Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia.

INTRODUCTION: Skeletal reconstruction in severe grades of hemifacial microsomia (HFM) continues to be challenging. Traditional techniques of autografts and osseous distraction for reconstruction of the glenoid fossa, condyle, and ramus can fall short of expectations and can create new problems. This intercontinental study analyzes the role of alloplastic skeletal rehabilitation in severe HFM. METHODS: Ten consecutive patients with Pruzansky grade III HFM were reconstructed between October 2014 and July 2017 at 2 craniofacial centers following the same protocol. Data were gathered retrospectively from the medical records, including photographs and virtual planning records. Pre and postoperative photos were taken to compare occlusal status, interincisal opening, sagittal mandibular projection, and posterior facial height. Alloplastic reconstruction was accomplished using a custom designed titanium implant. RESULTS: Ten consecutive skeletally mature patients with HFM with failed traditional reconstructions were successfully treated with virtually planned alloplastic reconstructions (11 joints) and simultaneous orthognathic surgery. The glenoid fossa, condyle, and ramus on the affected sides were reconstructed with custom designed titanium implants. All patients achieved occlusal stabilization, normalization of posterior facial height and sagittal mandibular projection, and maintenance or improved inter-incisal opening. There were no major complications or repeated surgeries. Follow-up ranges from 6 to 50 months. CONCLUSION: Alloplastic reconstruction allows for precise vertical reconstruction of the ramus and condyle and sagittal repositioning of the mandibular body. The glenoid fossa component is firmly anchored to the skull base assuring a stable centric relation on the reconstructed side. Consistent and acceptable results can be achieved in skeletally mature patients.

Smile Management: A Discussion with the Masters.

Smile design is an ongoing challenge in both dentistry and facial cosmetics surgery. Herein, some very common smile design scenarios are shared with six world known masters. Each case will be reviewed by 2 cosmetic dentists, 2 periodontists, and 2 oral and maxillofacial surgeons. At the end, contributors will describe current advances and future prospects of this evolving field.

Alternative bone expansion technique for implant placement in atrophic edentulous maxilla and mandible.

This clinical review is an evaluation of the effectiveness of the split ridge bone augmentation technique performed in the atrophic maxilla and mandible with buccolingual bony defects. The osseointegration success of implant placement in the area of split ridge bone augmentation is assessed and compared to implant success rates indicated in the literature. This evaluation includes 15 patients who were treated with alveolar split ridge bone augmentation at Tufts University School of Dental Medicine. During initial consultation, all patients were diagnosed with a buccolingual bone dimension of 3-5 mm on the edentulous alveolar crest. This bony buccolingual dimension was inadequate for placement of implants of desirable width and correct angulation as dictated by the prosthetic requirements. Crestal split augmentation technique involved a surgical osteotomy that was followed by alveolar crest split and augmentation after buccolingual bony plate expansion, prior to implantation. Implants were placed either immediately or 3 weeks after the initial augmentation. No fixation was used to stabilize the buccal bony cortex after the completion of the augmentation. All patients were placed on periodic follow-ups for a 24-month period postoperatively. Implant success was determined with the use of Buser's Criteria. In total, 33 implants were placed in 15 patients. The overall success rate of osseointegration of the endosseous implants placed in the area of split ridge bone augmentation was found to be 97%. One patient presented with facial bone resorption and implant mobility 4 months after the surgery. The implant was removed and the area was reconstructed with autogenous bone graft and later implanted with an endosseous implant. Our results indicate that the split crest bone augmentation technique is a valid reconstructive procedure that can be used to augment the buccolingual alveolar defect prior to implant placement providing good bone foundation for placement of implants with desirable width in favorable angulation. In comparison to traditional bone grafts techniques, crestal split ridge bone augmentation enables placement of dental implants immediately or 3 weeks after augmentation and eradicates the possible morbidity of the donor sites.

Effects of mandibular retropositioning, with or without maxillary advancement, on the oro-naso-pharyngeal airway and development of sleep-related breathing disorders.

PURPOSE: Literature suggests that patients without pre-existing sleep-related breathing disorders who undergo orthognathic surgery for treatment of facial asymmetry may experience changes in their oropharyngeal airway. Mandibular retropositioning can compromise the posterior airway space, alter the physiologic airflow through the upper airway, and predispose patients to development of obstructive sleep apnea syndrome (OSAS). PATIENTS AND METHODS: This study was a retrospective cohort analysis of 26 patients who underwent mandibular retropositioning with or without maxillary advancement within the past 5 years at Tufts University School of Dental Medicine. Pre- and postoperative lateral cephalometric radiographs were analyzed with digital DOLPHIN software (Dolphin Imaging, Chatsworth, CA) for evidence of changes to the posterior airway dimension. In addition, patients were evaluated postoperatively with SNAP polysomnography (model 4/6; SNAP Laboratories, Wheeling, IL) for evidence of OSAS. RESULTS: Results indicated that mandibular retropositioning greater than or equal to 5 mm decreased the posterior airway space below 11 mm (30.75%, P = .03) and showed evidence of soft palate elongation greater than 32 mm (15.39%, P = .037) in a significant number of patients. However, as determined by cephalometric analysis, mandibular retropositioning greater than or equal to 5 mm in combination with maxillary advancement had no significant effect on the posterior airway space or soft palate. CONCLUSION: Postoperative SNAP polysomnography showed higher incidence of mild to moderate OSAS in patients who underwent mandibular retropositioning greater than or equal to 5 mm (69.25%) compared with patients who underwent mandibular retropositioning in combination with maxillary advancement (38.46%, P = .039).

A clinico-pathologic correlation: primary Ewing's sarcoma of the mandibular body-ramus.

A 15-year-old Asian male was referred to the department of oral and maxillofacial surgery at Tufts University School of Dental Medicine (TUSDM) for evaluation of a radiolucent lesion on the posterior left mandible. The patient was initially evaluated by his primary dentist for pain of two months' duration associated with teeth #17 and 18. Radiographic examination was performed and the panoramic radiograph revealed a radiolucent lesion involving the left mandibular body and ascending ramus, along with resorption of the roots of the predetermined teeth. Considering odontogenic infection, the patient was placed on antibiotics and referred to TUSDM for further evaluation and treatment.