First and second branchial arch syndromes: multimodality approach.

First and second branchial arch syndromes (BAS) manifest as combined tissue deficiencies and hypoplasias of the face, external ear, middle ear and maxillary and mandibular arches. They represent the second most common craniofacial malformation after cleft lip and palate. Extended knowledge of the embryology and anatomy of each branchial arch derivative is mandatory for the diagnosis and grading of different BAS lesions and in the follow-up of postoperative patients. In recent years, many new complex surgical approaches and procedures have been designed by maxillofacial surgeons to treat extensive maxillary, mandibular and external and internal ear deformations. The purpose of this review is to evaluate the role of different imaging modalities (orthopantomogram (OPG), lateral and posteroanterior cephalometric radiographs, CT and MRI) in the diagnosis of a wide spectrum of first and second BAS, including hemifacial microsomia, mandibulofacial dysostosis, branchio-oto-renal syndrome, Pierre Robin sequence and Nager acrofacial dysostosis. Additionally, we aim to emphasize the importance of the systematic use of a multimodality imaging approach to facilitate the precise grading of these syndromes, as well as the preoperative planning of different reconstructive surgical procedures and their follow-up during treatment.

Influence of the primary cleft palate closure on the future need for orthognathic surgery in unilateral cleft lip and palate patients.

The aim of the study was to determine the influence of the dissection of the palate during primary surgery and the type of orthognathic surgery needed in cases of unilateral total cleft. The review concerns 58 children born with a complete unilateral cleft lip and palate and treated between 1994 and 2008 at the appropriate age for orthognathic surgery. This is a retrospective mixed-longitudinal study. Patients with syndromes or associated anomalies were excluded. All children were treated by the same orthodontist and by the same surgical team. Children are divided into 2 groups: the first group includes children who had conventional primary cleft palate repair during their first year of life, with extensive mucoperiosteal undermining. The second group includes children operated on according to the Malek surgical protocol. The soft palate is closed at the age of 3 months, and the hard palate at 6 months with minimal mucoperiosteal undermining. Lateral cephalograms at ages 9 and 16 years and surgical records were compared. The need for orthognathic surgery was more frequent in the first than in the second group (60% vs 47.8%). Concerning the type of orthognathic surgery performed, 2- or 3-piece Le Fort I or bimaxillary osteotomies were also less required in the first group. Palate surgery following the Malek procedure results in an improved and simplified craniofacial outcome. With a minimal undermining of palatal mucosa, we managed to reduce the amount of patients who required an orthognathic procedure. When this procedure was indicated, the surgical intervention was also greatly simplified.

Treatment of linear mandibular fractures using a single 2.0-mm AO locking reconstruction plate: is a second plate necessary?

PURPOSE: To prospectively evaluate the use of a single Arbeitsgemeinschaft für Osteosynthesefragen (AO) 2.0-mm locking reconstruction plate for linear noncomminuted mandibular fractures without the use of a second plate. PATIENTS AND METHODS: We analyzed the clinical and radiologic data of 45 patients with 74 fractures (21 single fractures, 22 double fractures, and 2 triple fractures). Fracture locations were the symphysis (n = 35, 47.3%), body (n = 15, 20.3%), and angle (n = 24, 32.4%). We recorded the mechanism of injury, time between admission to the hospital and surgery, gender and age, temporary maxillomandibular fixation and its duration, and the surgical approach. Postsurgical complications that were recorded as minor did not require surgical intervention, whereas major complications required further surgical intervention. RESULTS: All patients had satisfactory fracture reduction and a successful treatment outcome without major complications. Ten patients (22.2%) developed minor complications. CONCLUSION: The present study has demonstrated that treating linear noncomminuted mandibular fractures with a single AO 2.0-mm locking reconstruction plates is associated with no major complications and sound bone healing in all patients.

Accuracy and predictability in use of AO three-dimensionally preformed titanium mesh plates for posttraumatic orbital reconstruction: a pilot study.

The aim of this study was to prospectively evaluate the accuracy and predictability of new three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction.We analyzed the preoperative and postoperative clinical and radiologic data of 10 patients with isolated blow-out orbital fractures. Fracture locations were as follows: floor (N = 7; 70%), medial wall (N = 1; 1%), and floor/medial wall (N = 2; 2%). The floor fractures were exposed by a standard transconjunctival approach, whereas a combined transcaruncular transconjunctival approach was used in patients with medial wall fractures. A three-dimensional preformed AO titanium mesh plate (0.4 mm in thickness) was selected according to the size of the defect previously measured on the preoperative computed tomographic (CT) scan examination and fixed at the inferior orbital rim with 1 or 2 screws. The accuracy of plate positioning of the reconstructed orbit was assessed on the postoperative CT scan. Coronal CT scan slices were used to measure bony orbital volume using OsiriX Medical Image software. Reconstructed versus uninjured orbital volume were statistically correlated.Nine patients (90%) had a successful treatment outcome without complications. One patient (10%) developed a mechanical limitation of upward gaze with a resulting handicapping diplopia requiring hardware removal. Postoperative orbital CT scan showed an anatomic three-dimensional placement of the orbital mesh plates in all of the patients. Volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 2.5 cm(3). There was no significant difference in volume between the reconstructed and uninjured orbits.This preliminary study has demonstrated that three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction results in (1) a high rate of success with an acceptable rate of major clinical complications (10%) and (2) an anatomic restoration of the bony orbital contour and volume that closely approximates that of the contralateral uninjured orbit.

