Surgical Clinics
end-filling materials. Most authors feel the creation of a
hermetic seal at the apex is critical for the long-term
success of the case. Amalgam has previously been the
most well described material, but its use is of concern to
some patients. The use of a modified IRM material, Su-
per-EBA, has been reported to provide a more precise
apical seal without the concerns of implanting a mercu-
ry-containing compound. A newer material, mineral tri-
oxide aggregate (MTA), may show promise at providing
an excellent seal as well as promoting reformation of
bone at the apical region. However, the long-term suc-
cess of this material as well as independent verification
of its use is still pending.
References
Johnson BR: Considerations in the selection of a root-end filling
material. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:398,
1999
Lieblich SE: Periapical surgery: Clinical decision making. Oral Max-
illofacial Surg Clin North Am 14:179, 2002
Lieblich SE: Management of periapical infections by endodontic
surgery, in Piecuch JF (ed): OMS Knowledge Update, vol III. AAOMS
Publications, 2001, pp 65-74
Lieblich SE, McGivern B: Ultrasonic retrograde preparation. Oral
Maxillofac Surg Clin North Am 14:167, 2002
Trope M, Lost C, Schmitz H-J: Healing of apical periodontitis in dogs
after apicoectomy and retrofilling with various filling materials. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 81:221, 1996
S201
Guided Tissue Regeneration in Jaw
Reconstruction: Review and Applications
Pamela L. Alberto, DMD, Sparta, NJ
In 1982, a group of researchers reported that tissues
lost to periodontal disease could be regenerated by the
use of a surgical technique known as guided tissue re-
generation. Since then, tremendous progress has been
made in adapting these techniques to jaw reconstruc-
tion. Along with the development of guided tissue re-
generation procedures were the development of many
first-generation and second-generation membrane barri-
ers.
The current first-generation barriers available are
Gore-Tex and TefGen. Both are made from 100% medi-
cal-grade polytetrafluoroethylene, but differ in that Tef-
Gen 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, Osseo-
Quest, 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 completely
resorbed in 4 to 8 weeks. The material must be hydrated
in sterile water to saline for approximately 15 minutes
before final placements. BioGide is composed of colla-
AAOMS • 2004
gen 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
resorbs in 6 months. Capset composed of calcium sul-
fate. 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 re-
sults. 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 devel-
oped that are impregnated with polypeptide growth
factors, including platelet growth factor, insulin-like
growth factor, transforming growth factor-B, fibroblast
growth factor or bone morphogenic protein. Current
research shows some of theses materials to be promis-
ing.
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 os-
seous defects with implants using biodegradable second-
generation membrane, the dilemma arises in now know-
ing the amount of regeneration you obtained. Thus,
familiarity with these materials along with their applica-
tions will increase the success ratio of guided tissue
regeneration in jaw reconstruction.
References
Becker W, Beck B: Clinical applications of guided tissue regenera-
tion: Surgical considerations. Periodontology 1:1993, 2000
O’Neal R, Wang H: Cells and materials involved in guided tissue
regeneration. Curr Opin Periodontol 1994
Jovanovic SA: bone rehabilitation to achieve optimal aesthetics.
Pract Periodont Aesthetic Dent 9, 1997
S202
Naso-Orbital-Ethmoid Fractures: Past
and Present
James B. Holton, DDS, MSD, Tyler, TX
Injuries of the naso-orbital-ethmoidal (NOE) complex
present one of the greatest clinical challenges to the oral
and maxillofacial surgeon. Organizing the diagnostic ma-
terial into a logical surgical plan is the key to a successful
outcome. This clinic will give a historical perspective on
the evolving treatment of NOE injuries, from closed
treatment to wide-field open access. A detailed review of
current imaging techniques and classification of NOE
fractures will be utilized to enhance management of the
central fragments. Beginning with the anatomy and
89
Surgical Clinics
mechanisms of injury of the complex, a step by step
approach will be developed for surgical management.
The sequencing of this surgical clinic will be:
1. Introduction
2. Anatomy of the NOE
3. Mechanisms of injury
4. Clinical exam of the NOE
5. Diagnostic imaging of the NOE
6. Classification of NOE fractures
7. Principals of surgical management
8. Surgical access routes
9. Case presentations
10. Complications
11. Long-term follow-up
Isolated and combination injuries will be presented to
demonstrate why the NOE is the centerpiece of the
facial skeleton.
