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Osseointegration as an immune response
Osseointegration was discovered in animal experiments conducted by P-I Branemark of Gothenburg, Sweden in 1962. Three years later, the first patient was treated with osseointegrated oral implants. Intial clinical results were only in the 50% success range over 5 years, but with increasing experience clinical outcome improved significantly (Branemark et al 1977, Albrektsson et al 1981). Originally, osseointegration was defined based on light microscopical evidence of direct contact between titanium and bone tissue. The first investigator to see osseointegration as an immune reaction was Karl Donath in papers publised during the 1990s(Donath et al 1992).
Today, we have clear evidence that titanium results in a measureable immune response.(Trindade et al 2019) In fact, the implant metarial is perceived as a foreign body by the immune defense that immediately tries to isolate if from issues. In dentistry, we use the defense mechanisms of the body since the bone envelope created encompasses loading of the implant. Another possible immune defense of the organism is to reject the implant, a condition that occasionally results in what is regarded as primary failure of the implant.
Some coulleagues of ours have hypothesized that rules about teet apply to oral implants. This is clearly misconceived in the light of immune reactions to the implant; an implant is quite unrelated to a tooth(Albrektsson 2019). In the year of 2017, a novel definition of osseointegrations was presented:” Osseointegration is a foreingn bodt reaction where interfacial bone is formed as a defense reactionto shield off the implant from the tissues (Albrektsson et al 2017).
Branemark O I et al Scand J Plast reconstr Surg suppl 1 1977, pp1-132.
Albrektsson T, Branemark PI et al Acta Orthop Scanc 1981, pp155-170.
Donath K et al Virchows Archiv A Pathol, Anat,Histopathol 1992, pp131-127.
Trindale R On the immune regulation of bone response to biomaterials. Ph D theis, Dept of Prosthodotics, University of Gothenburg, Sweden
Albrektsson T J CLin Med 2019, pp1502-1505.
Albrektsson T et al JSM dental surgery 2017, pp1002-1028.
Challenges to Osseointegration
Clinical results of oral implants in the 96-99 per cent range at 10 years of follow up, provided properly trained individuals place clinically documented oral implants(Wennerberg et al 2018). The main threat to oral implants is that they are inserted by poorly trained individuals ora re selected ased on a cheap price instead of publised clinical documentation.
Some colleagues of ours have presented data indicative of that a particular implant disease entitled “peri-implantitis” is not only common, but also presents with clear threat to implant outcome. However, when evaluated critically, marginal bone loss has been found a condition rather than a disease and it is a condition that only rarely will threaten the clinical outcome of oral and orthopedic implants. (Albrektsson et al 2019)
Wennerberg et al 2018, Eur J Oral Implantol suppl
Albrektsson T et al 2019 Clin Oral Implant rel res
Management of Orbital Dystopia in Craniofacial Deformities
Few of the orofacial clefting processes only involves the orbit. Such defect may be unilateral or bilateral and very rarely found along the midline. In any situation, considerable sum of orbital bone mass may be missing or defective in size. Additional impairments such as those of ears, loss of adjacent structures or uncoordinated growth may impede the treatment goals. It is not uncommon to find associated disorders of nervous structures such as mengiocele or other neural defects. Very rarely associated cranial bones such as frontal bones may also be involved. Needless to say, if hypertelorism persists, that should be corrected. The final goal would be to correct any abnormal slants.
In any of the case, as in cleft lip and palate the goal would be to save the eyeball, if there is functional capacity. The next step would be to close the defects as much as possible to obliterate clefting. This would help to evolve proper feeding, swallowing, speech, prevent repeated nasal/sinus infections etc., Next stage would be reconstruction of the associated soft tissue defects. If involving nasal cavity, late rhinoplasty may be required to complete the nasal defect. The timing of the surgery needs to be extremely customized.
