Virtual Preoperative Planning and Intraoperative Navigation in Facial Prosthetic Reconstruction: A Technical Note.

This technical protocol outlines the use of computer-assisted image-guided technology for the preoperative planning and intraoperative procedures involved in implant-retained facial prosthetic treatment. A contributing factor for a successful prosthetic restoration is accurate preoperative planning to identify prosthetically driven implant locations that maximize bone contact and enhance cosmetic outcomes. Navigational systems virtually transfer precise digital planning into the operative field for placing implants to support prosthetic restorations. In this protocol, there is no need to construct a physical, and sometimes inaccurate, surgical guide. The report addresses treatment workflow, radiologic data specifications, and special considerations in data acquisition, virtual preoperative planning, and intraoperative navigation for the prosthetic reconstruction of unilateral, bilateral, and midface defects. Utilization of this protocol for the planning and surgical placement of craniofacial bone-anchored implants allows positioning of implants to be prosthetically driven, accurate, precise, and efficient, and leads to a more predictable treatment outcome.

Massive macroglossia secondary to angioedema: a review and presentation of a case.

Macroglossia is a rare condition, but can severely affect the oral and maxillofacial region. Angioedema is a condition resulting from multiple mechanisms, all of which can result in macroglossia. This report describes an unusual case of acquired macroglossia in an adult resulting from chronic edema secondary to angioedema in the setting of stroke. The patient had a morbidly enlarged tongue and presented with clinical signs and symptoms consistent with massive macroglossia. She required surgical intervention for acute management of her symptoms and definitive treatment of her macroglossia.

What is the role of biofilms in severe head and neck infections?

Most infections of the head and neck and virtually all of those encountered in the practice of dentistry are caused by bacteria that are organized into biofilms. A biofilm is a complex, usually multispecies, highly communicative community of bacteria that is surrounded by a polymeric matrix. Treatment of these types of infections with traditional antibiotics alone is ineffective, and surgical removal of diseased tissue is still necessary.

Applications of surgical navigational systems for craniofacial bone-anchored implant placement.

The following case reports describe the use of computer-assisted image-guided surgery to plan and place craniofacial bone-anchored implants (CBAI) for facial prosthetic reconstructions. During virtual planning, the soft tissue and bone visualizations are segmented from spiral computed tomography data and the patient's normal anatomy is mirrored onto the skull of the defect side, thus providing the ability to visualize the future prosthetic form. CBAI are planned in the anatomical area that leads to the best cosmetic results. Bone quantity is directly assessed at the surgical sites with the integrated instrumentation while the clinician navigates within the images and virtual planning scheme in real time. The aim of this report is to show a technique that incorporates computer-assisted image-guided surgery into the preoperative planning and surgical placement of CBAI. The use of this technology to plan and place implants in the most ideal location for facial prosthetic treatment eliminated the need for a conventional or prototyped surgical guide.

Pivotal, randomized, parallel evaluation of recombinant human bone morphogenetic protein-2/absorbable collagen sponge and autogenous bone graft for maxillary sinus floor augmentation.

PURPOSE: The purpose of this prospective study was to evaluate the safety and effectiveness of recombinant human morphogenetic protein-2 (rhBMP-2) on an absorbable collagen sponge (ACS) compared with an autogenous bone graft when used for 2-stage maxillary sinus floor augmentation. The study assessed new bone formation, placement integration, and functional loading after 6 months and long term for 2 years. MATERIALS AND METHODS: A total of 160 subjects were randomized, enrolled, and followed from January 1999 to February 2004 at 21 centers in the United States. The subjects with less than 6 mm of native bone height were treated with 1.50 mg/mL rhBMP-2/ACS or with an autograft. The height and density measurements were quantified by computed tomography scans. Core biopsies were obtained at dental implant placement and used for histological analysis. Safety was evaluated by oral examinations, radiographs, serum chemistries, and hematology. RESULTS: A significant amount of new bone was formed by 6 months postoperatively in each group. The mean change in bone height in the rhBMP-2/ACS subjects was 7.83 +/- 3.52 mm versus 9.46 +/- 4.11 mm for the bone graft subjects. At 6 months after dental restoration, the induced bone in the rhBMP-2/ACS group was significantly denser than that in the bone graft group. No marked differences were found in the histologic parameters evaluated between the 2 groups. The new bone was comparable to the native bone in density and structure in both groups. The success rate for the rhBMP-2/ACS group was 79% (64 of 81 subjects), and 201 of 251 implants placed in the bone graft group and 199 of 241 implants placed in the rhBMP-2/ACS group were integrated, retained, and functional at 6 months after loading. No adverse events were deemed related to the rhBMP-2/ACS treatment. The autograft group was noted to have a 17% rate of long-term parasthesia, pain, or gait disturbance related to the bone graft harvest. CONCLUSIONS: The results of our multicenter, randomized, prospective, clinical trial have shown the effectiveness and safety of rhBMP-2/ACS compared with bone graft for sinus floor augmentation. The study's primary endpoint was exceeded, and the implants placed in rhBMP-2/ACS and bone graft groups performed similarly after functional loading.

