Zygomatic implant guided rehabilitation based on inverted support technique: a pilot study.

OBJECTIVE: Zygomatic implant insertion surgery is a challenging operation. The primary aim of this pilot study was to assess the accuracy of EZgoma® "Inverted Support Technique" for the zygomatic implant-guided surgery. Secondly, any factors which may affect the surgical protocol results, such as implant-prosthetic virtual plan, surgical model matching, intra or post-operative complications, time rate between surgical procedure and prosthetic loading, zygomatic implant survival rate and implant success rate were analyzed. PATIENTS AND METHODS: A total of 20 zygomatic implants were placed in atrophic maxillae of 5 patients. The final position of zygomatic implants after surgery was compared with the pre-operative digitally planned position.  The analyzed parameters were zygomatic implants apex and base mean linear distance and zygomatic implants axis mean angular deviation. RESULTS: The comparison was provided by a tridimensional imaging elaboration platform, provided by Geomagic, which allows the overlay of virtual plan STL data with post-operative control CT scan DICOM data. As a result, all the mean values regarding the 20 placed zygomatic implants respected the universally agreed values in guided zygomatic implant surgery: the mean linear distance of the implant platform and of the implant apex were 1.59 mm and 1.62 mm respectively, while the mean angular deviation of the implant axis was equal to 1.74°. One of the patients had mucositis as a post-operative complication. In one patient the anterior wall of the maxillary sinus fractured, and in one zygomatic implant primary stabilization was not achieved. No other complications occurred. CONCLUSIONS: As a conclusion, data obtained from this study suggested that guided zygomatic implant rehabilitation may represent a reliable, efficient, rapid, ergonomic, and safe surgical protocol, however further investigations are needed.

Oral rehabilitation of oncology patients with dental implants after reconstruction surgery with autogenous flaps.

OBJECTIVE: Reconstruction after radical cancer surgery in terms of function and esthetics can be quite demanding. The aim of this study was to evaluate oral rehabilitation with autogenous flaps and dental implants for maxillofacial reconstruction in oncologic patients after implant insertions. MATERIALS AND METHODS: The study consisted of 19 patients diagnosed with either squamous cell carcinoma, fusocellular carcinoma, or mucoepidermoid carcinoma. The reconstruction of the maxillofacial defects was done with autogenous flaps (free fibular flap, antero-lateral thigh flap, radial forearm flap, or rotational pedicled temporal muscle flap). Implants were inserted on the average 32.03±19.51 months after reconstructive operations. A total of 82 implants were inserted. Mean follow-up after maxillo-facial surgery was 7.2 years (mean 86.56±22.04 months). Mean follow-up after implant insertions was 4.5 years (mean 54.6±21.82). Primary outcome was implant survival. Secondary outcome was evaluation of post-surgical complications. RESULTS: There were surgical revisions in seven patients after reconstructive surgery with flaps, mainly due to tumor relapse. Complications were seen in 11 patients. There was one implant failure. Overall implant survival rate was 98.8%. No relations were found between implant survival rate and gender, type of tumor, type of microvascular free flap, radiation therapy, chemotherapy, and prosthesis type. CONCLUSIONS: According to the results of this study, oral rehabilitation with dental implants inserted in free flaps for maxillofacial reconstruction after ablative oncologic surgery can be considered as a safe treatment modality with successful outcomes.

Survival and success rate of spiral implants inserted mandible.

The rehabilitation of the edentulous mandible is a relatively common clinical problem and dentatl implants are popular medical device routinely use in daily practice. Recently a new type of two-piece spiral implants has been introduced in the market. Here a retrospective study is reported. A total of 54 two-piece implants were inserted in mandible in the period between June and December 2017, 30 in female and 24 in males. The median age was 53 ± 8. Implants replaced 11 incisors, 6 cuspids, 23 premolars and 14 molars. Implant' length was 10 mm, 11,50 mm and 13 mm in 16, 19 and 19 cases, respectively. Implant' diameter was 3.3 mm, 3.75 mm and 4.2 mm in 22, 13, 19 cases, respectively. Twenty two fixtures were placed in totally edentulous patient and 32 in partially edentulous subjects. There were 4 single crowns, 28 implants bearing two or greater bridges, 4 removable dentures and 18 supporting Toronto bridge. The overall mean follow-up was 13 ± 2 months. One implant was lost so that survival rate (SVR) was 98.15%. Then peri-implant bone resorption (success rate, SCR) was used to investigate peri-implant bone stability. No implant have a crestal bone resorption greater than 1.5 mm so that the implants studied are reliable devices for oral rehabilitation with a very high SCR and SVR.