The presentation will take through the 25 years of experience in treating oro-facial clefts with special emphasis on orbital dystopia correction from simple clefts and missing orbital bones to complex, multiple Tessier’s orofacial clefting. Appropriate example from the author’s surgical experience will help to draw meaningful algorithm to plan and surgically treat the patients
Assoc. Prof. Dr. Süleyman BOZKAYA was born in 1976 in Afyonkarahisar. He finished Bolvadin High School in Afyonkarahisar and started his undergraduate education at Gazi University Faculty of Dentistry in 1992. He completed his undergraduate studies in 1997 and started his Ph.D. education at the Department of Oral and Maxillofacial Surgery in the same faculty. He presented his Ph.D. thesis entitled "Experimental Investigation of the Effects of Deproteinized and Demineralized Bone Grafts on Bone Healing" in 2005 and served as Lecturer in the same department until 2011. He was appointed as Assistant Professor in 2013. He has received the Associate Professor degree in 2015 and continued to work in the same department until July 2020. He is currently continuing his studies at Dokuz Eylül University Faculty of Dentistry. He is a Fellow of The International Team for Implantology (ITI) since 2011, and a member of The Turkish Association of Oral and Maxillofacial Surgery. Dr. BOZKAYA is married and father of two children. His areas of special interest are surgical applications for advanced implant surgery and crest augmentation techniques.
SHELL TECHNIQUE FOR ALVEOLAR RIDGE AUGMENTATION
Management of partially or totally edentulous patients with implants has been a routine treatment modality for decades, with reliable long-term successes. The predictability of the implant survival and the maintenance of long-term stability of implants in function are directly associated with the quality and quantity of the available bone for implant placement. In the case of alveolar ridges with insufficient bone volume or unfavourable vertical, horizontal or sagittal intermaxillary relationships, additional surgical procedures can be necessary to reconstruct and augment the deficiency. During the last 30 years, different techniques and materials have been recommended for the reconstruction of bony defects, such as autogenous, allogenic or alloplastic bone grafts. Autogenous bone, with its osteogenic, osteoinductive and osteoconductive characteristics, is often considered as the gold standard in bone re- generation procedures
combination with bone substitutes or bone grafts, but the reconstruction of vertical defects in the alveolar crest is still a challenge. Vertical augmentation using bone grafts from the iliac crest, sometimes in combination with distraction osteogenesis, sandwich techniques, or interpositional techniques, have been described, but because of greater resorption, and morbidity at the donor site, intraoral donor sites have become more popular.
Khoury introduced a new method for grafting ridge defects in 2007. This technique involved using thin cortical bony shells harvested from the ramus, and filling between these bone shells, in a 'sandwich' type manner, with cancellous bone harvested from the same site. Thin cortical bony shells are placed laterally to the residual bone and the space between the shell and the residual alveolar crest is filled with particulate bone. The shells serve as a natural barrier and prevent the in-growth of soft tissue. The shell technique using intraoral autogenous bone grafts has enabled predictable reconstruction of severe horizontal and vertical defects of the alveolar ridge; and long-term stability of the bone around the implant, and high rates of implant survival have been reported. In this course, the shell technique is going to be discussed via different case presentations under the light of the current literature.
Basic principles in arthroscopic TMJ surgery
The Pterygoid Implant: An added Value
Replacing of missing teeth in the posterior maxilla is always a challenge as the posterior maxilla has different obstacles in the form of quality, quantity, anatomy of the maxillary sinus and unaccessibilty.
The pteryro-maxillary region provides us an excellent place for the placement of an implant and rehabilitation of the posterior maxilla.
The placement of an implant has to be done through the maxillary tuberosity and into the pterygoid plate and so fare the implants are called pteryromaxillary implants.
The placement of the pterygoid implants involves the origination of the implant in the tuberosity region and follows an oblique mesiocranial direction proceeding posteriorly toward the pyramidal process. It subsequently proceeds upward between both the wings of the pterygoid process of the spenoid bone.
Due to the disadvantage such as tear of the sinus membrane during sinus lifting procedures, seepage of bone grafts into the sinus, loos off bone grafts due to the resorption during bone augmentation procedures, high morbidity seen in zygomatic implants, screw loosening or breakage of titled implants, a simple but effective method of rehabilitation of the posterior maxilla is the placement of implants in the pteryromaxillary region.
TREATMENT OPTION IN THE ATROPHIED BONE: The Cortically Fixed at Once Approach
Severely atrophied jaws and extremely resorbed alveolar bone with insufficient height (10mm) and width (6mm) for conventional implant placement present limitations for implant rehabilitation of edentulous jaws.
In some cases, there may be a need for extensive invasive procedures, which patients may not want to undergo either due to morbidity risks, economic reasons or other undisclosed genuine reasons.
