A New and Effective Procedure for Advanced Oral Cancer Therapy: The Potential of a Cancer Stem Cell Assay in Guiding Chemotherapy.

Introduction: Ineffective anticancer therapy can result in unnecessary toxicity and the development of resistant clones. Many types of solid tumors, including head and neck squamous cell carcinoma, have been found to contain a small population of cancer stem cells (CSCs) that contribute to tumor propagation, maintenance, and treatment resistance. Materials and methods: Selectively enriched CSCs from primary cancer cell cultures can be used in a chemosensitivity assay for a functional test (ChemoID) that uses patients' live tumor cells to indicate which chemotherapy agent (or "combinations") will kill not only the bulk of tumor cells but also the CSCs that are known to cause cancer to recur. This study aimed to show the potential of testing the sensitivity of CSCs enriched from oral cancer patients' biopsies to conventional chemotherapies. A case series of eleven patients affected by advanced oral squamous cell carcinoma (OSCC) have been included in this study. We compared the results of the CSC assay among all the patients and found that there was variability in the chemotherapy response predicted by the assay. Results: Variability in chemotherapy response was found by the CSC assay in advanced OSCC patients suggesting more precise and personalized therapies to the Oncologist. Conclusions: Variability in chemosensitivity for OSCC warrants the need to investigate further the use of the assay in larger cohorts to gain a broader understanding of the utility of the clinical test.

Mandibular Reconstruction after Resection of Ameloblastoma by Custom-Made CAD/CAM Mandibular Titanium Prosthesis: Two Case Reports, Finite Element Analysis and Discussion of the Technique.

Virtual surgical planning for CAD/CAM mandibular reconstruction by titanium prosthesis was recently reported for resected cases. Even if some advantages are evident, difficulties that may arise for TMJ function after reconstruction originate from prosthesis contamination through oral mucosa dehiscence. In these two cases reported of mandibular reconstruction after resection of ameloblastoma by custom-made CAD/CAM titanium prosthesis, the procedures were aimed to preserve the TMJ glenoid cavity and articular disc avoiding functional problems for hemi-mandibular resections that included the condyle (as in case #1) or with condylar preservation (as in case #2) and avoiding intraoral incisions in both cases. The entire surgical planning and prosthetic fabrication were explained with specifications and the sequence of the surgical procedure. Finite elements analysis (FEA) was performed to check the force distribution and efficacy of the prosthetic device (case 1 with hemi-mandibular resection and rehabilitation). Although successful in these two cases, surgical reconstruction of the mandibular defect after resection by a CAD-CAM custom-made prosthesis still shows some drawbacks and failure risks. Several advantages of this technique and the surgical success in these two cases were presented, but limitations and side effects must be considered when cases are selected.

Condylar Fractures: Multistep Surgical Planning by Mini-Invasive Approach, Patient Series.

PURPOSE: Surgical treatment for condylar fractures is a challenging procedure most debated in scientific literature without a broad consensus on the selection of surgical techniques to be used and relative indications.The goal of this work is to propose a multistep surgical planning for condylar fractures based on an effective mini-invasive approach and safe procedure aimed to avoid as much as possible skin incision in the aesthetic areas of the face and neck, to decrease the risk of facial nerve injury. METHODS: Ten patients with dislocated condylar neck fractures and sub-condylar fractures were included in this study.All the patients were studied with radiological images, computed tomography scans with three-dimensional reconstructions preoperatively and immediate postoperatively.Patients were evaluated pre- and post-operatively for dental occlusion, bone fragment alignment after reduction and after fixation, facial nerve functionality, skin scarring, temporomandibular joint functionality, temporomandibular joint symptomatology, and patient satisfaction. RESULTS: Results were satisfactory for different parameters evaluated. No significant complications resulted in follow-up, particularly for facial nerve injury. By using this multistep procedure with each stage functional to the following one, the authors achieved satisfactory results following treatment of dislocated condylar fractures.

Lip Reconstruction by Double Layer and Double Flap New Combination Technique: A Case Series.

