Our experience in complications of orthognathic surgery: a retrospective study on 3236 patients.

BACKGROUND AND OBJECTIVES: From 1989 to 2009, at the Department of Cranio-Maxillo-Facial Surgery, Umberto I Polyclinic, "Sapienza" University of Rome, 3236 patients affected by maxillo-mandibular malformations were submitted to orthognathic surgery, by means of rigid internal fixation. Follow-up highlighted the surgical complications and the possible functional and/or esthetical disorders in the treatment of those pathologies. The data collected have been compared with the ones reported in the literature. MATERIALS AND METHODS: 3236 patients were evaluated clinically and radiographically. The X-rays have been performed before the study, after 24-48 hours, at 6 months and year after surgery. RESULTS: The most frequent surgical complication was the mandibular nerve sensitivity deficit (19%), irreversible only in 2% of the cases. Temporomandibular joint disorders (TMD), which are widely reported in the international literature, have been relevant in our study too. In particular, TMD occurred in those patients who were already affected by the disorder (from 28.3% to 18.1%); besides, in 11% of cases the symptom appeared after surgery and was treated by means of splint or physiotherapy. Infectious complications occurred in 2% of cases and fractures of the bone elements in 1.5% of cases. The other complications quoted internationally occurred in an irrelevant percentage in our study. CONCLUSIONS: We believe that orthognathic surgery complications are quite rare and the percentages reported both in our study and in the literature have to be considered as surgical mistakes related to the surgeon experience or as real complications of the orthognathic surgery. Furthermore, as the success of this kind of surgery depends upon many factors, surgical complications represent only one of the causes of the failure. Other causes could be mistakes in planning, unsuitable orthodontic treatment and, finally, an unsuitable assessment of the patients' esthetical and functional problems.

Etiology and incidence of zygomatic fracture: a retrospective study related to a series of 642 patients.

BACKGROUND AND OBJECTIVES: The aim of this paper is to investigate epidemiological data (age, gender), sites, etiology and surgical approach of zygomatic fracture. MATERIALS AND METHODS: A 9 years retrospective clinical and epidemiologic study evaluated 642 patients treated for zygomatic fracture. There were 569 men and 77 women. The age range was 2 to 86 years with 205 (31.9%) in the 21 to 30 years age group. A number of parameters, including age, gender, cause of injury, site of injury, treatment modalities were evaluated. RESULTS: There were 552 (86%) zygoma fractures and 90 (14%) zygomatic arch fractures. The left zygoma was involved in 309 cases (56%); the right zygoma was involved in 243 cases (44%). Concerning the zygomatic arch, the left side was involved in 43 cases (48%) and the right side in 47 cases (52%). 7% of the patients were younger than 9 years old, about 70% between 10 and 39 years, and 18% between 40 and 59 years, while 4% were older than 60 years. Causes of zygoma fracture were traffic accidents in 151 (26%), assault in 117 (20%), accidental falls in 105 (19%), sports injuries in 56 (10%), home injuries in 45 (8%), work accidents in 34 (6%). Causes of zygomatic arch fractures 28 (29.1%) were assaults in 28 (29.1%), traffic accidents in 20 (21.5%), sports injuries in 14 (15.8%), accidental falls in 11 (14%), domestic accidents in 8 (8.8%) and work accidents in 4 (5%). The access to the fronto-zygomatic suture (74.6%) and the maxillary vestibular approaches (66.8%) were the commonest method of reduction of zygomatic fracture. About arch fractures, the Gillies temporal approach was the most used method of reduction (94.4%). CONCLUSIONS: The findings, compared with similar studies reported in the literature, support the view that the highest prevalence is in young male patients and, concerning cause, traffic accidents and assault are the most frequent.

Osteonecrosis of the jaws in patients assuming bisphosphonates and sunitinib: two case reports.

