Oral and Maxillofacial Surgery


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Oral and Maxillofacial Surgery

  1. 1. EDITORIAL Oral and Maxillofacial Surgery An Important and Evolving Specialty in DentistryPERHAPS THE MOST HIGHLY structured and extensive residency other important areas in both medicine and dentistry are subjectsprogram in dentistry is oral and maxillofacial surgery. OMFS is a that the oral and maxillofacial surgeon must draw upon to enablerather curious specialty with strong connections to dentistry and to him or her to practice the art and science of modern oral and max-some of the surgical specialties in medicine. As such, it is easy to illofacial surgery.understand why OMFS occupies an important place in both the pri- Oral surgeon Joel Friedman is guest editor of this issue of Thevate practice setting and in hospital-based care. NYSDJ, which is devoted to topics in oral and maxillofacial surgery. With the specialty’s early prominence in exodontias, and lead- Dr. Friedman is a highly respected clinician, educator, and a stronging up to the new vistas in facial and jaw reconstructive surgery advocate and leader in organized dentistry. He has enlisted severaland surgical implant procedures, we have witnessed a rapid devel- prominent oral and maxillofacial surgeons to contribute articles toopment in both the scope of OMFS practice and in the educational this issue.structure of the specialty. Oral and maxillofacial surgery residen- We hope that you enjoy this special edition of The NYSDJ, as wecies occupy a minimum of four years. There are a number of OMFS continue to appreciate and celebrate the evolution and contribu-programs which have a six-year residency requirement that are tions of the oral and maxillofacial surgery specialty to the dentalcombined with the conferring of an M.D. degree upon completion and medical professions.of the residency. Surgical techniques, hard- and soft-tissue response to a varietyof environments, pathology, anesthesia, growth and development,internal medicine, oral medicine, bioengineering, sophisticatedimaging modalities, dentofacial esthetics, psychology and many D.D.S. M.Sd4 NYSDJ • NOVEMBER 2005
  2. 2. NYSDA D i r e c t o r y OFFICERS Lawrence E. Volland, President John Asaro, Secretary-Treasurer 115 Professional Pky., Lockport 14094-5369 2707 Sheridan Drive, Tonawanda 14150 Alfonso J. Perna, President Elect Roy E. Lasky, Executive Director Sixth District Dental Society, 55 Oak St., 121 State St., Albany 12207 Binghamton 13905ADA Second District Trustee G. Kirk Gleason reads Steven Gounardes, Vice Presidentproclamation from ADA, delivered at ceremonies to 351 87th St., Brooklyn 11209 G. Kirk Gleason (ADA Trustee)mark founding of ADA in Niagara Falls. Event was 981 Rte.146, Clifton Park 12065 Brian T. Kennedy, Immediate Past Presidentheld during NYSDA Semi-Annual Meeting in June. 275 Pawling Ave., Troy 12180Other participants included, from left: BernardMcDermott, Washington, D.C., and Kathleen Roth,Wisconsin, candidates for office of ADA President-Elect; Joseph Accardo, 2005 Meeting Chairman; BOARD OF GOVERNORS NY County-Matthew J. Neary 7-Andrew G. VorrasiMark Feldman, ADA Treasurer. 501 Madison Ave., Fl. 22, New York 10022 2005-A Lyell Ave., Rochester 14606 NY County-Jeffrey R. Burkes 8-Jeffrey A. Baumler 875 Fifth Ave., New York 10021 2145 Lancelot Dr., Niagara Falls 14304 Delegates Choose Kathleen NY County-Robert B. Raiber 8-Kevin J. Hanley Roth to Head ADA in 2007 630 Fifth Ave., #1869, New York 10111 2-Michael L. Cali 959 Kenmore Ave., Buffalo 14223-3160 9-Neil R. Riesner 2003 E. 60th St., #1A, Brooklyn 11234 111 Brook St., 3rd Floor, Scarsdale 10583-5149A WISCONSIN GENERAL dentist has been 2-James J. Sconzo 9-Malcolm S. Graham 1666 Marine Parkway, Brooklyn 11234 170 Maple Ave., White Plains 10601tapped to head the ADA in 2007. Kathleen 2-Craig S. Ratner 9-David H. KraushaarS. Roth was elected president-elect for 1011 Richmond Rd.,Staten Island 10304-2413 623 Warburton Ave., Hastings-On-Hudson 10706 3-Mark J. Weinberger N-Lidia M. Epel2005-06 at the Annual Session of the ADA 961 Hoosick Rd., Troy 12180 165 N. Village Ave. #102, Rockville Centre 11570House of Delegates in October in Philadel- 3-Lawrence J. Busino N-David J. Millerphia. She is just the second woman in the 2 Executive Park Dr., Albany 12203 467 Newbridge Rd., E. Meadow 11554 4-Frederick W. Wetzel N- Laurence F. Shapirohistory of the ADA to hold the top post. The 1556 Union St., Niskayuna 12309 519 Bellmore Ave., E. Meadow 11554first woman was Geraldine Morrow of 4-Mark A. Bauman Q-Chad P. Gehani 157 Lake Ave., Saratoga Springs 12866 35-49 82nd St., Jackson Heights 11372Alaska, ADA President in 1991-92. 5-John J. Liang Q-Robert M. Trager Dr. Roth has represented Wisconsin 2813 Genessee St., Utica 13501 111-02 Farmers Blvd., Hollis 11412and Michigan (9th District) on the ADA 5-William H. Karp S-Steven I. Snyder 472 S. Salina St., #222, Syracuse13202 Suffolk Oral Surgery Associates, 264 Union Ave., Holbrook 11741Board of Trustees since 2001. At the ADA, 6-Robert G. Giannuzzi S-Alan Mazershe has chaired committees on diversity 107 Gates St., Binghamton 13903-2471 140 Terryville Rd., P.O. Box 985, Port Jefferson Sta. 11776 6-Scott Farrell B-Joel Friedmanand information technology, and was 39 Leroy St., Binghamton 13905 3333 Henry Hudson Pkwy, Bronx 10463senior trustee on the ADA Strategic 7-Richard F. Andolina B-Stephen B. Harrison 74 Main St., Hornell 14843 1668 Williamsbridge Rd., Bronx 10461Planning Committee. A 1974 graduate of Marquette Univer-sity School of Dentistry in Milwaukee, Dr. COUNCIL CHAIRPERSONS Annual Meetings Governmental Affairs Joseph A. Accardo Joseph R. Caruso OFFICERoth is a past president of the Wisconsin 121 State Street 515 Third St., Niagara Falls 14301 40-29 Utopia Pky., Flushing 11358Dental Association. She and her husband, Awards Insurance Albany, NY 12207 Jay I. Glat (518) 465-0044Daniel, also a dentist, were guests at the David M. Delaney 52 Summit St., White Plains 10607-1209 (800) 255-2100 447 Albany Shaker Rd.,NYSDA Semi-Annual Meeting in June in Chemical Dependency Loudonville 12211 Robert J. Herzog Roy E. LaskyBuffalo. While there, she participated in Membership & 16 Parker Ave., Buffalo 14214 Executive Director Communicationsceremonies marking the founding of the Dental Benefit Programs Deborah A. Pasquale Margaret Surowka Rossi Andrew Vorrasi 391 Manhattan Ave., General CounselADA in 1859 in Niagara Falls. Brooklyn 11211-1422 2005-A Lyell Ave., Rochester 14606 Michael J. Herrmann Dental Health Planning/ New Dentist Assistant Executive DirectorCorrection Hospital Dentistry Jonathan M. Schutze Finance-Administration David J. Miller 453 Dixon Rd., Queensbury 12804An article introducing candidates for the post of Judith L. Shub 467 Newbridge Rd., East Meadow 11554 Nominations Assistant Executive DirectorADA Second District Trustee that appeared in Brian T. Kennedy Dental Practice Health Affairsthe October NYSDA News incorrectly reported Brendan P. Dowd 275 Pawling Ave., Troy 12180 Sandra DiNotothat the current trustee, G. Kirk Gleason, would 6932 Williams Rd., #1900, Peer Review & Director Niagara Falls 14304 Quality Assurance Public Relationsbe leaving his office at the end of this year. It Dental Education & Licensure Richard Rausch Mary Grates Stollshould have said that Dr. Gleason will complete Robert M. Peskin 1 Rockefeller Plz., #2201, Managing Editorhis four-year term at the close of the ADA 601 Franklin Ave., #225, Garden City New York 10020-2003 11530-5742 Beth M. WanekAnnual Session next October in Las Vegas. We Relief Assistant Executive Directorregret the error. Ethics Bruce J. Dines Joseph A. Viola North Country OMS Grp., 531 1670 Empire Blvd., #300, Webster 14580 Washington St., Watertown 13601 NYSDJ • NOVEMBER 2005 5