In the past, lip reconstruction after ablative surgery has been performed by primary closure and more recently by free flap transfer technique. Cheek's skin flap has been used to reconstruct the lower lip cutaneous portion. This study presents a reconstructive method for the vermillion and the lip's cutaneous portion using the Goldstein-Robotti techniques (for the vermillion) and the buccinator flap to reconstruct the cutaneous lip portion and the perioral muscles. This procedure allows a complete reconstruction with a double layer technique for defects of more than one-third of both lips, together or alone, including modiolus, showing satisfactory functionality and aesthetics. The procedure was carried out by splitting the buccinator muscle and elongating the upper and lower buccinator bundles, together or alone. Soft tissue blunt dissection prevented most facial nerves and vessels injuries, ensuring blood supply and an amount of lip sensitivity. Even in the case of facial vessel ligatures after neck dissection, the technique was possible basing the flap pedicle on the internal maxillary artery branches (buccinator) and contralateral facial vessels (orbicularis). We present a case series of six reconstructions of various defects of the upper and lower lips, including the commissure after ablative surgery for squamous cell carcinoma and polymorphous adenocarcinoma. The results showed satisfactory functional and aesthetic outcomes, with similar tissue texture, static and dynamic symmetry achieved for all the patients.

New Minimally Invasive Intraoral Procedure for Condylar Fractures: Clinical Presentation and Considerations on Current Techniques.

ABSTRACT: Mandibular fractures are the third most prevalent maxillofacial traumatic events. Surgical approaches to the condyle are a debated topic. This study describes a mini-invasive technique for condylar fracture reduction. The patient of this study suffered multiple traumatic injuries including a carotid artery dissecting aneurysm, which contraindicated the standard open reduction and internal fixation technique. The novel minimally invasive technique involves intraoral access and fracture fragment realignment using a periosteal elevator, a molar occlusal splint, and intermaxillary fixation after intraoperative radiologic imaging confirmation of condyle reposition.The approach avoids skin incisions and tissue dissection, with good aesthetic outcomes and facial nerve preservation. This technique proved to be safe and simple to be less demanding for the patient, with a shorter recovery time than experienced with other techniques.The results suggest this technique is a good option for the surgical treatment of condylar neck fractures showing favorable rim morphology with primary stability after reduction.

Cancer Stem Cell Assay for the Treatment of Platinum-Resistant Recurrent Ovarian Cancer.

BACKGROUND: Disease recurrence and progression of ovarian cancer is a common event, which is accompanied by the development of platinum-resistant or refractory disease. The presence of chemo-resistant Cancer Stem Cells (CSCs) contribute to tumor propagation, maintenance, and treatment resistance of this difficult to treat disease. We have developed ChemoID, a cytotoxic synergy assay against CSCs that identifies the most effective chemotherapy treatment from a panel of FDA-approved chemotherapies using fresh cancer biopsies. PATIENTS AND METHODS: Ascites or interventional radiology biopsies were collected under physician order from 78 consecutive patients affected by 3rd relapsed ovarian cancer. Test results from the assay were used when possible to treat patients with the highest cell kill drugs, taking into consideration their health status and using dose reductions, if needed. A chart analysis and review of CT and PET scans were performed to determine patients' outcomes for tumor response, Progression-Free Survival (PFS), and Overall Survival (OS). RESULTS: We observed that recurrent ovarian cancer patients treated with high-cell kill chemotherapy agents guided by the CSCs drug response assay had an improvement in their median PFS and OS when compared to historical median PFS and OS and/or when compared to patients who could not receive high cell kill chemotherapies (PFS low cell kill 3.5 months vs. high cell kill 12.0 months; OS low cell kill 6.0 months vs. high cell kill 15.0 months). CONCLUSION: This data indicates that the drug cytotoxicity assay aimed at targeting CSCs may be a useful tool for optimizing treatment selection when first-line therapy fails, and when there are multiple clinically-acceptable and -equivalent treatments available.

Epi-Mucosa Fixation and Autologous Platelet-Rich Fibrin Treatment in Medication-Related Osteonecrosis of the Jaw.

Medication-related osteonecrosis of the jaw (MRONJ) frequently affects patients after treatments with bisphosphonates or denosumab, especially with high doses in patients with bone osteoporosis, neoplastic metastases, or possibly anti-angiogenic treatment for cancer. The aim of this article was to show a new treatment planning for stage 2 and stage 3 MRONJ using platelet-rich fibrin (PRF) at the surgical field to enhance healing in association with a new epi-mucosal fixation technique to prevent or treat mandibular fracture. Two cases were treated by epi-mucosa fixation and autologous PRF use for prevention of mandibular fracture risks related to necrotic bone resection or a narrow fracture reduction. Both cases were successfully treated by this new technique of epi-mucosa fixation combined with autologous PRF and achieved good results and good quality of life. Ability to wear prosthesis with good mastication in the absence of side effect such as infection, plate and screw mobilization, pain, and other disabilities or extension of necrosis was reported. After surgical removal of necrotic bone, no infection was detected without any extension of the necrosis.