Computer-aided volume measurement of posttraumatic orbits reconstructed with AO titanium mesh plates: accuracy and reliability.

PURPOSE: To prospectively evaluate the accuracy and reliability of "freehand" posttraumatic orbital wall reconstruction with AO (Arbeitsgemeinschaft Osteosynthese) titanium mesh plates by using computer-aided volumetric measurement of the bony orbits. METHODS: Bony orbital volume was measured in 12 patients from coronal CT scan slices using OsiriX Medical Image software. After defining the volumetric limits of the orbit, the segmentation of the bony orbital region of interest of each single slice was performed. At the end of the segmentation process, all regions of interest were grouped and the volume was computed. The same procedure was performed on both orbits, and thereafter the volume of the contralateral uninjured orbit was used as a control for comparison. RESULTS: In all patients, the volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 1.85 cm3 (7%). CONCLUSIONS: This preliminary study has demonstrated that posttraumatic orbital wall reconstruction using "freehand" bending and placement of AO titanium mesh plates results in a high success rate in re-establishing preoperative bony volume, which closely approximates that of the contralateral uninjured orbit.

Maxillary advancement and transpalatal expansion using internal distraction in a patient with cleft lip and palate.

Correction of sagittal and transverse maxillary discrepancies in patients with cleft lip or palate remains a challenge for craniofacial surgeons. Distraction osteogenesis has revolutionized the conceptualization and approach to the craniofacial malformations and has become a reliable and irreplaceable part of the surgical armamentarium. We are reporting a case of sequential maxillary advancement and transpalatal expansion using internal distraction in a patient with unilateral cleft lip and palate presenting with severe maxillary sagittal and transverse deficiencies.

[Diagnosis and management of sinusitis of odontogenic origin]. / Les sinusites d'origine dentaire: diagnostic et prise en charge.

Maxillary sinusitis are common infections. A dental origin is found in about 10% of the cases. The roots of the posterior maxillary teeth are adjacent to the sinus floor. Extensions of dental infections are therefore possible to the sinus. An odontogenic source should be considered in patients with a history of dental pain or recent oral surgery and those with extended unilateral sinusitis or unilateral sinusitis resistant to conventional treatment. Maxillary sinusitis of dental origin are polymicrobial infections. Conventional radiographs and CT-scans are required for the diagnosis and proper management. Dental treatments to remove the underlying cause combined with oral antibiotics to treat the infection are required. Endoscopic or open surgery may be necessary to complete the treatment and restore adequate sinusal function.

Successful treatment of a postpolio tinnitus with type a botulinum toxin.

OBJECTIVES/HYPOTHESIS: Objective tinnitus is a symptom often observed in patients with chronic hyperactivity of masticatory muscles. METHODS: We report here the unusual case of a 63-year-old woman who developed a distressing tinnitus related to contractions of reinnervated masticatory muscles. This reinnervation process was caused by a postpolio syndrome that gave rise to an acoustic resonance phenomenon transmitted to the middle ear as an audible sound. RESULTS: The tinnitus was successfully treated with electromyography-guided intramuscular injections of type A botulinum toxin. CONCLUSION: The intramuscular injection of botulinum toxin was found to be effective in relieving severe and disabling postpolio tinnitus.

Successful inferior alveolar nerve decompression for dysesthesia following endodontic treatment: report of 4 cases treated by mandibular sagittal osteotomy.

Endodontic overfilling involving the mandibular canal may cause an injury of the inferior alveolar nerve (IAN) resulting in disabling sensory disturbances such as pain, dysesthesia, paresthesia, hypoesthesia, or anesthesia. Two fundamental mechanisms are responsible for the injury: the chemical neurotoxicity and the mechanical compression caused by the extruded material. Although spontaneous resorption has been described for some materials, early surgical exploration with removal of the material and decompression of the IAN should be performed, irrespective of the material used, given that the importance of nerve damage increases with the duration of the injury. We report 4 cases of disabling dysesthesia and paresthesia following endodontic treatment of lower molars in which sagittal osteotomy was used to remove the endodontic paste and to perform nerve decompression. All the patients experienced immediate relief of dysesthesia and paresthesia.