  3. 3. OMFS GUEST EDITORIALWelcome to My LifeThe clinical world of today’s oral and maxillofacialsurgeon is vast and varied. I SPENT MANY WEEKS contemplating what I would say as the guest editor of this special issue of The New York State Dental Journal. I thought I could begin by paraphrasing an old Saturday Night Live line and say,“Oral surgery has been berry, berry good for me.” But that does- n’t do justice to what is and has been a most incredible and productive specialty of dentistry. Joel M. Friedman, D.D.S. Not too long ago,mock OMFS Boardswere administered at Columbia University Medical Center/New YorkPresbyterian Hospital. Residents and attendings from many of thelocal hospital residency programs participated.A review of the top-ics that were included in the exercise defines the scope of modernoral and maxillofacial practice. Topics were: routine dento-alveolarsurgery; implants; bone grafting; clefts; treatment planning; andconcomitant medical problems and how they impact treatment.Additional topics were: trauma; surgical treatment of craniofacialdefects; rhinoplasty; facial cosmetics; the treatment and recogni-tion of cardiac, respiratory, endocrine and immunocompromisedpatients; anatomy; nerve injury and repair; and the temporo-mandibular joint. Just reading this list of topics gives an enhanced appreciationof the breadth and complexity of the procedures today’s oral sur-geon is capable of performing. This issue of The NYSDJ is intended to provide further insightinto what the OMFS is doing pretty much routinely. To assemble it,I invited leaders in our field to contribute manuscripts that speak tothe variety inherent in the OMFS specialty. Therefore, you will findarticles on orofacial infections, implantology and advanced imag-ing techniques, as they relate to clinical practice, in the pages ahead.We’ve also included an article on Hugo Obwegeser, OMFS pioneerand a revered figure among oral surgeons.Dr. Friedman is associate clinical professor of oral and maxillofacial surgery at ColumbiaUniversity School of Dental and Oral Surgery and associate clinical professor of dentistry at AlbertEinstein College of Medicine. He practices in Riverdale. He is a NYSDA Governor and a memberof the Board of Directors of the New York State Society of Oral and Maxillofacial Surgeons. NYSDJ • NOVEMBER 2005 23
  4. 4. OMFS Implants Evolution of a Dental Implant Practice The Camlog Implant System Charles A. Babbush, D.D.S., M.Sc.D.Abstract Camlog OverviewAfter extensive experience with a variety of implant sys- The Camlog implant system is based on 10 years of implant research and clinical use and features a unique implant-abutmenttems, dating back to the late 1960s, the author has begun connection. A minimum number of components are required toplacing Camlog implants, developed by Dr. Axel Kirsch. use this implant. It is extremely user-friendly from the perspec- tive of both clinician/technicians and dental auxiliaries. The sys-The design of this system eliminates the risk of rotation tem addresses and solves the persistent problem of screw-loosening.and screw-loosening, while at the same time offering It is mechanically stable and incorporates components designed to eliminate any rotation. It has the deepest (5.4 mm long) andextraordinary ease of use. The treatment of three patients strongest precision internal connection in the global implantwith Camlog implants is described. marketplace. The Camlog implant system’s state-of-the-art characteristicsSINCE PLACING MY FIRST IMPLANT in 1968, I have continual- include the following:ly searched for a technology that would provide the best rehabil- ● A roughened surface (Promote™)itation, risk/benefit ratio and long-term success rates for ● Both straight-walled and tapered designspatients. Over the years, I have been involved with a number of ● A variety of lengths and platform sizesdifferent implant systems. In the late 1970s, I used the ITI ● Immediate placement capabilityStraumman1 and Lederman TPS Swiss Screw2 implant systems. ● Open- and closed-tray impression techniquesIn the early 1980’s, Dr. Paul Mentag and I were instrumental in ● A bio-sealed bevelintroducing the IMZ system3-5 to the United States. Later, I ● Built-in biological heightworked with the SteriOss and Replace/Replace Select technology, ● Zero degree of abutment rotationthe latter conceptualized by Dr. Jack Hahn.6-7 Now Dr. Axel Kirsch ● Multiple prosthetic optionshas created the Camlog implant system,8-10 and I have placed ● Temporization capabilitiesmore than 200 Camlog implants. The system includes four different implant geometries to give This article describes the cutting-edge technology of the clinicians maximum flexibility in treating different anatomical sit-Camlog implant system and offers examples of my use of it in treat- uations. These geometries are:ing three patients. ● Screw cylindrical implants (with self-tapping threads)24 NYSDJ • NOVEMBER 2005
  5. 5. ● Root-form implants (with self-tapping threads) To prevent rotation and micro-movement, the Camlog implants● Press-fit cylindrical implants incorporate a three-position lock with intimate engagement of the● Screw-line implants Camlog cams.This connection results in the smallest degree of rota- All of the platforms are identical and, hence, all components are tion of any two-part system on the market. The walls of the cams areinterchangeable. All surgical and prosthetic components are color parallel and are 1.2 mm in depth, rather than rounded, producing acoded.All the designs also include a 1.5 mm polished collar that allows form/base connection.The depth of the internal tube is 5.4 mm,giv-for good biological height yet ensures a shallow emergence.The shallow ing the abutment extraordinary strength and stability. The camsprofile makes for easy restorative management with little or no sulcus also allow angled abutments to be placed with extreme precision.collapse and superb esthetic results.Immediately apical to the polished The rotational stability eliminates micro-movement of prostheticcollar is a textured, machine-finished, 45-degree bevel that is 0.5 mm components and, therefore, eliminates the risk of screw loosening.tall. This Bioseal Bevel™ ensures that the region of osseointegration The Camlog root-form implant allows for immediate prosthet-is securely sealed even if the bony channel is slightly eccentric. ic loading. The tapered shape fits precisely into extraction sites and Below the bevel, the screw cylindrical, screw-line and root-form accommodates adjacent convergent roots or concavities on theimplants have a blasted acid-etched Promote™ surface that appears adjacent labial/buccal bone. The impression for the final fabricationto foster rapid osseointegration by means of the uptake of blood of the prosthesis can be taken at the time of surgery, to provide out-cells immediately onto the implant surface. The press-fit cylinders standing treatment options.have a traditional titanium, plasma-sprayed (TPS) surface. Whether the implant is to be immediately loaded or has alreadyFigure 1: Preoperative panoramic radiograph. Figure 2A: Preoperative clinical view of maxil- Figure 2B: Preoperative clinical view with lary right first bicuspid. existing prosthesis removed. 3A 3BFigures 3A,B: After maxillary bicuspid was extracted, length and diameter were measured to assist with Figure 4A: Post-extraction socket.proper implant selection. 5A 5BFigure 4B: 2.0 mm pilot drill was used to pre- Figures 5A,B: 5.0 mm (blue) form drill was used to prepare final shape and size of receptor site.pare initial depth and alignment of implant-receptor site. NYSDJ • NOVEMBER 2005 25
