Surgical Repositioning of the Premaxilla Using a Minimally Invasive Endonasal Approach.

OBJECTIVE: The aim of this study was to evaluate a technique for the surgical repositioning of the premaxilla using a minimally invasive endonasal approach. DESIGN: Retrospective review of clinical records. SETTING: Tertiary care, University Hospital, pediatric maxillofacial surgery unit. PATIENTS: Twenty-one patients (12 boys and 9 girls), ages ranging from 6 to 21 years, with BCLP+A and premaxillary malposition (PM). INTERVENTIONS: Surgical repositioning of the premaxilla (SRP) using a minimally invasive endonasal approach, from November 2007 to November 2015. MAIN OUTCOME MEASURES: Achieving maxillary arch alignment and premaxillary stability was defined as treatment success. Intraoperative and postoperative complications were also recorded. RESULTS: In all cases (100%), the treatment was successful either at first surgery or after reoperation. Two patients (9.5%) were reoperated-one due to premaxillary instability and one due to PM relapse. There were no perioperative complications. CONCLUSIONS: SRP using a minimally invasive endonasal approach is a safe and effective technique that levels and aligns the maxillary arch in preparation for SABG, which minimizes the risk of wound infection and premaxillary vascular compromise. The endonasal approach improves tissue quality of the mucoperiosteal flaps when performing the SABG procedure. Further prospective studies are needed to elucidate the best protocols and techniques for the management of PM in patients with BCLP+ A.

MR Imaging of the Temporomandibular Joint in Juvenile Idiopathic Arthritis: Technique and Findings.

The term juvenile idiopathic arthritis (JIA) encompasses a group of arthritides of unknown cause that begin before 16 years of age and last for at least 6 weeks. Temporomandibular joint (TMJ) involvement has been described in up to 87% of children with JIA and has been associated with all JIA subtypes. TMJ involvement is difficult to detect clinically. In one study, 71% of JIA patients with active TMJ synovitis were asymptomatic and 63% had normal physical examination results. Moreover, the main growth center of the mandible is located in the condyle, separated from the joint space by only a thin layer of fibrocartilage. This makes mandibular growth vulnerable to arthritic changes, eventually resulting in facial asymmetry and retrognathia. Therefore, early detection and treatment of TMJ arthritis are paramount to preserving motility and preventing deformity. As clinical symptoms and physical examination results are not good markers of TMJ involvement, imaging plays a key role in diagnosis and treatment monitoring. Magnetic resonance imaging is the technique of choice for the study of TMJ arthritis. It has the advantages of displaying both soft tissue and bone, is the most sensitive technique for detecting acute synovitis, and is the only one able to demonstrate bone marrow edema. In addition, it allows the assessment of changes to the joint over time and evaluation of the effectiveness of therapeutic interventions. ©RSNA, 2017.

SPECT-CT and intraoperative portable gamma-camera detection protocol for sentinel lymph node biopsy in oral cavity squamous cell carcinoma.

OBJECTIVE: The aim of this study was to evaluate a multimodality approach to sentinel lymph node biopsy (SLNB) detection with lymphoscintigraphy and single-photon emission computed tomography (SPECT)/computed tomography (CT). When combined with intraoperative imaging by a portable gamma camera (PGC), improved SLNB accuracy and detection rate may result. MATERIAL AND METHODS: A total of 42 patients selected for SLNB in node-negative T1 and T2 oral squamous cell carcinoma were retrospectively analyzed. The detection protocol consisted of preoperative lymphoscintigraphy and SPECT/CT performed the day before surgery. Intraoperative sentinel lymph node (SLN) detection was done with the aid of a PGC in association with hand-held gamma probe. RESULTS: All SLN detected in the preoperative study could be harvested except for one case. A total of 131 SLN were resected. This number was higher than the SLN depicted on lymphoscintigraphy (119 SLNs) and SPECT/CT (123 SLNs). Sublingual SLNs were observed in two cases (4.76%). These SLNs were detected by SPECT/CT but not by lymphoscintigraphy. Five (3.8%) additional SLNs not previously visualized on lymphoscintigraphy or on SPECT/CT were detected intraoperatively with the aid of the PGC. Positive SLNs were detected in eight cases (19%). Micrometastases were detected in five cases (62%) and macrometastases in three cases (38%). CONCLUSION: The SLNB detection protocol described contributes to more accurate study and detection.

