Virtual Surgical Planning for Mandible Reconstruction With a Double Barrel Fibula Flap and Immediate Implant Placement.

This brief clinical report describes our experience with virtual surgical planning in a case of mandibulectomy and mandibular reconstruction with a double barrel vascularized osteofasciocutaneous fibula free flap and immediate implant placement in a case of mandibular ameloblastoma. Fibular segments were positioned to obtain the best result both for masticatory function and for aesthetic facial appearance. Furthermore, in this particular case, as well as being positioned for future masticatory rehabilitation, the implants have served to stabilize the fibula segments in the reconstructive intraoperative phase. A superimposition of programed surgery and 6 months postoperative computed tomography scan was performed and results are presented.

Early Arising Sarcoma After Adjuvant Radiotherapy for Oral Squamous Cell Carcinoma.

Radiation-induced sarcoma of the head and neck (RISHN) is a rare and long-term complication of radiation therapy (RT). This report describes a case of RISHN characterized by early and insidious onset. An 80-year-old man was surgically treated for advanced oral squamous cell carcinoma of the left retromolar trigone (pT4aN0). Sixteen months after completion of adjuvant RT, an exophytic sessile lesion arose in the left border of the soft palate. Histologic assessment showed a malignant neoplasm with spindle-shaped cells and areas of bone matrix without perivascular or perineural invasion; such features in addition to immunohistochemical assessment (negative for pan-cytokeratin; positive for vimentin; negative for epithelial membrane antigen; negative for p63; Ki-67, 30%) are consistent with poorly differentiated sarcoma (cT1aN0M0). Fifteen months after a wide surgical resection, the patient was free of disease. RISHN is usually an aggressive neoplasm with insidious onset. Nevertheless, early diagnosis followed by complete surgical excision could make the prognosis comparable to that of spontaneous sarcoma.

Stage 3 Medication-Related Osteonecrosis of the Posterior Maxilla: Surgical Treatment Using a Pedicled Buccal Fat Pad Flap: Case Reports.

PURPOSE: Stage 3 medication-related osteonecrosis of the jaw (MRONJ) sometimes requires surgical treatment for resolution of the pathology and, in many cases, leads to oroantral communication in the posterior maxilla. The buccal fat pad flap is considered the best surgical choice for closure of large oroantral communications because it provides primary closure and guarantees adequate bone protection with sufficient blood supply for an effective bone healing process. MATERIALS AND METHODS: Five consecutive patients affected by stage 3 posterior maxillary MRONJ were treated with surgical removal of the necrotic bone and primary closure of the oroantral communication using a buccal fat pad flap. RESULTS: In each case, the size of the flap was always sufficient to perfectly close the defect without tension. There were no postoperative complications and the average postoperative hospital stay was 3 ± 1 days. The patients were seen at monthly follow-ups; after 12 ± 4 months of follow-up, no problems were noted in the treated area. CONCLUSION: Despite the limited number of cases, the results of this study suggest that, for stage 3 posterior maxilla MRONJ, managing the site with a pedicled buccal fat pad flap and primary closure might guarantee adequate bone protection with sufficient blood supply for an effective bone healing process.

Management of needle breakage using intraoperative navigation following inferior alveolar nerve block.

This report describes a peculiar case of needle breakage during inferior alveolar nerve block to perform third molar extraction that was removed with the aid of a BrainLAB VectorVision neuronavigation system. This report adds to the currently limited scientific literature on the image-guided removal of foreign bodies from the oral cavity.

Surgical Margins After Computer-Assisted Mandibular Reconstruction: A Retrospective Study.