Implants outcome inserted in different sites.

Oral rehabilitation by means dental implants has high standards of success. Recently, a new type of two-pieces spiral implants has been introduced in the market. Since few reports focus of the efficacy of this medical device as a reliable tool for oral rehabilitation, here a retrospective study is reported. In the period June-December 2017 one hundred and two spiral fixtures were inserted, half in females and 51 in males. The median age was 56 ± 8 (min-max 36-73 years). Forty-eight implants were inserted in upper jawbone and 54 in mandible. Two implants were lost and thus survival rate (SVR) is 99.9%. Then peri-implant bone resorption was used to investigate the clinical success (success rate, SCR) over time. No implants have a crestal bone resorption greater than 1.5 mm in the first year follow up. No studied variable has an effect on clinical outcome. In conclusion the studied implants have high SCR and SVR so that they are good tools for oral rehabilitation.

Clinical and functional outcomes of cad/cam mandibular reconstruction with free fibular flap comparing traditional versus micro-invasive intraoral surgical approaches.

The surgical incision plays a pivotal role in any surgical procedure. A good surgical approach should allow optimal visualization, respect the anatomy and ensure the best aesthetic outcome possible, especially when the lesions involve the face. In this retrospective study, carried out from June 2014 to April 2018, different types of surgical approaches to perform mandibular reconstruction were compared. Twentyone patients who underwent mandibular reconstruction with free fibular flap (FFFs) using CAD-CAM technology and Virtual Surgical Planning (VSP) were included in the study, regardless the condition, the timing of reconstruction (primary vs secondary), the number of fibular segments or the type and size of the mandibular defect. The patients were treated for mandibular defects secondary to benign or low-grade oncological lesions and different non-oncological conditions. However, patients requiring neck dissection were excluded from the study. Patients were divided into two groups according to the type of surgical approach used: 7 patients received a traditional transcervical approach together with an intraoral approach, while 14 patients were operated through an intraoral approach combined with different microinvasive approaches, including the sub-mandibular, the retro-mandibular and the preauricular approaches. Different factors were statistically compared: characteristics of the harvested fibula, surgical timing, days of hospitalization, as well as complication, functional and aesthetic outcomes. According to this study, no statistically significant differences were observed between the two groups in any of the features considered. These results support the hypothesis that the combination of different microinvasive approaches and the traditional approach are superimposable, and they can be safely exchanged when the underlying defects allow it.

Evaluation of factors influencing accuracy of virtual surgical planning in orthognatic surgery.

Three-dimensional virtual surgical planning has become routine practice in orthognatic and reconstructive surgery for the possibility to realize presurgical evaluation of intraoperative bones movements, the prediction of postoperative results and the high level of accuracy. Thanks to surface superimposition between 3D planned and 3D postoperative model of maxillo-facial skeleton, a medium discrepancy less than 1 mm was found in scientific literature, considering 15 different points of maxillofacial skeleton. In our study we decided to evaluate different factors that could invalidate that result in the same cohort of patients, such as sex, kind of dentofacial deformity, asymmetry, type of surgical approach and entity of maxillo-mandibular movements (more or less than 1 mm). We found out no significant differences among groups. We can state that virtual surgical planning and 3D surgical splints are a valid means of diagnosis, treatment and predictivity regardless factors that could influence post-operative results. In conclusion, virtual surgical planning and 3D surgical splints facilitated diagnosis, treatment planning and accuracy regardless of sex, dentofacial deformity class, surgery techniques, entity of advancement and asymmetry.

Screening of periodontopathic bacteria in Italian patients affected by periodontitis.

Periodontal disease (PD) is among the most common infectious diseases in the world, caused by pathogenic bacteria that trigger innate, inflammatory, and adaptive immune responses, leading to the destruction of supporting periodontal tissues and, if untreated, tooth loss. This study included 3593 patients, of them 1963 had a complete dataset and thus were analysed: 1088 (55%) were from Northern Italy, 749 (38%) from Central and 126 (7%) from Southern. Aggregatibacter actinomycetemcomitans, Porphyromonas gengivalis, Treponema denticola, and Tannerella forsythia, Campylobacter rectus, Fusobacterium nucleatum, and total bacterial load were investigated. There was a significant difference in geographic distribution as regard A. actinomycetemcomitans (p<0.001), C. rectus (p<0.001), F. nucleatum (p<0.001) and total bacterial load (p<0.001). No differences were detected as regard gender, whereas a significant higher F. nucleatum load was observed in younger patients.