Osteonecrosis of the jaw (ONJ) is an unremitting adverse outcome associated with bisphosphonate therapy, primarily intravenously administered, in patients with bone metastases from solid tumors, multiple myeloma and osteometabolic diseases. From 2003 many cases of bisphosphonates related osteonecrosis of the jaw (BRONJ) have been reported in literature. Sunititnib is a novel anticancer agent used in gastrointestinal cancers and renal cancers resistant to imatinib. Recent reports describe the onset of ONJ in patients treated with both sunitinib and bisphosponates. A case of osteonecrosis of the jaw related to sunitinib, without association of bisphosphonate (BP) medications has been recently reported. A recent hypothesis suggests that antiangiogenic drugs such as sunitinib could cause ONJ even without the association with BPs. We describe a case of two patients affected by renal carcinoma under BP and sunitinib medication who developed stage III bisphosphonates-related osteonecrosis of the jaw (BRONJ).

A retrospective analysis of the headache associated with temporomandibular joint disorder.

BACKGROUND: Headache is a common symptom, that can be extremely disabling, affecting 26 million of patients only in Italy. ICHD-II has reported two categories: "primary headaches" and "secondary headaches". Temporomandibular joint disorders can lead to a secondary headaches. AIM: We want to evaluate the prevalence and clinical features of headache among a series of patients having temporomandibular joint disorders and we illustrate the evolution of headache following medical treatament of temporomandibular joint (TMJ) disorders. MATERIALS AND METHODS: This is a retrospective study carried out on chart review of 426 consecutive patients with various degrees of temporomandibular disorders and treated with medical devices from 2007 to 2011. RESULTS: Headache was reported by 73 patients (17.14%). Headache was observed in 36 of 51 patients with lock and in 32 out of 130 patients with mandibular deflections (Table I). The remaining 5 patients with headache had articular noise. CONCLUSIONS: Headache is not a rare finding in a population with temporomandibular dysfunctions and is more often a tension-type rather than trigeminal headache.

Neonatal molding in deformational auricolar anomalies.

INTRODUCTION: Congenital auricular anomalies can be categorized either as malformational or deformational. The first are characterized by a partial absence of the skin or cartilage resulting in a constricted or underdeveloped pinna and require surgical correction. Deformations are characterized by a misshaped but fully developed pinna and are best treated by auricular molding. AIM: Authors want to present their case load in treatment of infants affected by deformational auricolar anomalies and describe their techniques using early splinting for congenital auricular deformities, like prominent ear, lop ear, constricted ear, Stahl's ear. PATIENTS AND METHODS: Between 2009 to 2011, in Maxillo and Oral Surgery Unit, a nonsurgical technique was used to treat 22 ears affected by deformational anomalies in 12 patients soon after birth. Four patients were female. This kind of nonsurgical correction of the deformed auricle was performed on lop ears (n=6), constricted ears (n=8), prominent ears (n= 4), Stahl's ear (n=4). Children more than two months old were also excluded. The mean of treatment time was 5.5 weeks. RESULTS: according to the Authors and the parents 100% of treated auricles improved. Improving at the end of the molding treatment was observed in 18% of the auricles, but recurrence to one year of stopping treatment. There were not complications caused by this procedure. CONCLUSIONS: The nonsurgical molding has the advantage to correct at a very early age a cosmetic abnormality, giving a natural and in the most of the time a satisfactory results, with a prevalence rate of complications of much less than surgical corrections.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ): 5 year experience in the treatment of 131 cases with ozone therapy.

BACKGROUND: Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) are the result of the assumption of such drugs. The most widely used molecules are pamidronate and zoledronic acid, which are pyrophosphate analogues and are usually given to patient with bone remodelling diseases. International literature reports showed an association between this therapy and avascular necrosis, thus leading to review the guidelines for their administer. AIM: The authors present their protocol based upon medical treatment, antibiotic and antimycotic, together with minimally invasive surgery and ozone therapy developed after a 5 year experience to assess the viability of this treatment. MATERIALS AND METHODS: In the last years researchers studied treatment protocols, both medical and surgical, for the management of BRONJ. Among these Ozone therapy is being adopted by several centers. From February 2004 and December 2010 a total number of 131 patients affected by BRONJ have been observed. Collected data include patients' age at the time of disorders, gender, presenting signs and symptoms, primary diagnosis, type and characteristics of the treatment performed, radiological findings and post-treatment results. CONCLUSIONS: At the present time there are no major guidelines in international literature for the treatment of BRONJ, the Authors then propose a therapeutic protocol based upon minimally invasive surgery, antibiotic and anti mycotic therapy with the adoption of ozone as regenerating factor for tissues. In 90% of the cases the results confirmed the procedure with successful outcomes.

