Surgical Mini-Lectures

The odontogenic keratocyst is a cyst of known recurrence potential. This is due to the potential of any one
single cell left behind to clone into a new cyst. Approaches to remove the entire cyst including wide access transoral approaches and extra oral approaches
reduce recurrence to less than 3%. Straightforward enucleation and curettage is all that is necessary if accomplished in a controlled direct vision access manner. The
use of adjuncts such as Carnoys solution, phenol, and
cryotherapy is unnecessary and only risks wound healing
complications and compromises bone regeneration in
the defect.
Odontogenic tumors typified by the ameloblastoma
are predictably cured by resective surgery with frozen
section control. Today this resective surgery is combined
with nerve preservation techniques, nerve re-anastomosis techniques, and more rarely nerve grafting to return
or restore sensation. In addition, when the condyle requires resection titanium condylar replacements in
adults allow for precise retention of occlusion and maximum function. In children, an allogeneic mandibular
condylar/ramus support acts as a scaffold for spontaneous bone regenerations that will include the condyle and
even the curettage later pterygoid attachment for protrusive and working functions of the mandible.
These improvements in surgical approach and materials permit surgeons to realize a higher quality outcome
and reduced recurrence rates.
References
Marx RE and Stern ed: Oral and Maxillofacial Pathology: A rationale
for diagnosis and treatment. Quintessence Publishing, Hanover Park,
IL, 2004
Carlson ER and Marx RE. The Ameloblastoma: Primary curative
surgical management. J Oral Maxillofac Surg 64:484-494, 2006
Marx RE: Mandibular Reconstruction. J Oral Maxillofacial Surg 51:
466-482, 1993

M641
Technology and Methods for Treatment
of the Perceived Difficult Case
Michael S. Block, DMD, Metairie, LA
Clinicians often are presented with clinical situations
which may appear challenging. These cases may include
the partially edentulous case with decisions concerning
space, tooth retention, lack of bone, esthetic challenges,
or the totally edentulous case with bone deficiency yet
the patients goals include fixed restoration.
A similar algorithm is used for all patients. This treatment algorithm creates a base of information which then
is used to determine several treatment plan options for
the patient. The plan starts with establishing the patients goals, including obtaining an accurate dental history from the restorative dentist. The surgeon will need
to obtain an accurate medical history and note specific

clinical findings related to an esthetic analysis, ridge

form, and the status of the remaining teeth, which may
include probing. The surgeon should obtain specific
imaging that illustrates the presence of bone in relation
to the teeth. The restorative dentist should provide a
diagnostic plan from which a treatment plan can be
made. Based on the planned restoration, the necessary
plans can be made to include orthodontics and prosthetic plans for provisionalization. A seemingly challenging situation can thus be simplified to several stages and
the patients final result mimics the planning.
For the totally edentulous patient a similar algorithm is
used. Often a new prosthesis is needed to finalize the
plan which will include imaging to determine the location of bone to the planned teeth. The final prosthetic
plan needs to be established in regard to fixed or removable prosthetics, which will alter the planned locations
of implants.

M642
Orthognathic Surgery: Treatment
Planning and Surgical Techniques
Larry M. Wolford, DMD, Dallas, TX
Surgical techniques in orthognathic surgery have and
will continue to undergo modifications and change in an
effort to improve the quality of patient care and outcome. This program will present state-of-the-art surgical
techniques and research results substantiating the efficacy of these surgical methods. The following modifications will be discussed:
1. Genioplasty
A. Augmentation
B. Tenon and mortise osseous genioplasty
2. Anterior mandibular subapical osteotomy
3. Mandibular body osteotomy
4. Mandibular ramus sagittal split osteotomy modifications
A. Ramus and inferior border osteotomy
C. Rigid fixation
5. Maxillary osteotomy modification
A. Maxillary step osteotomy and rigid fixation
B. Porous block HA grafting
6. Double jaw surgery
A. Selective alteration of the occlusal plane
B. Surgical Sequencing of the maxilla and mandible
C. Model surgery modifications
7. TMJ factors affecting orthognathic surgery outcomes
Implementation of these techniques by the experienced, skilled surgeon, coupled with accurate diagnosis
and treatment planning, should provide optimal functional and esthetic outcomes for our patients.