Rhytidectomy approach for mandibular reconstruction with microvascular free flaps after resection of mandibular benign tumors.

PURPOSE: Microvascular surgery has become the preferred method for mandibular reconstruction. A neck incision frequently is required for malignant tumor resections to carry out the dissection. The authors suggest a rhytidectomy approach for mandibular reconstruction with microvascular free flaps after the resection of benign tumors. PATIENTS AND METHODS: Seven patients with lateral mandibular defects resulting from resection of benign mandibular tumors were treated in the author's department. A combined rhytidectomy approach with an intraoral incision was used for mandibular resection and reconstruction of the defects using vascularized free osseous flaps. RESULTS: The study was comprised of 3 men and 4 women with a mean age of 37.57 years (range, 28 to 50 years). Follow-up ranged from 9 to 87 months after surgery (mean, 56.28 months). The iliac crest was used for reconstruction in 6 patients, whereas the fibula was used in 1 patient. Transient paresis of the marginal nerve was observed in 2 patients. Flap loss occurred in 1 patient and required repeat microvascular reconstructive surgery. Dental rehabilitation with osseointegrated implants was performed in 4 patients. At the end of the follow-up period, successful mandibular reconstruction was achieved in all patients. Functional outcome was regarded as excellent in all patients, whereas esthetic outcome was judged excellent in 6 patients and good in 1 patient. CONCLUSIONS: A rhytidectomy approach combined with an intraoral incision for microvascular mandibular reconstruction after the resection of benign tumors is a feasible technique that provides good exposure of the anatomic structures, an inconspicuous facial scar, and adequate facial contour and symmetry. Excellent clinical results are reported with the use of this technique, which should be included in the surgical armamentarium for mandibular reconstruction.

Review of secondary alveolar cleft repair.

INTRODUCTION: The alveolar cleft is a bony defect that is present in 75% of the patients with cleft lip and palate. Although secondary alveolar cleft repair is commonly accepted for these patients, nowadays, controversy still remains regarding the surgical technique, the timing of the surgery, the donor site, and whether the use of allogenic materials improve the outcomes. The purpose of the present review was to evaluate the protocol, the surgical technique and the outcomes in a large population of patients with alveolar clefts that underwent secondary alveolar cleft repair. MATERIALS AND METHODS: A total of 109 procedures in 90 patients with alveolar cleft were identified retrospectively after institutional review board approval was obtained. The patients were treated at a single institution during a period of 10 years (2001-2011). Data were collected regarding demographics, type of cleft, success parameters of the procedure (oronasal fistulae closure, unification of the maxillary segments, eruption and support of anterior teeth, support to the base of the nose, normal ridge form for prosthetic rehabilitation), donor site morbidity, and complications. Pre- and postoperative radiological examination was performed by means of orthopantomogram and computed tomography (CT) scan. RESULTS: The average patient age was 14.2 years (range 4-21.3 years). There were 4 right alveolar-lip clefts, 9 left alveolar-lip clefts, 3 bilateral alveolar-lip clefts, 18 right palate-lip clefts, 40 left palate-lip clefts and 16 bilateral palate-lip clefts. All the success parameters were favorable in 87 patients. Iliac crest bone grafts were employed in all cases. There were three bone graft losses. In three cases, allogenic materials used in a first surgery performed in other centers, underwent infection and lacked consolidation. They were removed and substituted by autogenous iliac crest bone graft. CONCLUSIONS: THE USE OF AUTOGENOUS ILIAC CREST FOR SECONDARY ALVEOLAR BONE GRAFTING ACHIEVES ALL THESE SEVERAL OBJECTIVES: (1) to obtain maxillary arch continuity, (2) to maximize bone support for the dentition, (3) to stabilize the maxillary segments after orthodontic treatment, (4) to eliminate oronasal fistulae, (5) to provide nasal alar cartilage support, (6) to establish ideal alveolar morphology, and (7) to provide available bone with attached soft tissue for future endosteal implant placement in cases where there is a residual dental space. We advocate for the use of a minimal incision to obtain the iliac crest bone graft and for the use of a corticocancellous block of bone in combination with bone chips.