Purpose: The use of virtual surgical planning in head and neck surgery is growing strongly. In the literature, its validity, accuracy and clinical utility for mandibular reconstruction are widely documented. Virtual planning of surgical bone resection and reconstruction takes place several days before surgery and its very sensitive nature can negatively affect an intervention aimed at maximum precision in term of oncological safety. Methods: The study focuses on a retrospective evaluation of the surgical margins in 26 consecutive cases with oral cavity malignancy and who underwent computer-assisted mandibular resection/reconstruction guided by the different types of bone, periosteal and peri-mandibular tissue involvement. The goal was to analyze the strategic and technical aspects useful to minimize the risk of positive or close margins and to vary the reconstructive strategy in the case of intraoperative findings of a non-radical planned resection. Results: No intraoperative or perioperative complications occurred. In 20 patients, virtual surgical planning permitted mandibular reconstruction to be performed using composite fibular free flaps, characterized by high accuracy and negative bone margins. In the remaining 6 patients, also virtually planned but otherwise reconstructed due to poor general condition (advanced age, severe comorbidity), negative bone margins were obtained. Intraoperative enlargement of the resection was carried out in one case and positive soft tissue margins were observed in another case. Conclusion: The results were satisfactory in terms of oncological radicality and precision. The functional benefits and reduction in operating times, previously demonstrated in other articles also by the authors, seem to justify the side effects related to the risk of modifying the planned surgery. During virtual planning, the surgeons must bear in mind that an unexpected progression of the tumor or a limited planned resection will entail modifying the extent of the resection intraoperatively and nullifying the virtual planning on which the reconstruction was based. Further investigations are necessary to clarify all aspects of virtual surgical planning in this setting.

Surgical extraction of impacted inferior third molars at risk for inferior alveolar nerve injury.

The objective of the study was to prospectively assess the intraoperative findings and the radiographic signs of a study population of patients with impacted third molars at risk of inferior alveolar nerve injury. One hundred thirty-four patients with impacted mandibular third molars at risk for nerve injury were included in the study. Radiographic signs of possible close relationship between the 2 structures and intraoperative exposition or damage of the inferior alveolar nerve were recorded. The follow-up controls comprised clinical examinations and assessment for the sensation of the lower lip and chin. In 24 patients, a real contiguity was encountered between the third molars and nerve. Among these, intraoperative neural exposition was observed in 19 patients. Four patients complained of postoperative temporary hypoesthesia. No deficit of sensibility was found in cases with no exposition of the nerve. The accidental exposition of the inferior alveolar nerve is associated with an increased risk for neural injuries. At panoramic radiograph, the presence of signs of bifid and radiolucent apex, superimposition, and radiolucent root band should be considered at high risk for neural damage.

Mucociliary function during maxillary sinus floor elevation.

Maxillary sinus floor elevation carries the potential risk of compromising the sinus physiology. The aim of this study was to prospectively assess mucociliary function during maxillary sinus augmentation in patients without preoperative signs of maxillary sinusitis. Ten patients underwent unilateral sinus floor elevation under local anesthesia and endoscopic control. Methylene blue was dropped on the floor of the maxillary sinus to evaluate mucociliary function until the ostium region during sinus augmentation. The drainage of methylene blue was noticed in the lateral, medial, posterior, and anterior walls and in the roof of the sinus. As for the sinus floor, only the detached part of mucosa in correspondence of the eroded bony window presented not drained methylene blue, showing an absence of mucociliary function. Mucociliary function is preserved even during the surgical procedure except for the detached area of the schneiderian membrane.

Temporomandibular disorders due to improper surgical treatment of mandibular fracture: clinical report.

A case of mandibular fracture surgically consolidated in a wrong position resulting in craniomandibular disorders is reported. The inadequate surgical alignment of the healed bony segments caused a malocclusion. This changed the original neuromuscular system such that compensatory mechanisms began to change the whole balance of the organism. The patient presented a mandibular crossbite, an asymmetry of the face, and extensive alteration of muscular, articular, and postural function. The bony malunion and malocclusion were treated using an interdisciplinary surgical-orthodontic treatment for correcting functional disorders and aesthetic deformity. Electromyography and computerized mandibular scanning were used to evaluate improvement of the muscular activity, during rest and function, and of the mandibular kinesiology. Timing of surgical treatment and adequate fixation and immobilization of fracture segments are very important to avoid complications such as infection, delayed union, nonunion, malunion, skeletal discrepancies, nerve injury, and (rarely) ankylosis. The surgical approach should be based on the general criteria of traumatologic therapy, restoring the original bone shape and the right occlusal relations as soon as possible.

Transient facial nerve paralysis after mandibular sagittal osteotomy.

Facial nerve injuries are rare complications after orthognathic surgery. A literature review shows that such damages can develop with various mechanisms and are usually transient. Two cases of delayed facial paralysis after mandibular osteotomy with spontaneous recovery are reported.