Andrew Horowitz

Applications of 3-Dimensional Virtual Computerized Tomography Technology in Oral and Maxillofacial Surgery: Current Therapy

With the recent introduction of in-office cone-beam volumetric tomography scanners and the development of computed tomographic-based proprietary third-party 3-dimensional dental implant software programs, the field of implant dentistry is moving toward the 3-dimensional evaluation and placement of dental implants according to a restoratively driven treatment plan. The goal is to place the dental implant according to where the final dental restoration will be fabricated. The precision, accuracy, and 3-dimensional visualization capabilities of these technologies open avenues for the oral and maxillofacial surgeon in the diagnosis, planning, and surgical management of many nonimplant-related cases. The combination of these technologies is useful in expanding our information in dentoalveolar, preprosthetic, trauma, pathology and reconstruction, orthognathic and craniofacial, and cosmetic esthetic implant surgical cases. This article discusses the use of these technologies in the practice of oral and maxillofacial surgery.

Computerized Implantology for the Irradiated Patient

Reconstruction of the irradiated head and neck cancer patient continues to be a challenge. Conventional prosthodontics can be very unpredictable and difficult in these patients. Implant-supported fixed prostheses are good alternatives. It is well-accepted that maxillofacial surgery for the irradiated head and neck cancer patients should be performed in an atraumatic fashion to minimize postoperative complications. We propose the use of computer generated surgical guides and flapless surgery for the placement of dental implants in the irradiated head and neck cancer patient. With these techniques, implants can be placed in an atraumatic, predictable, and accurate manner, according to a prosthetically driven treatment plan.

Facial Skeletal Augmentation Using Custom Facial Implants

Facial skeletal augmentation is one of many techniques used to enhance facial aesthetics. It is especially useful in the malar, mandibular angle, and genial areas. For many years, correction of facial contour deformities posed challenges for reconstructive surgeons. Two-dimensional radiographic and photographic imaging modalities provided limited diagnostic and treatment planning information. An arduous procedure could be undertaken to take a facial impression and create a stone facial model of the facial soft tissues. This three-dimensional (3D) model simulated the patient’s face but provided no information on the underlyingbony contours. The surgeonprimarily used their artistic ability to diagnose and treat facial contour deformities. Treatment was limited to the use of stock implants that were placed as is or altered at the time of surgery.With themorewidespread use of computed tomography (CT) in the 1980s, 3D representations of the patient’s facial skeletal anatomy became available. Computer technology has advanced to allow an accurate duplication of a patient’s facial skeletal and soft tissue anatomy. According to Winder and Bibb, medical rapid prototyping is defined as the manufacture of dimensionally accurate physical models of human anatomy derived from medical image data [1]. This technologywas originally described byMankowich and colleagues in 1990 [2].With the use of this technology, the ability to manufacture or fabricate custom craniofacial implants has evolved. Proprietary software programs allow computer-assisted design (CAD) and prototyping through computer-assisted manufacturing (CAM). These technologies allow the fabrication of custom implants to replace or augment the facial skeleton and enhance a surgeon’s ability to treat facial contour abnormalities [3,4]. The creation of custom implants with CAD/CAM technology provides the surgeon with several advantages over the use of stock implants. The 3D information and virtual software provide for better patient evaluation and treatment planning, especially in cases of facial asymmetry. If a surgeon wants to correct unilateral deformities, mirror imaging software can be used to fabricate an implant that duplicates the facial skeleton of the opposite side. Customized implants have a more precise fit because the undersurface of the implant is manufactured to fit precisely to the patient’s skeletal anatomy. These implants adapt to sharp curvatures and bony abnormalities that may be present [3]. This is particularly advantageous in posttraumatic facial contour abnormalities, in which the custom implants fit into irregular defects and the edges of the implants blend into the facial anatomy and are not visible or palpable. Custom implants require little if any surgical time to hand carve. It is not necessary to alter the bony anatomy as is often the case with stock implants, reducing surgical and anesthesia time. Disadvantages of 3D modeling for custom implants include the need for CT scans, increased preoperative time for planning, and increased expense to the patient for the CAD/CAM process. The purpose of facial augmentation is cosmetic enhancement, not functional improvement. It is important to consider the patient’s concerns and expected outcome when planning treatment. The clinical examination allows the best evaluation of contour deformities. 3D imaging allows the best

Cavernous Sinus Thrombosis as a Result of a Fungal Infection: A Case Report

Cavernous sinus thrombosis (CST) is a rare disease with the potential for significant morbidity and even death. Rapid diagnosis and aggressive medical and surgical management are imperative for patients with CST. The cause may be aseptic or infectious. When the cause is infectious in nature, it is most commonly from a bacterial origin. However, we present the case of a 57-year-old man with a fungally related CST that ultimately led to his death.