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Clinical Innovation and Technology in Craniomaxillofacial Surgery



Bernard J. Costello

Outcomes Research and the Challenge of Evidence-Based Surgery

Thomas B. Dodson
Outcomes research is focused on measuring the results or end products of health
care interventions, processes, and practices. Data derived from outcomes research
informs clinical practice, quality assurance, and patient safety activities, and can be
the nidus for hypothesis-driven, patient-oriented research. This article introduces
a definition of outcomes research, reviews how outcomes research may guide evidence-based surgical practice and health care processes, and reviews a model for
outcomes research.

Prenatal Diagnosis and Treatment of Craniomaxillofacial Anomalies

BernardJ. Costello and Sean P. Edwards

Many advances in health care are built on the evolution of technology. An entirely
new patient has emerged in fetal medicine, with these advances in prenatal imaging
allowing one to see and diagnose disease not previously appreciated. Clinicians can
better plan for the delivery of the neonate, with identified anomalies being optimally
managed and the impact on the neonates health minimized. The oral and maxillofacial surgeon offers expertise in the management of craniomaxillofacial anomalies,
including congenital tumors, facial clefts, craniosynostosis, micrognathia, and other
congenital abnormalities. The techniques for perinatal care of the patient with craniofacial abnormalities continue to evolve as the technology improves. The authors
describe their experience and some of the more common abnormalities with their
management considerations that may be encountered by the oral and maxillofacial
surgeon on the fetal diagnosis and treatment team.

Bone Morphogenetic Proteins in Craniomaxillofacial Surgery


Sarah D. Davies and Mark W. Ochs

Craniomaxillofacial surgery has many indications for bone regeneration and augmentation, ranging from socket preservation to reconstruction of large skeletal defects. The discovery of bone morphogenetic proteins (BMPs) as osteoinductive
agents and the subsequent development of commercially available recombinant
forms of BMPs have offered the potential to replace traditional grafting techniques
with de novo bone formation. Extensive preclinical and clinical research has focused
on establishing the safety and efficacy of using recombinant BMPs to regenerate
bone in the facial skeleton. This article reviews the development and current scientific basis behind the use of these new biologics.

Regenerative Medicine for Craniomaxillofacial Surgery

BernardJ. Costello, Gaurav Shah, Prashant Kumta, and Charles S. Sfeir
Regenerative medicine has recently seen much activity in basic and translational research. These advances are now making their way into surgical practice. A convergence of technologies has afforded opportunities previously not available with
conventional surgical reconstructive techniques. Patients requiring complex




reconstructive surgery in the craniomaxillofacial region typically benefit from local or

regional flaps, nonvascularized grafts, microvascular tissue transfer, or substitute alloplastic materials to restore function and form. In these clinical situations, grafting
procedures or alloplastic substitute materials provide best-case replacements for
resected, injured, or congenitally missing tissues. However, ideal reconstructive
goals, such as a complete return to original form and function, are frequently not
completely achieved. Regenerative techniques now in clinical use and at the translational research stage hold promise for custom-tailored constructs with the potential to regenerate tissue in the host without significant donor site morbidity. These
techniques may provide better structure, aesthetics, and function than the best currently available options. This article presents the latest concepts in craniomaxillofacial regenerative medicine and reviews the multipronged approach to restoring
architecture using novel smart multifunctional scaffolds, cellular technologies,
growth factors, and other novel regenerative medical strategies.

Cleft Lip and Palate Surgery: An Update of Clinical Outcomes for Primary Repair


Andrew Campbell, BernardJ. Costello, and Ramon L. Ruiz

The comprehensive management of cleft lip and palate has received significant attention in the surgical literature over the last half century. It is the most common congenital facial malformation and has a significant developmental, physical, and
psychological impact on those with the deformity and their families. In the United
States, current estimates place the prevalence of cleft lip and palate or isolated cleft
lip at approximately 1 in 600. There is significant phenotypic variation in the specific
presentation of facial clefts. Understanding outcome data is important when making
clinical decisions for patients with clefts. This article provides an update on current
primary cleft lip and palate outcome data.

Orbital Surgery: State of the Art


Jason Liss, S.Tonya Stefko, and William L. Chung

Much has been written about the repair of orbital fractures, yet some debate still exists among surgeons with regard to indications for and timing of fracture repair and
various surgical techniques. Controversies regarding the surgical maneuvers include
the incision, surgical approach, and methods of wound closure. More detailed imaging modalities have allowed clinicians to understand the injuries more completely
and plan for and execute more ideal reconstructions. Recent advances in orbital implant materials and the role of endoscopy in orbital fracture repair add to this debate
about which techniques would be best for particular injuries. This article discusses
these issues and provides the most current literature review regarding the management of various orbital fractures.

Technology in Microvascular Surgery

Alessandro Cusano and Rui Fernandes
With the refinement of microvascular technique, free-tissue transfer has emerged as
the standard of care in head and neck reconstruction. Success rates and reductions in
operative time have reduced flap take from being the marker of reconstructive success to being an expectation. Interest has now shifted to improvement of technique,
with surgeons placing increasing importance on donor site morbidity, quality of tissue
harvested, and esthetic and functional outcomes. Much of the recent success can be
attributed to technological advance through improvement in instrumentation and
technique and enhancement of the understanding of flap physiology and anatomy.
This article reviews some of the recent advances and how they have affected microvascular surgery from preoperative, operative, and postoperative standpoints.



