Does Middle Meatal Antrostomy Prevent the Onset of Maxillary Sinusitis After Zygomatic Implant Placement?

PURPOSE: To evaluate the role of middle meatal antrostomy in preventing the onset of maxillary sinusitis after placement of zygomatic implants. We hypothesized that middle meatal antrostomy might reduce the incidence of this complication. MATERIALS AND METHODS: A prospective longitudinal study was performed of patients who had undergone placement of 4 zygomatic implants and concurrent middle meatal antrostomy with an endoscopic approach at the maxillofacial surgery unit of Verona University. The radiological results of the maxillary sinuses were evaluated on computed tomography scans performed 12 months after surgery using the Lund-Mackay staging system. Clinical symptoms were evaluated both preoperatively and 12 months after surgery using the Sino-Nasal Outcome Test-20 (SNOT-20). Intraoperative violation of the Schneiderian membrane was also assessed. The outcomes from the present study were compared with historical controls. RESULTS: The sample included 13 patients, 26 maxillary sinuses with negative radiologic findings of sinonasal pathologic features, and 52 zygomatic implants. A moderate increase was found in radiologic findings of sinonasal pathologic features postoperatively compared with preoperatively, with mucosal hypertrophy in 3 maxillary sinuses (11.5%). The incidence and severity of mucosal hypertrophy was significantly lower than the outcomes of the historical controls. The average preoperative SNOT-20 score was 13.45, and the postoperative SNOT-20 score was 1.18. The Schneiderian membrane was pierced in 13 sinuses in 9 patients. CONCLUSIONS: Shrinkage of the ostiomeatal complex seems to play a fundamental role in the onset of sinonasal pathologic features after zygomatic implant placement compared with implant-related causes. Although functional endoscopic sinus surgery is a supplementary surgical method in implant placement, it seems to provide statistically significant improvement in the health of the sinonasal system. Perforation of the Schneiderian membrane does not appear to correlate with the onset of sinus opacification and sinonasal symptoms.

Does Piezosurgery Influence the Severity of Neurosensory Disturbance Following Bilateral Sagittal Split Osteotomy?

The present paper aims to evaluate the long-term incidence and severity of the neurosensory disturbance (NSD) of the inferior alveolar nerve following bilateral sagittal split osteotomy (BSSO) of the mandibular ramus performed with piezosurgery. A retrospective study on patients referred to the Maxillofacial Surgery and Dentistry Clinic of the University of Verona for orthognathic surgery between March 2013 and October 2015 was performed. Inclusion criteria were having undergone BSSO with piezosurgery and follow-up lasting at least 24 months. Exclusion criteria were history of surgical infection, osteosynthesis failure or re-do surgery. The extent of mandibular repositioning movements was retrieved and patients underwent 4 clinical neurosensory tests. Descriptive statistical analysis was performed. 52 patients met the inclusion criteria. Average follow-up was 40 months (range 24-75). 83% of the nerves examined have no or slightly altered sensitivity. Seventy-one percent of patients perceive a moderate to none discomfort and none describes the discomfort as serious (Visual Analogue Scale [VAS] >7). The extent of mandibular repositioning did not have significant influence on the development and severity of the NSD. Resulting data led the Authors to infer that using piezosurgery in BSSO, the severity of the NSD of inferior alveolar nerve is reduced, but the incidence of permanent nerve lesions remains unchanged, compared to historical controls.

Sequential morphometric evaluation at UnicCa® and SLActive® implant surfaces. An experimental study in the dog.

AIM: To study sequential osseointegration around implants with nano-technologically modified surfaces at different periods of healing. MATERIALS AND METHODS: After 3 months, two different implant systems with different nano-technologically modified surfaces were randomly installed in the edentulous molar regions of the mandible of 12 dogs. One surface was acid-etched surface, and subsequently modified with calcium ions (UnicCa® ), while the other was a hydrophilic sandblasted with large grit and acid-etched (SLActive® ) surface. The implants were fully submerged, and biopsies were obtained representing the healing after 1, 2, 4 and 8 weeks (n = 6 per period). A morphometric evaluation of densities of new soft tissues (provisional matrix and immature bone marrow), new and old bone, mature bone marrow, vessels and other tissues (bone debris/particles and clot) was performed in the spongiosa compartment of the sites of implantation. RESULTS: After 1 week of healing, the soft tissues, mainly composed of provisional matrix, were present at 41.5 ± 23.9% and 30.1 ± 20.0% at the UnicCa® and SLActive surfaces, respectively. These percentages were >40% at both surfaces after 2 weeks of healing, presenting greater amount of immature bone marrow. Subsequently, these percentages decreased up to disappear after 8 weeks of healing. New bone increased progressively between 1 and 8 weeks of healing from 8.2 ± 3.0% to 77.1 ± 6.4% and from 6.8 ± 2.8% to 67.9 ± 6.8% at the UnicCa® and SLActive® , respectively. Old bone decreased progressively over time. CONCLUSIONS: The patterns of healing at highly hydrophilic surfaces occurred through the early formation of a provisional matrix followed by the formation of new bone and marrow at various stages of maturation. The healing was similar to those described in different animal models, anatomical sites and surgical procedures.