Impact of reconstructive microsurgery on patients with cancer of the head and neck: a prospective study of quality of life, particularly in older patients.

Treatment of cancer of the head and neck often requires extended resection and major reconstructive surgery, both of which can have great functional and emotional impact. It is fundamental to evaluate the outcome with respect not only to the clinical aspects but also to the quality of life (QoL) perceived by the patients. In the light of the reported increasing incidence of oral cancer in older patients, we decided to see if there was an association between QoL and age. Between June 2015 and December 2016 we submitted the Italian version of the 36-item Short Form Health Survey (SF-36) to 30 patients (mean (range) age 65.5 (23-87) years) who had had resection and microsurgical reconstruction at the Ospedale Maggiore Policlinico of Milan. The questionnaires were completed before operation, and 12 months afterwards, and clinical and personal data were also collected. From the results of SF-36 we obtained the Short Form 12 (SF-12), Physical Health Composite Score (PCS), and Mental Health Composite Score (MCS) and looked at how age influences the variation in QoL scores. The variation between SF-36 and SF-12 results (preoperatively and postoperatively) did not seem to correlate with age. Our study confirmed that reconstructive microsurgery can be realistically proposed to older as well as younger patients because, according to the QoL index, older patients are able to manage (and therefore take advantage of) this complex surgical technique.

Bilateral coronoid hyperplasia: a report of six cases.

Bilateral coronoid process hyperplasia is a rare condition defined as an abnormal elongation of the mandibular coronoid process, formed of histologically normal bone. Coronoid process hyperplasia usually develops progressively, and the clinical symptoms are often similar to those of temporomandibular joint disorders (TMD). Therefore, it is often misdiagnosed as TMD initially. From 2013 to 2016, six patients were referred to our maxillofacial surgery unit by their dentist, to evaluate mouth opening with suspected TMJ disorder. Average age was 30 years No hypertrophy of the masseter muscles was found and the patient had no history of pain and/or dysfunction of the temporomandibular joint. Average maximal incisal opening was 16.3 mm. (Rance 13-20 mm). At the end of surgery the average mouth opening achieved was of 40.3 mm. After 6 months from surgery an average mouth opening of 41 mm was obtained, with no recidivism in the coronoid process growth or decrease in the mouth opening. The only successful treatment to restore the mouth opening caused by coronoid process hyperplasia is surgical correction of coronoid-malar interference by coronoidectomy or coronoidotomy. Commencement of physiotherapy is recommended to begin between three days and one week after surgery. We also recommend the use of the TeraBite®, a simple manual physiotherapy device.

Bacterial colonization of the implant-abutment interface of conical connection with an internal octagon: an in vitro study using real-time PCR.

Bacterial leakage at the implant-abutment connection of a two-piece implant system is considered the main cause of peri-implantitis. Prevention of bacterial leakage at the implant-abutment connection is mandatory for reducing inflammation process around implant neck and achieving bone stability. Micro-cavities at implant-abutment connection level can favour bacterial leakage, even in modern two-piece implant systems. The conical connection with an internal octagon (CCIO) is considered to be more stable mechanically and allows a more tight link between implant and abutment. As P. gingivalis and T. forsythia penetration might have clinical relevance, it was the purpose of this investigation to evaluate molecular leakage of these two bacteria in a new two-implant system with an internal conical implant-abutment connection with internal octagon (Shiner XT, FMD Falappa Medical Devices S.p.A. Rome, Italy). To verify the ability of the implant in protecting the internal space from the external environment, the passage of genetically modified Escherichia c oli across implant-abutment interface was evaluated. Four Shiner XT implants (FMD, Falappa Medical Devices®, Rome, Italy) were immerged in a bacterial culture for 24 h and bacteria amount was measured inside implant-abutment interface with Real-time PCR. Bacteria were detected inside all studied implants, with a median percentage of 6% for P. gingivalis and 5% for T. forsythia. Other comparable studies about the tightness of the tested implant system reported similar results. The gap size at the implant-abutment connection of CCIOs was measured by other authors discovering a gap size of 1­2µm of the AstraTech system and of 4µm for the Ankylos system. Bacterial leakage along implant-abutment connection of cylindrical and tapered implants, Shiner XT, (FMD Falappa Medical Devices S.p.A. Rome, Italy) showed better results compared to other implants. Additional studies are needed to explore the relationship in terms of microbiota of the CCIO. In addition, the dynamics of internal colonization needs to be thoroughly documented in longitudinal in vivo studies.