  6. 6. 6A 6BFigures 6A,B: 5.0 mm x 16 mm Camlog root-form implant was removed from sterile package and inserted Figure 7: Postoperative panoramic radiographinto receptor site. demonstrating position of 5.0 mm x 16 mm Camlog root-form implant.Figure 8: Clinical view with immediate post- Figure 9A: View of internal aspect of Camlog Figure 9B: Occlusal view of impression postsurgical transitional prosthesis in place. implant at four months post-insertion. in position.Figure 10A: Clinical view of try-in of impres- Figure 10B: Impression tray and material in Figure 10C: .050 wrench removing impressionsion tray. oral cavity. post screw from assembly. 11A 11B 12AFigures 11A,B: Soft-tissue master model. Figures 12A,B: Completed porcelain-fused- to-metal individual crowns. 12B Figure 13: View of internal aspect of Camlog implant Figure 14: Clinical occlusal view of individual with surrounding healthy soft tissue of gingival sulcus. crowns cemented into position.26 NYSDJ • NOVEMBER 2005
  7. 7. Figure 15: Clinical view of facial aspect of Figure 16: Final panoramic radiograph with Figure 17: Preoperative panoramic radiograph.final prosthesis. prosthesis in position.Figure 18: 2.0 mm pilot drill in position. Figure 19A: 3.8 mm x 13 mm (yellow) form Figure 19B: 3.8 mm thread cutter is ready to drill as it creates final preparation of length and complete threading process at speed not to diameter of receptor site. exceed 50 RPM’s.Figure 20A: Final osseous receptor site. Figure 20B: Camlog 3.8 mm x 13 mm (yellow) Figure 21: Implant and handgrip in final Smart Pac with implant, mounted placement position in mouth. head and blue handgrip. 24AFigure 22: Postoperative panoramic radi- Figure 23: Parallel wall cylinder 3.8 mm x 4.0 mm Figures 24A,B: Panoramic radiograph andograph demonstrating implant in maxillary left healing abutment in position, following recontouring clinical view of final prosthesis.first bicuspid position. of soft tissue with electrosurgical loop at Stage II. 24B Figure 25: Preoperative panoramic radiograph Figure 26A: Preoperative clinical view of left showing edentulous posterior left maxillary area. posterior edentulous maxilla. NYSDJ • NOVEMBER 2005 27
  8. 8. osseointegrated, impression taking is accomplished with transfer Case Iabutments and transfer caps. The only tool required is a .050 screw- The 71-year-old female patient sustained a fracture of the maxil-driver. Camlog allows for both open- and closed-tray impressions to lary right second bicuspid. The tooth was considered non-restor-be taken by using color-coded transfer caps. For both procedures, able. Her past medical history was essentially non-contributory.the transfer abutment is then removed from the fixture and an ana- The treatment plan recommended to this patient consisted oflog applied and repositioned in the final impression for accurate extraction followed by immediate placement of an implant and afabrication of the master model. provisional prosthesis (Figures 1-2B). A ceramic abutment option is available and used most com- The procedure was carried out under intravenous sedationmonly in anterior situations, where esthetics are of concern, gingi- and local anesthesia. The tooth was surgically removed in an atrau-val tissue is thin, and/or the patient has a high smile line. The matic fashion, without any loss of adjacent hard or soft tissueprepable plastic Peek temporary abutment is intended for provi- (Figures 3-4A). A Camlog root-form implant, 5.0 mm wide by 16sional restorations for immediate or delayed implant placement. mm long, was placed using the standard surgical protocol. Once theThis abutment is ideal for gingival contouring and temporization implant was in its final position, a standard cylinder (parallel-after second-stage surgical exposure. It is also used in single-stage walled) healing abutment (5.0 mm x 4.0 mm) was placed instead ofimplant placement to obtain proper emergence. the standard surgical healing screw (Figures 4B-7). A temporary Both surgeons and restorative doctors require very few instru- heat-processed provisional prosthesis was placed immediatelyments to use the Camlog system.All healing caps, fixing screws and postoperatively (Figure 8). Four months later, the final porcelain-impression copings use the industry-standard .050 hex driver. The fused-to-gold individual crown was cemented in place on a stan-system also includes a so-called “wrench-et,” a combination dard Camlog abutment, using Improv cement (Figures 9-16).implant placement wrench and adjustable abutment ratchet. Thiscan be adjusted in a range from 10 to 30 Ncm. Case II This article focuses on the root-form Camlog implants, which The 47-year-old female originally presented with three retainedcome in diameters of 3.8, 4.3, 5 and 6 mm and lengths of 9, 11, 13 deciduous teeth. She first chose to have the two that were located inand 16 mm. The following cases demonstrate the use of the Camlog the right maxilla extracted and restored with root-form endostealimplant system. implants. Very pleased with those results, she then chose to move28 NYSDJ • NOVEMBER 2005
  9. 9. Figure 26B: Surgical template on diagnostic Figure 26C: Surgical template in position over Figure 27A: Mucoperiosteal flaps are reflected tomodel. edentulous left maxilla. expose surgical site. 3.0 mm silk suture is used to main- tain palatal flap and is tied cross-arch to residual dentition.Figure 27B: 2.0 mm pilot drill passing Figure 27C: Clinical view demonstrates Figure 28A: 5.0 mm x 13mm (blue) shapethrough surgical template to mark proper posi- several of pilot holes once surgical template drill is used to complete posterior osseoustion for most-anterior implant receptor site. is removed. receptor site.Figure 28B: All four osseous implant-receptor Figure 29A: 5.0 mm x 13mm (blue) root-form Figure 29B: All four implants in final positionsites have been created. implant is ready for insertion in left posterior in left maxilla. maxilla.Figure 30A: Final four implants in position with Figure 30B: Color-coated sealing screws in Figure 31: Mucoperiosteal flaps have beenmounted placement heads removed. place in each implant: yellow (3.8 mm), red (4.3 repositioned and sutured with 4-0 chromic mm) and blue (5.0 mm). interrupted sutures.Figure 32: Immediate postsurgical panoramic Figure 33A: Four-month post-implant- Figure 33B: Crestal incision made at Stage IIradiograph showing position of four root-form implants. insertion appearance of healed soft tissues. to expose implants (mirror view). NYSDJ • NOVEMBER 2005 29
  10. 10. Figure 34: All four implants are exposed. Notice Figure 35A: .050 mm wrench engaging a 4.3 mm Figure 35B: All four healing abutments are inscalloped palatal tissue created with electrosur- wide-body, tapered, second-stage healing screw. position, and soft tissue is sutured.gical loop to improve soft-tissue architecture.Figure 36: Articulated model. Figure 37A: Soft-tissue master laboratory Figure 37B: Camlog standard abutments in model with root-form implant analogs in position. position on master model. 38A 38B 39AFigures 38A,B: Prepared abutments on model and articulator. Figures 39A,B,C: Prepared labial/buccal surfaces and castings of four individual crowns. 39B 39C Figure 40: Final individual crowns cemented over implant abutments.Figure 41: Final panoramic radiograph ofcompleted case.30 NYSDJ • NOVEMBER 2005