Sequential morphometric evaluation at UnicCa® and DCD® implant surfaces. An experimental study in the dog.

AIM: To study tissue components adjacent to implants with nanotechnologically modified surfaces at different periods of healing. MATERIAL & METHODS: In 12 beagle dogs, two different implant systems with different surface configurations were randomly installed in the edentulous premolar regions of the mandible. One surface was first acid-etched and subsequently, nanotechnologically modified with calcium ions (UnicCa® ), while the other was first sandblasted and acid-etched, and then additionally treated with a nanometer calcium phosphate deposition (discrete crystalline deposition; DCD® ). The implants were fully submerged; surgeries and sacrifices were planned to harvest biopsies after 1, 2, 4 and 8 weeks of healing (n = 6 per period). A morphometric evaluation of percentages of new and old bone, bone debris/particles and clot, new soft tissues (provisional matrix and immature marrow), mature bone marrow and vessels was performed in the spongiosa compartment adjacent to the implant surface up to a distance of about 0.4 mm from the surface. RESULTS: After 2 weeks of healing, the soft tissues were represented by 41.0% at the UnicCa® and 37.9% at the DCD® surfaces, in both cases mainly being composed of provisional matrix. These percentages decreased over time, being composed of greater amounts of immature bone marrow, and disappeared after 8 weeks. New bone increased progressively between 1 and 8 weeks of healing from 9.7 ± 6.3% to 70.0 ± 8.4% and from 8.2 ± 3.5% to 67.0 ± 6.1% at the UnicCa® and DCD® surfaces, respectively. Pristine bone was progressively resorbed. CONCLUSIONS: Throughout the periods of healing observed, the formation of a provisional matrix followed by the formation of new bone and marrow was revealed in a similar fashion as for other modified surface configurations.

Is the Retromandibular Transparotid Approach a Reliable Option for the Surgical Treatment of Condylar Fractures?

PURPOSE: This study evaluated the outcomes and complications of the surgical treatment of condylar fractures by the retromandibular transparotid approach. The authors hypothesized that such an approach would be safe and reliable for the treatment of most condylar fractures. MATERIALS AND METHODS: A retrospective evaluation of patients who underwent surgical reduction of a condylar fracture from January 2012 to December 2014 at the Clinic of Dentistry and Maxillofacial Surgery of the University Hospital of Verona (Verona, Italy) was performed. Inclusion criteria were having undergone surgical treatment of condylar fractures with a retromandibular transparotid approach and the availability of computed tomograms of the preoperative and postoperative facial skeleton with a minimum follow-up of 1 year. Static and dynamic occlusal function, temporomandibular joint health status, presence of neurologic impairments, and esthetic outcomes were evaluated in all patients. RESULTS: The sample was composed of 25 patients. Preinjury occlusion and temporomandibular joint health were restored in most patients. Esthetic outcomes were deemed satisfactory by clinicians and patients. Neither permanent neurologic impairments nor major postoperative complications were observed. CONCLUSIONS: According to the results of the present study, the retromandibular transparotid approach is a viable and safe approach for the surgical treatment of condylar fractures.

Peri-implant tissues morphometry at SLActive surfaces. An experimental study in the dog.