Condylar Neck and Sub-Condylar Fractures: Surgical Consideration and Evolution of the Technique with Short Follow-Up on Five Cases.

Condylar neck and sub-condylar fractures of the mandible are a frequent occurrence in maxillofacial surgery. The indication for surgical treatment of these fractures has changed over time, and several techniques have been developed with different results in the attempt to avoid the most worrisome adverse event, i.e., facial nerve injury. In this study, we present a new technique that combines an intraoral and a cutaneous pre-auricular access, which allows for easy and safe access to the surgical site, preventing facial nerve injury and avoiding surgical scars in high-impact aesthetic areas of the neck. Five consecutive patients affected by condylar neck or sub-condylar fractures were treated at a single institution using a combined intraoral and pre-auricular access. Results were evaluated after three months from surgery in terms of mandibular mobility, occurrence of complications, and patient's satisfaction. All five patients had good outcome, with complete healing of the fracture and no occurrence of complications, including no facial nerve palsy. A key point of the technique is the safe reduction of the two mandibular fragments realized by a combined intraoral and a cutaneous pre-auricular surgical access. The periosteal plan of the ramus can be widely and safely elevated with the intraoral approach and connected to the condylar bone plane by the pre-auricular cutaneous approach without any need for soft tissue dissection at the fracture rim, thereby avoiding facial nerve injuries. Wide ramus periosteum elevation creates an "optical space", allowing fragment reduction and fixation under direct oblique view without any endoscopic need. Our results strongly suggest that with our technique it is possible to treat sub-condylar and condylar neck fractures safely, avoiding facial nerve injury, which is an unacceptable complication due to its heavy impact on a patient's life.

Clinical relevance of cancer stem cell chemotherapeutic assay for recurrent ovarian cancer.

INTRODUCTION: Disease recurrence and progression of ovarian cancer is common with the development of platinum-resistant or refractory disease. This is due in large part to the presence of chemo-resistant cancer stem cells (CSCs) that contribute to tumor propagation, maintenance, and treatment resistance. We developed a CSCs drug cytotoxicity assay (ChemoID) to identify the most effective chemotherapy treatment from a panel of FDA approved chemotherapies. METHODS: Ascites and pleural fluid samples were collected under physician order from 45 consecutive patients affected by 3rd-5th relapsed ovarian cancer. Test results from the assay were used to treat patients with the highest cell kill drugs, taking into consideration their health status and using dose reductions, as needed. A retrospective chart review of CT and PET scans was used to determine patients' outcomes for tumor response, time to recurrence, progression-free survival (PFS), and overall survival (OS). RESULTS: We observed that recurrent ovarian cancer patients treated with high-cell kill chemotherapy agents guided by the CSCs drug response assay had an improvement in the median PFS corresponding to 5.4 months (3rd relapse), 3.6 months (4th relapse), and 3.9 months (5th relapse) when compared to historical data. Additionally, we observed that ovarian cancer patients identified as non-responders by the CSC drug response assay had 30 times the hazard of death compared to those women that were identified as responders with respective median survivals of 6 months vs. 13 months. We also found that ChemoID treated patients on average had an incremental cost-effectiveness ratio (ICER) between -$18,421 and $7,241 per life-year saved (LYS). CONCLUSIONS: This study demonstrated improved PFS and OS for recurrent ovarian cancer patients treated with assay-guided chemotherapies while decreasing the cost of treatment.

A Modified Novel Technique for Condylar Positioning in Mandibular Bilateral Sagittal Split Osteotomy Using Computer-Assisted Designed and Computer-Assisted Manufactured Surgical Guides.

Current techniques for orthognathic surgery after Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO) rely on intermediate and final occlusal splints for proper positioning of the dental arches without any control in positioning the condyle and ramus segments. Setting the 2 condyles in centric relation in the glenoid fossae at fixation is paramount for condylar function and the accuracy and stability of postoperative occlusion. Usually the 2 ramus segments are manually positioned and fixated in the final position according to the surgeon's experience. This report describes a novel technique to position the condyle and ramus segments in centric relation using skeletal guides designed by computer-assisted designed and computer-assisted manufactured (CAD-CAM) technology. The skeletal guides have a double-U shape designed to be tooth borne on the distal segment and bone borne on the proximal segment. The guides fit on the last molar crown and the anterior border of the ramus; using these reference points will position the mandibular arch and 2 ramus segments in ideal centric occlusion and centric relation. The condyle position in the sagittal, horizontal, and transverse planes was analyzed by computed tomography and differences in measurements were calculated. This technique confirms precise control of the condylar segment in centric relation with stable centric occlusion using CAD-CAM guides during BSSO.