  11. 11. forward with extraction of the left maxillary deciduous tooth, fol- 99% in the maxilla and five-year success rates in excess of 97% in thelowed by immediate implant placement (Figure 17). mandible. When all cases are combined, maxilla-mandible, anterior and This procedure was carried out under intravenous sedation posterior aspect of the oral cavity,the success rate exceeds 98%.11 ■and local block and infiltration anesthesia. The deciduous toothwas surgically removed, with good preservation of the surrounding I would like to thank Drs. Evan Tetelman, Richard Streem and Gary Resnik for the prosthetic reconstruction on Cases I, II and III, respectively.hard and soft tissue. A Camlog root-form implant, 3.8 mm wide by13 mm long, was placed using the standard surgical protocol REFERENCES(Figures 18-22). The patient did not desire a temporary prosthesis. 1. Babbush CA. ITI endosteal hollow cylinder implant systems. Dent Clin Am 1986;30(1): Four months later, second-stage surgery was carried out using 133-149. 2. Babbush CA, Kent JN, Misiek DJ. Titanium plasma-sprayed (TPS) screw implants for thea standard 3.8 mm x 2.0 mm cylindrical healing abutment (Figure reconstruction of the edentulous mandible. J Oral Maxillofac Surg 1986;44,274-282.23). Subsequently, the patient was restored with a porcelain-fused- 3. Babbush CA, Shimura M. Five-year statistical and clinical observations with the IMZ two-stage osseointegrated implant system. Int J Oral Maxillofac Surg;8(3):245-253.to-gold crown, which was secured with resin cement on a standard 4. Babbush CA, Kirsch A, Mentag PJ, Hill B. Intramobile cylinder (IMZ) two-stage osteoin-Camlog abutment (Figure 24). tegrated implant system with the intramobile element (IME): Part 1. Its rationale and procedure for use. Int J Oral Maxillofac Surg 1987;2(4):203-216. 5. Babbush CA, Kirsch A, Mentag PJ, Hill BR The IMZ endosseous two-phase osteointegra-Case III tion implant system. Scientific 1987 Alpha Omegan 52-61. 6. Babbush CA. Immediate implant placement in fresh extraction sites. Dent Surg ProdThe 79-year-old male patient had functioned for some time with a max- 1988. April/May: 32-38.illary removable partial denture that supplied him with replacement of 7. Hahn J, Babbush CA. Immediate implant placement after extraction: contemporary materials and techniques. In: Dental Implants: The Art and Science, 305-334, W. B.his posterior left dentition.He chose to continue using this when he had Saunders, Philadelphia, 2001.the right mandibular posterior region restored with root-form implants. 8. New Horizons in Implant Prosthetics. Multidisciplinary Collaboration in Prosthodon-The results of that reconstruction were so satisfactory that the patient tics, Vol. 2 No. 1, 2000. 9. Kirsch A, Ackermann KL, Neuendorff G, Nagel RJ. Requirements for a reliable implantdecided to replace his partial denture with four Camlog root-form prosthetic treatment concept; tooth for tooth restoration. Quintessence 1999;50(10):1-18.implants and a tooth-for-tooth prosthetic restoration (Figure 25). 10. Camlog Implant System Handbook. Altatec Biotechnologies, 12/11/2003. 11. Nagel R, Ackerman KL, et al. Six-year clinical investigation: screw vs. cylinder success Under intravenous sedation and local block and infiltration rate. Presented at the 18th Annual Meeting of the Academy of Osseointegration, Feb. 27-anesthesia, four Camlog root-form implants were placed using the Mar. 1, 2003, Boston, MA.standard surgical protocol (Figures 26-31). The sizes of theimplants were, from anterior to posterior, 3.8 x 16 mm, 3.8 x 16mm, 4.3 x 16 mm, and 5.0 x 16 mm (Figure 32). Because the patientchose not to have a provisional prosthesis fabricated, the case wascarried out as a classic two-stage procedure. The second stage was carried out four months after implantplacement under local infiltration anesthesia. The palatal soft tis-sue was sculptured, using an electrosurgical loop to create a morefavorable soft-tissue architecture. The Camlog wide-body, tapered,second-stage healing abutments (all 4.0 mm in length) were placed(Figures 33-35). Final impressions were obtained two weeks afterStage II, and four porcelain-fused-to-metal crowns were fabricatedon three of the implants (Figures 36-39). An all-gold crown wasused on the most distal implant. The crowns were cemented indi-vidually over Camlog standard abutments (Figures 40-41).SummaryMy experience with the Camlog implant system to date has been over-whelmingly successful.Two hundred and seven implants have been placedin a total of 86 patients,36 male and 50 female.Eighty-five were extraction,immediate implant placement, and 122 were non-extraction, with 159 ofthose implants receiving some form of augmentation bone grafting and 48no grafting procedure.Sixty-four of the implants placed were single-toothindications. Only one failure implant in this series occurred in a seven-implant maxillary reconstruction with no negative outcome. In reviewing outcomes,Dr.Kirsch reports outstanding clinical resultswith Kaplan-Meir statistical analysis six-year success rates in excess of NYSDJ • NOVEMBER 2005 31
  12. 12. OMFS Imaging Role of Computerized Tomography in Management of Impacted Mandibular Third Molars Thomas B. Dodson, D.M.D., M.P.H.Abstract The anatomic relationship of the IAN canal and the M3 can beNerve injury following mandibular third molar (M3) removal ascertained preoperatively with readily available imaging tech- niques. The purpose of this article is to review briefly imaging tech-is a rare but serious complication. The purpose of this arti- nology to facilitate clinical decision-making in treatment planningcle is to review the role of currently available imaging tech- M3 surgery. The two specific aims of this article are: 1. to review thenologies to facilitate clinical decision-making in the setting role of the panoramic radiograph to assess IAN injury risk; and 2. to demonstrate the role of computerized tomography (CT) in the set-of M3 surgery. Given findings suggestive of high risk for ting of M3 surgery given high-risk findings on panoramic imaging.inferior alveolar nerve (IAN) injury, the clinician should The IAN canal can be readily visualized using panoramic radiographs. Rood, et al. reported on radiographic findings associ-consider additional imaging to assess better the anatomic ated with an increased risk for IAN injury.1 These findings includerelationship of the IAN and M3. superimposition of the IAN canal and the M3 with narrowing of the IAN canal, darkening of the M3 root, diversion of the IANTHE OPERATIVE MANAGEMENT of impacted third molars (M3s) canal or loss of the white cortical outline(s) of the IAN canal.is a predictable procedure characterized by minimal morbidity. When one or more of these findings are present, the risk of IANInjuries to the trigeminal nerve, that is, lingual or inferior alveolar ranges from 1.4% to 12%, with the baseline risk of IAN injurynerve (IAN), are uncommon but serious complications of M3 averaging about 1%.2 If one or more high-risk radiographic find-surgery. Anatomy is destiny. Trigeminal nerve injury following M3 ings are evident on a panoramic radiograph, there may be a rolesurgery is frequently the direct result of an intimate anatomic rela- for additional imaging to ascertain better the anatomic relation-tionship between the nerve and the impacted M3. ship of the IAN canal and the impacted M3. Suggested imaging Currently, there are no predictable ways to assess, preopera- alternatives include periapical films or tomography. Conversly,tively, the relationship of the lingual nerve to the impacted M3. absent any of the radiographic signs noted above, the risk of IANPrevention of lingual nerve injuries is a function of careful operative injury is very low (<1%).2,3 Additional imaging studies beyond thetechnique, for example, incision placement, avoiding perforation of panoramic radiograph are of little incremental value. If one orthe lingual plate with a bur and limiting the soft tissue dissection of more high-risk radiographic findings are evident on a panoramicthe lingual soft tissue. radiograph, there may be a role for additional imaging to ascertain32 NYSDJ • NOVEMBER 2005