Mandibular osteoradionecrosis in squamous cell carcinoma of the oral cavity and oropharynx: incidence and risk factors.

OBJECTIVE: Mandibular osteoradionecrosis (ORN) is a serious complication of radiotherapy (RT) in head and neck cancer patients. The aim of this study was to analyze the incidence of and risk factors for mandibular ORN in squamous cell carcinoma (SCC) of the oral cavity and oropharynx. STUDY DESIGN: Case series with chart review. SETTING: University tertiary care center for head and neck oncology. SUBJECTS AND METHODS: Seventy-three patients treated for stage I to IV SCC of the oral cavity and oropharynx between 2000 and 2007, with a minimum follow-up of 2 years, were included in the study. Treatment modalities included both RT with curative intent and adjuvant RT following tumor surgery. The log-rank test and Cox model were used for univariate and multivariate analyses. RESULTS: The incidence of mandibular ORN was 40% at 5 years. Using univariate analysis, the following risk factors were identified: oral cavity tumors (P < .01), bone invasion (P < .02), any surgery prior to RT (P < .04), and bone surgery (P < .0001). By multivariate analysis, mandibular surgery proved to be the most important risk factor and the only one reaching statistical significance (P < .0002). CONCLUSION: Mandibular ORN is a frequent long-term complication of RT for oral cavity and oropharynx cancers. Mandibular surgery before irradiation is the only independent risk factor. These aspects must be considered when planning treatment for these tumors.

Human fetal bone cells in delivery systems for bone engineering.

The aim of this study was to culture human fetal bone cells (dedicated cell banks of fetal bone derived from 14 week gestation femurs) within both hyaluronic acid gel and collagen foam, to compare the biocompatibility of both matrices as potential delivery systems for bone engineering and particularly for oral application. Fetal bone cell banks were prepared from one organ donation and cells were cultured for up to 4 weeks within hyaluronic acid (Mesolis®) and collagen foams (TissueFleece®). Cell survival and differentiation were assessed by cell proliferation assays and histology of frozen sections stained with Giemsa, von Kossa and ALP at 1, 2 and 4 weeks of culture. Within both materials, fetal bone cells could proliferate in three-dimensional structure at ∼70% capacity compared to monolayer culture. In addition, these cells were positive for ALP and von Kossa staining, indicating cellular differentiation and matrix production. Collagen foam provides a better structure for fetal bone cell delivery if cavity filling is necessary and hydrogels would permit an injectable technique for difficult to treat areas. In all, there was high biocompatibility, cellular differentiation and matrix deposition seen in both matrices by fetal bone cells, allowing for easy cell delivery for bone stimulation in vivo.

Intraoral open reduction and internal fixation of displaced mandibular angle fractures using a specific ad hoc reduction-compression forceps: a preliminary study.

OBJECTIVES: To preliminarily evaluate prospectively the accuracy and reliability of a specific ad hoc reduction-compression forceps in intraoral open reduction of transverse and displaced mandibular angle fractures. STUDY DESIGN: We analyzed the clinical and radiologic data of 7 patients with 7 single transverse and displaced angle fractures. An intraoral approach was performed in all of the patients without using perioperative intermaxillary fixation. A single Arbeitsgemeinschaft Osteosynthese (AO) unilock reconstruction plate was fixed to each stable fragment with 3 locking screws (2.0 mm in 5 patients and 2.4 mm in 2 patients) at the basilar border of the mandible, according to AO/American Society of Internal Fixation (ASIF) principles. Follow-up was at 1, 3, 6, and 12 months, and we noted the status of healing and complications, if any. RESULTS: All of the patients had satisfactory fracture reduction as well as a successful treatment outcome without complications. CONCLUSION: This preliminary study demonstrated that the intraoral reduction of transverse and displaced angle fractures using a specific ad hoc reduction-forceps results in a high rate of success.

[Reconstruction of the floor of the mouth with double free flap: report of three cases]. / Reconstrucción con doble colgajo libre del piso anterior de la boca. Informe de tres casos.

BACKGROUND: We undertook this study to describe three cases of reconstruction of the floor of the mouth with two simultaneous free flaps. METHODS: Three patients with cancer of the anterior floor of the mouth were subjected to segmental resection of the mandible and resection of the floor of the mouth with subsequent reconstruction using two simultaneous osseous and fasciocutaneous free flaps. RESULTS: All patients had a satisfactory evolution. Two patients underwent adjuvant radiotherapy, one due to the initial clinical stage and the other due to positive surgical margins. The third patient had neoadjuvant postoperative radiotherapy and concomitant chemoradiotherapy. CONCLUSIONS: If a tumor involves osseous structures of the anterior floor of the mouth, it is best to perform surgery with wide margins with segmental resection of the mandible. Surgical technique is the decision of the surgeon: how many and which types of flaps will be used for reconstruction of the anterior floor of mouth. When there is necrosis of a free flap in the head and neck region, attempt with another free flap is recommended.

