Daniel J. Meara

Fixation of Le Fort I Osteotomies With Poly-dl-Lactic Acid Mesh and Ultrasonic Welding—A New Technique

PURPOSE This report describes a technique for use of resorbable mesh (Resorb-X) and an ultrasonic sonotrode unit (SonicWeld Rx) to bond a pin (SonicPin Rx) to the mesh and underlying bone for Le Fort I osteotomy fixation, precluding the need to tap, shortening the time needed for fixation, and eliminating many disadvantages of titanium. In total, 659 cases have been performed from October 2005 through December 2010. This study examined the first 103 consecutive Le Fort osteotomies performed with this resorbable system and thus those with the longest follow-up. MATERIALS AND METHODS One hundred three consecutive patients who had completed growth and presurgical orthodontics were operated on using the Resorb-X plating system and SonicWeld Rx. Intraoperative adverse events were monitored and a minimum 12-month postoperative follow-up for complications was completed. RESULTS One patient (0.9%) had maxillary mobility at initial postoperative evaluation that resolved without malocclusion. Two patients (1.9%) exhibited signs of residual soreness and swelling in the maxilla, attributed to sterile abscess formation. At last follow-up, all patients demonstrated a clinically stable maxilla with correction of their malocclusion. CONCLUSION Use of ultrasonic-aided pins in fixation of resorbable mesh plates, in Le Fort I osteotomies, is a viable technique and superior resorbable plating system because it is easy to use, results in adequate fixation strength, and shortens time of application by eliminating the need for tapping. In addition, this resorbable system eliminates many disadvantages associated with using all-titanium fixation.

Sinonasal Disease and Orbital Cellulitis in Children

Sinonasal disease is common in the pediatric population because of anatomic, environmental, and physiologic factors. Once paranasal sinusitis develops, orbital cellulitis is a concerning sequela that can result in loss of visual acuity and even intracranial disease. Thus, a clear history and physical examination in conjunction with radiographic studies are critical to a correct diagnosis and timely institution of treatment that may include hospitalization, serial ophthalmologic examinations, intravenous antibiotics, and surgery. The serious nature of orbital cellulitis in children cannot be overestimated; but, if prompt and appropriate treatment is initiated, the prognosis is excellent and long-term sequelae should be limited.

Industrial-Grade Silicone Injections Causing Intermittent Bilateral Malar Swelling: Review of Safety and Efficacy of Techniques and Products Available

Silicone and other fillers have become a popular aid to increase soft tissue density, decrease static skin rhytids, and treat muscle wasting, particularly in the face. As a result, injectable silicone has become popular in patients with the human immunodeficiency virus (HIV). It has been postulated that highly active antiretroviral therapy detrimentally induces the physiologic process of fat atrophy of the temporal and buccal fat pads of the face and regional fat wasting of the arms, legs, and buttocks and that HIV protease inhibitors may induce fat atrophy by binding and inhibiting homologous human proteins that are involved in fat metabolism. The classic hollowed-out facial appearance linked to HIV positivity can have detrimental social implications in infected patients who are otherwise very functional. In consequence, facial implantation, fat transplantation, and dermal and subcutaneous fillers have been used to aid in the restoration of facial appearance. This report describes the case of a patient who underwent multiple rounds of silicone injections and complained of intermittent facial swelling and pain long after the injections. The authors report on the safety of specific medical-grade injectable fillers and techniques found to be safely effective, especially in the HIV-positive population.

Myositis ossificans of the temporalis muscle: case report and review of the literature.

Myositis ossificans, also known as traumatic myositis ossificans or myositis ossificans circumscripta, is the product of an unusual reactive process of mesenchymal stem cells within the muscle produced secondary to a traumatic insult or inflammatory process. In approximately 75% of cases, the process has a direct correlation with a single or repetitive, traumatic, penetrating, or crushing injury to the muscle. However, in up to 25% of cases, there is no recollection of a traumatic event. The most commonly accepted mechanism of traumatic etiology includes the embedment and lysis of bone fragments within the soft tissue causing subsequent exposure of bone morphogenic proteins to extraosseous cells. This environment stimulates osteoblasts to form true bone, dystrophic calcifications, or a calcified chondroid matrix. A concomitant mechanism that occurs involves the overproduction of bone morphogenic protein-4 produced by the muscle cells or the muscle fascia.

Idiopathic bone cavities of the mandible: an update on recurrence rates and case report

Idiopathic bone cavities (IBCs) are usually an incidental finding, often found in long bones but also in the craniofacial skeleton. Typically solitary, IBCs can present at multiple sites. Surgical exploration alone has proved effective, although recurrence does occur, particularly in cases with multiple lesions. The average time necessary to observe either recurrence or complete healing has been reported to be more than 3 years. Previously reported low recurrence rates for IBCs in the craniofacial skeleton may have been artificially low because of insufficient long-term follow-up. Providers should be prepared for long-term follow-up and care of these patients. The case of the patient presented here supports the need for long-term follow-up.

Mandibular Replacement Utilizing TMJ TJR Devices

Throughout this book, authors have comprehensively presented the basic principles and rationale for the use of alloplastic temporomandibular joint total joint replacements (TMJ TJR). Pearls and pitfalls of the basic surgical techniques as well as more sophisticated procedures such as combined TMJ TJR/orthognathic surgery have also been described. This chapter offers the unique perspective of using alloplastic TMJ TJR for the reconstruction of acquired mandibular defects that involved the TMJ. It is not the authors’ intention to provide management protocols of the primary process that created the defect but instead to illustrate potential solutions for these challenging cases.