  13. 13. better the anatomic relationship of the IAN canal and the impact-ed M3. Suggested imaging alternatives include periapical films ortomography. Given high-risk findings on panoramic imaging, CT radiogra-phy is my preferred imaging choice. CT imaging is readily available;the images can be reformatted in multiple planes of space, forexample, axial, sagittal and coronal; and they consistently demon-strate the anatomic relationship of the IAN canal and M3. Whenindicated, the information provided by CT imaging is invaluable formaking decisions regarding M3 management, that is, operative ornonoperative (see Cases Two and Three below), or planning theoperation to decrease the risk of inadvertent IAN injury (see CasesOne and Two below). Figure 1. Close-up of panoramic radiograph illustrating superimposition of IAN canal and mandibular right M3 and loss of cortical outline, suggesting increased risk for IAN injury associated with M3 removal.Case OneThe patient was a 24-year-old female who presented for evaluationof her impacted teeth. She had a history of intermittent pain asso-ciated with her M3s. There was moderate pericoronal inflammationassociated with the lower left M3. The lower right M3 was unerupt-ed, but could easily be probed with a periodontal probe. On panoramic radiograph (Figure 1), there was superimposi-tion of the IAN canal and the mandibular right M3, with loss ofthe white cortical margins of the IAN canal. To ascertain betterthe relationship between the IAN canal and M3, the patient wasscheduled for CT imaging, with the images reformatted to becompatible with Simplant® (Materialise, Inc, Glen Burnie, MD), one ofseveral commercially available interactive software programs forviewing CT images. Figure 2 demonstrates the reformatted CT images with the IANpassing to the buccal of the mandibular right M3 root apex. The Figure 2. Reformatted CT images demonstrating buccal position of IAN canal relative to M3 root. Note how crosshairs on coronal image (#170) correlate withIAN canal is clearly separate and distinct from the roots of the M3 axial (upper left) and sagital views (lower left) clearly demonstrating buccal posi-and, as such, the risk for IAN injury is low. Intraoperatively, follow- tion of IAN canal. CT findings also suggest avoiding manipulating tooth during extraction that produces buccal movements of root apex.ing M3 removal, the IAN was not visualized. Postoperatively, thepatient’s neurosensory examination was normal.Case TwoThe patient was a 22-year-old female who presented for evaluationof her impacted M3s. She had no complaints regarding her M3s.The mandibular left M3 was partially erupted and associated withmildly inflamed pericoronal tissues. The mandibular right M3 wasunerupted and could not be probed with a periodontal probe. On panoramic radiograph, the mandibular left M3 had no posi-tive radiographic high-risk finding, suggesting an increased risk forIAN injury following M3 extraction.The mandibular right M3 demon-strated superimposition of the IAN canal and M3 root and darkeningof the root where it was crossed by the IAN canal (Figure 3). The patient was referred for CT imaging, and the images were Figure 3. Close-up of panoramic radiograph illustrating superimposition of IANreformatted to be compatible with an interactive CT image-viewing canal and mandibular right M3 with darkening of root, suggesting increased riskprogram (Simplant®, Materialise, Inc., Glen Burnie, MD). In the CT images for IAN injury. NYSDJ • NOVEMBER 2005 33
  14. 14. Figure 4. Reformatted CT images demonstrating lingual position of IAN canal Figure 5. Close-up of panoramic radiograph illustrating superimposition of IANrelative to M3 root. In addition, one can see deformation of canal as it crosses canal and mandibular left M3 with darkening of root, suggesting increased risk forM3, suggesting intimate anatomic relationship between IAN canal and M3. IAN injury. Figure 7. Radiograph is axial CT. On left side, IAN canal passes to buccal of impacted M3, but there is concavity in root surface to accommodate IAN canal. On right side, IAN canal appears to pass through substance of M3.Figure 6. Close-up of panoramic radiograph illustrating superimposition of IANcanal and mandibular right M3 with darkening of the root, suggesting increased riskfor IAN injury. Other findings include slight narrowing of canal as it passes by M3. (Figure 4), the IAN canal is adjacent to the lingual aspect of the M3 root surface with no clear distinction between the cortical margin of the canal and the root surface. Based on the history and physical and radiographic findings, I recommended that the mandibular left M3 be removed and the mandibular right M3 be monitored. The mandibular left M3s were removed without complication. To date, the mandibular right M3 continues to be asymptomatic by history and physical and radiographic examinations, and there are no abnormal signs noted on physical or radiographic examination. Case Three The patient was a 26-year-old female who presented for evaluation of her M3s. She had no complaints regarding her M3s. On physical examination, none of the M3s was erupted. The mandibular right M3 could be probed with a periodontal probe, but the left mandibular M3 could not be probed. On panoramic radiographic examination (Figures 5 and 6), both mandibular M3s had radiographic findings associated with an increased risk for IAN injury following M3 removal.There was super- imposition of the IAN canal and M3 roots, darkening of the roots where the IAN canal crossed and narrowing of the canal bilaterally. To further assess the risk for IAN injury, the patient was sched- uled for CT imaging with coronal and sagital reformatting of the axial images.Figure 7 is an axial CT view demonstrating the IAN canal pass- ing to the buccal of the M3, but there is a concavity on the root surface because of the canal. On the right side (Figure 7), the IAN canal34 NYSDJ • NOVEMBER 2005
  15. 15. When evaluating a patient considered at increased risk for IAN injury based on the panoramic findings, CT imaging is invaluable Figure 8. Radiograph for planning the operation. If M3 surgery is unavoidable because of is reformatted symptoms or failure of medical management, CT imaging can coronal CT image of demonstrate the location of the IAN canal relative to the M3. This right side, information assists the operator in planning the procedure to min- demonstrating IAN canal imize the risk of IAN injury. Specifically, if you know the IAN canal passing Figure 9. Radiograph is reformat- is located near the root apex on the lingual aspect of the M3, the through ted sagital CT image of right side, substance demonstrating IAN canal passing operator can quickly and efficiently use a buccal approach, confi- of M3. through substance of M3. dent that there is little risk to the IAN. When the patient is completely asymptomatic by history and byappears to pass through the substance of the tooth.This observation is physical and radiographic examinations, CT imaging can facilitateconfirmed on the coronal (Figure 8) and sagital views (Figure 9). decision-making in terms of operative versus nonoperative manage- Based on the history and physical and radiographic findings, I ment of the M3s. If CT imaging suggests a low-risk of IAN injury, forrecommended monitoring the mandibular M3s. In the event the example, anatomic separation of the IAN canal and M3, the patientmandibular right M3 needed to be treated operatively, I would rec- and clinician may elect to proceed with operative management. If,ommend a coronectomy. however, there is high risk for an IAN injury following operative man- agement of the M3,annual monitoring of the M3 by physical and radi-Discussion ographic examinations may be the more prudent clinical decision. ■Most patients undergoing M3 surgery do not need, nor would theybenefit from, preoperative CT imaging. To obtain CT imaging for REFERENCESevery M3 patient would be a wasteful use of resources. Between 1. Rood JP, Nooraldeen Shehab BAA. The radiologic prediction of inferior alveolar nerveNovember 1999 and January 2004, the author ordered CT imaging injury during third molar surgery. Br J Oral Maxillofac Surg 1990;28:20. 2. Blaeser BF, August MA, Donoff RB, Dodson TB. Panoramic radiographic risk factors forfor 30 subjects (one study every seven weeks). There is, however, a inferior alveolar nerve injury after third molar surgery. J Oral Maxillofac Surglimited, well-defined role for CT imaging of M3s for patients with 2003;61:417-21. 3. Sedghatfar M, August M, Dodson TB. Panoramic radiographic findings and the risk forpanoramic radiographic findings suggesting an increased risk for inferior alveolar nerve injury following third molar extraction. J Oral Maxillofac SurgIAN injury following M3 surgery. 2002;60 (Suppl 1):100. NYSDJ • NOVEMBER 2005 35