OBJECTIVE: The objective was to study tissue components around implants with highly hydrophilic surfaces during early healing. MATERIALS AND METHODS: In 12 Labrador dogs, the second and third mandibular premolars were extracted bilaterally. After 3 months of healing, full-thickness flaps were elevated in the edentulous region of one side of the mandible. An implant was installed, and the flaps were sutured to allow a non-submerged healing. The timing of the implant installations in the other side of the mandible until sacrifices were performed in such a way to collect biopsies representing healing after 4, 7, 15, and 60 days. An n = 6 was achieved for each healing period. Paraffin sections were obtained for morphometric analyses. RESULTS: Provisional matrix with a percentage of 32.9 ± 16.7% was found already after 4 days. This percentage became 37.3 ± 8.5%, 24.3 ± 9.1%, and 1.6 ± 1.7 after 7, 15, and 60 days, respectively. New bone was found after 7 days of healing, at a percentage of 26.2 ± 3.2%. This proportion increased to 36.0 ± 9.6% and 50.4 ± 8.3% after 15 and 60 days, respectively. Marrow spaces free from a blood clot, inflammatory cells, and provisional matrix represented a low proportion of the tissues after 4 days (1.6 ± 2.4%). This proportion increased over time to 9.2 ± 6.4%, 20.3 ± 12.9%, and 37.9 ± 9.6%, respectively. The percentage of old bone was noted in a similar percentage (~8%) up to 15 days. The percentage decreased to ~5% at 60-day of observation. CONCLUSION: The tissue changes observed during the healing were similar to those from historic controls studying healing in a chamber adjacent to implants. Hence, the characteristics of the implant surfaces may not be reflected in the tissue composition adjacent to the implant but rather affect the adhesion of tissue onto the implant surfaces.

Sequential healing at implants installed immediately into extraction sockets. An experimental study in dogs.

OBJECTIVE: To compare the sequential healing at implants installed in a healed alveolar bony ridge or immediately after tooth extraction without functional load. MATERIAL AND METHODS: In the mandible of 12 dogs, the mesial roots of the first molars were endodontically treated, the tooth hemisected, and the distal roots extracted. After 3 months, the mesial roots of the fourth premolars were endodontically treated, the tooth hemisected, and the distal roots extracted in one side of the mandible. Implants were placed immediately into extraction sockets (IPIES) of the fourth premolar and in the healed sites in the molar regions. Healing abutments were placed, and the flaps were sutured to allow a non-submerged healing. The time of surgery and of sacrifices were planned in such a way to obtain biopsies representing the healing after 1 and 2 weeks and 1 and 3 months, respectively. Ground sections were prepared for histological evaluation of tissues components on the implant surface and the coronal termination level of osseointegration (M-B). RESULTS: New bone apposition on the implant surface was slightly higher at the healed compared to the IPIES sites, being 7.4% and 4.1% after 1 week, and 67.3% and 65.3% after 3 months, respectively. Old bone was progressively resorbed, from 27.0% and 21.9% after 1 week, to 2.5% and 2.0% after 3 months, at healed and IPIES sites, respectively. M-B was 1.4 mm and 2.6 mm after 1 week, 1.2 mm and 1.2 mm after 3 months, at healed and IPIES sites, respectively. CONCLUSIONS: Similar patterns of sequential osseointegration were found at implants installed in healed alveolar bone or in alveolar sockets immediately after tooth extraction. The coronal termination level of osseointegration, that was different after 1 week, was found similar at the 3-month observation.

Sinus floor elevation outcomes following perforation of the Schneiderian membrane. An experimental study in sheep.

OBJECTIVE: To assess the influence of a collagen membrane covering a perforation of the sinus (Schneiderian) membrane on the outcome (bone fill) of a sinus floor elevation. MATERIALS AND METHODS: Eighteen Pelibuey sheep were used. The animals underwent sinus floor elevation on both sides of the upper jaw. A perforation of 5 × 4 mm in dimension of the sinus mucosa was performed on both sides and, at a randomly selected test site, a collagen membrane was placed to cover the perforation. A graft of biphasic calcium phosphate (60% HA/40% beta-TCP) was subsequently placed bilaterally, and the access window was closed with a membrane made of polylactic acid and a citric acid ester acetyl. The sacrifices were performed after 2, 4, and 12 weeks of healing. RESULTS: After 2 weeks of healing, the augmented volume was filled with biomaterial surrounded by connective tissue and minimal new bone was detected. After 4 weeks of healing, new bone was found mainly in connection with the sinus bony walls with percentages of 18.0 ± 12.9% at the test and 12.3 ± 7.9% at the control sites. After 12 weeks of healing, similar amounts of newly formed bone were found compared to the previous healing period, namely 16.7 ± 8.0% and 13.7 ± 10.1% at the test and control sites, respectively, with the highest amount detected in the bottom of the sinus cavity. The newly formed bone was distributed more evenly within the sinus cavity also including the central areas. The differences between test and control sites did not reach statistical significance. CONCLUSION: Even though there were trends for more bone formation when applying a collagen membrane on a sinus mucosal perforation of relatively small dimensions, this study failed to establish the absolute necessity of such a procedure to achieve bone fill in the sinus cavity.

