removable prostheses with sinus augmentation. References Timmenga NM, Raghoebar GM, Boering G, et al: Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg 55:936, 1997 Misch CE: The maxillary sinus lift and sinus graft surgery, in Contemporary Implant Dentistry (ed 2). St. Louis, MO, Mosby, 1999, pp 469-493 Pikos MA: Maxillary sinus membrane repair: Report of a technique for large perforations. Implant Dentistry 8:29, 1999
munity acknowledges the need for rigorous testing and research. Promoters of unconventional concepts and treatments, however, deny the need for scientific testing. Knowledge of the scientific literature is essential for evaluating the rapid accumulation of new medical and dental information and sophisticated marketing promotions, especially with the internet. The acceptance and popularity of unconventional practices is undeniable and used by more than 40% of the American public. OMS must be aware of this and modify established procedures to identify users of potentially harmful therapies and products that may affect or complicate OMS patients and treatments. Patient beliefs are important tools in managing chronic and incurable conditions. Understanding characteristics of unconventional care users and providers may help OMS improve the effectiveness of practice. Under some circumstances, OMS may find unconventional practices a helpful tool in patient management. Unfortunately, many unconventional products and procedures, especially in dentistry, are more invasive and harmful than established treatments. OMS must be familiar with numerous unconventional dental and medical practices to avoid risks of patient harm or disciplinary and malpractice actions. Effective patient care requires awareness of multiple risks in providing or treating with unproven modalities. This clinic will discuss ‘‘alternative/complementary’’ care, including case reports, scientific issues, medical legal issues, ethical issues, and patient care issues. Specific topics to be discussed include temporomandibular disorders, chronic pain, cancer, jaw bone cavities, herbal products, and homeopathy. References The National Center for Complementary and Alternative Medicine website. Available at http://nccam.nih.gov Zollman C, Vickers A: ABC of complementary medicine. (Series of papers) BMJ 319:693-696, 836-838, 901-904, 973-976, 1050-1053, 1115-1118, 1176-1179, 1254-1257, 1346-1349, 1419-1422, 1486-1489, 1558-1561, 1999 QuackWatch web site. Available at www.quackwatch.com
S412 Alternative/Complementary Medicine for the Oral and Maxillofacial Surgeon Burton H. Goldstein, DMD, MS, Vancouver, BC, Canada Oral and maxillofacial surgery (OMS) increasingly deals with challenges to traditional science-based practice generally termed ‘‘alternative/complementary’’ practice. Controversies range from the definition of ‘‘alternative’’ to issues of pseudoscience, junk science, quackery, fraud, and malpractice. Scientific evidence is lacking for many established OMS procedures and treatments, and the scientific com136
S413 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 because of cancer phobia, which delays diagnosis, the fear of surgery for a mass that is cosmetically detracting while not interfering with funcAAOMS
Surgical Clinics tion, 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 two 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, and 1 kg of tumor tissue is thought to be the lethal burden of tumor. Malignant tumors that double in short periods have been shown to be more sensitive to radiation therapy or chemotherapy compared with 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 radiosensitivity 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. Because debulking surgeries are known to induce the reentry of Go cells into the active cell cycle, postoperative radiation 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 often share 2 additional common denominators: the need to provide immediate soft tissue reconstruction of these defects and the production of 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 of the Oral and Maxillofacial Surgery Clinics of North America. Philadelphia, PA, Saunders, 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