  16. 16. OMFS Infection Orofacial Infections in the 21st Century Stewart K. Lazow, M.D., D.D.S.Abstract It is currently thought that most odontogenic infections initiallyIn the 21st century, most orofacial infections are routinely present as a cellulitis caused by aerobic bacteria. The cellulitis, if untreated,produces a hypoxic,acidotic environment favoring anaerobicmanaged with proper clinical assessment, selective diag- ingrowth.As the infection becomes more severe, a mixed flora of aero-nostic imaging, appropriate antibiotic therapy and timely bic/anaerobic bacteria proliferates. The anaerobic bacteria producesurgical intervention. A thorough understanding of con- various proteolytic enzymes, endotoxins and exotoxins, with resultanttemporary microbiology, pharmacology and surgical tissue degradation, combined with the ingress of white blood cells, to lead to abscess formation and pus. Ultimately, if the host defenseanatomy will enable the clinician to minimize the morbidity mechanisms are successful in containing the infection as a well cir-and mortality of orofacial infections. cumscribed abscess, only anaerobic bacteria survive in this milieu. The early component of orofacial infections consists predomi-IN THE 21ST CENTURY, most orofacial infections are managed nantly of aerobic gram+ cocci, such as the -hemolytic Strepto-routinely with proper clinical assessment, selective diagnostic coccus viridans group—often implicated in subacute bacterialimaging, appropriate antibiotic therapy and timely surgical inter- endocarditis—and the Streptococcus milleri group—often impli-vention. These infections rarely develop into life-threatening cated in dental abscesses. Recently, Streptococcus pyogenes, a -complications, such as Ludwig’s angina, necrotizing fasciitis, medi- hemolytic streptococcus, has gained notoriety as the “flesh-eatingastinitis, cavernous sinus thrombosis or brain abscess. A thorough streptococcus” in necrotizing fasciitis. Staphylococcus aureus isunderstanding of contemporary microbiology, pharmacology and implicated in toxic shock, endocarditis in intravenous drugsurgical anatomy will enable the clinician to minimize the morbid- abusers, chronic osteomyelitis, postoperative wound infections andity and mortality of orofacial infections. acute parotitis. Haemophilus influenza, an aerobic gram- bacillus, is found in acute sinusitis and otogenic infections.Microbiology The subsequent anaerobic component of orofacial infectionsWith the advent of more sophisticated anaerobic culture techniques, includes anaerobic gram+ cocci, which have been reclassified aswe now know that most orofacial infections are polymicrobial syn- the Peptostreptococcus species, and anaerobic gram- rods, suchergistic aerobic and obligate anaerobic pathogenic processes. In as the Bacteroides and Fusobacterium species. To further com-one study of 27 dentoalveolar abscess specimens obtained by ster- plicate matters, the Bacteroides species has been reclassified intoile extraoral aspiration, only three (11%) contained solely aerobic two separate taxonomic genera, Porphyromonas and Prevotella.bacteria and seven (26%) solely anaerobic bacteria, whereas 15 The mixed aerobic/anaerobic combination of Streptococcus mil-(56%) yielded combined aerobic/anaerobic bacteria, while in two leri and Fusobacterium has been implicated in severe lateral and(7%), no organisms were seen.1 retropharyngeal descending infections.36 NYSDJ • NOVEMBER 2005
  17. 17. Figure 1. Incision placement for drainage of deep space infections.(A) temporal; Figure 2. Sagittal section through neck showing danger space 4. (Adapted from(B) submental; (C) submandibular; (D) parotid; (E) lateral and retropharyngeal; (F) Hollinshead WH: Fascia and fascial spaces of the head and neck. In Anatomy forcanine (intraoral). Surgeons: Head and Neck. Vol. 1, ed. 2. New York:Harper & Row. 1968:306.)Antibiotic Therapy Certainly, antibiotic management of persistent outpatientAppropriate antibiotic strategy must now take into account an odontogenic infections or more major inpatient orofacial infectionsunderstanding of the microbiology and timing of the infection, must be tailored to culture and sensitivity reports. Infectious dis-antibiotic resistance, patient compliance and cost. As mentioned ease consultation may be appropriate prior to initiating intra-above, early outpatient pharmacologic management of orofacial, venous aminoglycosides, vancomycin, imipenem, etc.specifically odontogenic, infections must be directed at aerobicstreptococcal pathogens. Since their clinical introduction in 1941, Radiologythe penicillins have remained the most widely prescribed class of Diagnostic imaging has assumed a prominent role in the manage-antibiotics. Fortunately, the reported penicillin-resistance rate ment of orofacial infections. Current armamentarium includes plainamong outpatient odontogenic infections remains low (6%-12%).2 films, ultrasound, CT scan, MR imaging and radionuclide scanning.In penicillin-allergic patients, erythromycin and the newer The information gleaned from these modalities is essential in accu-macrolide antibiotics, such as clarithromycin and azithromycin, rately delineating the anatomic extent of the infectious process,may be substituted. Cephalosporins, such as the first generation demonstrating fluid collections to be drained, assessing airwaycephalexin or second generation cefaclor, are another reasonable patency and evaluating involvement of contiguous vital structures.alternative. However, the 10% cross-allergenicity between the Simply stated,plain radiographs are more than adequate to assesscephalosporins and the penicillins must be considered. the vast majority of odontogenic infections. MR imaging, ultrasound In chronic or severe infection, coverage must be directed and radionuclide scanning are worthwhile adjuvant modalities foragainst anaerobic gram- rods, which are often penicillin resistant select cases. Contrast-enhanced CT remains the gold standard for(25%-60%). Clindamycin is the empiric antibiotic of choice to cover diagnosing major orofacial infections.3 Examples will be shown below.both streptococcus and anaerobes. Metronidazole is also an excel-lent choice against anaerobes, in combination with ampicillin ver- Surgical Managementsus oral streptococci. Metronidazole remains the drug of choice to This section will attempt to provide an overview of the pertinenttreat antibiotic-associated pseudomembranous colitis caused by anatomy, likely etiology and surgical approach (Figure 1) for defin-Clostridium difficile. itive drainage of orofacial, deep, fascial space infections. The read- Other empiric antibiotic choices of this author include amoxi- er is referred to the classic works of Grodinsky and Holyoke4 (1938)cillin/clavulanate for sinusitis, sialadenitis, and animal or human or Hollinshead5 (1968) on the deep fascial spaces of the head andbites. The fluoroquinolones, such as the original ciprofloxacin or neck (Figure 2). The ominous quintet of life-threatening complica-newer once-a-day dosing derivatives, provide excellent coverage tions of orofacial infections include Ludwig’s angina, cervicofacialagainst staphylococcal wound infection or osteomyelitis. Fluco- necrotizing fasciitis, descending necrotizing mediastinitis, cav-nazole and ketaconazole are good antifungal agents. ernous sinus thrombosis and brain abscess. Although rare, the NYSDJ • NOVEMBER 2005 37