Pleomorphic adenoma of the lacrimal gland: two clinical cases.

INTRODUCTION: Pleomorphic adenoma of the lacrimal gland is uncommon but it is the most common benign epithelial tumor of this gland. In the literature few cases have been reported in patients aged between 6 years and 80 years with a mean age of 39 years. A correct diagnosis and treatment is fundamental in order to avoid a relapse and sometimes their malignant transformation. An incisional biopsy is better to be avoided because it could injure the capsule, leading to dissemination of tumoral cells in the orbital tissues with a recurrence rate of 30% over 5 years. AIM: This papers want to support the use of mini-invasive surgery for the treatment of orbital lesions when it is possible. MATERIALS AND METHODS: We report two clinical cases of pleomorphic adenoma affecting the lacrimal gland treated with two different surgery approaches. The radiographic and photographic documentation of the patients was collected in the pre-and post-operatively. All patients underwent a CT scan and MRI. CONCLUSIONS: This lesions requires a well-grounded clinical and therapeutic protocol to avoid the risk of malignant transformation or disease recurrence, very dangerous at this site. CT scan and MRI scan are very important to recognize different types of lesions involving the lacrimal gland and fossa. A mini-invasive surgery reduces hospitalization, risk of complications, surgical times and bleedings and guarantees an excellent functional and esthetic result when performed by a skilled surgeon.

Le Fort III osteotomic variants.

INTRODUCTION: Midface hypoplasia is a skeletal defect involving all three space planes, hence needing a three-dimensional repositioning. This research study shows two cases of cranio-facial dysostosis, on which two Le Fort III variants were performed. CASE REPORT: In the first case we report the performing the two types of osteotomy simultaneously. Le Fort I, however, has been performed without any pterygomaxillary disjunctions, thus accomplishing a complete midface mobilization without any variation of the occlusal ratios. In the second case a modified Le Fort III osteotomy has been performed with median disjunction; reduction of the transverse interdacryal diameters and of the pyriform opening. DISCUSSION: Among all osteotomic variants we would like to mention the one introduced by Obwegeser in 1969 where, in patients with acceptable dental occlusal ratios, Le Fort III and Le Fort I have been performed in conjunction. This technique allows a different midface and dental occlusion repositioning. CONCLUSIONS: In adult patients with permanent dentition and normal occlusal ratios this technique may be chosen for a midface advancement without compromising the dento-skeletal relations, in order to achieve the best functional and aesthetical results.

New parameter for the evaluation of disgnathic patient's surgical planning: a preliminary report.

BACKGROUND: Indications for treatment of patients with maxillo-mandibular malformations have to be researched both in the severity of anatomical alteration affecting the face and psychological outcomes. Indeed, it has been underlined that patients decide to undergo orthodontic and orthognathic procedure mainly for aesthetical issues. Moreover the early combined functional and surgical treatment improves relationship skills in young adults. Dealing with these "aesthetic" features pre surgical planning presents some additional challenges. Even if orthognatic surgery aims to the correct repositioning of skeletal bases but we must achieve complete patient satisfaction. AIM: The Authors present a new parameter to be considered in the planning of patients who undergo orthognatic procedure being the restitution of the face the patient would have had without any pathologic mechanism with respect of the aesthetic features of the family. MATERIALS AND METHODS: Authors identified a series of parameters discussed by Arnett et al and performed a clinical and photographic evaluation of these parameters, in latero-lateral view, directly on the relatives of the patients. A cephalometric analysis, was performed and a series of parameters has been taken into account. CONCLUSIONS: It is very difficult to standardize universal parameters acceptable and applicable for every single case, considering that patient's awareness of the anatomical defect and post-surgical satisfaction don't relate to the correct cephalometric evaluation and the real aesthetic outcomes.

Giant submandibular sialolith: a case report.

Introduction: Salivary glands lithiasis (Sialolithiasis) is defined as calcified concretions in the salivary glands. Most common localization is in submandibular gland. Usually, submandibular stones are mainly located in Wharton's duct, whereas parotid stones are more often located in the gland parenchyma. Sialoliths are usually 5-10 mm in size, and stones more than 10 mm are unusual sizes. Exact etiology of sialolith formation is still unknown. Case Report: We discuss a case of a 70-year-old patient, presenting painful swelling and a giant submandibular gland sialolith successfully treated with open surgery. Conclusions: A careful anamnesis and physical examination of the patient are important in the diagnosis of sialolithiasis. In addition, several imaging techniques, such as panoramic X-rays and Ultrasound, can be applied. The management can be both medical and surgical.