Various anatomical reasons limit the use of conventional intraosseous implants in restoring some edentulous spaces.
The Cortically Fixed at Once approach implant system was recently introduced to improve management of various edentulous cases and to give patients wide treatment options where conventional implant has failed.
The CF@O system incorporates ranges of treatment options for management of edentulism, and it is an alternative to extensive surgical procedures in situations where there is substantial bone resorption.
The CF@O Implant system consists of several type of components specially developed for different locations in the jaws.
EVALUATION OF FACIAL TRAUMA
After life-threatening conditions are stabilized, the patient is cleaned and the face is examined..An intranasal examination should eliminate a septal hematoma. Changes in occlusion should be noted. Attention is then directed to the examination of the scalp, ears, and neck (lacerations, hematoma, foreign body). Imaging is directed by the primary survey, mechanism of injury, and suspected injuries. Facial fractures are evaluated by computed tomography (CT) scan, and 3-dimensional CT reconstructions may be helpful..
Le Fort Fractures
Le Fort type I is a horizontal fracture through the maxilla superior to the maxillary dentition. Type II is a pyramidal fracture through the maxilla, orbit, and nasal radix. Type III is a fracture separating the facial bones from the skull through the nasal radix and lateral orbital rims.The treatment of Le Fort fractures should reestablish the continuity of the facial bones with the cranium and the preinjury occlusion. Initial MMF maintains proper occlusion and provides a stable foundation for the remainder of the repair.
Nasal bone fractures are the most common facial fractures.1 The nasal bones should be assessed by palpation and an intranasal examination should be performed to rule out a septal hematoma or fracture. Radiographic imaging in isolated nasal bone fractures is of little benefit.
Zygomatico-maxillary complex (ZMC) fractures
involve fractures of the lateral orbital wall, orbital floor, inferior orbital rim, anterior maxillary sinus wall, lateral maxillary sinus wall, and zygomatic arch. They can cause significant aesthetic deformity because the malar eminence of the zygoma is the most anterior projection of the lateral midface and the zygomatic arch is the most lateral projection of themidface. The goal of treatment of a ZMC fracture is to restore the bone to its preinjury location and maintain orbital volume, thereby enhancing both the functional and cosmetic outcome.
The goal of orbital fracture repair is to restore orbital contour and volume. Assessment should include palpation of the orbital rims, evaluation of eyelid and globe condition and position, visual acuity check with extraocular muscle function, and evaluation of forehead and midface sensation. . Surgical access for orbital fractures is obtained through a lateral eyebrow, subtarsal, subciliary, transconjunctival, transcaruncular, or bicoronal incision. Eyelid complications are increased with subciliary approaches to the orbit compared with the transconjunctival approach.
Mandible fractures are the second most common facial fracture. Mandible fractures are classified according to the location of the fracture: symphysis-parasymphysis, body, angle, ramus, coronoid process, and condyle.
Several recent prospective RCTs suggest improved outcomes with open repair of displaced condylar fractures. Closed management of condylar fractures requires early mobilization and aggressive physiotherapy. Even then, the condyle is not in its normal position and there is diminished ramus height.
COMPLICATIONS IN ORTHOGNATHIC SURGERY
Complications are usually experienced by all clinicians and learning from our own experience is of paramount importance to improve our outcomes. Orthognathic surgery is the science dealing with the cause and treatment of malposition of the bones of the jaws and it has gone from a simple surgical technique to a very sophisticated specialty at the present time. The better knowledge of the surgical approaches represents the key-factor for the treatment plan and to avoid complications.
According to some principles reported by Hugo Obwegeser:
- Inadequate planning may easily lead to a disastrous result functionally as well as aesthetically.
- In the correction of facial skeletal anomalies the surgeon's eyes, experience and intuition are more important than tracings and computer planning.
- Treatment planning of facial skeletal anomalies is an intellectual product based on fundamental knowledge of the subject, experience, imagination and intuition.
- The computer can show what you achieve with your planning but cannot plan for you.
ecause of the wide range of complications the surgeon should keep prevention protocols in mind and be prepared to treat them should they occur. Moreover Maxillofacial surgeons must have a full understanding of the types, causes, and treatment of complications, and should deliver this information to patients who develop these complications.