Nasal reconstruction: our experience.

The nose is a critically important aesthetic and functional portion of the face. We can explore nasal defects following trauma or tumor resections. Reconstructive techniques based on primary closure, skin graft, local flap, regional flap and microvascular free tissue transfer provides an algorithmic framework applicable to any reconstructive problem. From 2010 to 2016, 33 patients were treated with nasal reconstruction. Malignant tumor resection was the main cause of nasal defect. The most common tumor resected was BCC (basal cell carcinoma) followed by SCC (squamous cell carcinoma). Recurrence of malignant tumor were also treated. As described in the literature, we used the most common reconstructive techniques to handle post-resection defects. Most of the defects involved the dorsum and the ala of the nose, only rarely had the skeleton been affected by the resection. When the cartilage had been sacrificed, a graft from the septum or from the ear flap was harvested. All patients resulted in optimal reconstruction. In any case, a second surgery was needed. All the surgical procedures were performed in one single stage except for the paramedian forehead flap that required a second stage for division and inset of the flap. All donor sites did not show functional and aesthetic damage. All patients resulted in a morpho-functional restoration of the area affected by the resection with a high success rate. Following the algorithm when restoring the anatomical subunit is the base purpose has determined satisfactory results.

Cone-morse implant connection system significantly reduces bacterial leakage between implant and abutment: an in vitro study.

Osseointegrated implants are very popular dental treatments today in the world. In osseointegrated implants, the occlusal forces are transmitted from prosthesis through an abutment to a dental implant. The abutment is connected to the implant by mean of a screw. A screw is the most used mean for connecting an implant to an abutment. Frequently the screws break and are lost. There is an alternative to screw retained abutment systems: the cone-morse connection (CMC). The CMC, thanks to the absence of the abutment screw, guarantees no micro-gaps, no micro-movements, and a reduction of bacterial leakage between implant and abutment. As P. gingivalis and T. forsythia penetration might have clinical relevance, it was the purpose of this investigation to evaluate molecular leakage of these two bacteria in a new CMC implants systems (Leone Spa®, Florence, Italy). To identify the capability of the implant to protect the internal space from the external environment, the passage of genetically modified Escherichia coli across implant-abutment interface was evaluated. Four cone-morse Leone implants (Leone® Spa, Florence, Italy) were immerged in a bacterial culture for 24 h and bacteria amount was then measured inside implant-abutment interface with Real-time PCR. Bacteria were detected inside all studied implants, with a median percentage of 3% for P. gingivalis and 4% for T. forsythia. Cone-morse connection implant system has very low bacterial leakage percentage and is similar to one-piece implants.

Free flap loss caused by heparin-induced thrombocytopenia and thrombosis (HITT): a case report and literature review.

Heparin-induced thrombocytopenia and thrombosis (HITT) represents a dramatic condition that is difficult to diagnose because of nuanced clinical presentation. Therefore, in every case of microvascular thrombosis during heparin-therapy prompt suspicion about HITT is necessary to avoid flap necrosis. We present a case of HITT which, as the 8 other articles reviewed, clearly shows that HITT is difficult to diagnose and complex to manage. Microvascular reconstruction is the first choice in head and neck reconstruction; unfortunately, dramatic outcomes in free flap surgery due to unpredictable thrombotic events are still reported in the English literature. More knowledge is required about HITT and reaching a consensus about thrombotic prevention in microsurgery could be helpful. Furthermore, a careful anamnesis can help minimise unexpected situations.

Evaluation of three-dimensional mandibular movements after reconstruction with free fibula flap.