Screening patients affected by common variable immunodeficiency.

Chronic immunoglobulin administration decreases the incidence of bronchial and pulmonary infections in patients affected by chronic variable immunodeficiency (CVI). In this study, an ENT screening was carried out in 22 patients affected by chronic variable immunodeficiency and treated with chronic immunoglobulin administration. All the patients underwent ENT physical examination, nasal endoscopy by fiberoptics, mucociliary transport test (MTT), anterior rhinorheomanometry (RRM), nasal provocation test with cold water (ANPT), audiometry and impedentiometry, olfactory evaluation, and paranasal sinus X rays. Dysphagia was present in 91% of the patients, nasal secretion and obstruction in 77%, and hypoacusia, tinnitus, and otodinia in 57%. Rhinitis and pharyngitis were observed in 86% of the patients, and serous middle ear effusion in 50%. Confirmed maxillary sinusitis was observed in five patients. Hyposmia was observed in 50% of the patients. MTT was significantly longer in the patients than in the controls (18.0 +/- 10.5 vs. 11.2 +/- 2.4 min; p < .05). Nasal resistance was lower in patients than in controls (0.46 +/- 0.32 vs. 1.11 +/- 0.22 Pa/L.s-1; p < .001). ANPT was positive in 9 patients out of 25 versus 1 control out of 15 (p < .05). Finally, seven patients were affected by transmissive hypoacusia, and one patient by neurosensorial hypoacusia. Our results suggest that chronic immunoglobulin administration in CVI patients is not effective against ENT disorders, probably because of the important role played by nasal hyperreactivity. Frequent ENT examination and early treatment of ENT disorders are therefore suggested in order to prevent chronic disease.

Behaviour on the nasal provocation test in patients affected by conjunctivitis and/or asthma of allergic origin.

In the Allergo-Immunological Centre of Rome University we selected 120 patients of both sexes, ranging from 5-65 years of age, affected by asthma and/or conjunctivitis without past or present history of nasal impairment (itching, sneezing, hydrorrhea). As a result of the allergometric tests carried out, the authors divided the samples into three groups: 1) positive reaction to Dermatophagoides Pteronissimus (66.6%); 2) positive reaction to the Graminacee (28.3%); 3) positive reaction to Parietaria officinalis (5.1%). After having undergone the rhinoreomanometric test of nasal provocation, 50% of the patients revealed a positive reaction to the specific allergen, more specifically at 50 PNU/ml 40% of the case were positive, and at 100 PNU/ml 50% were positive. These results are discussed in the light of modern biological knowledge on the mastocytes in normal subjects and in those suffering from allergy.

Aspecific nasal reactivity in allergic and non-allergic rhinopathy.

The Allergo-Immunology Department of the 2nd ENT Division of Rome University studied the behaviour of aspecific nasal provocation with methacholine bromide and with H2O at 2-4 degrees C in five groups of patients thus divided: normal subjects, subjects affected by allergic rhinitis, subjects with positive reaction to Graminacee in and out of season, subjects affected by perennial rhinitis due to D.Pt., and those affected by perennial rhinitis of non-allergic origin. All subjects underwent complete E.N.T. check-ups, anterior rhinorheomanometry (RRM), mucociliary clearance test (MCT) and evaluation of amount of nasal secretion. We were able to observe that nasal provocation with methacholine bromide, though on the one hand it was not able to provoke a significant reaction in the mucociliary transport function even though it caused a substantial reaction in the conductance in all five groups, on the other hand it caused a significant modification of nasal secretion with varying levels in the different groups. Furthermore, it was to be observed that nasal provocation with a cold water solution set at 2-4 degrees C caused a more significant reduction of the nasal conductance in subjects affected by perennial rhinitis of non-allergic origin in comparison to the other groups taken into consideration, even though it did not cause particular variations in the parameters relative to mucociliary transport and nasal secretion.

