Multimodal transcutaneous auricular vagus nerve stimulation: An option in the treatment of sleep bruxism in a "polyvagal" context.

OBJECTIVE: To consider the possible role of the vagus nerve (VN) in the pathophysiology of sleep bruxism (SB) and introduce a multimodal protocol of transcutaneous auricular stimulation of the VN in the treatment of SB patients. METHODS: Ten patients with SB underwent four sessions of electric transcutaneous auricular vagus nerve stimulation (ta-VNS) in specific auricular areas. The patients were advised to manually stimulate the same areas between sessions. Masticatory muscle activity and sleep parameters were measured by a polysomnography (PSG) before and after the treatment. Heart rate variability (HRV) parameters were measured during each stimulation. RESULTS: PSG analysis revealed a statistically significant reduction in tonic SB index and tonic contraction time. HRV parameters showed a statistically significant increase in mean values of the vagal tone after each session of stimulation. No side effect was reported. CONCLUSION: The stimulation of the VN might have a role in the treatment of SB.

Piezosurgery: a safe method to perform osteotomies in young children affected by hemifacial microsomia.

Piezosurgery is a new innovating technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. It was conceived by Tomaso Vercellotti, MD, DDS, and it was first reported for preprosthetic surgery, as alveolar crest expansion, sinus grafting, and, more recently, alveolar distraction. The purpose of this report was to introduce and justify the use of Piezosurgery to perform osteotomies during mandibular distraction in cases of hemifacial microsomia.

Bifunctional sculpturing of the bone graft for 3-dimensional augmentation of the atrophic posterior mandible.

Short implant procedures may suffer from fixture instability, if incorrectly planned and performed, and from an esthetically compromised rehabilitation, due to increased interarch distance and increased crown-implant ratio. Several procedures have been proposed to achieve alveolar ridge augmentation with different success and complication rates: onlay grafts, alveolar sandwich osteotomies, titanium micromesh, alveolar distraction, and alveolar nerve transposition. The edentulous posterior mandible suffers from the presence of a compact cortical layer, which tends to limit graft osteogenesis, because of a low permeability to the osteogenic elements (microvessels and cells). This report introduces a variant to the endochondral onlay bone graft, in which an external cortical layer is placed above a biologically active core of cancellous bone and platelet-rich plasma. This solution provides easy 3-dimensional conformation of the graft, enhancing its mechanical stability. The presence of the biologically active core provides better vascular support and a valid interface between graft and the osteogenetic cell lines.

Condylar positioning devices for orthognathic surgery: a literature review.

In the past few years, many devices have been proposed for preserving the preoperative position of the mandibular condyle during bilateral sagittal split osteotomy. Accurate mandibular condyle repositioning is considered important to obtain a stable skeletal and occlusal result, and to prevent the onset of temporomandibular disorders (TMD). Condylar positioning devices (CPDs) have led to longer operating times, the need to keep intermaxillary fixation as stable as possible during their application, and the need for precision in the construction of the splint or intraoperative wax bite. This study reviews the literature concerning the use of CPDs in orthognathic surgery since 1990 and their application to prevent skeletal instability and contain TMD since 1995. From the studies reviewed, we can conclude that there is no scientific evidence to support the routine use of CPDs in orthognathic surgery.

Piezosurgery: a new method for osteotomies in rhinoplasty.

Two basic techniques for lateral osteotomy have been developed to date; the internal (endonasal) continuous technique and the external (percutaneous) perforating method. Numerous investigators have subjectively reported that the application of the two techniques results in less postoperative ecchymosis and edema compared to the use of other techniques, but an alternative and gentle method for performing lateral osteotomy or bony hump removal has not been proposed yet. The authors present a new soft technique to perform nasal osteotomy in rhinoplasty using piezoelectric ultrasonic vibrations, and emphasize the advantages of this method.

Intraoral endoscopically assisted treatment of temporomandibular joint ankylosis: preliminary report.

Temporomandibular joint (TMJ) ankylosis is characterized by the formation of a bony or fibrous mass that replaces the normal articulation. To avoid a possible re-ankylosis it is mandatory to perform a radical, complete resection of the bony/fibrous mass. We treated a patient affected by right temporomandibular joint ankylosis performing the osteotomy of the ankylotic mass through a preauricular and intraoral approach under endoscopic control. Then a temporalis muscle and fascia flap were used as the interpositional material. Through the endoscope it was easy to check the medial aspect of the resection and suture the flap. At 1-year follow-up the patient had significantly increased maximal mouth opening. No evidence of relapse of the joint ankylosis was shown by radiological studies. Intraoral endoscopic assistance may be useful to make the removal of the ankylotic mass safer, and the anchorage of the temporalis muscle and fascia flap more accurate, reducing the risk of re-ankylosis.

Surgical treatment of Aspergillus mycetomas of the maxillary sinus: review of the literature.

The present study reviews the literature concerning the surgical treatment of Aspergillus mycetoma (AM) in the last 20 years to identify a gold standard surgical technique. Aspergillus mycetoma of the maxillary sinus, or mycetoma (fungus ball), is a noninvasive or extramucosal mycotic infection. Surgical removal of the sinus fungal masses to ensure drainage and aeration is performed using the traditional Caldwell-Luc (CL) procedure or endoscopic sinus surgery (ESS). Results of this review suggest that the gold standard surgical technique for AM is ESS with middle meatal antrostomy. General or local antifungal drugs are not indicated. Combined approach with an intraoral surgical access from the anterolateral wall of the maxillary sinus has to be reserved for selected cases in which ESS doesn't permit complete extraction of all fungal concretions or foreign bodies. The CL procedure should be avoided, because it has detrimental consequences for sinus physiology.

Endoscopic surgical treatment of chronic maxillary sinusitis of dental origin.

