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Treatment of facial skin lesions
Surgical Clinics and effective long-term management modality in a patient population with the conditions listed above. References 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 Mercuri LG: The TMJ Concepts Patient Fitted Total Temporomandibular Joint Reconstruction Prosthesis. Oral Maxillofac Surg Clin North Am 12:73, 2000 Mercuri LG, Wolford LM, Sanders B, et al: Long-term follow-up of the CAD/CAM total temporomandibular joint reconstruction system. J Oral Maxillofac Surg 60:1440, 2002
S110 Rotation of the Maxillomandibular Complex (alteration of the occlusal plane): Indications, Treatment Planning, and Treatment Outcomes Johan P. Reyneke, MChD, FCMFOS(SA), Rivonia, South Africa Introduction: The principle of rotation of the maxillomandibular complex (MMC) as orthognathic treatment design is not always fully understood. This surgical design is used in cases where the desired aesthetic results cannot be achieved by conventional treatment designs. Indications: The indications for this alternative surgical treatment design will be discussed by using clinical examples. Geometry: The geometry of rotations of the MMC in all 3 dimensions (clockwise and counterclockwise in a sagittal plane, as well as transverse and coronal rotations) and the expected soft tissue results will be discussed. The importance of selecting the correct point around which the MMC should be rotated for specific cases with the focus on development of a visual treatment objective will be demonstrated. Clinical cases: Cases demonstrating the importance of rotation point and direction of rotation will be presented. References Reyneke JP, Evans WG: Surgical manipulation of the occlusal plane. Int J Adult Orthod Orthognath Surg 5:99, 1990 Reyneke JP: Surgical manipulation of the occlusal plane: New concepts in geometry. Int J Adult Orthod Orthognath Surg 13:307, 1998 Reyneke JP: Surgical cephalometric prediction tracing for the alteration of the occlusal plane by means of rotation of the maxillomandibular momplex. Int J Adult Orthod Orthognath Surg 14:55, 1999
S111 Drug-Drug Interactions and Pharmacology Update: Important for the Oral and Maxillofacial Surgeon Jeffrey Bennett, DMD, Farmington, CT (no abstract provided) AAOMS • 2003
S112 The 3 Bs of Upper Face Rejuvenation: Blepharoplasty, Browlifting, and Botulinum Steven Guttenberg, DDS, MD, Washington, DC Ptosis of the upper-face soft tissues can lead to the appearance of aging, which is easily noticed by our patients and their peers. Rejuvenation of this facial third is relatively straightforward and can lead to dramtic improvement of the maturing visage. After one has evaluated the patient and arrived at a diagnosis, there are several office-based, outpatient procedures that can be 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, and genetic and environmental factors can lead to the descent of periorbital and intraorbital fat, which contributes to an unaesthetic appearance. Upper and lower blepharoplastic procedures to correct this baggy eyelid deformity can aid greatly in cosmetic improvement of this facial zone. Use of the carbon dioxide laser to perform the procedures results in virtually bloodless operations and minimizes postoperative complications. The laser can also be used for resurfacing the upper eyelids and the lower eyelid skin in conjunction with transconjunctival 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 below the superior orbital rim, brow/forehead lifting is a technique that has gained popularity. Much of the reluctance of patients to undergo this procedure has been diminished by virtue of an advancement in technology. Specifically, use of the endoscope with small, hidden incisions has all but replaced the previously used “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.