Seven patients who underwent mandibular reconstruction with a fibula free flap (one on the midline, six on either right or left side) and were rehabilitated with implant supported prostheses, performed free mandibular border movements (maximal mouth opening and closing, right and left lateral excursions, protrusion) that were recorded by a non-invasive motion analyser. Temporomandibular joint (TMJ) kinematic parameters were compared to those calculated in healthy control subjects using z-scores. Maximum mouth opening was reduced in all patients, with z-scores ranging from -2.742 to -0.106, and performed with a reduced sagittal plane mandibular rotation. Interincisal point forward movement during protrusion was reduced in all but one patient. Lateral mandibular movements (displacement of the interincisal point) and bilateral condylar movements during mouth opening were very variable and sometimes asymmetrical. Mandibular rotation was also variable, with z-scores ranging from -1.265 to 1.388. Together with mandibular range of motion, we investigated biomechanical characteristics of TMJ motion that can provide further information about the joint without submitting the patient to harmful procedures, and that can be followed-up during healing. The investigation indicates those areas that need to be given special attention in preoperative planning, patient information and rehabilitation.

Arterial microanastomoses on the reverse flow of the internal carotid artery reverse flow: an extreme solution in free-flap revascularisation. How we do it.

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels, which are frequently compromised by prior surgery, radiotherapy, or size of the tumour. A surgical description of an arterial free flap pedicle anastomosis on the reverse internal carotid arterial flow in a vessel-depleted neck is presented. A 66-year-old male with a relapse of hypopharyngeal squamous cell carcinoma previously treated with both surgical and radiation therapy for carcinoma of the tongue and the larynx was successfully reconstructed using a free forearm flap with reverse internal carotid arterial flow. The involvement of the carotid glomus and prior surgery excluded the other vessels as recipients. The forearm free flap survived without any complications. This procedure can be considered an alternative rescue technique for salvage reconstruction in a vessel-depleted neck.

Tracheocoele in a Duchenne muscular dystrophy patient. Case report.

Tracheocoele, a congenital or acquired lesion, is rarely detected radiologically and even more rarely diagnosed clinically. This tracheal lesion is characterised by the presence of a single cystic lesion filled with air or a mixture of liquid and air, of extremely variable size, occurring in almost all cases, in a locus minoris resistentiae situated in the right posterolateral portion of the trachea. The rare case is described of a voluminous tracheocoele located in the left paratracheal region, extending from the cricoid to sternal notch, manifesting clinically, 3 months prior to evaluation in our hospital in a 27-year-old male suffering from Duchenne muscular dystrophy since the age of 5 years. For 10 years, the patient had been treated with intermittent positive pressure ventilation via nasal mask, due to progressive deterioration of respiratory function. Diagnosis of tracheocoele, initially made at computed axial tomography scan, was confirmed by flexible laryngotracheoscopy under local anaesthesia. Due to severe comorbidity associated with the clinical picture described, the absence of a significant set of symptoms, and the problems concerning anaesthesiological management of the patient, palliative treatment was the only choice. This consisted in cervical compression bandaging during assisted nasal ventilation. Close follow-up was performed in order to monitor any progression of the lesion or onset of related complications. This is the second case of tracheocoele originating in the left paratracheal region reported in the literature, and the first associated with Duchenne muscular dystrophy and prolonged use of a positive pressure respirator. The aetiopathogenic mechanisms that may have determined the formation of this rare lesion are then taken into consideration.

[Laryngeal carcinoma associated with congenital tracheobronchomegaly (Mounier-Kuhn syndrome): a case report]. / Un caso di carcinoma laringeo associato a tracheobroncomegalia congenita (sindrome di Mounier-Kuhn).

Congenital tracheobronchomegaly or Mounier-Kuhn Syndrome is a rare disorder of controversial etiology. It is characterized by an abnormal enlargement of the trachea and primary bronchi, because of atrophy or absence of their elastic fibers and smooth muscles. Such alterations lead to the collapse of the respiratory tract during forced exhalation, making expectoration by coughing of little use. Subjects with this disorder are, therefore, predisposed to the development of phlogistic bronchopulmonary pathologies such as bronchitis, emphysema, bronchiectasis and pulmonary fibrosis. The present work reports the case of a 65-year-old man suffering from asymptomatic congenital tracheobronchomegaly which was unknown until preoperative testing was performed (standard chest x-ray, tracheobronchoscopy) following a diagnosis of squamous cell carcinoma of the larynx. The patient underwent total laryngectomy and bilateral neck dissection without any intra- and postoperative complication. This is the first case reported in the literature of an association between laryngeal carcinoma and Mounier-Kuhn Syndrome, although a cause-effect relationship between the two pathologies cannot be advanced at this time. This paper also reports how the patient was managed in terms of anesthesiology and surgical technique, both conditioned by the marked tendency for anteroposterior tracheal wall collapse and its high reactivity to mechanical insults.