A randomized controlled trial showing efficacy of once daily intranasal budesonide in nasal polyposis.

A randomized, double-blind, placebo-controlled trial was performed to assess the efficacy of once daily budesonide in patients with nasal polyps. After a 2-week run-in period, 157 patients with symptomatic bilateral nasal polyposis were randomized to receive budesonide, 140 micrograms once or twice daily or 280 micrograms once daily (delivered doses) via Turbuhaler, or placebo for 8 weeks. Polyp size was assessed endoscopically and, in two centres, by magnetic resonance imaging (MRI). Nasal symptoms (blocked nose, runny nose, sneezing) were recorded daily, and patients provided an overall assessment of efficacy at the end of the study. Budesonide, 280 micrograms/day (280 micrograms o.d. and 140 micrograms twice daily), significantly reduced polyp size, compared with placebo, whereas budesonide, 140 micrograms once daily, had no significant effect. Nasal polyp mass score, measured by MRI, was also significantly reduced in patients receiving 280 micrograms/day. All three doses of budesonide significantly reduced symptom scores, and there were no significant differences between the groups. Overall, approximately 70% of patients receiving budesonide, 280 micrograms/day, reported substantial or total control of symptoms, compared with 45% of placebo-treated patients. It is concluded that budesonide, 280 micrograms once daily, reduces polyp size and relieves symptoms in patients with nasal polyposis.

Incidence of allergic rhinitis in children.

The authors give an account of the outcome of research done in the Allergo-Immunological Centre of the IInd ENT Division of Rome University, carried out among 210 children who were affected by nasal atopy. Particular stress was placed on the involvement of the nasopharyngo-tubal system. The age of the children ranged from 2-12 years and they underwent: 1) ENT visit; 2) allergy tests; 3) anterior rhinorheomanometry; 4) tubal function tests; 5) mucociliary clearance time; 6) X-ray examination of paranasal sinuses. The results revealed that the most frequent symptom in these children is rhinitis, whatever the allergic sensitization was. The forms of atopy which manifested themselves by chronical allergic patients (D.Pt. and P.O.) were the cause of: 1. asthmatic-type syndromes; 2. early onset of atopic symptoms around 4-7 years of age (9-10 years in the seasonal forms); 3. greater degree of extrinsic rhinitis with edema of the turbinates - the first step towards a polypoid degeneration of such subjects; 4. tubal functional deficit (60% of subjects allergic to P.O. and 50% allergic to D.Pt whereas only 27% are found in the seasonal forms); 5. mucociliary clearance linked directly with the length of disease; involvement of the paranasal sinuses (53/61 patients allergic to D.Pt., 9/28 allergic to P.O., 9/56 allergic to Graminacee). Furthermore the nasal patency was more insufficient in patients affected by the chronical forms of the atopy. In the light of these results the authors advocate focus attention on the significance of an early diagnosis of nasal atopy in children and the need for interdisciplinary collaboration among specialists.

Secretory immune response after nasal vaccination with live attenuated influenza viruses.

Immunoglobulins and virus-specific antibody in nasal secretions were measured in 18 volunteers before and after intra-nasal vaccination with two live-attenuated type A influenza virus strains. Specific serum antibody rises occurred in 14 out of 18 vaccinees; of those, 11 and 10, respectively, showed significant increase of IgA concentration and of virus-specific antibody in nasal secretions collected 2-4 weeks after vaccination. In one case, a volunteer showed appreciable increase of virus neutralizing antibody in nasal secretions without increase of local IgA concentration and of serum HI antibody. This data indicate that administration of live virus vaccines by upper respiratory route confers effective immunity associated with local antibody synthesis.

Rhino-rheo-manometric (R.R.M.) nasal provocation test.

The nasal provocation test--which has been considered till now too much time-consuming and troublesome for the patient--becomes rapid and simple by the use of the rhino-rheo-manometry. It is possible, by this method, to evaluate the conductance of a single nasal fossa and its reduction after allergen challenge. The results of test performed in patients suffering from extrinsic perennial nasal atopy by Dermatophagoides pt. have proved that the test becomes rapid and not troublesome by using the rhino-rheo-manometry. This method, giving a provocation threshold, may be used both in diagnosis and control of specific immunotherapy.