Complex orbito-fronto-temporal reconstruction using computer-designed PEEK implant.

Cosmetic and functional reconstruction of large and complex calvarial defects remains a challenge for craniofacial surgeons. Computer-designed alloplastic implants have revolutionized the conceptualization and approach to these reconstructions and have become a reliable and irreplaceable part of the surgical armamentarium. We are reporting a case of complex orbito-fronto-temporal reconstruction using a computer-designed PEEK (polyetheretherketones)-Patient Specific Implant (PSI). To the best of our knowledge, no other similar cases regarding the use of these implants in cranial reconstruction have been reported previously.

Maxillary expansion using transpalatal distraction in patients with unilateral cleft lip and palate.

BACKGROUND: The goal of this study was to evaluate prospectively the use of a transpalatal distractor for surgically assisted rapid palatal distraction osteogenesis in the treatment of severe unilateral maxillary constriction of patients with cleft lip and palate following alveolar bone grafting. METHODS: The authors analyzed the clinical and radiographic data of eight patients with unilateral cleft lip and palate. Follow-up examinations were performed at 1, 3, 6, and 12 months. RESULTS: All of the patients had satisfactory palatal expansion and correction of the dental crossbite without major complications. None of the children in this study were noncompliant with the prescribed duration of the active distraction period. CONCLUSIONS: Surgically assisted rapid palatal distraction osteogenesis using a transpalatal distractor results in a high rate of success in correcting maxillary transverse width discrepancies and dental crossbite and offers a harmonious maxillary arch shape in patients with unilateral cleft lip and palate.

Simultaneous maxillo-mandibular distraction osteogenesis in hemifacial microsomia: a new technique using two distractors.

BACKGROUND: The goal of this study was to prospectively evaluate the use of two distractors for a simultaneous maxillo-mandibular distraction osteogenesis without the use of intermaxillary fixation in the restorative treatment of hemifacial microsomia. METHODS: The authors analyzed the clinical and radiological data of five patients with type I hemifacial microsomia (one patient), type IIa hemifacial microsomia (two patients), and Goldenhar syndrome (two patients). Follow-up examinations were performed at 1, 3, 6, and 12 months. RESULTS: All the patients had satisfactory correction of the facial asymmetry without complications. Complete horizontalization of the occlusal plane was achieved in three patients, whereas a cant of 2 degrees persisted in two patients. None of the children in this study were noncompliant with the prescribed duration of the active distraction period, nor did they experience technical problems with the two devices. CONCLUSIONS: Simultaneous maxillo-mandibular distraction osteogenesis resulted in a high rate of success in correcting facial asymmetry as well as occlusal plane cant. It offered good aesthetic satisfaction.

Myxoid fibroblastic tumor of the maxillary sinus in a 21-month-old child: An unusual diagnosis.

Myxoid tumors of the soft tissue are a heterogeneous group of lesions with significant differences in behavior, from being totally harmless to malignant tumors with metastasizing potential. We describe the unusual case of a 21-month-old boy who developed a paranasal low-grade myxoid neoplasm with recurrent potential. The histological findings showed a proliferation of spindle cells within a vascular and myxoid background. The immunohistochemistry had the features of myofibroblasts and fibroblasts with strong Vimentin and light Smooth Muscle Actin reactivity. Close collaboration between clinician and pathologist is necessary to deal with these unusual lesions to predict their local aggressiveness and long-term behavior. Most of these cellular myxomas have been described in adults, involving primarily the limbs, but this case shows that any localization is possible.

Congenital intracranial frontotemporal dermoid cyst presenting as a cutaneous fistula.

BACKGROUND: Intracranial extension and a cutaneous sinus tract are rarely seen with craniofacial dermoid cysts, with few cases reported in the literature. METHODS: We report a case of a 1-year-old girl who was initially seen with a cutaneous fistula of the frontotemporal region, which revealed an intracranial dermoid cyst. RESULTS: The patient underwent a right lateral orbitotomy by a bicoronal approach. The cyst was seated within the lateral orbital wall, with intracranial extension through the temporal and sphenoidal bones to the dura of the temporal lobe. Histopathologic analysis confirmed the diagnosis of a dermoid cyst. CONCLUSIONS: Craniofacial dermoid cysts may be associated with a cutaneous sinus tract and/or intracranial extension. Failure to recognize and promptly treat these lesions may lead to a progressive skeletal distortion and/or recurrent infection with a potential for meningitis or cerebral abscess. Therefore, detailed CT and MRI scans are mandatory before surgical treatment of any cutaneous fistula in the head and neck region.