S414 Treatment Planning for Implant Success Richard A. Kraut, DDS, Bronx, NY This session will present a simple, common-sense approach to everyday treatment planning for implants. From the patient’s perspective, the success or failure of an implant case rests with the prosthetic restoration, so treatment planning begins with consideration of the options that are available to the patient and the restorative doctor. We then work back through the steps necessary to achieve the desired result. A variety of scenarios will be discussed, including single tooth replacements as well as more comprehensive cases for fully or partially edentulous patients. For each scenario, we will discuss the optimum number, length, and spacing of implants. Using a case study approach, we will discuss accurate radiographic assessment techniques, including straightforward guidelines for determining when the use of CT scanning is appropriate. We will discuss current concepts of temporization, including immediately loaded implants and staged implants. This discussion will include an examination of the risks and benefits of each option. Throughout the session, the restorative costs associated with the treatment options will be discussed. References Radiological planning for dental implants, in Block MS, Kent JN (eds): Endosseous Implants for Maxillofacial Reconstruction. Philadelphia, PA, Saunders, 1995, pp 113-134 Kraut RA: Interactive CT diagnostics, planning and preparation for dental implants. Implant Dentistry 7:19, 1998
S415 Blepharoplasty for the Oral and Maxillofacial Surgeon 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 eyes are an area of great expression and among the first structures to show the results of facial aging. The rejuvenation of the eyes can have a dramatic effect on the overall appearance of the face. Blepharoplasty surgery can be a great adjunct to the modern practice of Oral and Maxillofacial Surgery. The population of the typical oral and maxillofacial surgery practice is ideal for blepharoplasty. Those patients undergoing orthognathic surgery are aesthetically minded. In addition, implant patients, preprosthetic patients, and the parents of the third molar patients often inquire about facial cosmetic surgery. The surgeon interested in blepharoplasty surgery will 137
Surgical Clinics learn the fundamentals of the procedure. The procedure will be discussed in a stepwise fashion, including preoperative appointments, the technique of the procedure, and the postoperative course. In addition, the indications, contraindications, risks, and complications will be discussed. The ideal patient and the patient to avoid will be discussed. On completion of the course, the clinician should have a good understanding of this procedure, and a great start to incorporating blepharoplasty into the practice.
References Baker TJ, Gordon HL, Stuzin JM: Surgical Rejuvenation of the Face (ed 2). St Louis, MO, Mosby-Yearbook, 1996 Tardy ME, Thomas JR, Brown RJ: Facial Aesthetic Surgery. St Louis, MO, Mosby-Yearbook, 1995
S416 Cutaneous Laser Surgery and the Management of Associated Complications William McMunn III, DDS, MD, Shreveport, LA Cosmetic laser skin resurfacing has recently become a part of the expanded scope in our profession. Removal of facial wrinkles by resurfacing of photoaged skin with the laser can be performed with minimal risk of complications. Adherence to specific clinical treatment protocols and patient selection based on appropriate indications and contraindications is necessary to achieve this goal. Laser cosmetic skin resurfacing is a deceptively simple procedure once one becomes familiar with the laser unit. A thorough understanding of anatomy, wound healing, laser physics, and preoperative and postoperative tissue management protocols are absolutely mandatory to achieve predictably good results with minimal morbidity. The various complications that may arise in the perioperative period include hyperpigmentation, hypopigmentation, scarring, persistent erythema, and development of milia cyst, to name a few. Protocols to manage these complications as well as others need to be instituted as soon as possible to prevent long-term sequelae. The surgeon must use cautious enthusiasm when treating patients and be prepared to manage complications that may arise.