Incorporating Simulation Into Oral and Maxillofacial Surgery Residency Education and Training: Christiana Care's Method

Surgical residency education has undergone a paradigm shift, with more emphasis being placed on the value of simulation as a core educational tool. As a result, the Halstedian education model of ‘‘see one, do one, teach one’’ is no longer the preferred method of initial procedural and cognitive training. Patient care involves a more experienced and confident interaction with the resident, likely resulting in enhanced patient care and safety. This requires a change for residents and faculty alike. Although there is considerable literature describing the use of simulation in general surgery and anesthesia residency education, there is scant information specifically on its use in oral and maxillofacial surgery (OMS) residency training. Programs need to balance the reality of clinical duties with the importance of patient safety and proficiency-based trainingthatsimulation canprovide. Simulation provides the ability to tailor specific educationalgoalstofittheneedsofaprogram’sstrengthsand resources and ensures that residents gain experience in high-risk, low-volume procedures and to make the learning conducive to all levels of learners within the residency. 1 The process of implementing simulation education involves a change in philosophy with regard to current residency education. This new philosophy requires that the learner, not the patient, be the educational focus and itensuresthat errorsare used asteaching points. 2 Further, it fosters competency based on validatedmeasurements. 2 TheOMSresidencyprogram at Christiana Care is developing and implementing simulation with the institution’s Virtual Education and Simulation Training Center into the core curriculum of residency training. Six core areas of residency training were identified: surgical skills, physical diagnosis, ethics and professionalism, Advanced Cardiovascular Life Support (ACLS), anesthesia, and patient management. Simulation models are being developed that cover these core areas. Currently, scant information is available in the literature on implementing simulation into OMS residency education; thus, we present an initial novel approach toward residency education. In the implementation of this pilot program, sessions were developed and scheduled over the course of the academic year: 1) management of difficult airways, 2) local skin flaps (Fig 1), 3) laparoscopic fundamentals for arthroscopy of the temporomandibular joint, 4) objective structured assessment of technical skills for formative assessment of laceration closure, 3 5) delib

Acquired defects of the nose and naso-orbitoethmoid (NOE) region.

Nasal injuries coupled with midface fractures of the orbit and ethmoids constitute a nasoorbitoethmoid (NOE) fracture pattern, which is typically the most challenging facial fracture to repair. Hard and soft tissue defects of this region may require advanced reconstruction techniques, including local rotational flaps, free tissue transfer, and even prosthetics. The restoration of form and function dictates treatment, and the success of primary repair is paramount, because secondary correction is challenging in this area of the midface. Because of the complex nature of this region, this discussion is divided into hard tissue defects, with a focus on trauma, and soft tissue defects, with a focus on oncology.

Osteotomy vs Augmentation Genioplasty: Which Is Best?

Patients seeking improved lower facial esthetics through genioplasty are often confrontedwith the options of bony advancement osteotomy vs implant augmentation. The choice of one of these options vs the other is often based on surgical experience and training rather than evidence-based data.1 Implant surgery is less invasive and reversible but carries the risks of underlying bony resorption and hardware infection.2-5 Osteotomy ismore versatile and long lasting and can provide functional improvements, if the genial tubercles are involved in the design, but is more invasive and technically more challenging.6,7 Chan and Ducic suggest that advancement genioplasty should bemore readily used because of the potential functional benefits that accompany its esthetic changes.8 They report it to be a safe, reliable, and effectivemethod that is reproducible by all surgeons, regardless of whether trained inotolaryngology, plastic surgery, or oral and maxillofacial surgery. Oral andmaxillofacial surgeons tend to performbony advancement osteoplasty on the basis of their surgical training, which includes significant bony procedures, such as orthognathic surgery and facial fracture reconstruction. As a result, most oral andmaxillofacial surgeons find the procedure relatively simple andoftenperform it in theoffice settingbut consider implant augmentation when a less invasive approach is preferred. Plastic surgeons and otolaryngologists-facial plastics surgeons are more familiar with soft-tissue surgery and seemingly prefer implant augmentation. This raises the key question: What is the best surgery for patients? A literature search does little to answer this question and only reinforces the risks or benefits of each technique. Thus, a clinically relevant prospective study is needed to assess patient outcomes and thepreferredmethodofgenioplasty.Until this isdone, the surgeon must continue to perform the surgery best suited to each individualpatienton thebasis ofpatientneed rather than historical training methods. Addressing this issue, ChanandDucic present theirmodified technique, performed on 126 patients during 17 years, in which theosteotomydesign is basedon intersecting lineswith the mental foramen as the key landmark. This creates a predictable surgical procedure for the novice and expert alike, minimizing the allure of alloplastic augmentation. It should benoted,however, that theosteotomydesigndone in theprocedure raises the concerns of possible notching of the inferior border and shorteningof the lower thirdof the face.Apure advancement genioplasty avoids an acute-angle osteotomy and extends posteriorly toward the first molars to alleviate these concerns. However, the point of the article is clear in that advancement genioplasty ismore versatile, with less long-term risk than alloplastic augmentation, and should be usedmore routinely by all surgeons.

Evaluation of Third Molars: Clinical Examination and Imaging Techniques

Third molars are thought to have once been a necessity for early human ancestors in order to efficiently chew and digest the cellulose that comprised the plant foliage, which was an integral part of the dietary intake. Due to evolutionary changes and societal advancements, human diets are less plant based, jaw size has become smaller, and the functional need for third molars minimal [1]. Third molars, or wisdom teeth, however, are still present in the majority of people and often require removal to prevent or treat third molar–associated disease states. Critical to the determination of third molar management is the clinical examination and radiographic analysis.