Healing of BoneCeramic™ at buccal dehiscence defects at implants installed immediately into extraction sockets. An experimental study in dogs.

OBJECTIVE: To assess the healing outcomes at buccal dehiscence defects after 4 months following implant placement immediately into extraction sockets (IPIES) and filled with a mixture of synthetic hydroxyl apatite (HA) 60% and ß-tri-calcium phosphate (ß-TCP) 40% in comparison with leaving a blood clot. MATERIAL AND METHODS: Eight Labrador dogs were used, and an implant was placed immediately following tooth extraction into the distal alveolus of the third premolars, bilaterally. Standardized buccal defects, 8 mm in depth and 4 mm in width at the coronal and 2 mm in width at the apical outlines were created. A mixture of synthetic HA 60% and ß-TCP 40% was used to fill the defects at the test sites, while the control sites were left unfilled. Collagen membranes were used to cover the defects at both sides, and a non-submerged healing was allowed. After 4 months of healing, biopsies were obtained and processed for morphometric analysis. RESULTS: A vertical gain in the extent of the bony crest and of osseointegration levels of 4.2 ± 2.4 and 3.3 ± 2.1 mm at the test sites and of 5.0 ± 0.8 and 4.6 ± 1.0 mm at the control sites, respectively, were observed. BIC% within the buccal defects reached similar levels (37-42%) both at test and control sites. None of the means of the variables differed significantly between the two groups. New bone formation within the defects was higher, and the percentage of the connective tissue was lower at the control (65.7 ± 11.7% and 2.5 ± 3.3%, respectively) compared to the test sites (16.8 ± 11.3% and 48.9 ± 29.5%, respectively). These differences were statistically significant. CONCLUSIONS: The use of a mixture of synthetic HA 60% and ß-TCP 40% to fill surgically created buccal dehiscence defects at IPIES sites covered with a collagen membrane did not improve osseointegration in the defect area.

Hydroxyapatite/Collagen Composite Is a Reliable Material for Malar Augmentation.

PURPOSE: To evaluate the long-term results of cheekbone augmentation using porous hydroxyapatite granules mixed with microfibrillar collagen in a large group of patients. MATERIALS AND METHODS: Four hundred thirty patients who underwent zygomatic augmentation and intermaxillary osteotomy were evaluated clinically, radiologically, and histologically. RESULTS: Complications were found in 13 patients (1.56%). There were no relevant radiologic differences in prosthesis volume after 1 month (T1) or after 24 months (T2) in any patient; there were no clinically relevant differences in 110 patients after 36 months. At T1, the prosthesis had a granular structure and the granules had not migrated; at T2, the prosthesis was staunchly adhering to the underlying bone. Over time, the radiopacity of the material increased. Histologic results of 19 biopsy specimens obtained from 8 patients 2 years after the procedure showed prominent ossification with low inflammation, confirming new bone formation over time. According to the visual analog scale, the patients were generally satisfied with the aspects that were considered. CONCLUSION: Hydroxyapatite and collagen composite used during malarplasty produced a successful outcome. Its main drawback is a learning curve that is longer than for more frequently used implantable biomaterials.

Are Zygomatic Implants Associated With Maxillary Sinusitis?