Dynamic changes of MMP-9 plasma levels correlate with JCV reactivation and immune activation in natalizumab-treated multiple sclerosis patients.

The aim of the study was to investigate the changes of matrix metalloproteinase (MMP)-2 and MMP-9 plasma levels during natalizumab treatment and their correlation with JC virus (JCV) reactivation and T-lymphocyte phenotypic modifications in peripheral blood samples from 34 relapsing-remitting multiple sclerosis (RRMS) patients. MMP-9 levels were assessed by zymography in plasma samples. JCV-DNA was detected through quantitative real time PCR in plasma samples. T-lymphocyte phenotype was assessed with flow cytometry. MMP-9 plasma levels resulted increased from 12 to 24 natalizumab infusions. Stratifying plasma samples according to JCV-DNA detection, MMP-9 plasma levels were significantly increased in JCV-DNA positive than JCV-DNA negative samples. MMP-9 plasma levels resulted positively correlated with JCV viral load. CD4 immune senescence, CD8 immune activation and CD8 effector percentages were positively correlated to MMP-9 plasma levels, whereas a negative correlation between CD8 naïve percentages and MMP-9 plasma levels was found. Our data indicate an increase of MMP-9 plasma levels between 12 and 24 natalizumab infusions and a correlation with JCV-DNA detection in plasma, T-lymphocyte immune activation and senescence. These findings could contribute to understand PML pathogenesis under natalizumab treatment, suggesting a potential role of MMP-9 as a predictive marker of PML in RRMS patients.

JC Virus-DNA Detection Is Associated with CD8 Effector Accumulation in Peripheral Blood of Patients with Multiple Sclerosis under Natalizumab Treatment, Independently from JC Virus Serostatus.

Although natalizumab (anti-α4 integrin) represents an effective therapy for relapsing remitting multiple sclerosis (RRMS), it is associated with an increased risk of developing progressive multifocal leukoencephalopathy (PML), caused by the polyomavirus JC (JCV). The aim of this study was to explore natalizumab-induced phenotypic changes in peripheral blood T-lymphocytes and their relationship with JCV reactivation. Forty-four patients affected by RRMS were enrolled. Blood and urine samples were classified according to natalizumab infusion number: 0 (N0), 1-12 (N12), 13-24 (N24), 25-36 (N36), and over 36 (N > 36) infusions. JCV-DNA was detected in plasma and urine. T-lymphocyte phenotype was evaluated with flow cytometry. JCV serostatus was assessed. Ten healthy donors (HD), whose ages and sexes matched with the RRMS patients of the N0 group, were enrolled. CD8 effector (CD8 E) percentages were increased in natalizumab treated patients with detectable JCV-DNA in plasma or urine compared to JCV-DNA negative patients (JCV-) (p < 0.01 and p < 0.001, resp.). Patients with CD8 E percentages above 10.4% tended to show detectable JCV-DNA in plasma and/or urine (ROC curve p = 0.001). The CD8 E was increased when JCV-DNA was detectable in plasma or urine, independently from JCV serology, for N12 and N24 groups (p < 0.01). As long as PML can affect RRMS patients under natalizumab treatment with a negative JCV serology, the assessment of CD8 E could help in the evaluation of JCV reactivation.

Platelet-Rich Fibrin (PRF) in Implants Dentistry in Combination with New Bone Regenerative Flapless Technique: Evolution of the Technique and Final Results.

