Arnulf Baumann

Application of the buccal fat pad in oral reconstruction

PURPOSE This report evaluates the use of the buccal fat pad in reconstruction of defects of the hard and soft palate. PATIENTS AND METHODS Twenty-nine patients with different indications (oroantral fistula, tumor of the hard and soft palate, posterior fistula in cleft patients, covering of bone transplants in augmentation procedure) were treated with a pedicled buccal fat pad without lining. The maximum reconstructed defect was 5.5 x 4 cm. RESULTS All inserted fat grafts healed well without any aesthetic disturbances. The surface of the fat converted to normal mucosa. CONCLUSIONS Use of the buccal fat pad is a safe and easy method to reconstruct defects in the posterior maxilla and soft palate. Good vascularization, ease of access, and minimal donor site morbidity make it a reliable soft tissue graft.

Transcaruncular approach for reconstruction of medial orbital wall fracture

Medial orbital wall fractures can cause horizontal diplopia and enophthalmos. Therefore, reconstruction of displaced medial wall fractures should be considered. We used a transcaruncular approach in five male patients to reconstruct the medial orbital wall after acute injuries and also as a secondary procedure for enophthalmos correction. Four of these patients had a concomitant orbital floor fracture. The incision was made in the caruncule and extended in the conjunctiva superior and inferior into the fornices for 10-12 mm. The tissue was bluntly dissected in an anteroposterior direction. The periosteum was incised dorsal of the posterior lacrimal crest and after elevation of the periosteum, the fractured orbital wall was visible. Transplants up to a height of 2 cm could be inserted for reconstruction of the medial orbital wall. In the cases of acute trauma, the medial wall was reconstructed using a resorbable polydioxanone plate. Cortical bone was used for the reconstruction of late enophthalmos. No postoperative complications were found. The transcaruncular approach gave a rapid entry to the fractured medial orbital wall without a visible scar.

Minimal invasiver Sinuslift

The minimal invasive sinus lift is a procedure done by osteotome technique via a crestal approach in contrast to the sinus elevation via lateral osteotomy to achieve adequate bone-height for setting of implants. The purpose of this anatomical and clinical study was to evaluate by endoscopic control if the minimal sinus lift is practicable by a residual bone height of less than 8 mm without mucosal damage. An endoscopic controlled sinus lift was done on 10 fresh cadavers. The original bone height was 3-6 mm in the lateral maxilla. The sinus mucosa was elevated by an osteotome at least up to 10 mm. A sinus augmentation was performed with a bone substitute material (Algipore) over the implant bed. There was no tear visible on endoscopic control. Finally, the maxilla was removed and the mucosa inspected. No laceration of the mucosa was found in any case. The clinical study included 7 patients. 5 Patients had bone condensation, augmentation of bone and implantation of 13 mm implants in a one stage procedure. The originally bone height was between 6-8 mm in all patients. One of the five patients did show a small perforation of the mucosa during mucosal elevation at one implant-bed. The implant was inserted and an endoscopic control after 6 weeks showed regular mucosa. 2 patients received augmentation only at a primary bone height of only 3-5 mm. A post-operative CT-scan showed that the bone height was augmented to a total height of 13-16 mm. As a result of our study a sufficient bone height can be achieved by the minimal invasive sinus lift procedure. The advantage of this crestal approach is the protection of the intraosseous vessels in the maxilla and less postoperative morbidity. As a disadvantage, the insertion of bone material limited only to the area surrounding the implant bed, might be discussed.Zusammenfassung Implantate im atrophen Oberkieferseitenzahnbereich können meist erst nach einer Knocheneinlagerung im Bereich des Kieferhöhlenbodens gesetzt werden. Der minimal invasive Sinuslift ermöglicht über einen Zugang am Alveolarkamm durch die Knochenkondensation die Implantatsetzung bei ausreichender Knochenhöhe. Im Rahmen einer anatomischen und klinischen Studie sollte unter endoskopischer Kontrolle überprüft werden, ob auch bei geringerem Knochenangebot (< 8 mm) die Schleimhaut soweit abpräpariert werden kann, daß nach Einlagerung von Knochen Implantate gesetzt werden können. An 10 Leichen mit zahnlosem Oberkiefer wurde der minimal invasive Sinuslift vorgenommen. Die Knochenhöhe im Seitenzahnbereich betrug zwischen 3 und 6 mm. Die Schleimhaut, die bis auf 10 mm abhebbar war, war sowohl endoskopisch als auch nach der Oberkieferentnahme nicht verletzt. Die klinische Anwendung erfolgte bei 7 Patienten. Bei 5 Patienten konnte bei einer minimalen Restknochenhöhe von 6 mm durch Knochenkondensation und Einsetzen eines Knochen-Algipore ® -Gemisches ein Implantat von 13 mm Länge inseriert werden. Bei einer Implantatsetzung kam es zu einer Perforation der Schleimhaut, die bei einer endoskopischen Kontrolle 6 Wochen später reizlos erschien. Bei 2 Patienten wurde bei einer Knochenhöhe von 3–5 mm unter endoskopischer Kontrolle eine alleinige Knochenaugmentation vorgenommen. Die erzielte absolute Knochenhöhe betrug im Dental-CT zwischen 10 und 13 mm. Die Limitation des Operationsverfahrens liegt darin, daß der Knochen nur über das Implantatbett appliziert werden kann. Der minimal invasive Sinuslift ermöglicht durch die endoskopische Kontrolle einen alveolären Zugang und schont gleichzeitig die intraossären lateralen Knochengefäße. Ferner ist die Denudation des Weichgewebes vermindert. Summary The minimal invasive sinus lift is a procedure done by osteotome technique via a crestal approach in contrast to the sinus elevation via lateral osteotomy to achieve adequate bone-height for setting of implants. The purpose of this anatomical and clinical study was to evaluate by endoscopic control if the minimal sinus lift is practicable by a residual bone height of less than 8 mm without mucosal damage. An endoscopic controlled sinus lift was done on 10 fresh cadavers. The original bone height was 3–6 mm in the lateral maxilla. The sinus mucosa was elevated by an osteotome at least up to 10 mm. A sinus augmentation was performed with a bone substitute material (Algipore®) over the implant bed. There was no tear visible on endoscopic control. Finally, the maxilla was removed and the mucosa inspected. No laceration of the mucosa was found in any case. The clinical study included 7 patients. 5 Patients had bone condensation, augmentation of bone and implantation of 13 mm implants in a one stage procedure. The originally bone height was between 6–8 mm in all patients. One of the five patients did show a small perforation of the mucosa during mucosal elevation at one implant-bed. The implant was inserted and an endoscopic control after 6 weeks showed regular mucosa. 2 patients received augmentation only at a primary bone height of only 3–5 mm. A post-operative CT-scan showed that the bone height was augmented to a total height of 13–16 mm. As a result of our study a sufficient bone height can be achieved by the minimal invasive sinus lift procedure. The advantage of this crestal approach is the protection of the intraosseous vessels in the maxilla and less postoperative morbidity. As a disadvantage, the insertion of bone material limited only to the area surrounding the implant bed, might be discussed.