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Surgical Mini-Lectures
References
Wolford LM: The Use of Porous Block Hydroxyapatite. Chapter 28,
Part II, in Modern Practice in Orthognathic and Reconstructive Surgery
(Editor Bell WII) W.B. Saunders Co., Philadelphia, 1992
Wolford LM, Chemello PD, Hilliard FW: Occlusal Plane Alteration in
Orthognathic Surgery. J Oral Maxillofac Surg 51:730-740, 1993
Cottrell DA, Wolford LM: Altered Orthognathic Surgical Sequencing
and a Modified Approach to Model Surgery. J Oral Maxillofac Surg
52:1010-1029, 1994

M643
Esthetic Soft Tissue Management A to Z
Daniel R. Cullum, DDS, Coeur dAlene, ID
Synopsis: As surgeons, our ability to predictably produce soft tissue quality and quantity at implant sites is
critical for a successful outcome. We will discuss assessment and management of a continuum of treatment
challenges from inadequate attached tissue, thin biotype
and immediate implant sites through more complex defects using:
Modified flap design for apical or lateral repositioning
Free connective tissue grafting with closed donor
site harvest
Split and full thickness recipient site preparation
Pedicle flap design and modifications
Vestibular flap fixation
Combination procedures
Role of growth factors and hard/soft tissue lasers
Attendees will be challenged to advance their soft
tissue techniques with progressive skill development in
situations that present every day in our practices. A
minimally invasive approach to predictably manage defects at the time of extraction and with combined procedures will be discussed.

M644
Clinical Applications of Recombinant
Human Bone Morphogenetic Protein-2
(rhBMP-2)
Robert E. Marx, DDS, Miami, FL
R. Gilbert Triplett, DDS, PhD, Dallas, TX
Human Bone Morphogenetic Proteins (BMP) are a
group of bone inductive proteins that determine and
form the human skeleton. In the adult, they reform bone
after osteoclastic resorption as part of the normal bone
turnover cycle. The concentration of BMP in human and
animal bone is exceedingly small negating its clinical
usefulness for bone induction via xenogenic or allogenic
bone grafts. However, molecular biotechnology has
cloned the BMP-2 genes to produce clinically effective
concentrations in a recombinant form.
Recombinant human bone morphogenetic protein-2
in an Acellular Collagen Sponge (rhBMP-2/ACS) is cur-

rently FDA cleared for lumbar spinal fusions and fresh

tibial fractures, ridge preservations of the jaws, and maxillary sinus augmentations. In addition, the authors off
label use of rhBMP-2 indicates its ability to regenerate
bone de novo in other oral and maxillofacial surgery
procedures such as horizontal and vertical ridge augmentation, naso alveolar clefts, cystic defects, and as an
enhancement to or replacement of autogenous bone
grafts in large continuity defects. The ability of rhBMP-2
to regenerate bone de novo in facial and jaw defects is
limited only by the scaffolding matrix, the dose of rhBMP-2, and the availability of mesenchymal stem cells
that can respond to it. To date, the initial clinical experience in small bony defects has now also shown good
de novo bone regeneration in extended applications
such as those noted above.

M645
Periodontal Plastic Surgery for the
Implant Patient
Anthony G. Sclar, DMD, South Miami, FL
With recent biotechnological developments and the
widespread employment of implant dentistry periodontal plastic surgery has become synonymous with oral
plastic surgery and implant site development having
applications in both cosmetic dentistry and implant therapy. Traditional periodontal plastic surgery procedures
were used to manage vestibular insufficiency, aberrant
frenum, marginal tissue recession, excessive gingival display and lost interdental papillae. The realm of contemporary periodontal plastic surgery continues to expand
with the evolution of procedures and technologies used
to preserve and reconstruct alveolar ridge tissues in
preparation for conventional or implant restorations. In
order to provide optimal care for their patients, the
implant surgeons should qualify themselves by obtaining
additional education to keep abreast with the rapidly
developing fields of oral plastic surgery and implant site
development.
Prerequisites for the successful oralplastic-implant
surgeon includes: an in depth knowledge of the anatomy
and biology of periodontal and peri-implant soft tissues
and a clear understanding of the anatomic basis for the
successful application of periodontal plastic surgery
techniques around the natural dentition and dental implants. To begin with, the peri-implant soft tissues lack a
connective tissue attachment to the permucosal implant
structures, and do not enjoy the blood supply normally
derived from the periodontal ligament. In addition, the
peri-implant connective tissue is acellular when compared to its periodontal counterpart and lacks the sophisticated organization of connective tissue fibers designed to provide mechanical protection and stability for
the natural dentition. Furthermore, the peri-implant soft

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