Microvascular reconstruction for the Head and Neck
Facial, Head and Neck defects can be secondary to Trauma, post benign and malignant tumour resection and developmental defects. The defects can vary in size, involve, skin, muscle, bone, nerves or be composite defects. The reconstruction needs to address the various soft and hard tissue with aesthetic and functional considerations. Head and Neck reconstruction is challenging as it is a variable problem. The myriad options are dependent on surgeon expertise, multiple tissue reconstruction, preexisting pathology and patient comorbidities and variables.
The aim is one stage Functional & Aesthetic reconstruction, which can be primary, staged or secondary
For defects that can’t be reconstructed with local or regional techniques transferring of vascularised tissue from distant sites has become a mainstay of Head & Neck Reconstructive practice.
The aim of this lecture is to elucidate and discuss the considerations, planning and various options for microvasular reconstuction in the head and neck region. We shall also present the recent advances in virtual surgical planning, perforator flaps, neurotized and vascularised free flaps for facial reanimation.
Orthognathic Surgery in Transversal Dimension
In orthognathic surgery, correct treatment planning in sagittal, vertical and transversal dimensions is very important for an ideal esthetic result and a stable occlusion. While the diagnosis of sagittal and vertical problems are easy, transversal problems may be more difficult to diagnose as they are not noticeable like other directional problems. In this presentation, especially the clinical findings of maxillary transversal deficiencies, the points to be considered in diagnosis and treatment planning and the critical parts for success in surgical treatment will be discussed.
Indications und limitations of splint-less orthognathic surgery
The benefit of computer-assisted planning in orthognathic surgery has been extensively documented over the last decade. These systems are proved to offer a more secure surgical procedure. Meanwhile some of them enable also a virtual planning of the dental occlusion and splint-less orthognathic surgery. However, the precise fabrication of an accurate patient specific implants is still a challenge. Since these systems do not represent a complete 3D planning software they have to be supplemented by additional software tools and hardware devices. In consequence, the handling of these systems is of experimental nature and the splint-less orthognathic surgery is not feasible in a daily routine. The purpose of this presentation was to demonstrate a novel, user-friendly all in one 3D planning solution for splint-less orthognathic surgery.
Retrospectively 20 Patients were treated using patient specific implants produced via selective laser melting (KLS-Martin and DePuy Synthes). Primary outcome was to compare the planning was the results. After 6-8-month patient were examined clinically again.
Advantages of maxillary positioning could be examined. Mandible positioning was very time consuming. It could be demonstrated, that the accuracy of 1,5 mm vertical maximum deviation could be achieved.
Regarding the advantages of this user-friendly all in one 3D planning software, this technique will play a major part in orthognathic surgical procedures and will address widespread general methodological solutions in multidisciplinary orthodontic and surgical treatment.
New refinements in facial rejuvenation: facelifts and maxillofacial remodelling
Objectives: Determining which facelift procedures yield the most long-term rejuvenating effects and stability over time is an important question in cosmetic surgery: does radical and invasive surgery produce the most long-lasting results?
Introduction: The experience of our team suggests that using a combination of various techniques (open lipectomy, myotomies and myomectomies, suspensions, regenerative medicine techniques, salivary glands and digastric muscles management, ) appears to be essential to achieve satisfactory, lasting results. In this lecture, we describe the lower facelift and neck rejuvenation combined method.
Materials / method: To assess the outcomes of this technique, we conducted a prospective study of 50 patients treated at our hospital by the same surgeon between 2013 and 2016. For assessment purposes, we used the FACE-Objective Assessment Scale developed by our team. The scores obtained by three blinded graders before surgery and 12 months after surgery were compared using a paired t-test. A p value < 0.05 was considered significant.
Results: The results were satisfactory, with improvement in the appearance of treated areas. A significant difference between the pre- and postoperative scores was observed (p < 0.00001).
Conclusion: The lower face and neck rejuvenation combined method addresses the factors that contribute to the appearance of ageing in the lower third of the face and neck. In our study, this method resulted in positive, lasting outcomes, with few complications.
Arthroscopy of the TMJ
New Technologies in Orthognathic Surgery
From traditional treatment planning with dental model surgery and face bow transfer to three-dimensional virtual treatment planning.