Non-specific nasal provocation test with histamine. Analysis of the dose-response curve.

Non-Specific Nasal Hyper-reactivity (NSNH) is described as a clinical condition characterized by the presence of rhinitic symptoms that are a consequence of non-specific stimulations. Because of its effects on vascular, epithelial, and glandular receptors, NSNP Test (NSNPT) with histamine allows the study of NSNH. The aims of this study are 1. to analyze the behavior of NSNH both in non-allergic chronic vasomotory patients and in healthy control subjects 2. to correlate total nasal resistance(TNR) to each dosage of histamine to derive the dose/response curves and 3. to study these curves to analyze and possibly define different stages according to the intensities of response of NSNH. We have studied 26 subjects affected by non-allergic vasomotor rhinitis and 10 healthy control subjects. We sprayed a NSNPT with histamine-phosphate (0.2-0.3-0.4-0.5-0.6-0.8 mg) in different sessions to avoid accumulation phenomena. Five minutes before and five minutes after each challenge, TNR was determined by active anterior rhinomanometry. TNR was correlated to the doses of histamine by an empirical equation. The most important results of this study are as follows: a) the variation of TNR follows a model of exponential curve, b) it is possible to classify NSNH, as a function of the regression b coefficient belonging to the empirical equation used, in reactivity classes, c) from one reactivity class to another, post-stimulation TNRs double; 0.5 mg of histamine of the NSNPT is the optimal dose, d) there is an overlap between the responses of some normal subjects and rhinopathic patients that will be the subject of a further study. Finally, our data suggest that, in a future perspective, it is possible to use the NSNPT with histamine for diagnostic, prognostic and therapeutic control purposes.

Specific local immunotherapy in the treatment of hay fever.

The authors refer results of a 3-year study carried out on ten patients suffering from hay fever, diagnosed by means of skin tests, specific nasal provocation and serum RAST who underwent specific local immunotherapy consisting of application of an aqueous allergenic extract, the initial level of which was based on threshold values resulting from the nasal provocation test. The two-monthly check ups were based on the evaluation of mucociliary clearance, anterior rhinorheomanometry, specific nasal provocation and the test of Maunsell for blocking antibodies, as well as on the drawing up of a daily symptomatological diary for each single patient. The results were extremely interesting: subsidence of symptoms during the pollinating season, an increase in the number of blocking serum antibodies and of threshold values relative to specific nasal provocation. Conductance and mucociliary clearance, which were both decidedly pathological before beginning the local immunotherapy, slowly returned to the norm. The authors, furthermore, refer that the use of disodium cromoglycate during the first months of specific local immunotherapy which allows them to reach doses 5-7 times greater than those obtainable with the above mentioned form of treatment, offers uncertain advantages as far as local and above all general immunity is concerned and this alone does not justify the use of nasal applications in the treatment of bronchial asthma of allergic origin.

Intranasal immunotherapy with Dermatophagoides extract: in vivo and in vitro results of a double-blind placebo-controlled trial.

Intranasal immunotherapy (IT) has been proposed as a means to induce an effective immunity of the nasal mucosa in patients with allergic rhinitis, avoiding systemic side effects. In the present study 20 individuals with chronic allergic rhinitis, and skin prick test reactive to Dermatophagoides pteronyssinus (DP) only, were randomized and subjected to a three months' double-blind placebo-controlled trial of intranasal IT with DP extract. All patients received also sodium cromoglycate as pre-medication. Before and at the end of the treatment the patients performed specific nasal provocation tests, and samples of serum and nasal secretions were collected to measure total and specific IgE, levels of eosinophil cationic protein (ECP), and mast-cell-derived tryptase. A clinical score was computed by the symptoms indicated by the patients. The clinical score did not change in the two groups after the treatment, whereas a decrease in nasal reactivity was observed. Total IgE increased only in secretions from placebo-treated patients, but were not modified in sera. IgE to DP in sera and nasal secretions did not change significantly. Tryptase levels in nasal secretions decreased in both groups, while ECP was unchanged after IT. Serum ECP levels decreased more in actively treated patients than in the placebo group. The data suggest that changes of IgE and inflammatory mediators may be affected by the use of sodium cromoglycate in both groups, but some parameters change early in different directions in IT- and placebo-treated groups.