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The odontogenic keratocyst is a cyst of known recur-rence potential. This is due to the potential of any one

single cell left behind to clone into a new cyst. Ap-proaches to remove the entire cyst including wide ac-cess transoral approaches and extra oral approachesreduce recurrence to less than 3%. Straightforward enu-cleation and curettage is all that is necessary if accom-plished in a controlled direct vision access manner. The

use of adjuncts such as Carnoys solution, phenol, andcryotherapy is unnecessary and only risks wound healingcomplications and compromises bone regeneration in

the defect.Odontogenic tumors typified by the ameloblastoma

are predictably cured by resective surgery with frozensection control. Today this resective surgery is combined

with nerve preservation techniques, nerve re-anastomo-sis techniques, and more rarely nerve grafting to returnor restore sensation. In addition, when the condyle re-quires resection titanium condylar replacements inadults allow for precise retention of occlusion and max-

imum function. In children, an allogeneic mandibularcondylar/ramus support acts as a scaffold for spontane-ous bone regenerations that will include the condyle andeven the curettage later pterygoid attachment for pro-trusive and working functions of the mandible.

These improvements in surgical approach and materi-als permit surgeons to realize a higher quality outcomeand 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 curativesurgical management. J Oral Maxillofac Surg 64:484-494, 2006

Marx RE: Mandibular Reconstruction. J Oral Maxillofacial Surg 51:

466-482, 1993

M641Technology and Methods for Treatmentof the Perceived Difficult Case

Michael S. Block, DMD, Metairie, LA

Clinicians often are presented with clinical situations

which may appear challenging. These cases may includethe partially edentulous case with decisions concerningspace, tooth retention, lack of bone, esthetic challenges,or the totally edentulous case with bone deficiency yetthe patients goals include fixed restoration.

A similar algorithm is used for all patients. This treat-ment algorithm creates a base of information which then

is used to determine several treatment plan options forthe patient. The plan starts with establishing the pa-tients goals, including obtaining an accurate dental his-tory from the restorative dentist. The surgeon will needto 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 pros-thetic plans for provisionalization. A seemingly challeng-

ing 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 loca-

tion of bone to the planned teeth. The final prosthetic

plan needs to be established in regard to fixed or remov-

able 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 out-

come. This program will present state-of-the-art surgical

techniques and research results substantiating the effi-

cacy of these surgical methods. The following modifica-

tions 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 modifi-

cations

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 out-

comes

Implementation of these techniques by the experi-

enced, skilled surgeon, coupled with accurate diagnosis

and treatment planning, should provide optimal func-

tional and esthetic outcomes for our patients.

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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

M643Esthetic Soft Tissue Management A to Z

Daniel R. Cullum, DDS, Coeur dAlene, ID

Synopsis: As surgeons, our ability to predictably pro-duce soft tissue quality and quantity at implant sites iscritical for a successful outcome. We will discuss assess-ment and management of a continuum of treatmentchallenges from inadequate attached tissue, thin biotypeand immediate implant sites through more complex de-

fects using: Modified flap design for apical or lateral repositioning

Free connective tissue grafting with closed donorsite 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 softtissue techniques with progressive skill development insituations that present every day in our practices. A

minimally invasive approach to predictably manage de-fects at the time of extraction and with combined pro-cedures will be discussed.

M644Clinical Applications of RecombinantHuman 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 agroup of bone inductive proteins that determine andform the human skeleton. In the adult, they reform boneafter osteoclastic resorption as part of the normal boneturnover cycle. The concentration of BMP in human andanimal bone is exceedingly small negating its clinicalusefulness for bone induction via xenogenic or allogenic

bone grafts. However, molecular biotechnology hascloned the BMP-2 genes to produce clinically effectiveconcentrations in a recombinant form.

Recombinant human bone morphogenetic protein-2in an Acellular Collagen Sponge (rhBMP-2/ACS) is cur-

rently FDA cleared for lumbar spinal fusions and freshtibial fractures, ridge preservations of the jaws, and max-

illary sinus augmentations. In addition, the authors offlabel use of rhBMP-2 indicates its ability to regeneratebone de novo in other oral and maxillofacial surgeryprocedures such as horizontal and vertical ridge augmen-tation, naso alveolar clefts, cystic defects, and as anenhancement to or replacement of autogenous bone

grafts in large continuity defects. The ability of rhBMP-2to regenerate bone de novo in facial and jaw defects islimited only by the scaffolding matrix, the dose of rh-

BMP-2, and the availability of mesenchymal stem cellsthat can respond to it. To date, the initial clinical expe-rience in small bony defects has now also shown goodde novo bone regeneration in extended applicationssuch as those noted above.

M645Periodontal Plastic Surgery for the

Implant PatientAnthony G. Sclar, DMD, South Miami, FL

With recent biotechnological developments and the

widespread employment of implant dentistry periodon-tal plastic surgery has become synonymous with oralplastic surgery and implant site development havingapplications in both cosmetic dentistry and implant ther-apy. Traditional periodontal plastic surgery procedures

were used to manage vestibular insufficiency, aberrantfrenum, marginal tissue recession, excessive gingival dis-play and lost interdental papillae. The realm of contem-

porary periodontal plastic surgery continues to expandwith the evolution of procedures and technologies usedto preserve and reconstruct alveolar ridge tissues inpreparation for conventional or implant restorations. Inorder to provide optimal care for their patients, theimplant surgeons should qualify themselves by obtainingadditional education to keep abreast with the rapidlydeveloping fields of oral plastic surgery and implant sitedevelopment.

Prerequisites for the successful oralplastic-implant

surgeon includes: an in depth knowledge of the anatomyand biology of periodontal and peri-implant soft tissues

and a clear understanding of the anatomic basis for thesuccessful application of periodontal plastic surgerytechniques around the natural dentition and dental im-plants. To begin with, the peri-implant soft tissues lack aconnective tissue attachment to the permucosal implantstructures, and do not enjoy the blood supply normallyderived from the periodontal ligament. In addition, the

peri-implant connective tissue is acellular when com-pared to its periodontal counterpart and lacks the so-phisticated organization of connective tissue fibers de-signed to provide mechanical protection and stability forthe natural dentition. Furthermore, the peri-implant soft

Surgical Mini-Lectures

110 AAOMS 2009

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