Sterling R. Schow

Autologous bone grafts and endosseous implants: Complementary techniques

PURPOSE This article describes predictable techniques to augment contour- or height-deficient edentulous alveolar processes with autologous bone grafts for simultaneous or secondary placement of endosseous implants. METHODS Augmentation bone grafts harvested from the ilium and mandible were used to reverse alveolar atrophy of the maxilla and mandible. Endosseous implants were either placed simultaneously with the graft or 6 to 9 months after grafting. Implant success was calculated only after an implant-supported prosthesis was in function for a minimum of 12 months. RESULTS One hundred twenty-nine autologous bone grafts were placed in 99 patients. This included 70 grafts in the maxillary sinus, 32 onlay grafts, 14 veneer grafts, 9 saddle grafts, and 4 inlay grafts. Of these, 117 (90.7%) were successful. A total of 364 implants were placed in the grafted areas, 134 at the time of grafting and 230 6 to 9 months after grafting to allow time for osseous healing and remodeling. Three hundred twenty (87.9%) of the 364 implants placed in grafted areas were successful; 112 (83.6%) of the implants placed at the time of bone grafting and 208 (90.4%) of the implants placed secondarily in consolidated grafts. A total of 51 implants were placed in non-grafted areas in the same group of patients. Of these, 49 (96%) were successful. CONCLUSION Autologous bone grafts can be used successfully to improve the ability to place endosseous implants. The successful placement of implants in autologous grafts is more predictable when the implants are placed secondarily, 6 to 9 months after bone grafting. Failure of individual implants does not imply failure of the bone graft. In most instances when implants failed to osseointegrate, enough bone graft remains to allow subsequent successful implant placement 6 to 9 months later.

Osseous regeneration in the presence of four common hemostatic agents

The iliac crest is a common site for bone procurement in oral and maxillofacial surgery. The goal of this study was to evaluate the potential for bone regeneration in the presence of four common hemostatic agents in a manner that parallels iliac bone procurement in humans. The agents evaluated were 1) Avitene (microfibrillar collagen; Medchem Products, Inc, Woburn, MA); 2) bone wax (beeswax with isopropyl palmitate; Ethicon, Inc, Somerville, NJ); 3) Gelfoam (absorbable gelatin sponge; The Upjohn Company, Kalamazoo, MI); and 4) Surgicel (oxidized regenerated cellulose; Johnson & Johnson Products, Inc, Patient Care Division, New Brunswick, NJ). Five surgical defects in each of four dogs were created for placement of the four materials; one defect served as an empty control site. The dogs were then allowed to heal over a 2-month period. Radiographic and histologic examination showed new bone formation in the presence of Avitene, Surgicel, and Gelfoam. Residual material incorporated in bone, without foreign-body response, was noted in the Avitene and Gelfoam sites. Bone wax, however, showed an intense foreign-body reaction, characterized by giant cells, plasma cells, fibrous granulation tissue, and lack of bone reformation. On the basis of these initial findings, it was concluded that Surgicel, Avitene, and Gelfoam may be adequate hemostatic agents for use in iliac bone procurement, whereas the use of bone wax appears to be contraindicated.

Life-threatening hemorrhage from a Le Fort I osteotomy

On July 29, 1980, a healthy 32-year-old white woman was admitted to the Oral and Maxillofacial Surgery Service of another hospital for correction of vertical maxillary excess and mandibular retrognathia. This was to be accomplished via Le Fort I osteotomy and mandibular autorotation. The review of systems, past medical history, and past surgical history was noncontributory. Physical examination was significant for vertical maxillary excess, increased lower facial height, mandibular retrognathia, and lip incompetence. The remainder of her examination was unremarkable. On July 30, 1980, the patient was taken to the operating room, where. under general nasoendotracheal anesthesia. a Le Fort I osteotomy was accomplished by incorporating a bilateral 8 mm ostectomy posteriorly and a bilateral 6 mm ostectomy anteriorly. The osteotomies were made with a reciprocating saw. The lateral nasal walls and nasal septum were sectioned with a forked nasal gouge and the bilateral pterygomaxillary dysjunction was effected with a curved osteotome. No significant bleeding was encountered to this time. Manipulation of the maxilla into a down-fractured position was attended with profuse arterial hemorrhage from the right posterior region. Attempts to visualize the source of the bleeding were unsuccessful. Immediate measures to stabilize the patient included multiple arterial and venous cutdowns, infusion of 15 units of packed erythrocytes, two units of autologous whole blood, four units of plasmanate, and four units of fresh frozen plasma. The right external carotid artery was

Surgical management of a pneumatized articular eminence of the temporal bone

Abstract A case of unilateral pneumatized temporal bone eminence discovered during eminectomy in a 19-year-old man is presented. Successful obturation of the defect was accomplished by using the removed portion of the eminence as a free autologous graft. The procedure resulted in normal joint function.