Most common techniques for alveolar bone augmentation are guided bone regeneration (GBR) and autologous bone grafting. GBR studies demonstrated long-term reabsorption using heterologous bone graft. A general consensus has been achieved in implant surgery for a minimal amount of 2 mm of healthy bone around the implant. A current height loss of about 3-4 mm will result in proper deeper implant insertion when alveolar bone expansion is not planned because of the dome shape of the alveolar crest. To manage this situation a split crest technique has been proposed for alveolar bone expansion and the implants' insertion in one stage surgery. Platelet-rich fibrin (PRF) is a healing biomaterial with a great potential for bone and soft tissue regeneration without inflammatory reactions, and may be used alone or in combination with bone grafts, promoting hemostasis, bone growth, and maturation. AIM: The aim of this study was to demonstrate the clinical effectiveness of PRF combined with a new split crest flapless modified technique in 5 patients vs. 5 control patients. MATERIALS AND METHODS: Ten patients with horizontal alveolar crests deficiency were treated in this study, divided into 2 groups: Group 1 (test) of 5 patients treated by the flapless split crest new procedure; Group 2 (control) of 5 patients treated by traditional technique with deeper insertion of smaller implants without split crest. The follow-up was performed with x-ray orthopantomography and intraoral radiographs at T0 (before surgery), T1 (operation time), T2 (3 months) and T3 (6 months) post-operation. RESULTS: All cases were successful; there were no problems at surgery and post-operative times. All implants succeeded osteointegration and all patients underwent uneventful prosthetic rehabilitation. Mean height bone loss was 1 mm, measured as bone-implant most coronal contact (Δ-BIC), and occurred at immediate T2 post-operative time (3 months). No alveolar bone height loss was detected at implant insertion time, which was instead identified in the control group because of deeper implant insertion. CONCLUSION: This modified split crest technique combined with PRF appears to be reliable, safe, and to improve the clinical outcome of patients with horizontal alveolar crests deficiency compared to traditional implanting techniques by avoiding alveolar height-loss related to deeper insertion of smaller implants.

Analysis of Chemopredictive Assay for Targeting Cancer Stem Cells in Glioblastoma Patients.

INTRODUCTION: The prognosis of glioblastoma (GBM) treated with standard-of-care maximal surgical resection and concurrent adjuvant temozolomide (TMZ)/radiotherapy remains very poor (less than 15 months). GBMs have been found to contain a small population of cancer stem cells (CSCs) that contribute to tumor propagation, maintenance, and treatment resistance. The highly invasive nature of high-grade gliomas and their inherent resistance to therapy lead to very high rates of recurrence. For these reasons, not all patients with similar diagnoses respond to the same chemotherapy, schedule, or dose. Administration of ineffective anticancer therapy is not only costly but more importantly burdens the patient with unnecessary toxicity and selects for the development of resistant cancer cell clones. We have developed a drug response assay (ChemoID) that identifies the most effective chemotherapy against CSCs and bulk of tumor cells from of a panel of potential treatments, offering great promise for individualized cancer management. Providing the treating physician with drug response information on a panel of approved drugs will aid in personalized therapy selections of the most effective chemotherapy for individual patients, thereby improving outcomes. A prospective study was conducted evaluating the use of the ChemoID drug response assay in GBM patients treated with standard of care. METHODS: Forty-one GBM patients (mean age 54 years, 59% male), all eligible for a surgical biopsy, were enrolled in an Institutional Review Board-approved protocol, and fresh tissue samples were collected for drug sensitivity testing. Patients were all treated with standard-of-care TMZ plus radiation with or without maximal surgery, depending on the status of the disease. Patients were prospectively monitored for tumor response, time to recurrence, progression-free survival (PFS), and overall survival (OS). Odds ratio (OR) associations of 12-month recurrence, PFS, and OS outcomes were estimated for CSC, bulk tumor, and combined assay responses for the standard-of-care TMZ treatment; sensitivities/specificities, areas under the curve (AUCs), and risk reclassification components were examined. RESULTS: Median follow-up was 8 months (range 3-49 months). For every 5% increase in in vitro CSC cell kill by TMZ, 12-month patient response (nonrecurrence of cancer) increased two-fold, OR=2.2 (P=.016). Similar but somewhat less supported associations with the bulk tumor test were seen, OR=2.75 (P=.07) for each 5% bulk tumor cell kill by TMZ. Combining CSC and bulk tumor assay results in a single model yielded a statistically supported CSC association, OR=2.36 (P=.036), but a much attenuated remaining bulk tumor association, OR=1.46 (P=.472). AUCs and [sensitivity/specificity] at optimal outpoints (>40% CSC cell kill and >55% bulk tumor cell kill) were AUC=0.989 [sensitivity=100/specificity=97], 0.972 [100/89], and 0.989 [100/97] for the CSC only, bulk tumor only, and combined models, respectively. Risk categorization of patients was improved by 11% when using the CSC test in conjunction with the bulk test (risk reclassification nonevent net reclassification improvement [NRI] and overall NRI=0.111, P=.030). Median recurrence time was 20 months for patients with a positive (>40% cell kill) CSC test versus only 3 months for those with a negative CSC test, whereas median recurrence time was 13 months versus 4 months for patients with a positive (>55% cell kill) bulk test versus negative. Similar favorable results for the CSC test were observed for PFS and OS outcomes. Panel results across 14 potential other treatments indicated that 34/41 (83%) potentially more optimal alternative therapies may have been chosen using CSC results, whereas 27/41 (66%) alternative therapies may have been chosen using bulk tumor results. CONCLUSIONS: The ChemoID CSC drug response assay has the potential to increase the accuracy of bulk tumor assays to help guide individualized chemotherapy choices. GBM cancer recurrence may occur quickly if the CSC test has a low in vitro cell kill rate even if the bulk tumor test cell kill rate is high.