References Fitzpatrick RE, et al: Pulsed carbon dioxide laser resurfacing of photoaged facial skin. Arch Dermatol 132:395, 1996 Monheit GD: Skin preparation: An essential step before chemical peeling or laser resurfacing. Cosmetic Dermatology 9:9, 1996
Bernstein LJ, et al: The short and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surgery 23:519, 1997
S417 Syringe Liposuction and Beyond Robert R. Lemke, DDS, MD, San Antonio, TX Liposuction remains a very popular cosmetic procedure. Most oral and maxillofacial surgery practices contain an unlimited source of patients who would benefit from treatment of their facial lipomatosis. Current liposuction techniques have progressively moved away from machine liposuction and more toward syringe liposuction. This technique was originally popularized by Klein and allows the infiltration of dilute local anesthetics with dilute vasoconstrictors for regional anesthesia. The tumescent technique produces an indurated surgical field with excellent intraoperative vasoconstriction and postoperative anesthesia. Reduced negative-pressure liposuction techniques have been introduced, and it is now possible to perform liposuction in a virtually bloodless field with minimal chance for postoperative bleeding or hematomas. Liposuction instrumentation has likewise been simplified, and it is now possible to perform in-office liposuction using intravenous sedation using only an infiltrator, a cannula, and a 50-mL Toomey syringe. Although liposuction techniques are commonly performed either alone or in conjunction with orthognathic procedures, they also have utility in rhytidectomy, platysmaplasty with neck excision, neck lifts, fat injection, and scar revisions. Specific indications for the use of syringe liposuction of the face using tumescent anesthesia, as well as a variety of adjunctive procedures, will be discussed. References Klein JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 16:248, 1990 Giampapa VC, DiBernardo BE: Neck recontouring with suture suspension and liposuction: An alternative for the early rhytidectomy candidate. Aesth Plast Surg 19:217, 1995 Pinski KS, Roenigk HH: Autologous fat transplantation. J Dermatol Surg Oncol 18:179, 1992
S418 Surgical Pathology: Considerations in Diagnosis and Treatment Victor Escobar, DDS, PhD, Pearland, TX This presentation will review the principles of differential diagnosis and surgical management of pathologic conditions of the maxillofacial complex. Emphasis will AAOMS
Surgical Clinics be on nasal pathways, nasopharnyx, maxillary sinus, orbital floor, and maxillary bone. The main objective is to guide the participants in the evaluation and work up of patients to arrive to a realistic diagnosis and appropriate surgical treatment. The course will include, histology, differential diagnosis, and surgical management. Course outline 1. Principles of Differential Diagnosis 2. The Pathologist View vs the Surgeon’s View 3. Brief Review of Surgical Anatomy 4. Biopsy Types Incision Excision Shave Punch FNA Choice of biopsy type for lesion 5. Soft Tissue Lesions Diagnosis Biopsy Histology Surgical management 6. Cyst and Cyst-Like Lesions of Bone Surgical management 7. Management of Malignant Tumors Treatment choices Radiotherapy Chemotherapy Debulking 8. Management of Premalignant Mucosal Lesions Leukemia Erythroplakia Submucosal fibrosis 9. Maximizing Outcome 10. Summary References Cawson RA, Binnie WH, Eveson JW: Color Atlas of Oral Disease. Mosby-Yearbook Europe Limited. Wenig BM: Atlas of Head and Neck Pathology. Philadelphia, PA, Saunders
S419 Enhancing Survival and Quality of Life for Patients With Oral Cancer Richard P. Szumita, DDS, Paterson, NJ Meredith Blitz, DDS, Paterson, NJ This presentation is designed to deal with enhancing the survival and quality of life for patients with head and neck cancers. Many factors are related to the survival and quality of life of these patients, and they will be discussed in detail. AAOMS
One of the most important areas to evaluate are the obstacles to early detection of oral and oropharyngeal carcinoma. The best hope for increased survival is directly related to the early detection of disease. We will discuss patient factors and educational issues, including the role of the primary care physicians and dentists. We will also touch on financial and social issues as they are related to this area. Because early detection has such a tremendous impact, we will spend time discussing high-risk populations and the anatomic sites most commonly involved. The earliest appearance of the asymptomatic squamous cell carcinoma and the best biopsy sites will be heavily stressed. Biopsy techniques and new screening tools will be shown. All treatment modalities, from wide local excision to large resection, will be reviewed in detail. Evaluation of neck disease is crucial in survival outcomes and surgical planning, and review of literature and planning surgical techniques in combination with radiation is included. Because radiation therapy has become a critical and common treatment for a significant number of patients, proactive treatments for postradiation sequelae will be thoroughly discussed, including maintenance of the dentition, xerostomia, and prevention of osteoradionecrosis. Finally, and possibly most importantly, quality of life enhancement issues will be discussed in detail. Psychosocial issues, nutritional support, hyperbaric oxygen therapy, surgical techniques, and advancements in reconstruction techniques will be heavily stressed.
