1

Practice & Scope

of

Oral-Craniomaxillofacial Surgery

Roberto M. Pangan DMD., MD.

Clinical Assoc. Prof

Craniomaxillofacial-Plastic Surgery Section

Dept. of ENT – U.P. P.G.H.

D.M.D. / D.D.S.

Otorhinolaryngology

Plastic surgery

Ophthalmology

Craniomaxillofacial Surgery

orthopedic

Neurosurgery

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Pathologic Physiologic

ANATOMIC UNIT

( Face )

Functional - Aesthetic

Reconstructive Surgery

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4

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Cleft Anomaly

Persistence of embryonic clefts

Cleft lip-palate Facial cleft

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Clinical Approach

surgical procedures non-surgical procedures

cheiloplastypalatoplastyventilation tube insertionalveolar bone graftingvelopharyngoplastycolumellar lengtheningorthognathic surgerydistraction osteogenesisrhinoseptoplastylip revision

parent counselingmolding appliancespeech therapypt.counselingdental careorthodontic tx.

Multidisciplinaryteam

Interdisciplinary referralvs.

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Multidisciplinary team

SurgeonOtologist

Pediatrician

Orthodontist

PedodontistProsthodontist

Rehabilitation Med.Speech therapist

Psychiatrist

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12

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14

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Surgical Goals

• Complete anatomical closure of cleft -palate

• Functioning velopharyngeal mechanism

Criteria for Success

• Normal speech development

• Absence of fistula

• No secondary maxillary growth inhibition

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17

18

19

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ConceptConcept•skeletal surgery

•alveolar bone grafting•orthognathic surgery

•rhinoseptoplasty

•revision cheiloplasty

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ANKYLOSISTMJ Ankylosis

8th weektemporal blastemas

condylar blastemas

9th – 10th wk.ossification

formation of condylar cartilage

12th wk. formation of lower joint compartment

14th wk. formation of upper joint compartment

Embryology

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26

27

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Cranio-maxillofacial trauma

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Indications

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Surgical Approaches

Intraoral

Extraoral

Combined extraoral - intraoral

Fixation Method

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postcondylar fracture syndrome

mandibular deviation

shortened vertical ramus height

canting of oclussal plane

decreased translation

internal derangement

Assael, l. A. : Hard tissue Trauma. Temporomandibular Disorders: 1990

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Developmental Anomalies

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35

Neoplastic disorders

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Ameloblastoma( benign epithelial odontogenic tumor )

Adamantinoma ( Malassez, 1885 )

Ameloblastoma ( Churchill, 1934 )

Potential epithelial sources:

- enamel organ

- reduced enamel epithelium

- odontogenic rests (rests of Malassez/Serres)

- epithelial lining of dentigerous cysts

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Histologic Classification

- follicular- plexiform- Acanthomatous- spindle

* unicystic

Treatment Strategies

Radical Surgery( Axhausen )

Conservation Surgery ( Pichler, Trauner )

1. Marsupialization/Enucleation2. Enucleation w/ curettage3. Enucleation w/ peripheral

ostectomy

Primary Reconstruction

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unicystic ameloblastoma

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“Ameloblastomas exhibit biological heterogeneity andhistological appearances do not always allow their behavior to be predicted.”

Oral Dis. 1999 Apr. 5 (2) : 111-6Ong’uti MN, Howells GL,Williams DM

Oral Diseases Research Center,Royal London School of Medicine and Dentistry, UK

Ameloblastoman = 35

SOLID Cystic

1995 - 2005

11/35 = 31% 24/35 = 67%

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Ameloblastoma (solid type)

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Ameloblastoma

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1995 – 2005

N = 24 PatientsCystic Mandibular

Ameloblastoma

Mandibular conservation surgery

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Conservative treatment

1. Surgical enucleation of cystic ameloblastoma

2. Smoothening of bony septations and loculations

3. Exteriorize bony cavity

4. 4% 5FU cream application into healing bony cavity q 3-4 days x 4weeks.

Ameloblastoma n=24

3/24 = 12% 16/24 = 67%

5/24 = 21%

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25.0%Associated w/ unerupted tooth

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0

1

2

3

4

5

0-10yrs 11-20yrs. 21-30yrs. 31-40yrs. 41-50yrs.

femalemale

age/sex distributionN=24 patients

Female = 58% Male = 42%

=

=

=

25%

62.5%

12.5%

Distribution of mandibular ameloblastoma in 24 patients

N= 6

N= 15

N= 3

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Cystic ameloblastoma

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Cystic ameloblastoma w/intraluminal tumor nodules

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0 1 2 3 4 5 6 7 8 9 10123456789

101112131415161718192021222324

follow-up period

N=24

yrs.

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Results

(+) bone regeneration

(+) functional rehabilitation

15/24 = 63% w/o residual sensory deficit

4/24 = 17% w/ minimal mandibular asymmetry

6/24 = 25% w/ mild sensory deficit

3/24 = 12% w/ bothersome sensory deficit

2/24 = 8% -pathologic fracture

Treatment period : 6-12 months