The potential risks, complications, and prevention of deep vein thrombosis in oral and maxillofacial surgery patients

PURPOSE Deep vein thrombosis is a complication in surgical patients with a potential for disastrous results. This article discusses the pathogenesis, prevention, and treatment of this condition. CONCLUSION Surgeons should be acutely aware of the potential development of deep vein thrombosis and should take prophylactic measures to prevent this problem as part of their surgical routine.

Enhanced Surgical Exposure for the High Extracranial Internal Carotid Artery

The need for enhanced surgical exposure for the high extracranial (Zone III) internal carotid artery is not uncommon. In certain circumstances, the posterior border and angle of the mandible may interfere with access to the distal internal carotid artery (ICA). The use of modified mandibular osteotomies has provided vascular surgeons in our institution with improved exposure of the ICA in selected cases. The intraoral sagittal split and extraoral vertical ramus osteotomies of the mandible allow manipulation of the posterior border and angle of the mandible with low morbidity and minimal postoperative complications. These procedures can be performed for both dentate and edentulous patients without the need for intermaxillary fixation. This paper introduces these modifications and discusses the benefits over previously described methods of mandibular manipulation.

Lingual nerve injury associated with overpenetration of bicortical screws used for fixation of a bilateral mandibular sagittal split ramus osteotomy

A rarely described complication of the mandibular sagittal ramus split osteotomy is lingual nerve injury. White et al’ and Schendel and Epke? described lingual nerve injuries during sagittal osteotomies in 1969 and 1980, respectively. In 1990, Hegtvedt and Zuniga3 described the occurrence of lingual nerve anesthesia, which they concluded was caused by direct nerve injury as a complication of a rigidly fixed sagittal ramus osteotomy. They suspected the injury was caused by rotary instrument penetration of the lingual cortical plate of the mandible and failure to protect the soft tissues in the area. Shortly thereafter, Meyer,4 in a letter to the editor of

Prevention of the misdirected sagittal split

If a misdirected split occurs and is recognized, additional surgery is necessary for correction. Two methods may be used. The original medial osteotomy may be extended to the posterior border of the ramus, or, alternatively, a more inferiorly placed osteotomy can be made. Both of these methods result in added tissue trauma and require additional time. The purpose of this paper is to present an explanation for the occurrence of the misdirected sagittal split and to suggest an approach for its prevention.

Intraoperative control and stabilization of the distal osseous segment in genioplasty

Genioplasty procedures using an anterior mandibular horizontal osteotomy or ostectomy are common operations for most oral and maxillofacial surgeons. This technical note describes a procedure that has been found helpful in controlling the mobilized segment, assisting in its accurate repositioning, and improving its final stabilization. It uses instrumentation that is readily available to most surgeons. The genioplasty procedure maintains a broad soft-tissue pedicle, not compromised by either the surgery or the method of stabilization. Exposure of the operative site is obtained with a standard, full-thickness vestibular incision. Mucoperiosteal flaps are elevated superiorly and inferiorly sufficiently to expose the osteotomy site and to allow for subsequent stabilization. The midline is marked with a vertical line etched in the labial cortical bone with a 701 fissure bur. The proposed osteotomy is also etched from the right to the left inferior mandibular border, crossing the midline reference (Fig 1). A midline, labial cortical perforation is then made near gnathion with a 703 bur to allow insertion of a CarrollGirard screw inferior to the osteotomy. The osteotomy is completed with a reciprocating saw. The mobilized

Comparison of soft-tissue enhanced and conventional cephalometric radiographs

Pretreatment evaluation of the orthognathic surgery patient includes hard-tissue and soft-tissue analysis. Although the soft-tissue analysis can be made easier by the use of a Quint intensifying screen (Quint X-Ray Co, Inc, Los Angeles) which enhances the soft-tissue image, when the enhanced cephalometric radiograph was compared with a standard, nonenhanced radiograph, it was found to have the same level of diagnostic accuracy.