S420 Recognition and Treatment of Implant Complications Charles A. Babbush, DDS, MScD, Beachwood, OH I. Proper diagnosis and treatment planning A. Determine bone quality and quantity B. Determine the proper size and number of implants II. Etiologic factors involving complications and failures A. Design of prosthesis B. Soft tissue factors C. Maintenance/hygiene D. Parafunctional habits III. Various treatment modalities for the ailing/failing implant A. Antibiotics B. Bone grafts C. Barrier membrane 139
S421 Contemporary Functional and Aesthetic Implant Restoration of the Partially Edentulous Patient Louis F. Clarizio, DDS, Portsmouth, NH This presentation is geared for the surgeon and the restorative dentist. The focus will be on how to simplify placement and the restoration of dental implants. Our goal will be to make implants more predictable without violating basic principles of dentistry. In this presentation you will learn ideal positioning to achieve aesthetic and functional results. The focus will be on the maxillary central incisor and mandibular and maxillary first molar implant restorations. Factors such as crown-to-root ratio, pocket depth, and emergence profile will be discussed. Depth of the implant itself will be critically examined. The nonsubmerged or one-stage approach will be discussed as a way to increase case acceptance, decrease chair time and discomfort for the patient, and gain excellent soft tissue healing before restoration. An extraction site protocol for replacing or maintaining alveolar bone will be discussed. Cases involving the restoration of missing alveolar bone using bone grafts taken from the tuberosity, chin, or iliac crest will be presented. Finally, a basic presentation on the subantral augmentation procedure will be given.
S422 Laser Surgery in the Management of Snoring and Sleep Apnea Robert A. Strauss, DDS, Richmond, VA Laser-assisted uvulopalatoplasty (LAUP) was first introduced by Kamami in 1990 and has been used extensively in the treatment of snoring. Because it is a relatively simple, low-morbidity procedure that can usually be performed in an office setting with local anesthesia or intravenous sedation, this technique rapidly gained popularity and recognition as an alternative to the many nonsurgical therapies or traditional uvulopalatopharyngoplasty (UPPP). Despite this clinical popularity, the procedure has generated significant controversy because of the initial lack of objective data regarding its effectiveness for snoring, and perhaps more importantly, its use in the management of obstructive sleep apnea syndrome (OSAS). It is beginning to appear evident in the literature that this procedure can be useful in either of these conditions, but only after appropriate and considerable evaluation has delineated the diagnosis. Once known, this technique 140
becomes one in a multitude of therapies that, when used in a logical multistep protocol, can be helpful in the treatment of these patients. The indications, alternatives, postoperative management, and complications of the procedure must be understood and will be presented along with a number of technical variations. Specific treatment protocols and techniques will be discussed in detail. Subjective and objective studies showing the usefulness of these procedures will be reviewed, including a subjective study of nearly 300 procedures performed at the Medical College of Virginia since December 1993. During this presentation, the importance of thorough preoperative evaluation and appropriate utilization of these procedures will be stressed.
References Kamami Y-V: Laser CO2 for snoring: Preliminary results. Acta Otorhinolaryngol Belg 44:451, 1990 Strauss RA: Laser-assisted uvulopalatoplasty, in Catone, Alling (eds): Laser Applications in Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 1996 Strauss RA: 1995 Conference of the International Association of Oral and Maxillofacial Surgeons, Budapest, Hungary
S423 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. Two areas of the maxillofacial complex frequently requiring reconstruction are the mandible and the maxilla. Mandibular defects can be divided into marginal defects, continuity defects, and continuity defects that include the mandibular condyle. Treatment varies amongst these three types of defects and also depends a great deal on the quantity and quality of the surrounding soft tissue. Mandibular defects with well-vascularized surrounding soft tissue of good volume can be treated by a variety of techniques utilizing free autogenous bone grafts. When the soft tissue is deficient in quantity and/or quality, they must be improved or replaced prior to 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 AAOMS
Surgical Clinics 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 compatable 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, three 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
approach 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, pp 873-948 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