PURPOSE: The purpose of the present study was to analyze the relation between zygomatic implants and symptomatic and radiologic modifications of the maxillary sinuses. MATERIALS AND METHODS: A retrospective cohort study of patients who underwent zygomatic implant rehabilitation at the Clinic of Dentistry and Maxillofacial Surgery of the University of Verona from January 2005 through May 2014 was designed. The primary predictor variable was time (pre- vs postoperative). Concerning outcome variables, radiologic findings of thickened mucosa or opacification of the maxillary sinuses were evaluated on computed tomograms using the Lund-Mackay Staging System. Clinical symptoms were evaluated using the Sino-Nasal Outcome Test-20 (SNOT-20). The parameters assessed underwent descriptive statistical analysis. RESULTS: The sample was composed of 41 patients (mean age, 54 yr; 61% women). Preoperatively, 12% had sinus findings. Postoperatively, 46% had sinus findings (P = .0001 by McNemar paired test). Preoperatively, 12% had a SNOT-20 score higher than 11. Postoperatively, 15% had a SNOT-20 score higher than 11 (P = 1 by McNemar paired test). CONCLUSIONS: In accordance with data in the literature data, placement of zygomatic implants does not seem to be associated with severe rhinosinusitis complications. However, in a considerable number of patients, asymptomatic radiologic alterations of the paranasal sinuses were observed. Therefore, it is important to plan assessments of the prosthetic and peri-implant components of the procedure and the postoperative homeostasis of the maxillary sinuses.

Is Le Fort I Osteotomy Associated With Maxillary Sinusitis?

PURPOSE: The purpose of the present study was to investigate the association between Le Fort I osteotomy and the anatomic, radiologic, and symptomatic modifications of the maxillary sinus. MATERIALS AND METHODS: Subjects who had undergone Le Fort I osteotomy from January 2008 to December 2013 were enrolled in a retrospective cohort study. The eligibility criteria were the availability of a cone beam computed tomography (CBCT) scan taken before and 12 to 24 months after the procedure. The exclusion criteria were the unavailability of CBCT scans, the use of tobacco, and previous orthognathic procedures. The primary predictor variable was time (pre-vs postoperative). The primary outcome variables were the sinus volume, mucosal thickening, iatrogenic alterations in the sinus anatomy, and rhinosinusitis symptoms, evaluated using the Sino-Nasal Outcome 20-item Test (SNOT-20). Descriptive statistics were computed for each variable, and paired analyses were used to compare the pre- and postoperative values. RESULTS: The data from 64 subjects (mean age 27; 59.4% were female; median follow-up 32.4 months, range 13 to 66 months) were studied. Postoperatively, 1.6% of the sample (0% preoperatively) had moderate-to-severe and 15.6% (3.1% preoperatively) had mild-to-moderate sinusitis symptoms. The rest of the sample presented with mild to no symptoms. The increase in the SNOT scores after surgery was statistically significant (P = .016). Radiologic evidence of postoperative inflammatory processes affecting the paranasal sinuses was found in 27.3% of the sinuses (9.4% preoperatively). The postoperative Lund-Mackay scores were significantly greater (P = .0005). A 19% decrease was found in the mean postoperative sinus volume, with a 37% incidence of iatrogenic injury. CONCLUSIONS: The study results indicate that Le Fort I osteotomies can have an important impact on sinus health. The postoperative radiologic evidence of maxillary sinus inflammatory processes and the incidence of rhinosinusitis symptoms and iatrogenic damage in these patients have led us to conclude that CBCT scans and the SNOT-20 questionnaire should be used routinely during postoperative monitoring. Larger long-term studies are warranted to clarify the postoperative outcomes and complications.

Dimensional changes in soft tissues around dental implants following free gingival grafting: an experimental study in dogs.

OBJECTIVE: To study the buccal dimensional tissue changes at oral implants following free gingival grafting, with or without including the keratin layer, performed at the time of implant installation into alveolar mucosa. MATERIAL AND METHODS: The mandibular premolars and first molars were extracted bilaterally in six Beagle dogs. In the right side of the mandible (Test), flaps were first elevated, and the buccal as well as part of the lingual masticatory mucosa was removed. An incision of the periosteum at the buccal aspect was performed to allow the flap to be coronally repositioned. Primary wound closure was obtained. In the left side, the masticatory (keratinized) mucosa was left in situ, and no sutures were applied (Control). After 3 months of healing, absence of keratinized mucosa was confirmed at the test sites. Two recipient sites were prepared at each side of the mandible in the region of the third and fourth premolars. All implants were installed with the shoulder placed flush with the buccal alveolar bony crest, and abutments were connected to allow a non-submerged healing. Two free gingival mucosal grafts were harvested from the buccal region of the maxillary canines. One graft was left intact (gingival mucosal graft), while for the second, the epithelial layer was removed (gingival connective tissue graft). Subsequently, the grafts were fixed around the test implants in position of the third and fourth premolars, respectively. After 3 months, the animals were euthanized and ground sections obtained. RESULTS: Similar bony crest resorption and coronal extension of osseointegration were found at test and control sites. Moreover, similar dimensions of the peri-implant soft tissues were obtained at test and control sites. CONCLUSIONS: The increase in the alveolar mucosal thickness by means of a gingival graft affected the peri-implant marginal bone resorption and soft tissue recession around implants. This resulted in outcomes that were similar to those at implants surrounded by masticatory mucosa, indicating that gingival grafting in the absence of keratinized mucosa around implants may reduce the resorption of the marginal crest and soft tissue recession.