Vertical distraction osteogenesis of a free vascularized fibula flap in a reconstructed hemimandible for mandibular reconstruction and optimization of the implant prosthetic rehabilitation. Report of a case.

Free vascularized fibular flap is considered the treatment of choice in mandibular reconstruction for extensive bone defects (over 6 centimeters) resulting from trauma, infections or tumor resections. But, when the reconstruction involves a dentate mandible, the fibula has the limit as it does not offer sufficient bone height to restore the alveolar arch up to the occlusal plane. Therefore, the deficiency in bone height makes implant placement impractical. We report a case of vertical distraction osteogenesis of a free vascularized fibula flap used to reconstruct a hemimandible after resection of an odontogenic myxoma, for optimization of the implant prosthetic rehabilitation. The distraction device was applied intraorally. After 10 days of latency period, distraction protocol was performed at a distraction rate of 0.5 mm per day. A consolidation period of 3 months followed. Afterwards the distraction device was removed and 3 osseointegrated dental implants were placed in the distracted area. As a result, the vertical discrepancy between the fibula and the native hemimandible was corrected. The amount of vertical height achieved after distraction was 17 milimeters. The increase of vertical bone height was stable and enabled placement of dental implants without any complications. In conclusion, we consider that vertical distraction osteogenesis of free vascularized flaps is a reliable technique that optimizes implant positioning for ideal prosthetic rehabilitation, after mandibular reconstruction following tumor surgery.

Lateral pterygoid muscle dystonia. A new technique for treatment with botulinum toxin guided by electromyography and arthroscopy.

Lateral pterygoid muscle dystonia is characterized by mandibular displacement towards the opposite side of the affected muscle. It may be associated with functional disorders affecting speech, swallowing, chewing and facial symmetry. Injection with botulinum toxin is recognized as the most effective treatment. Locating the lower head of the lateral pterygoid muscle for the injection is not difficult using electromyographic guidance; however, location of the upper head is more complicated, even with electromyography. We report a case of lateral pterygoid muscle dystonia in which precise injection of the upper head was achieved with the aid of arthroscopy.

A 12-year retrospective analytic study of the implant survival rate in 177 consecutive maxillary sinus augmentation procedures.

PURPOSE: This retrospective study sought to demonstrate the outcome of maxillary sinus elevation surgery in a series of 177 procedures performed over 12 years and to determine the existence of variables that could independently predict implant survival. MATERIALS AND METHODS: A retrospective descriptive and analytic study of a series of maxillary sinus elevation procedures performed between 1996 and 2007 was undertaken. The sample was composed of patients with severe atrophy of the posterior maxilla who had been rehabilitated with osseointegrated implants placed in grafted maxillary sinuses. Several features of the patients (smoking habit, presence of comorbidities, and previous oral carcinoma) and of the surgical procedure (grafting material, associated procedures, associated materials, simultaneous/delayed implant placement, and complications) related to implant survival or failure were monitored during the follow-up period. Implant survival and the existence of variables that could predict implant survival independently were analyzed statistically. RESULTS: One hundred seventy-seven sinus augmentation procedures were performed in 119 consecutive patients (mean age 50.02 years; SD 11.5). Of the 272 implants placed in sinus-augmented regions, 19 were lost. The mean follow-up period was 60.7 months (SD 36.5). The overall cumulative implant survival rate was 93% after 5 years. The multivariate analysis showed that the presence of complications related to the sinus augmentation procedure (membrane perforation and sinusitis) and peri-implantitis were factors in predicting implant failure. CONCLUSIONS: On the basis of this retrospective analysis, it might be concluded that sinus augmentation is a very versatile procedure. Its efficacy and predictability in terms of implant survival rate is extremely high and independent of the graft material, surgical technique, associated comorbidities, smoking habits, and timing of implant placement. Complications such as membrane perforation, sinusitis, and peri-implantitis appeared to influence implant failure.