Management of Zygomatic Fractures in Young Patients: Technical Modifications for Aesthetic and Functional Results.

INTRODUCTION: The zygomaticomaxillary complex is very vulnerable to injury because of its intrinsically prominent convexity. There are 2 different surgical approaches for the therapy of these fractures: closed reduction and open reduction. In the open reduction 2 or 3 fixation points with related incisions are usually necessary in dislocated fractures: osteosynthesis must be performed starting from zygomaticofrontal suture when dislocated at this site, followed by zygomatic body fixation on the anterior sinus wall, anterior orbital floor margin fixation, and finally orbital floor reconstruction in case of eye globe dislocation with diplopia. AIM: This study evaluated the combination of the transconjunctival (TC) approach without canthotomy in association with the transoral maxillary approach and lateral rim skin incision (SI) without canthotomy for frontozygomatic dislocated fractures to achieve proper reduction and stabilization without any aesthetic decay in young patients. A less invasive and more aesthetic technique is shown for treating dislocated zygomaticomaxillary complex fractures with 2 or 3 fixation points and platelet-rich fibrin (PRF) use to promote tissue healing. MATERIALS AND METHODS: Ten patients (mean age: 32) were referred for dislocated zygomaticomaxillary complex fracture. Five patients were treated by TC approach without canthotomy in association with the transoral maxillary approach and, when needed, eyebrow SI without canthotomy for frontozygomatic dislocated fractures (group 1). Five more patients were treated by traditional subciliar incision at lower eyelid and vertical lateral incision at lateral margin of the orbit (group 2). Autologous PRF for orbital floor reconstruction was used. The follow-up period was 6 months long. Follow-up radiographs (TC) and photos were routinely used to evaluate the adequacy of reduction and lower eyelid right position or retraction. RESULTS: All cases were successful; there were no problems at surgery and postoperative time. During the 6-month follow-up, all 5 patients of group 1 showed satisfactory facial symmetry, no noticeable scarring, no ectropion or lower eyelid significant droop, and no functional impairment. Mean difference for lower eyelid droop between the 2 groups of patients was 1.4 mm at T1 and 1.2 mm at T2. DISCUSSION: Aesthetic result is a priority in the treatment planning of orbitozygomatic fractures because of the fundamental role of the eye and lid area in the aesthetic of the face. In our experience best aesthetic results were achieved through a latero cantal horizontal SI combined to a vertical periosteal incision at the frontozygomatic rim without canthotomy, thus performing a different double-layer incision. In the patients with large orbital floor dislocation, reconstructive titanium mesh was covered by autologous PRF membranes, which can improve the vascularization of the surgical site, by promoting neoangiogenesis. CONCLUSIONS: In young patients these techniques are indicated because of the need of better aesthetic results that can be achieved by preventing postoperative functional impairment with lower eyelid droop and unnatural aesthetic asymmetry of the 2 lower lids. This more conservative technique resulted in better aesthetic results, avoiding most common complications.

Osteodistraction With Dental Implant-Borne Devices for Bone Regeneration in Atrophied Premaxilla.

Aim of this work is to present the evolution of an innovative technique for tooth/implant supported bone distraction, leading to proper oral rehabilitation in patients with atrophic alveolar bone, even when a complete premaxilla expansion is needed, or in patients in whom implants were already present, but inserted in wrong position.Distraction osteogenesis was selected because of its moderate invasiveness, the few surgical steps needed, and the proper cost/benefits balance. This procedure is particularly suited for young patients with remarkable aesthetic demands related to active social and working life, as for elderly patients expecting lower surgical stress and risks.