S201 Treatment of Facial Skin Lesions Michael F. Zide, DMD, Fort Worth, TX Skin cancer can be part of any practice that treats patients over age 35. Approximately 1 million new cases are diagnosed per year in the United States alone. This talk will discuss which patients are most suscep109
Surgical Clinics tible as well as provide a simple yet formal method to incorporate skin cancer into the daily practice. The talk will highlight the 4 critical aspects of care: 1. Patient evaluation 2. Lesion therapy 3. Defect reconstruction 4. Appropriate follow-up Patient evaluation will be discussed in light of medical and social problems and how they influence care. A simple biopsy method will be shown. Lesion therapy will provide a delayed method that will eliminate fear of the deep margin as well as fear that the defect will progress beyond surgical capabilities. Decision making will show how one chooses an appropriate reconstructive method—secondary epithelialization graft or flap. The methods of harnessing the full capabilities of the adjacent akin will be discussed, including inherent extensibility, mechanical creep, and biological creep. References Zide MF: Treatment decisions for skin cancer of the head and neck. Selected Readings Oral Maxillofac Surg 8, 1999 Zide MF, Dean J: Lip reconstruction, in Booth PW, Schendel S, Hauaanien JB (eds): Maxillofacial Surgery. Edinburgh, Churchill Livingstone, 1999, pp 735-756 Escobar V, Zide MF: Delayed repair of skin cancer defects. J Oral Maxillofac Surg 57:271, 1999
S202 Intraoral Maxillofacial Distraction Osteogenesis David Walker, DDS, MS, Toronto, Ontario, Canada Distraction osteogenesis is a powerful technique for creating new bone during significant lengthening of the mandible or maxilla, without the need for bone grafting and associated donor site morbidity. Controversy exists regarding the application of distraction osteogenesis techniques versus conventional surgical procedures. Clinical experience and documentation in the literature confirm that large maxillary and mandibular advancements frequently require simultaneous bone grafting and may develop significant postsurgical relapse. Intraoral distraction osteogenesis techniques allow greater lengthening of the mandible and maxilla with improved soft tissue response and skeletal stability, compared with conventional surgical procedures. Craniofacial syndromes and patients who have undergone previous orthognathic surgery or reconstructive surgery present with challenging bony anatomy. Distraction osteogensis techniques can be applied to rudimentary or unusual bony anatomy of the maxilla and mandible with simple osteotomy design compared with conventional osteotomies. Distraction histogenesis, the gradual soft tissue 110
adaptation, and cellular proliferation can be particularly beneficial if there is a scarred soft tissue bed that is difficult to manage with acute movements. A thorough understanding of the biologic basis of distraction osteogenesis is important to apply the parameters of distraction to a given clinical situation. Parameters such as type of osteotomy, latency period, rate and rhythm of distraction, and consolidation time may be modified based on many different factors. Animal model research has been integral in determining the appropriate parameters for maxillofacial distraction osteogenesis, which varies from limb distraction osteogenesis. Preoperative planning for distraction osteogenesis is particularly important to determine adequate occlusal outcomes and skeletal harmony. Preoperative 3-dimensional vectorselection is based on careful clinical, radiographic, and CT scan analysis, with complex model surgery. Intraoral distraction osteogenesis device selection is based on the device design, existing bony anatomy, and the ability to adjust the vector or distraction after device placement. Multidirectional intraoral distraction osteogenesis devices have overcome the complications and obstacles of external distraction devices. Simultaneous or secondary orthognathic surgical procedures may be required to correct additional areas of skeletal disharmony. Concomitant orthodontic therapy can enhance distraction osteogenesis occlusal outcomes. In growing patients, postdistraction osteogenesis functional appliance therapy can allow occlusal manipulation that may avoid and/or decrease further surgical procedures at the completion of growth. Fixed orthodontic appliances are used in patients who have passed the mixed dentition stage, to aid in