  18. 18. morbidity and mortality of these five infections remain significant even in the 21st century. Clinically, airway evaluation and management is the priority in treatment of deep fascial space infections of the head and neck. The timing of surgical drainage of orofacial infections is controversial even among oral and maxillofacial surgeons. Some clinicians claim that these infections should be treated expectantly with antibiotics until frank pus is detected or there is evidence of rapid deteriora- tion. It is the experience of this author and most colleagues that securing the airway, definitive drainage of all involved spaces and removal of the offending etiology are best accomplished as soon as possible. Hospitalization is certainly indicated if the orofacial infec- tion patient presents with airway compromise (difficulty breathing, swallowing, voice changes, handling secretions), fever >102F, leukocytosis, dehydration, need for sophisticated imaging or mon- itoring, or need for inpatient management of systemic disease. Ludwig’s angina is classically described as a brawny cervicofa- cial cellulitis with elevation of the floor of the mouth involving five fascial spaces, including bilateral submandibular, bilateral sublin- gual and the submental space (Figure 3). Airway obstruction and overwhelming sepsis were the causes of a 40% to 50% mortality in the preantibiotic era. In the 1940s Dr. Walter Guralnick ofFigure 3. Axial CT scan of Ludwig’s angina. Note phlegmon with airway com-pression and deviation. Massachusetts General Hospital used a protocol of immediate air- way control, aggressive early surgery and penicillin to decrease the mortality rate to 10%.6 Current diagnostic management of Ludwig’s angina includes prompt clinical evaluation and CT scan of the neck (if tolerated) to determine airway patency or deviation and fluid collections. The airway must be secured in a controlled operating room setting, which may necessitate nasal intubation via fiberoptic laryngoscopy or tracheotomy. Bilateral extraoral submandibular incisions and a midline submental incision are connected with through and through drains to insure adequate drainage of all five involved spaces. High-dose penicillin or clindamycin is started empirically until definitive culture and sensitivity reports are available. Cervicofacial necrotizing fasciitis (CFNF) is a fulminant bacte- rial infection that causes necrosis of the fascial planes superficial and deep to the platysma muscle, along with concurrent systemic toxicity leading to a 30% mortality rate, even in the antibiotic era. Necrotizing fasciitis was first described in 1871 by Joseph Jones, a Confederate Army surgeon who referenced more than 2,600 cases of “hospital gangrene” with a 46% mortality rate.7 Most commonly, necrotizing fasciitis presents in the extremities, trunk and perineum; the head and neck account for only 3% to 4% of all cases. The original etiology is usually minor trauma in 75% of cases, with only 25% of odontogenic or peritonsillar origin.8 Predisposing concomitant medical conditions include diabetes mellitus, obesity, malnutrition, alcoholism and chronic renal failure. CFNF is not age specific, and there is no race or sex predilection. The pathognomonic sign of CFNF is a dusky discoloration of the skin with small, ill-defined purplish patches. Crepitation may38 NYSDJ • NOVEMBER 2005
  19. 19. be palpable, caused by the presence of subcutaneous gas in overone-third of cases as seen on CT scan (Figure 4). Untreated, theinfection progresses to frank cutaneous gangrene that forms asuperficial slough, beneath which can be seen fat liquefaction andnecrosis of the fascia. The patient decompensates in remarkablyrapid fashion with fever, weakness, apathy, confusion, leukocytosis,anemia and hypocalcemia. The microbiologic composition ofCFNF includes Streptococcus pyogenes or Staphyloccocus aureus,often in synergy with an obligate anaerobe. Successful treatment demands early recognition, prompt airwaymanagement, aggressive surgical debridement, appropriate intra-venous antibiotics, supportive intensive care and, possibly, hyperbar-ic oxygen. The initial debridement often extends well beyond thegross limits of CFNF to healthy, bleeding tissue. This often necessi-tates an apron neck incision with “bear claw” fasciotomy incisions.The hallmark of CFNF is the ease with which blunt finger dissectionpasses along the involved fascial sheath through gray, foul-smelling“dishwater” exudate well beyond the skin demarcation. The woundis packed open; multiple secondary debridements are the rule.Ultimately, skin grafts or flap reconstruction is undertaken. Gravecomplications include internal jugular vein thrombosis, carotidartery erosion and disseminated intravascular coagulation. Death Figure 4. Axial CT scan of fulminant CFNF. Note subcutaneous gas.results from overwhelming sepsis and multi-organ failure. Mediastinitis is a life-threatening infection involving the NYSDJ • NOVEMBER 2005 39
  20. 20. The patient with DNM presents with high fever, tachycardia, tachypnea, hypotension and leukocytosis. best accomplished via a vertical neck incision as described by Mosher9 at the anterior border of the sternocleidomastoid muscle. This incision may be extended across the midline over the suprasternal notch to allow for transcervical blunt finger dissection of the anterior, superior mediastinum. Most thoracic surgeons agree with Estrera,10 who recommended formal posterolateral tho- racotomy if the mediastinitis spreads inferior to the carina anteri- orly or the fourth thoracic vertebra posteriorly. DNM retains a 30% to 40% mortality rate. Grave comorbidities include pleural and pericardial effusions, pyopneumothorax, thoracic empyema, peri- carditis, vena cava compression, cardiac tamponade, great vessel rupture, bronchial erosion, esophageal rupture and multisystem organ failure. The two most dreaded intracranial complications of orofacialFigure 5. PA chest radiograph of DNM. Note widened mediastinum and right infection are cavernous sinus thrombosis (CST) and brain abscess.pleural effusion. It is well documented that odontogenic infections may spread to the cavernous sinus via an anterior and posterior pathway. The anteriorconnective mediastinal tissue that fills the interpleural space and route involves a retrograde septic thrombophlebitis of the valvelesssurrounds the median thoracic organs. The most lethal form of veins coursing through the infraorbital (canine) space from themediastinitis, with a 40% mortality rate, is descending necrotiz- angular vein to the inferior ophthalmic vein through the inferioring mediastinitis (DNM). Delay in diagnosis, reported to average orbital fissure into the cavernous sinus. The posterior route involvesover two days after initial presentation, contributes to the high buccal or infratemporal space infections (maxillary molars) thatmortality rate. The descending infection spreads from an oropha- may pass via emissary veins from the pterygoid venous plexus toryngeal source, either odontogenic or peritonsillar, through the the inferior petrosal sinus into the cavernous sinus.retropharyngeal space into the danger space (space 4 of The patient with CST may present with fever, headache, nau-Grodinsky and Holyoke) between the alar and prevertebral fascia sea, vomiting, supraorbital paresthesia, ophthalmoplegia, propto-to gain access to the posterior mediastinum. This necrotizing sis, chemosis, photophobia and eye pain. Classically, the abducensinfection is often polymicrobial and gas producing; streptococcus nerve VI is the first cranial nerve affected. Swift, definitive drainageand fusobacterium have been implicated. of the infraorbital or infratemporal spaces and treatment of the DNM is predominantly a disease of healthy young men. The original etiology are essential. High-dose antibiotics that cross thepatient with DNM presents with high fever, tachycardia, tachypnea, blood brain barrier, such as third generation cephalosporins, naf-hypotension and leukocytosis. Pleuritic chest pain, dyspnea and cillin, or chloramphenicol, are indicated. Steroids and anticoagula-retrosternal discomfort may be elicited from the patient. Brawny tion remain controversial.induration of the neck and chest may be visible and crepitus may It is postulated that only 1% to 2% of all brain abscesses are ofbe palpable. The