Treatment of refractory facial pain diagnosed as atypical trigeminal neuralgia: a case report.

This case report describes an effective treatment protocol, the healing process, and the recovery of the patient to a pain-free status after more than 25 years of failed treatment for facial pain. Features of this case report include: 1. A procedure to produce a phenomenon useful as a pathognomonic sign of autonomic nervous system neuropathy, as a determination of the location of the origin of pain, and as a monitoring device for the effectiveness of treatment. 2. A digital pressure intervention procedure that appears effective as a treatment modality to relieve pain and to effect healing. 3. A method to improve posture of the body affecting the relationship of the maxilla to the mandible, the dental occlusion, and the etiology of facial pain. 4. A description of the nature and intensity of the different levels of the pain experienced in the face from the most severe state of pain to a no-pain condition. 5. A diagnosis using a diagnostic term that has developed since the initial diagnosis of atypical trigeminal neuralgia in this case.

De novo bone induction by recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation.

PURPOSE: This phase II study was designed to evaluate 2 concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) for safety and efficacy in inducing adequate bone for endosseous dental implant in patients requiring staged maxillary sinus floor augmentation. MATERIALS AND METHODS: Patients were treated with rhBMP-2 (via an absorbable collagen sponge [ACS]), at concentrations of 0.75 mg/mL (n = 18), 1.50 mg/mL (n = 17), or with bone graft (n = 13). Bone induction was assessed by alveolar ridge height, width, and density measurements from computed tomography scans obtained before and 4 months after treatment and 6 months post-functional loading of dental implants (density only). RESULTS: Mean increases in alveolar ridge height at 4 months after treatment were similar among the groups; 11.3 mm, 9.5 mm, and 10.2 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups. Mean increases in alveolar ridge width (buccal to lingual) at the crest of the ridge were statistically different among the treatment groups; 4.7 mm, 2.0 mm, and 2.0 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL treatment groups (P

Osseointegration of dental implants complexed with rhBMP-2: a comparative histomorphometric and radiographic evaluation.

PURPOSE: To evaluate the effect of rhBMP-2 on implant osseointegration using histomorphometric and radiographic imaging analyses and determine the diagnostic accuracy of periapical radiographs regarding clinical bone-implant contact levels. MATERIALS AND METHODS: Hollow-cylinder implants were filled with an absorbable collagen sponge soaked with recombinant human bone morphogenetic protein-2 (rhBMP-2) or left empty and implanted in the mandibles of dogs. Animals were followed for 2, 4, 8, or 12 weeks. At the end of each time interval, the animals were sacrificed and specimens were collected for histomorphometric and radiographic evaluation of the bone-implant contact levels. RESULTS: Both groups exhibited the same mean histologic bone-implant contact on the outer surface of the implant, except for the 4-week group. The radiographic evaluation of bone-implant contact overestimated the actual osseointegration levels by at least 30%, a significant amount. DISCUSSION: The osteoinductive and regenerative potential of rhBMP-2 is of clinical benefit in cases where bone augmentation is indicated and improved levels of osseointegration are expected. Radiographic evaluation has been the most widely employed technique in clinical practice for assessing bone levels around dental implants and comparing changes over time. However, there is a limit to the diagnostic accuracy of conventional radiographs when compared to the data obtained by histologic analysis. CONCLUSION: Application of rhBMP-2 within the confined boundaries of the hollow chamber of the implant had a limited effect on the osseointegration level along its outer surface, perhaps because of physically restricted diffusion. Radiographic evaluation resulted in the overestimation of bone-implant contact, and poor correlation with the histomorphometric data was found.

Evaluation of ocular changes secondary to blowout fractures.