Bifocal transport osteogenesis for the reconstruction of adult calvarial defects: a new surgical technique.

Calvarial defects are common problems in craniofacial surgery. They may be explained by surgical interventions, infectious processes, cranial trauma or congenital anomalies. Calvarial defects are particularly challenging because they do not heal spontaneously in humans older than 24 months. The feasibility of using bifocal transport distraction osteogenesis to repair calvarial defects has been successfully evaluated in numerous experimental models. To our knowledge, it has not been used for the reconstruction of human skull defects. We report the first case of human calvarial defect healed by transport distraction osteogenesis.

Bilateral mental nerve neuropathy as the sole presenting symptom of Burkitt's Lymphoma.

There are several pathologies that may cause alteration of the lower lip sensation, therefore a differential diagnosis is needed. Among these pathologies, we have focused on intrabone growing tumours such as Burkitt's Lymphoma. Burkitt's Lymphoma is a malignant tumour of B-Cell lymphocyte origin, classified as a Non-Hodgkin's Lymphoma. Three clinical subtypes are described: endemic, sporadic and HIV associated. It is characterized by very fast growing, undifferentiated lymphocytes and bone marrow infiltration. A high incidence of Burkitt's Lymphoma has been reported in African children. It is known to have a good response to radiotherapy and chemotherapy treatment. This report describes the case of a 29 year-old Spanish man diagnosed with Burkitt's Lymphoma, in which his first and only symptom was bilateral anaesthesia of the lower lip. We have also described the clinical evolution, steps for diagnosis and treatment.

Endoscopically-assisted transoral approach for the treatment of subcondylar fractures of the mandible.

INTRODUCTION: Treatment of subcondylar fractures of the mandible is one of the most controversial aspects in the field of maxillofacial traumatology. This controversy centers on the positive and negative aspects of open and closed approaches for the treatment of this kind of fractures. Open techniques lead to good reduction and osteosynthesis, but have a high risk of injury to the facial nerve and produce facial scars. Closed techniques (intermaxillary fixation) reduce all the above-mentioned risks but rarely produce correct anatomic reduction, and complications such as ankylosis, condylar necrosis and inhibition of mandibular growth, causing abnormal occlusion, may occur. Despite all the associated risks, closed techniques are currently the most popular treatment. OBJECTIVES: To introduce the endoscopically-assisted transoral approach for the treatment of subcondylar fractures, presenting three cases treated in our department. A description of the technique has been included as well as the clinical and radiographic results obtained. MATERIAL AND METHODS: The study is based in three patients with subcondylar fractures of the mandible who were treated by an endoscopically-assisted transoral approach. A description of the surgical technique is included. The results were assessed by postsurgical radiographic control (orthopantomography), maximum mouth opening, occlusion and pain. RESULTS: Three reductions of subcondylar fractures with transoral endoscopically-assisted approach were undertaken. The follow-up period was 6 months. Postsurgical radiographic control showed good reduction of the fracture in all three cases. None of the patients showed any sign of temporomandibular dysfunction after 6 months. CONCLUSION: Endoscopic treatment by transoral approach combines the positive aspects of both conventional techniques: closed and open reduction; allowing anatomic reduction and a stable fixation leaving no visible facial scars and with a minimum risk of injury to the facial nerve.