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s comparable to asthma. Understanding the modalitiessed in the diagnosis and treatment of OSA will facilitate

nformed decisions in patient management. This is espe-ially important when considering that OSA is under-iagnosed and the potential long-term complicationseg, daytime hypersomnolence, hypertension, automo-ile and work-related accidents). The etiology of OSA indults has been elucidated to result from upper airwaylosure and resistance. The determinants of altered air-ay resistance in adults include anatomical or static

actors and physiologic or dynamic factors.Cephalometric radiographs have been the mostidely used imaging modality to study patients whoave OSA. Cephalometric imaging is used to identifyotential sites of upper airway obstruction using specificoft tissue (eg, reduced posterior airway space, long softalate) and skeletal (eg, inferiorly positioned hyoidone, micrognathia, reduced maxillary and mandibularrojection) craniofacial dimensions. A cephalometric ra-iograph with the patients protruding their mandibleay provide treatment planning information for changes

n the posterior airway space and hyoid position. Ceph-lometry has several advantages, including reproducibil-ty, low cost, easy access, minimal radiation exposure,nd is noninvasive. The limitations of this techniquenclude lack of correlation between skeletal cephalomet-ic findings and severity of OSA, 2-dimensional imaging,oor correlation to surgical efficacy, and dynamichanges in the airway when comparing awake and up-ight with sleeping and supine patients. Frontal cepha-ogmetric imaging may provide additional informationbout the transverse dimensions of the velopharynx.ther diagnostic tests that appear promising to dynam-

cally evaluate upper airway resistance during sleep in-lude MRI, acoustic rhinometry, acoustic reflectometry,ptical coherence tomography, pressure catheter-ma-ometry, and the combining cephalometry and theueller Maneuver.The oral and maxillofacial surgeon is uniquely quali-

ed to diagnose and treat patients with OSA and futuredvances that accurately identify dynamic changes alonghe upper airway obstruction will facilitate improvedreatment strategies.

References

Kuna S, et al. JAMA, Volume 266, No. 10, 1991Schwab R, et al. Am J Respir Crit Care Med, Volume 152, No. 5, 1995Faber CE, et al. Sleep Breath, Volume 7, No. 2, 2003

115andibular Reconstruction–Theotpourri of Available Techniquesoward Ian Holmes, DDS, DipOMFS, FICD, Toronto,N, Canada

hmed Jan, DDS, Toronto, ON, Canada t

AOMS • 2009

Mandibular reconstruction is a common clinical pro-edure practiced by several surgical disciplines to affordhe restoration of osseous tissue, lost or destroyed byrauma, infectious and oncologic ablation, or is develop-entally absent, or subjected to atrophy. Presently, au-

ogenous bone of some type is the most common anduccessful graft system available. Techniques of recon-truction have and are continuously evolving, thus af-ording a variety of treatment options suitable to thepecific needs of the different clinical circumstance thatay be encountered.This clinic will provide a systematic approach to man-

ibular reconstruction based on a historical perspectivef its evolution, clinical experience and evidence basededicine. The place for primary and secondary recon-

truction will be reviewed and the various techniques oflloplastic, free non vascularized autogenous bone graftsblock, particulate marrow), composite and free micro-ascular grafts will be presented. As well the use ofesorbable meshes and morphogenic proteins will bexemplified and discussed.In the era of bioresorbables, 3-D imaging with model

rototyping and tissue engineering traditional tech-iques have improved in their accuracy and efficiencynd we may well be approaching a millennium of con-entional graft procurement obsolescence.

References

Gullane, P., Holmes, H. Newer Concepts in Mandibular Reconstruc-ion. Archives Otolaryngology. (Head & Neck Surgery) ll2: 714, 1986

Louis, P., J. Holmes, et al. (2004). Resorbable mesh as a containmentystem in reconstruction of the atrophic mandible fracture. J Oralaxillofacial Surg 62(6): 719-23Moghadan, H. Sandor, G. Holmes H., Clokie C.: Histomorphometric

valuation of Bone Regeneration using Allogenic and Alloplastic Boneubstitutes. J Oral Maxillofac Surg 2004; 62(2):202-213

116ow to Make a Chair-Side Immediate

crew-Retained Provisional Crownoward Park, DMD, MD, Santa Monica, CA

Maintaining proper gingival architectures in the max-llary esthetic zone can be a challenging task when aooth is to be removed and the implant placement islanned. While a removable treatment partial dentureith a properly contoured ovate pontic can mitigate

ome of the pitfalls, patients often raise objections toaving to wear a removable prosthesis. Such a concernan create additional barrier to accepting implant treat-ent options. Even when the implant can be placed

mmediately following the extraction, it is difficult toefer these patients back to the referring dentists on theame day for the fabrication of immediate fixed provi-ionals, as these immediate “emergency implant” pa-

ients can place tremendous burden on their daily sched-

113

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les. Emergency patients presenting to have these teethemoved need not return to referring dentists for fabri-ation of provisional prosthesis when teeth can be ex-racted and the implants placed with immediate fixedrovisional crowns. By utilizing this unique service inhich a surgeon can place the implant and fabricate a

hair-side immediate provisional crown, the patients willeadily accept it as the preferred treatment option, es-ecially if a properly contoured fixed provisional crownan preserve the esthetics of soft tissue architecture.hen these patients return to the referring dentists,

sthetic definitive restorations can be delivered withinimal or no further tissue manipulations.