Intramuscular innervation patterns of the brachialis muscle.

The aim of this study was to provide accurate anatomical descriptions of the patterns of innervation of the brachialis muscle by the musculocutaneous, radial, and median nerves. Sihler's staining method was applied to 20 brachialis muscles from 10 cadavers to reveal the intramuscular distribution patterns of the musculocutaneous, radial, and median nerves. Three patterns of innervation of the brachialis muscle by the three studied nerves were found: single, double, and triple. These innervation patterns were categorized into four types: Type I--only the musculocutaneous nerve; Type II--double innervation by the musculocutaneous and radial nerves; Type III--double innervation by the musculocutaneous and median nerves; and Type IV--triple innervation by all three nerves. Single, double, and triple innervation patterns occurred 25%, 70% (Type II, 55%; Type III, 15%), and 5% of the samples, respectively. The brachialis muscle is not solely innervated by the musculocutaneous nerve but also by the radial and median nerves, thus making it a potentially triply innervated muscle. Double innervation of this muscle with either the musculocutaneous and median nerve or the musculocutaneous and radial nerves was also observed.

Influence of presence or absence of keratinized mucosa on the alveolar bony crest level as it relates to different buccal marginal bone thicknesses. An experimental study in dogs.

OBJECTIVE: To investigate the influence of the presence or absence of keratinized mucosa on the alveolar bony crest level as it relates to different buccal marginal bone thicknesses. MATERIAL AND METHODS: In six beagle dogs, the mandibular premolars and first molars were extracted bilaterally. In the right side of the mandible (test), flaps were elevated, and the buccal as well as part of the lingual masticatory mucosa was removed. The flap was released coronally to allow a primary wound closure. In the left side, the wounds were left unsutured with the keratinized mucosa remaining (control). After 3 months of healing, a complete absence of keratinized mucosa was found at the test sites. Two recipient sites were prepared at each side of the mandible, one in the premolar and one in the molar region. A buccal bony ridge width of approximately 1 and 2 mm was obtained at the premolar and molar region, respectively. Implants were installed with the shoulder flush with the buccal alveolar bony crest, and abutments were connected to allow a nonsubmerged healing. At least 2 mm of keratinized mucosa was surrounding the control sites, while at the test sites, the implants were bordered by alveolar mucosa. After 3 months, the animals were euthanized and ground sections obtained. RESULTS: A higher vertical bony crest resorption was observed at the test compared with the control sites both at the premolar and molar regions, the differences being statistically significant. The top of the peri-implant mucosa was located more coronally at the control compared with the test sites. The horizontal resorption measured 1 mm below the implant shoulder was similar at the test and control sites. Only limited differences were found between premolar and molar sites, with the exclusion of the horizontal resorption that was higher at the test compared with the control sites. CONCLUSIONS: A higher alveolar buccal bony crest resorption and a more apical soft tissue marginal position should be expected, when implants are surrounded with thin alveolar mucosa at the time of installation, independently of the thickness of the buccal bony crest.

Orbital metastasis or idiopathic orbital pseudotumor? A case report from a patient previously diagnosed with primary breast cancer.

INTRODUCTION: Cancer metastatic to the orbit may be difficult to distinguish from idiopathic orbital pseudotumor at clinical and radiological examination. This case report describes clinical, radiological features, differential diagnosis, and treatment options for orbital neoplasms of unknown origin. PRESENTATION OF CASE: A 63-year-old woman presented to our Unit because of orbital swelling, ocular pain, globe displacement, conjunctival chemosis, and progressive vision loss. The patient had been seen by an ophthalmologist at another hospital. The initial diagnosis was idiopathic orbital pseudotumor. Steroid therapy did not resolve clinical symptoms. Her medical history held decisive clues: ten years before this presentation she had been diagnosed with double primary breast cancer, invasive lobular breast carcinoma, and invasive ductal breast carcinoma. Orbital biopsy was performed for differential diagnosis. DISCUSSION: Considering the rapid onset and severity of symptoms, the radiological features of the orbit, and the patient's medical history of breast cancer, orbital metastasis should have been the most likely diagnosis. Orbital biopsy was performed because of the history of multiple primary cancers and because metastatic origin had to be determined to define the best treatment strategy. CONCLUSION: Biopsy is necessary under specific circumstances in the diagnosis of orbital metastasis, especially when presentation is ambiguous and when differential diagnosis is challenging. A patient's medical history may hold vital clues to correct diagnosis.