There has been extensive debate over the standard of care of orbital fractures. Entrapment, diplopia, and hypoglobus, with or without enophthalmos, are the most common clinical indications for surgical intervention. Evaluation of these injuries is often limited in the early postinjury period because of edema. In assessing the severity of the injury, the clinician often uses parameters such as changes in visual acuity, patient-reported diplopia, gross changes in globe position, and an evaluation of the extraocular muscles. Many of these parameters are only grossly assessed and therefore are not specifically documented and tracked. The decision to proceed with surgical intervention may be based only on these gross clinical findings. The purpose of this article is to present a reliable and repeatable method for evaluating the degree of diplopia and the globe position of the orbital trauma patient by describing the use of the double Maddox rod test (Wilson Ophthalmic, Mustang, OK) and Hertel exophthalmometer (Wilson Ophthalmic). These methods can provide sequential documentation of the progression of the injury and help better define the need for surgical intervention and to follow the postoperative course.

Proximal tibia bone harvest: review of technique, complications, and use in maxillofacial surgery.

Autologous bone grafts for alveolar ridge augmentation are the gold standard for restoring atrophic residual ridges in preprosthetic surgery. Many indications, donor sites, and techniques have been reported. The purpose of this article is to review the anatomy, surgical technique, and potential complications associated with proximal tibia bone harvest. A consecutive series of 44 patients who underwent proximal tibia bone graft harvest between 2000 and 2003 was studied by retrospective chart review. Five major and 7 minor complications were observed; overall morbidity was low. A significant amount of corticocancellous bone may be harvested from the proximal tibia with minimal morbidity.

Interactive imaging for implant planning, placement, and prosthesis construction.

PURPOSE: This review describes a new interactive imaging program that allows computed tomography (CT) images to be used to virtually place dental implants and construct a precise guide splint and final prosthesis for delivery at the time of implant placement. MATERIALS AND METHODS: Patients with edentulous arches were recruited to participate in a trial program to assess the feasibility of using CT images in a 3-dimensional image-based program (Oralim; Medicine NV, Belgium) for planning and placing dental implants. Patients meeting the criteria received a CT of the appropriate arch using a denture with radiopaque markers indexed to the opposing arch. Acquisition slices of 0.6 mm or less was required. The software allowed precise planning for implant placement after which the planned case was sent to a manufacturing facility for splint and prosthesis construction. RESULTS: The guide splint and final prosthesis were returned to the clinical site for implant placement. An implant map was provided for each patient showing the diameter and length of the implant and abutments to be used in each predetermined implant site. The surgery was accomplished without a flap, and the prosthesis was delivered immediately. Occlusion required only minor adjustments in all cases, and immediate function was accomplished. CONCLUSION: Interactive computer imaging can allow precise planning for implant position and the images can be used for guide splint and final prosthetic fabrication prior to surgery. This technology is powerful, easy to use, and is a significant advance in implant dentistry.

Rescue procedure for the Brånemark Novum protocol.

The Brånemark Novum protocol for immediate functional loading of a mandibular fixed implant-supported prosthesis has been an effective alternative for selected patients. In the event of the loss of an implant, a rescue set that allows continuous use of the original fixed restoration while restoring tripod osseointegrated support at the implant level is available.

Implant materials, design, and surface topographies: their influence on osseointegration of dental implants.

The purpose of this review is to describe commonly used dental implants with reference to their material composition, design factors, and surface topographies. The review includes a discussion of the biological principle of osseointegration and how this process of bone-implant interaction is influenced by different implant materials, designs, and surface characteristics

Bone reduction surgical guide for the Novum implant procedure: technical note.

The Novum System offers a unique opportunity to create a definitive, immediately loaded fixed prosthesis on the edentulous mandible for patients who meet specific presurgical criteria. Since this system is based on precisely placed implants and prefabricated bar structures, the surgical techniques are critical in obtaining a satisfactory result. It is especially important that the bone reduction required to create space for the implants and bar assembly be in the proper plane and deep enough to leave room for eventually setting and processing teeth. The surgical guide described here can be an important adjunct during bone reduction to assure proper spatial positioning of the preformed titanium bars. Mounted casts of the correct or corrected maxillary dentition and mandibular arch are required at the appropriate vertical dimension of occlusion. The mandibular cast is reduced in prescribed dimensions to allow the subsequent creation of a processed resin surgical guide for use during the initial stages of surgery. This guide, when used for bone reduction during surgery, eliminates the arbitrary removal of osseous structure and helps assure the plane of implant placement is appropriate for each patient. When used routinely, a significant complication of the Novum procedure can be minimized or eliminated completely. Setting of teeth and processing are subsequently simplified, especially in the posterior dimensions, with this guide technique.