References

Karamanis S, Angelopoulos C, Tsoukalas D, Parissis N: Immediateapless implant placement and provisionalization: Challenge for opti-um esthetics and function: a case report J Oral Implantol, 34(1):52,

008Walker, L: The emergency implant: A practice growth Strategy.

ournal of Oral and Maxillofacial Surgery suppl 1 64:121, 2006Palattella P, Torsello F, Cordaro, L: Two-year prospective clinical

omparison of immediate replacement vs. immediate restoration ofingle tooth in the esthetic zone. Clin Oral Implants Res. 19(11):1148,008 Nov

121icrosurgical Repair of Trigeminalerve Injuriesincent B. Ziccardi, DDS, MD, Newark, NJ

Sensory disturbances to the peripheral branches of therigeminal nerve can be a debilitating disruption to pa-ients leading to problems with speech, mastication,ood and liquid incompetence and difficulty with activ-ties of daily living. These injuries may arise from aumber of causes in oral and maxillofacial surgery. Theost common cause of trigeminal nerve injury results

rom the removal of impacted third molars. There are aariety of other causes including orthognathic surgery,ndodontic surgery, implant placement, fractures, pre-rosthetic surgery and treatment of maxillofacial pathol-gy.Some of the etiological factors resulting in trigeminal

erve injury are unpreventable, however, more preciseurgical techniques and better imaging modalities mayelp reduce the incidence of these injuries. Injuries tohe trigeminal nerve branches are a known and acceptedisk in oral and maxillofacial surgery. It is important forractitioners to explain these risks to patients as part ofhe informed consent process and to recognize and doc-ment the presence of nerve injuries. Patients should bereated in a timely fashion or referred to practitionerskilled in microsurgical techniques for optimal sensorymprovement. This surgical clinic shall review the etiol-gies of trigeminal nerve injury, neurosensory testing

nd documentation, classification schemes, indications O

14

or treatment and referral, microsurgical techniques andutcome assessments.

References

Ziccardi, V.B. and Assael, L.A. Mechanisms of Trigeminal Nervenjuries. Atlas Oral Maxillofac Surg Clin. 2001; 9(2): 1-11

Rutner, T., Ziccardi, V.B., Janal, M. Long-Term Outcome Assessmentor Lingual Nerve Microsurgery. J Oral Maxillofac Surg. 63:1145-1149;005Ziccardi, V.B. and Zuniga, J.R. Traumatic Injuries of the Trigeminal

erve in Oral and Maxillofacial Trauma. Third edition. Fonseca, R.J.,etts, N.J., Barber, H.D. (eds.) Elsevier Saunders, Co., Philadelphia.005. Volume 2. Chapter 29. Pages 877-914Ziccardi, V.B. and Steinberg M.J. Timing of Trigeminal Nerve Micro-

urgery: A Review of the Literature. J Oral Maxillofac Surg. 65:1341-345; 2007

122OT Therapy—CO2 Microablative Skinesurfacing

odd Sawisch, DDS, Fort Lauderdale, FL

The carbon dioxide (CO2) laser remains the gold stan-ard in facial skin resurfacing. Dermal Optical Thermol-sis (DOT) therapy is the latest innovation of micro-blative skin rejuvenation, and offers an alternative toraditional laser skin resurfacing. The treatment is per-ormed using a CO2 laser with a computerized scanningnterface. This advanced technology allows the cliniciano formulate a specific laser treatment for each individualatient. DOT therapy stimulates collagen growth, im-roves skin texture, eliminates surface irregularities,vens pigmentation and photo-damage, and ultimatelyemoves potentially precancerous cells.

This course will familiarize the practitioner with ad-ances in CO2 laser physics and the biology of con-rolled dermal optical interaction. Optimal patient selec-ion, and surgical application with treatment protocolsill be discussed. Selected case presentations will dem-nstrate the ease of surgical technique, postoperativeecovery and clinical results.

References

Alexiades-Armenakas M, Dover J, Arndt K. The spectrum of laser skinesurfacing: nonablative, fractional, and ablative laser resurfacing J Amcad Dermatol. 2008 May;58(5):719-37Watson S, Sawisch T. Cosmetic ablative skin resurfacing Oral Max-

llofac Surg Clin North Am. 2004;16(2):215-30Alexandra Y, Zhang A, Obagi S. Diagnosis and Management of Skin

esurfacing–Related Complications Oral Maxillofac Surg Clin Northm. 2009;21(1):1-12

123odern Management Preserving the

alivary Glands

ded Nahlieli, DMD, Ashkelon, Israel

AAOMS • 2009