occlusal preparation prior to or after distraction osteogenesis techniques. Long-term growth follow-up postdistraction osteogenesis needs further documentation. Distraction osteogenesis techniques in growing patients often use overcorrection as the genetic growth potential of the maxilla or mandible appears unchanged by distraction osteogenesis techniques. Intraoral distraction osteogensis devices and techniques have continued to undergo refinement allowing predictable successful outcomes. Distraction osteogenesis is suited to the most complex and challenging deformities where traditional surgical techniques have resulted in less favorable outcomes. Distraction osteogenesis is an important technique in the armamentarium of oral and maxillofacial surgeons and is here to stay. References Walker D: Management of severe mandibular retrognathia in the adult patient using distraction osteogenesis. J Oral Maxillofac Surg 60:1341, 2002 Samchukov M, Cope J, Cherkasin A (eds): Craniofacial Distraction Osteogenesis. St Louis, MO, Mosby, 2001 Arnaud E, Diner P (eds): Third International Congress on Cranial and Facial Bone Distraction Osteogenesis, Paris, France/Bologna, Italy, Monduzzi Editore, 2001
AAOMS • 2003
S110 Rotation of the Maxillomandibular Complex (alteration of the occlusal plane): Indications, Treatment Planning, and Treatment Outcomes Johan P. Reyneke, MChD, FCMFOS(SA), Rivonia, South Africa Introduction: The principle of rotation of the maxillomandibular complex (MMC) as orthognathic treatment design is not always fully understood. This surgical design is used in cases where the desired aesthetic results cannot be achieved by conventional treatment designs. Indications: The indications for this alternative surgical treatment design will be discussed by using clinical examples. Geometry: The geometry of rotations of the MMC in all 3 dimensions (clockwise and counterclockwise in a sagittal plane, as well as transverse and coronal rotations) and the expected soft tissue results will be discussed. The importance of selecting the correct point around which the MMC should be rotated for specific cases with the focus on development of a visual treatment objective will be demonstrated. Clinical cases: Cases demonstrating the importance of rotation point and direction of rotation will be presented. References Reyneke JP, Evans WG: Surgical manipulation of the occlusal plane. Int J Adult Orthod Orthognath Surg 5:99, 1990 Reyneke JP: Surgical manipulation of the occlusal plane: New concepts in geometry. Int J Adult Orthod Orthognath Surg 13:307, 1998 Reyneke JP: Surgical cephalometric prediction tracing for the alteration of the occlusal plane by means of rotation of the maxillomandibular momplex. Int J Adult Orthod Orthognath Surg 14:55, 1999
S111 Drug-Drug Interactions and Pharmacology Update: Important for the Oral and Maxillofacial Surgeon Jeffrey Bennett, DMD, Farmington, CT (no abstract provided) AAOMS • 2003
S112 The 3 Bs of Upper Face Rejuvenation: Blepharoplasty, Browlifting, and Botulinum Steven Guttenberg, DDS, MD, Washington, DC Ptosis of the upper-face soft tissues can lead to the appearance of aging, which is easily noticed by our patients and their peers. Rejuvenation of this facial third is relatively straightforward and can lead to dramtic improvement of the maturing visage. After one has evaluated the patient and arrived at a diagnosis, there are several office-based, outpatient procedures that can be 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, and genetic and environmental factors can lead to the descent of periorbital and intraorbital fat, which contributes to an unaesthetic appearance. Upper and lower blepharoplastic procedures to correct this baggy eyelid deformity can aid greatly in cosmetic improvement of this facial zone. Use of the carbon dioxide laser to perform the procedures results in virtually bloodless operations and minimizes postoperative complications. The laser can also be used for resurfacing the upper eyelids and the lower eyelid skin in conjunction with transconjunctival 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 below the superior orbital rim, brow/forehead lifting is a technique that has gained popularity. Much of the reluctance of patients to undergo this procedure has been diminished by virtue of an advancement in technology. Specifically, use of the endoscope with small, hidden incisions has all but replaced the previously used “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.