Cleft lip and palate outcomes: Multidisciplinary approach for comprehensive management.

In patients with cleft lip and palate the most common associated dental problem is lateral incisor agenesis, often associated with lack of support and definition of the nasal tip. In many cases, adhesions deriving from surgical procedures and skeletal discrepancy make orthognathic surgery and rhinoseptoplasty unavoidable. In the present case report a dental rehabilitation with canine substitution and prosthetic-implant treatment in a posterior area is described. The use, during rhinoseptoplasty, of a customized titanium prosthesis, which provides projection for the tip of the nose, is also introduced. The patient was administered two questionnaires in order to assess the psychological aspects related to the cleft outcomes and the influence that the treatment conveyed.

Biphasic solitary fibrous tumor of the orbit with distant metastases.

The aim of this study is to report the first case of biphasic solitary fibrous tumor (SFT) of the orbit with documented histological transformation and metastatic diffusion. We describe a case of a 23-year-old Caucasian man with recurrent SFT of the right orbit with intracranial invasion. The patient underwent surgical tumor removal via a right fronto-orbital approach. Histopathological examination showed a biphasic tumor pattern with both spindle cell and epithelioid components. The histopathological re-evaluation of previously removed lesions (1999 and 2004) confirmed the diagnosis of SFT, without any evidence of epithelioid component at that time. The patient developed local recurrence and systemic metastases (occipital foramen and clivus, paravertebral muscles and peritoneum) three years after surgery. We are unaware of previous reports of biphasic solitary fibrous tumor of the orbit with documented histological transformation and metastatic diffusion.

Secretory carcinoma of salivary glands with NTRK3 break-apart molecular rearrangement: Potential misdiagnosis with mucoepidermoid carcinoma.

A woman presented a right submandibular gland lesion with cytologic diagnosis of mucoepidermoid carcinoma. Patient underwent sialoadenectomy en bloc with supraomohyoid neck dissection. Positivity for ETV6-NTRK3 genes fusion on surgical sample led to final diagnosis of secretory carcinoma (SC). Secretory carcinoma has been renamed by WHO in 2017 from mammary-analogue-secretory carcinoma (MASC). Only 649 have been reported until 2019. While cytologic alteration are shared with other neoplasms as the acinic cell and mucoepidermoid carcinomas, ETV6-NTRK3 rearrangement is pathognomonic of SC. Although usually indolent and with low-stage presentation, SC has higher rate of local recurrences and nodal involvement than ACC. Surgical treatment represent the gold standard. Real prevalence of SC is probably underestimated due to the recent WHO 2017 reclassification. While cytologic analysis does not allow to discriminate SC from other malignancies, chromosomal examination is recommended. When low-grade SC is diagnosed, complete surgical resection assures good prognosis.

Folded Radial Forearm Free Flap for the Reconstruction of Total Soft Palate Defects: Operative Technique.

The surgical plan to reconstruct the palate must be carefully prepared given the morphological peculiarity of the soft palate forming both the roof of the mouth and the floor of the nasal cavity. This article focuses on the use of folded radial forearm free flaps to manage isolated defects of the soft palate in the absence of tonsillar pillar involvement. Methods: Three patients affected by squamous cell carcinoma of the palate underwent resection of the soft palate and immediate reconstruction with a folded radial forearm free flap. Results: All three patients showed good short-term morphological-functional outcomes as far as swallowing, breathing, and phonation were concerned. Conclusions: The folded radial forearm free flap seems to be an efficacious way to manage localized defects of the soft palate, given the positive outcomes of the three patients treated, and in accordance with other authors. In general, the radial forearm free flap was confirmed to be a versatile solution for those intraoral defects of the soft tissue requiring a limited quantity of volume as in the case of the soft palate.