chest radiograph (Figure 5) will typically show documented dental origin.11 Pathogens can reach the brain bywidening of the mediastinum, pneumomediastinum, pleural effu- hematogenous spread or by direct extension from contiguoussion, and obliteration of the retrosternal or retrocardiac clarity. CT spaces. Most brain abscesses are rhinogenic by direct extensionscan of the neck and chest may reveal a widened retropharyngeal from the paranasal sinuses to the frontal lobe or otogenic from thespace, mediastinal fluid collections, with or without gas bubbles, middle ear and mastoids to the temporal lobe. Postmortem exami-pericardial effusion and empyema. nations have revealed multiple routes of orofacial infection along Treatment of DNM is based on early recognition, prompt air- fascial planes to the cranial base. These include: mandibular molarway control, aggressive surgical intervention, appropriate antibi- infections along cranial nerve V3 through the foramen ovale to theotics, intensive supportive care and, possibly, hyperbaric oxygen. temporal lobe, maxillary molar infections through the maxillaryDefinitive surgical drainage of the retropharyngeal component is sinus into the orbit and onto the frontal lobe, and mandibular40 NYSDJ • NOVEMBER 2005
  21. 21. REFERENCES 1. Levi MH. The microbiology of orofacial abscesses and issues in antimicrobial therapy. In Piecuch JF (ed). OMS Knowledge Update, Vol 3. Rosemont, IL: AAOMS. 2001; p. 6. 2. Flynn TR. Update on antibiotic therapy for oral and maxillofacial infections. In Piecuch JF (ed). OMS Knowledge Update, Vol 3. Rosemont, IL: AAOMS. 2001; p. 39 3. Kim D, Lazow SK. Imaging head and neck infections. Oral Maxillofac Surg Clin North Am 2001;13:585-601. 4. Grodinsky M, Holyoke EA. The fasciae and fascial spaces of the head, neck, and adjacent regions. Am J Anat 1938;63:367. 5. Hollinshead WH. Fascia and fascial spaces of the head and neck. In Anatomy for Surgeons: Head and Neck, Vol 1, Ed 2. New York:Harper & Row. 1968; p. 306. 6. Flynn TR, Simos C. The timing of incision and drainage. In Piecuch JF (ed). OMS Knowledge Update, Vol 3. Rosemont, IL: AAOMS. 2001; p. 78. 7. Lazow SK. Necrotizing fasciitis and mediastinitis. Atlas Oral Maxillofac Surg Clin North Am 2000;8:101. 8. Balcerak RJ, Sisto JM, Bosack RC. Cervicofacial necrotizing fasciitis: report of three cases and literature review. J Oral Maxillofac Surg 1988;46:450. 9. Mosher HP. The submaxillary fossa approach to deep pus in the neck. Trans Am Acad Ophthalmol Otolaryngol 1929;34:19. 10. Estrera As, Landay MJ, Grisham JM, et al. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545. 11. Flynn TR.Anatomy and surgery of deep fascial space infections of the head and neck. In Kelly JPW (ed): OMS Knowledge Update, Vol 1. Rosemont, IL: AAOMS. 1994; p. 104. 12. Izzo SR, Lazow SK. Early diagnosis and surgical management of necrotizing fasciitis, mediastinitis, and brain abscess. In Piecuch JF (ed): OMS Knowledge Update, Vol 3. Rosemont, IL: AAOMS. 2001; p. 102.Figure 6. Gadolinium-contrast, T1-weighted MRI of brain abscess. Note ringenhancement of abscess capsule.molar infections involving the submasseteric space to the infratem-poral space through the temporal bone via emissary veins to thetemporal lobe. The classic triad of brain abscess symptoms includes fever,headache and focal neurological deficits. Contrast-enhanced CTscan shows the typical well-demarcated ring enhancement of theabscess capsule. Gadolinium-enhanced, T1-weighted MRI high-lights the classic ring in the mature abscess (Figure 6). The micro-biology of the brain abscess is consistent with the primary focus—sinus, otogenic or odontogenic. Treatment of brain abscess requires a combination of surgeryand antibiotic therapy with suitable penetrability as discussedabove. Surgical options include aspiration or excision. Repeatedaspiration, possibly stereotactically guided, may be necessary priorto resolution of the abscess. Excision of the lesion may result inmore rapid resolution but may cause more residual neurologicdeficits. Mortality rates persist at upwards of 20%.12ConclusionThe vast majority of orofacial infections are rather routine, rela-tively benign and easily treated by all dental practitioners. Whenconfronted with deep fascial space infections of the head and neck,proper clinical assessment, selective diagnostic imaging, appropri-ate antibiotic therapy, prompt airway control and timely surgicalintervention are of paramount importance to avoid the rare butlife-threatening quintet of complications discussed above. ■ NYSDJ • NOVEMBER 2005 41
  22. 22. OMFS History Hugo Obwegeser: Forty Years Later Robert Bruce MacIntosh, D.D.S. At a time when it needed it most, the specialty of oral surgery was revitalized in the United States by a surgeon from Switzerland, who taught his American colleagues to be more aggressive in the application of their knowledge and skills.BY MID-WAY THROUGH THE 1960s, the American specialty of surgery and transform the American specialty forever. In a feworal surgery lay, by many accounts, dead in the water. Indeed, it had short days of spectacular lectures, films and commentaries at theestablished its expertise in exodontia, had demonstrated in two Walter Reed Army Medical Center, Dr. Obwegeser demonstrated hismajor military conflicts its predominance in the management of vast experience with an array of surgical procedures about whichfacial fractures, had contributed significantly to the literature of his American audience had never dreamed.orofacial infections and had established its preeminence in the He demonstrated that these procedures were within the scopedelivery of outpatient general anesthesia. But, by then, from all of dentistry and oral surgery and beyond the ken and interest orquarters, the specialty had become besieged professionally, politi- molestation of other surgical specialties; and, perhaps most impor-cally and administratively. It was inhibited from making skin inci- tantly, he inspired and encouraged his audiences to believe that hissions in many parts of the nation, and from managing midface experience could be their experiences, that anything he had doneinjuries in most; obtaining its own grafts was disallowed; dual they could do. Time magazine (July 1, 1966) commented:admission protocols for its inpatients were mandated; and whatev- “….last week, 500 of the most eminent U.S. oral surgeons sater gains it had achieved in the management of clefts in previous on the edges of their chairs at Washington’s Walter Reed Armydecades had been lost. Training rotations on anesthesia services Medical Center as a respected Swiss practitioner described his radi-occurred regionally and only rarely, and on general surgery or med- cal jaw-splitting procedures...American oral surgeons have neverical services chiefly in the minds of imaginative mentors. Only a been so impressed….”few of our training centers dealt comprehensively with maxillofa- Memorably, Dr. Obwegeser brought orthodontic surgery intocial trauma, the temporomandibular joint, clefts or malignant dis- common parlance and practice (orthognathic was a later, Americanease; and our correction of maxillo-mandibular imbalance dealt modification). Certainly the single most impressive procedurealmost exclusively with mandibular “progs.” “Orthodontic surgery” introduced at that time, and the one within orthognathic surgery byand “orthognathics” were terms foreign to our lexicon. which Dr. Obwegeser even today is most readily recognized, was the bilateral sagittal ramus osteotomy, the venerable sagittal split. Dr.Beginnings and Clinical Impact Obwegeser was not the first person to propose approaching theIn mid-June 1966, Hugo Obwegeser, in his first American lectures, ramus in sagittal fashion, but, in his writings of 1957 and his lec-set a charge to events that would change all that hampered oral tures in 1966, he did demonstrate his particular technique, the42 NYSDJ • NOVEMBER 2005