References
Ellis E: Sequencing treatment for naso-orbital-ethmoidal fractures.
J Oral Maxillofac Surg 51:543, 1993
Leipziger LS, et al: Naso-ethmoidal-orbital fractures: Current con-
cepts and management principles. Clin Plast Surg 19:193, 1992
Daly BD, Russell JL, Davidson MS, Lairb JT: Thin-section computed
tomography in the evaluation of naso-ethmoidal trauma. Clin Radiol
41:272, 1990
S203
Open Rhinoplasty: The Unified Tip
Concept
Lester Machado, MD, DDS, MS, FRCS(Ed), Chula Vista,
CA
Rhinoplasty continues to be one of the most challeng-
ing fields in oral and maxillofacial surgery. The open
rhinoplasty technique has certainly enhanced the surgi-
cal training experience for our residents and fellows.
A higher level of nasal structural enhancement has
been possible since the advent and widespread use of
open rhinoplasty techniques introduced in the 1980s.
The unified tip concept is one of the refinements to the
basic open structure rhinoplasty techniques originally
described. The careful suturing together of the individ-
ual components of the septum, lower lateral cartilages
and upper lateral cartilages with the appropriate grafts
was proposed to enhance stability and reduce late de-
formation and asymmetry.
This surgical clinic will explore the technical details as
well as the advantages and the disadvantages of the
unified tip concept as a part of open structure rhino-
plasty. Long term results will be evaluated that help
demonstrate the appropriate application of the concept.
A review of a basic approach to rhinoplasty, with
indications for closed versus open rhinoplasty will also
be undertaken. The course is designed for the oral an
90
maxillofacial surgeon with a special interest in elective
cosmetic rhinoplasty and arises from the perspective of
15 years of personal experience.
S204
Treatment of Pediatric Obstructive Sleep
Apnea by Mandibular Distraction
Adi Rachmiel, DMD, PhD, Haifa, Israel
Micha Peled, DMD, MD, Haifa, Israel
Obstructive sleep apnea (OSA) in pediatric popula-
tions is often associated with congenital craniofacial mal-
formations, as Pierre Robin syndrome, hemifacial micro-
somia, resulting in decreased pharyngeal airway, which,
in severe cases, leads to tracheostomy dependence. A
total of fourteen children were treated, six patients had
tracheostomies placed and another eight patients were
considered tracheostomy candidates. The mean age of
the patients was four years old, ranging from 9 months
to 7 years. The patients that are without tracheostomy
are respiratory distressed and have various complaints of
OSA, as noisy breathing during sleep, waking episodes,
pauses in respiration, daytime somnolence and are con-
sidered tracheostomy candidates. OSA, due to congenital
malformations, was treated by mandibular distraction
osteogenesis. Mandibular distraction osteogenesis was
performed bilaterally in the mandibular body using two
extraoral distraction devices. After a latency period of
four days, a gradual distraction in a rate of 1 mm/day was
performed followed by consolidation period of eight
weeks. The expansion of mandibular framework was
analyzed using bony cephalometric landmarks and 3D
CT. The size of the pharyngeal airway preoperatively and
post-treatment was evaluated by measurements of lateral
(sagittal) and axial width and by 3D CT. The results
demonstrate average mandibular elongation of 34mm on
each side, and an increase in mandibular volume and
pharyngeal airway. To date, all six patients are decannu-
lated and in the other eight patients there is improved
airway with improvement of signs and symptoms of OSA
and elimination of oxygen requirement. Then, continu-
ous treatment of the palate and the velopharyngeal
sphincter was possible without impairing the airway.
Conclusions: Bilateral mandibular distraction is a use-
ful method in younger children with OSA expanding the
mandible and concomitantly advancing the base of
tongue and hyoid bone increasing the pharyngeal air-
way.
References
Cohen SR, Simms C, Burstein FD: Mandibular distraction osteogen-
esis in the treatment of upper airway obstruction in children with
craniofacial deformities. Plast Reconstr Surg 101:312, 1998
AAOMS • 2004