Advantages and disadvantages in 3 D virtual planning.
3 D virtual planning as the source for patient specific implants and cutting guides.
Indications for cutting guides and individualized plates in dependance of the movement of the maxilla.
Substitute for cutting guides, laser robotic surgery.
Description of the practical use of a cold ablation laser ostetome (CARLO) in a first in man study, performing Le Fort I osteotomies in 12 patients.
Zygoma implantation. Searching for new solutions.
Introduction. Prosthodontic rehabilitation of severe atrophic maxilla is one of the challenging problems. In such cases treatment protocol usually includes – total or partial removable prosthesis or surgical reconstruction of atrophic maxillae by the means of different bone grafts with subsequent non-removable prosthetic devices. However, patient could achieve rehabilitation 12-18 month only, while complications of surgical procedure could increase the time of one. Over the past decades zygoma implants becomes powerful alternative for severe maxillary atrophy rehabilitation. Today developed clinical protocols include guidelines that could be implemented in cases of different degrees of bonny atrophy: starting from mild to severe atrophy of the maxillae. However, there are some clinical cases that are not fitted to these protocols, in which zygoma implants could be effective alternative to bone reconstruction. Moreover, in maxillofacial surgery we are facing with cases of maxillary defects, that are not included into protocols as well. The aim if the current study is to assess the possibilities of application of zygoma implantation in challenging cases.
Materials and methods. Patients with moderate and sever degree of maxillary atrophy, as well as, with maxillectomy defects was included into this study. All patients have history of previous wearing of removable denture. According to preoperative protocol all patients has been asses clinically and radiologically (CT scan, Toshiba multislice 128 head). Acquired CT scan data in DICOM format was loaded into virtual planning software (Materialise Mimims 19.0, Materialise Matics 19.0, Belgium). In all cases preoperative fabrication of total removable prosthesis, that was used as temporary non-removable one in postoperative period of time was done. Postoperative follow-ups included clinical and radiological investigations done on step of fabrication permanent non-removable prosthesis and 2 years postoperatively.
Results. No significant complications were detected. In all cases prosthesis fixed on zygoma implants showed good stability, patients have good mastication function and satisfaction from esthetic properties.
Conclusions. Brånemark introduced the zygoma implant not only as a solution to obtain posterior maxillary anchorage but also to expedite the rehabilitation process. Zygoma implant has been an effective option in the management of the atrophic edentulous maxilla as well as for maxillectomy defects. Within current study it was demonstrated that both in cases of severe atrophic jaws and maxillectomy defects insertion of zygoma implants and prosthetic device gives reasonable result. Therefore, one could extend the indications for zygoma implantation.
Sialendoscopy: indications, results and complications
Sialendoscopy has increased the treatment options of obstructive and inflammatory salivary gland disorders by direct visualization and exploration of the salivary ductal system. The procedure enables extraction of salivary gland stones and reduced the need for submandibulectomy and (superficial or near-total) parotidectomy, which are associated with a relative high rate of complications.
Sialendoscopy may be used as a diagnostic procedure (calculi, mucous plugs, ductal stenosis and inflammatory changes) and a interventional procedure (removal of calculi, mucous plugs, dilatation of stenosis and biopy). It is also used to reduce the oral dryness in patients with Sjögren’s syndrome.
Although proven to be effective and safe, the procedure is not free of complications. Most complications are related to interventional procedures and are mainly minor and temporary.
Maxillofacial Trauma Management - Tips and Tricks
Last decades have shown a tremendous evolution in the management of the maxillofacial trauma. A more aggressive approach to complex maxillofacial trauma can be observed depending on ever improving osteosynthesis systems and advanced CAD/CAM sytems for planning and reconstruction.
The use of individual designed and fabricated implants supported by CAD planning software is essential for a good functional and aesthetic result.
Six major advances influence the progress in maxillofacial trauma management:
the technique of approach, internal fixation techniques using miniaturized plates and screws, optimized materials such as titanium, resorbable plates, ceramics, modern imaging techniques as spiral CT, MRT and DVT and finally CAD/CAM 3D software, models and individual designed osteosynthesis and reconstruction plates by the SLM techniques.
This lecture briefly reviews the current concepts in the management of maxillofacial fractures, illustrated by tips and tricks for a good functional and aesthetic outcome.