Temporary Skeletal Anchorage Devices for Orthodontics



BernardJ. Costello, Ramon L. Ruiz, Joseph Petrone, andJacqueline Sohn

This article discusses the recent advances and basic concepts of skeletal anchorage devices of various types and reviews the current literature on their use. Temporary skeletal anchorage devices allow orthodontic movements that were previously
thought to be difficult if not impossible. Much like the concepts introduced during the
beginnings of orthognathic dentofacial teams, treatment that uses skeletal anchorage requires interdisciplinary collaboration and planning with regular interaction,
continuing education, and a regular review of the latest relevant literature.

Advances in Head and Neck Imaging


Tao Ouyang and Barton F. Branstetter

Imaging plays a key role in dental implantation, management of maxillofacial trauma,
facial reconstruction, temporomandibular joint pathology, and evaluation and treatment of neoplasms and infections. In addition to traditional conventional radiography, recent advances in computer tomography, magnetic resonance imaging, and
positron emission tomographycomputed tomography fusion technology have
made radiology an even more vital component of patient care in dental and craniomaxillofacial practice.

Computer-Assisted Craniomaxillofacial Surgery


Sean P. Edwards
Computer-assisted surgery (CAS) describes all forms of surgery planning or execution that incorporate various forms of advanced imaging, software, analysis, and
planning and, in some cases, rapid prototyping technology, robotics, and imageguidance systems. Innovation is progressing rapidly, and new forms of technology
continue to be incorporated and evaluated for their value in improving daily operations. This article reviews imaging, enhanced three-dimensional diagnostics, tactile
models, CAS concepts, reconstructive surgery, bone flap shaping, distraction osteogenesis, and orthognathic surgery in relation to craniomaxillofacial surgery.

Computer Planning and Intraoperative Navigation in Cranio-Maxillofacial Surgery


R. Bryan Bell
Preoperative computer design and stereolithographic modeling combined with intraoperative navigation provide a useful guide for and possibly more accurate reconstruction of a variety of complex cranio-maxillofacial deformities. Although probably not
necessary for routine use, the authors early experience confirms that of other surgeons
with more than a decade of experience: computer-assisted surgery is indicated for
complex posttraumatic or postablative reconstruction of the orbits, cranium, maxilla,
and mandible; total temporomandibular joint replacement; orthognathic surgery; and
complex dental/craniofacial implantology. Further study is needed to provide outcomes data and cost-benefit analyses for each of these indications.

Endonasal Surgery of the Ventral Skull Base^Endoscopic Transcranial Surgery

Amol M. Bhatki, Ricardo L. Carrau, Carl H. Snyderman, Daniel M. Prevedello,
Paul A. Gardner, and Amin B. Kassam
Skull base surgery is evolving from traditional transfacial and transcranial approaches
to the endoscopic endonasal approach, a less intrusive corridor for accessing the
ventral skull base. This technique eliminates facial scars, expedites recovery, and



obviates brain retraction. The goals of surgical excision, whether palliative or curative,
are identical: an approach that is less disruptive to normal tissues. By exploiting the
sinonasal corridor, the entire ventral skull base may be accessed to successfully treat
benign and malignant lesions. The expanding limits of endoscopic skull base surgery
have been accompanied by commensurate innovations in reconstructive techniques
that are reliable and have been shown to limit postoperative complications. This article describes the basis for this approach and provides the latest outcome data supporting the current state of the art for endoscopic skull base surgery.

Endoscopic Techniques in Oral and Maxillofacial Surgery


Fred Pedroletti, Brad S. Johnson, andJoseph P. McCain

Oral and maxillofacial surgery is entering a new era. Surgeons can use the latest
technological advances in equipment in an attempt to improve patient outcomes.
Minimally invasive surgery with the use of the endoscope has improved in recent
years because of technological advancements in optics and associated instrumentation. Trauma, orthognathic, sialoendoscopy, and temporomandibular joint surgery
are commonly performed with the assistance of the endoscope. From an educational standpoint, surgical anatomy and various other principles can easily be taught
to trainees with the assistance of the endoscope. The operating surgeon can visualize an area via the endoscope, and instruct regarding the surgical maneuvers on
the monitor, without obstructions to view. This technique also allows others in and
out of the room to view the image. Endoscopically assisted surgery is gaining popularity and is becoming a tool frequently used by surgeons to assist in and simplify
some of the more difficult techniques that often require more extensive surgical exposure for visualization.

Molecular Diagnostics for Head and Neck Pathology


Elizabeth Bilodeau, Faizan Alawi, BernardJ. Costello, andJoanne L. Prasad

Molecular diagnostic techniques are quickly finding a role in the detection and diagnosis of tumors, and in predicting their behavior. They may also prove useful in developing new therapeutic approaches to head and neck cancer. The surgeon working in
the craniomaxillofacial region should have an understanding of these technologies,
their availability in various settings, and how they affect various aspects of treatment,
particularly in the detection and treatment of malignancies. This article offers an overview of recent advances in molecular diagnostic techniques, with their implications for
diagnosis and management of head and neck tumors.

Adhesive Use in Oral and Maxillofacial Surgery


Michael J. Buckley and Eric J. Beckman

Presently, tissue adhesives and sealants have limited use in oral and maxillofacial
surgical procedures. Skin closure occurs regularly with cyanoacrylate adhesives.
Sealing of dural tears in conjunction with dural closure has been shown to be very
successful. With the development of more head and neck reconstructive procedures
and cosmetic procedures, demand will increase for better surgical adhesives. Clinical trials are beginning for newly developed adhesives with the chemical characterizations, the safe reabsorptive profile, and the adhesive strength necessary to
benefit oral and maxillofacial surgery patients in the near future. Adhesives for
bone fixation, while in early development, also show a promising chemical profile
and will be of significant benefit to oral and maxillofacial surgical patients.