PURPOSE: Chronic maxillary sinusitis of dental origin (CMSDO) is a common disease that requires treatment of the sinusitis as well as of the odontogenic source. We present our surgical experience performing contemporary treatment of the odontogenic source and endoscopic sinus surgery (ESS) in patients with CMSDO. PATIENTS AND METHODS: Seventeen patients with CMSDO underwent contemporary treatment of the odontogenic source and ESS. Five patients presented chronic oroantral fistula (OAF); 5 patients presented odontogenic cysts occupying the maxillary sinus; 2 patients had inflammatory cysts of the molars; 2 patients had maxillary sinus infection secondary to peri-implantitis; 3 patients had foreign bodies pushed through the root canal into the sinus. The first surgical step was the treatment of the odontogenic source. The second step was ESS with opening and calibration of the maxillary natural ostium. RESULTS: Foreign bodies were extracted from the sinuses through the endonasal approach. No major complications after ESS were observed. The average time for ESS was +/-25 minutes. Good distant results without symptoms and complete closure of the fistula were obtained in all patients. CONCLUSION: When significant sinus disease is found, an endoscopic approach to drainage in all of the involved sinuses can promote predictably successful closure of OAF. The endoscopic approach to chronic maxillary sinusitis of dental origin is a reliable method associated with less morbidity and lower incidence of complications.

Intraoperative awakening of the patient during orthognathic surgery: a method to prevent the condylar sag.

PURPOSE: The intraoperative diagnosis, during orthognathic procedures, of an unfavorable condylar position is highly desirable. A simple technique that can reliably identify a malpositioned condyle intraoperatively has obvious advantages. The manual positioning of the condyle is easier, but it requires the utmost care and an experienced operator. Muscle tone is described as maintaining contact across the temporomandibular joint. The anesthetized and curarized patient has a condylar position posterior to that in the same patient when he is awake, with the same seating force applied. Under general anesthesia, the condyle may be inferior and might not feel stable until it moves posteriorly and has adequate compression of the retrodiscal tissues on the posterior wall. Relapse of the occlusion as a result of changes in the condylar position may occur immediately after the removal of the temporary intermaxillary fixation (IMF). The surgeon needs to understand the mechanism of condylar sag and the specific patterns of malocclusion that it may produce. This will enable him to make a diagnosis and to implement the appropriate corrective measures, providing the opportunity for immediate correction of condylar position, thereby obviating the need for a second operation or orthodontic compromise. MATERIALS AND METHODS: A study group (group A, 76 patients) and a control group (group B, 73 patients) were randomly formed from the dysgnathic patients scheduled for bimaxillary orthognathic surgery (Le Fort I osteotomy and bilateral sagittal split osteotomy). The free mandibular proximal segment was gently and manually positioned in the glenoid fossa. All the mandibles were fixed with bicortical screws. In group A, immediately after the fixation, IMFs were removed and the occlusions were checked with light digital pressure on the chin, then the patients were rapidly awakened (maintaining the intubation) in a state of conscious analgo-sedation and asked to open and close, and to laterally move the mandible. If clinical examination of the passive and active movements of the mandible was suitable, the anesthesia was reinforced and the operation was concluded. RESULTS: In 11 of the 76 patients of group A, malocclusion was noted, after the rigid fixation, with the method of digital pressure on the chin; the intraoperative awakening of the patients confirmed the clinical appearance and it provided further clinical signs to identify the offending condyle and to favor appropriate corrections. In 8 of the group A patients, malocclusions were not noted with manipulation of the mandible, but they were pointed out during the intraoperative awakening, and then they were appropriately corrected. In 2 of the group B patients, malocclusion was noted, after the rigid fixation, with the method of digital pressure on the chin, and it was immediately corrected. In 7 of the group B patients, malocclusion was not noted during the operation with the method of digital pressure on the chin, but it was noted at the end of the surgical procedure (12-24 hours after). CONCLUSION: Muscle tone, muscular activity, and proprioception appear to have important roles in the clinical evidence of a postoperative malocclusion during the intraoperative awakening; they can reliably implement the accuracy of the diagnosis of condylar sag, and they can favor its correction.

Stability of skeletal class III malocclusion after combined maxillary and mandibular procedures: rigid internal fixation versus wire osteosynthesis of the mandible.

PURPOSE: The aim of this study was to evaluate skeletal stability after double-jaw surgery for correction of skeletal Class III malocclusion to assess whether there were any differences between wire and rigid fixation of the mandible. PATIENTS AND METHODS: Thirty-seven Class III patients had Le Fort I osteotomy stabilized with plate and screws for maxillary advancement. Bilateral sagittal split osteotomy for mandibular setback was stabilized with wire osteosynthesis and maxillomandibular fixation for 6 weeks in 20 patients (group 1) and with rigid internal fixation in 17 patients (group 2). Lateral cephalograms were taken before surgery, immediately after surgery, 8 weeks after surgery, and 1 year after surgery. RESULTS: Before surgery, both groups were balanced with respect to linear and angular measurements of craniofacial morphology. One year after surgery, maxillary sagittal stability was excellent in both groups, and bilateral sagittal split osteotomy accounted for most of the total horizontal relapse observed. In group 1, significant correlations were found between maxillary advancement and relapse at the posterior maxilla and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. In group 2, significant correlations were found between mandibular setback and intraoperative clockwise rotation of the ramus and between mandibular setback and postoperative counterclockwise rotation of the ramus and mandibular relapse. No significant differences in postoperative skeletal and dental stability between groups were observed except for maxillary posterior vertical position. CONCLUSIONS: Surgical correction of Class III malocclusion after combined maxillary and mandibular procedures appears to be a fairly stable procedure independent of the type of fixation used to stabilize the mandible.