S201 Treatment of Facial Skin Lesions Michael F. Zide, DMD, Fort Worth, TX Skin cancer can be part of any practice that treats patients over age 35. Approximately 1 million new cases are diagnosed per year in the United States alone. This talk will discuss which patients are most suscep109
Surgical Clinics tible as well as provide a simple yet formal method to incorporate skin cancer into the daily practice. The talk will highlight the 4 critical aspects of care: 1. Patient evaluation 2. Lesion therapy 3. Defect reconstruction 4. Appropriate follow-up Patient evaluation will be discussed in light of medical and social problems and how they influence care. A simple biopsy method will be shown. Lesion therapy will provide a delayed method that will eliminate fear of the deep margin as well as fear that the defect will progress beyond surgical capabilities. Decision making will show how one chooses an appropriate reconstructive method—secondary epithelialization graft or flap. The methods of harnessing the full capabilities of the adjacent akin will be discussed, including inherent extensibility, mechanical creep, and biological creep. References Zide MF: Treatment decisions for skin cancer of the head and neck. Selected Readings Oral Maxillofac Surg 8, 1999 Zide MF, Dean J: Lip reconstruction, in Booth PW, Schendel S, Hauaanien JB (eds): Maxillofacial Surgery. Edinburgh, Churchill Livingstone, 1999, pp 735-756 Escobar V, Zide MF: Delayed repair of skin cancer defects. J Oral Maxillofac Surg 57:271, 1999
S202 Intraoral Maxillofacial Distraction Osteogenesis David Walker, DDS, MS, Toronto, Ontario, Canada Distraction osteogenesis is a powerful technique for creating new bone during significant lengthening of the mandible or maxilla, without the need for bone grafting and associated donor site morbidity. Controversy exists regarding the application of distraction osteogenesis techniques versus conventional surgical procedures. Clinical experience and documentation in the literature confirm that large maxillary and mandibular advancements frequently require simultaneous bone grafting and may develop significant postsurgical relapse. Intraoral distraction osteogenesis techniques allow greater lengthening of the mandible and maxilla with improved soft tissue response and skeletal stability, compared with conventional surgical procedures. Craniofacial syndromes and patients who have undergone previous orthognathic surgery or reconstructive surgery present with challenging bony anatomy. Distraction osteogensis techniques can be applied to rudimentary or unusual bony anatomy of the maxilla and mandible with simple osteotomy design compared with conventional osteotomies. Distraction histogenesis, the gradual soft tissue 110
adaptation, and cellular proliferation can be particularly beneficial if there is a scarred soft tissue bed that is difficult to manage with acute movements. A thorough understanding of the biologic basis of distraction osteogenesis is important to apply the parameters of distraction to a given clinical situation. Parameters such as type of osteotomy, latency period, rate and rhythm of distraction, and consolidation time may be modified based on many different factors. Animal model research has been integral in determining the appropriate parameters for maxillofacial distraction osteogenesis, which varies from limb distraction osteogenesis. Preoperative planning for distraction osteogenesis is particularly important to determine adequate occlusal outcomes and skeletal harmony. Preoperative 3-dimensional vectorselection is based on careful clinical, radiographic, and CT scan analysis, with complex model surgery. Intraoral distraction osteogenesis device selection is based on the device design, existing bony anatomy, and the ability to adjust the vector or distraction after device placement. Multidirectional intraoral distraction osteogenesis devices have overcome the complications and obstacles of external distraction devices. Simultaneous or secondary orthognathic surgical procedures may be required to correct additional areas of skeletal disharmony. Concomitant orthodontic therapy can enhance distraction osteogenesis occlusal outcomes. In growing patients, postdistraction osteogenesis functional appliance therapy can allow occlusal manipulation that may avoid and/or decrease further surgical procedures at the completion of growth. Fixed orthodontic appliances are used in patients who have passed the mixed dentition stage, to aid in occlusal preparation prior to or after distraction osteogenesis techniques. Long-term growth follow-up postdistraction osteogenesis needs further documentation. Distraction osteogenesis techniques in growing patients often use overcorrection as the genetic growth potential of the maxilla or mandible appears unchanged by distraction osteogenesis techniques. Intraoral distraction osteogensis devices and techniques have continued to undergo refinement allowing predictable successful outcomes. Distraction osteogenesis is suited to the most complex and challenging deformities where traditional surgical techniques have resulted in less favorable outcomes. Distraction osteogenesis is an important technique in the armamentarium of oral and maxillofacial surgeons and is here to stay. References Walker D: Management of severe mandibular retrognathia in the adult patient using distraction osteogenesis. J Oral Maxillofac Surg 60:1341, 2002 Samchukov M, Cope J, Cherkasin A (eds): Craniofacial Distraction Osteogenesis. St Louis, MO, Mosby, 2001 Arnaud E, Diner P (eds): Third International Congress on Cranial and Facial Bone Distraction Osteogenesis, Paris, France/Bologna, Italy, Monduzzi Editore, 2001
AAOMS • 2003