Segmental maxillary osteotomy in cleft lip and palate patients: a stepwise planning in the orthodontic pre-surgical preparation with Invisalign.

AIM: To show the potential of Invisalign in multi-segmental Le Fort I preparation with the aid of an occlusogram-like method. METHODS: Nine patients treated with Invisalign before segmental osteotomy of the maxilla (study sample) were matched for diagnosis, surgical procedure, and complexity of orthodontic preparation with nine patients treated with fixed appliances (control sample). A superimposition technique was adapted to complement the Invisalign software to carry out an appropriate ClinCheck in segmental pre-surgical treatments. The correct pre-surgical positions of the maxillary teeth were guided with the use of virtual added curves that followed the lower arch. The number of impressions needed in both groups to reach adequate pre-surgical coordination of the segmented arches was compared. CONCLUSION: With the aid of the proposed superimposition method, during the digital simulation of presurgical movements, clear aligner therapy appears to be an effective treatment even in patients with skeletal discrepancies and craniofacial anomalies involving the need for segmental Le Fort I osteotomies. More sophisticated software will certainly be implemented in the future.

Iliac crest fresh-frozen allografts and autografts in maxillary and mandibular reconstruction: a histologic and histomorphometric evaluation.

AIM: The aim of this paper was to compare histologically and histomorphometrically the osseointegration of iliac crest fresh-frozen allografts and autografts in human pre-prosthetic maxillary and mandibular onlay bone blocks reconstruction. METHODS: Twelve patients with edentulous atrophic ridges, scheduled for implant-supported prosthetic restorations, underwent reconstruction using iliac crest fresh-frozen allografts (group A, six patients) or autografts (group B, six patients). Four-to-nine months later implants were placed in the augmented areas and bone specimens were simultaneously obtained using trephine burs. The specimens were processed for ground sections and evaluated histologically and histomorphometrically. RESULTS: The postoperative course was uneventful in all patients in group B and in all except one in group A. Late complications occurred in 5 patients of group A. Dental implants could be inserted in all cases. Specimens from group A showed a vascularized bone with osteoprogenitor stem cells and medium-high grade of bone remodeling. Small areas of necrotic bone were observed sporadically. Sections obtained from group B revealed an advanced stage of bone remodeling. The histomorphometric analysis showed in group A a mean proportion of 24.7±14.7% for lamellar bone, 28.4±13.3% for newly formed bone and 46.9±16.9% for bone marrow; in group B the corresponding values were 25.3±15.3%, 22.9±11.0%, 51.7±15.7%. No statistically significant difference was found (Wilcoxon Test; P>0.05). CONCLUSION: There were no significant histological differences between group A and B. Larger studies with long term follow-up are needed to confirm that fresh-frozen allografts are a reliable alternative to autografts.

The role of the dentist and the orthodontist in early diagnosis of Gorlin-Goltz syndrome: a cephalometric and photometric study.

AIM: The aim of this study was to analyse the facial characteristics and the craniofacial morphology in GGS patients in order to enable an early diagnosis. BACKGROUND: Gorlin-Goltz syndrome (GGS) is a autosomic dominant disease, characterised by basal cell carcinoma, palmar/plantar pits, maxillary and mandibular keratocysts and dental abnormalities. METHODS: Nine out of a sample of 24 GGS patients had complete cephalometric and photographic records at an average age of 8.7 years. Cephalometric and photometric analysis were carried out with standard analyses and compared with healthy patients matched for sex and age. CONCLUSION: Early diagnosis of GGS based on clinical features could be useful to identify the presence of keratocysts through x-ray examination proceeding with surgical removal at an early stage, limiting space occupying damages.

Non-surgical treatment of vertical excess of the premaxilla in growing bilateral cleft lip and palate patients.

Patients with bilateral complete cleft lip and palate (BCLP) may present a vertical excess of the premaxilla in childhood. This is a severe functional and aesthetic problem, where bone grafting is more challenging. The aim of this study was to describe a simple and reproducible non-surgical orthopaedic treatment for vertical excess of the premaxilla in the deciduous/early mixed dentition phase in BCLP patients. Six growing patients with complete BCLP with a severe vertical excess of the premaxilla were included. An intrusion device associated with a bonded rapid palatal expander was applied to intrude the premaxilla. Radiographic and photographic records obtained before and at the end of the orthodontic intrusion, at short- and long-term follow-up, were available. A flattening of the occlusal plane was achieved in all patients. Normalization of the position of the maxillary incisors and gingival display in relation to the upper lip was obtained, and an improvement in anterior nasal spine position was also observed in all cases. The novel technique described might be of assistance in treating BCLP children with vertical excess of the premaxilla during the deciduous/early mixed dentition phase. This simplified, easily reproducible method may allow the burden of care of this rare but complex problem affecting BCLP patients to be reduced significantly.

Lingual nerve lesion during ranula surgical treatment: case report.

Iatrogenic lingual nerve (LN) injuries are quite common in oral surgery both in maxillo-facial surgery and in oral surgery. LN runs superficially into the lateral mouth floor just beneath the mucous layer and this position enhances damage frequency. This article lists the different aetiologies of iatrogenic LN injuries and it almost focuses on lesions due to surgical treatment of ranulas. In the case report a LN lesion due to oral ranula excision is discussed; the patient experienced anaesthesia and hyperpatia in the corrisponded tongue side. It was treated with a microneurosugical anastomosis of LN, after amputation neuroma excision. The partial and definitive recovery of perception happened in six months and was deemed satisfying with 70% of functionality restored (results compared with the functionality of the contralateral side). An algorithm for diagnosis and therapy indication for iatrogenic injuries to nerves is also proposed. In case of surgical treatment, funcitonal recovery manifests after 4-6 month; a functional recovery of 70% of total nerve function is possible. The variable that most affects nerve functional recovery is surgical treatment timing; it must be performed as soon as possible.

Maxillary shape at the end of puberty in operated unilateral cleft lip and palate: A geometric morphometric assessment using computer tomography.

INTRODUCTION: Cleft lip and palate (CLP) surgery interferes with maxillary growth and contributes to transversal and sagittal growth impairment. Our retrospective descriptive study aimed to evaluate maxillary bone shape in a homogenous unilateral CLP patient group using geometric morphometrics based on CT-scan data. MATERIAL AND METHODS: We included all patients with available CT-scans at the end of pubertal growth and operated on at Smile House of Milan, according to the standard protocol, involving two surgical steps: (1) primary closure of the lip and soft palate at 6 months of age and (2) early secondary gingivoalveoloplasty (GAP) associated with hard palate repair at 18-36 months. Shape differences between CLP and an age-matched control group were characterized using geometric morphometrics based on 15 3D landmarks. RESULTS: We included 16 unilateral CLP patients and 20 age-matched controls. Principal component and canonical variate analyses showed that the maxillary shape in CLP was significantly different from controls but that this difference was limited. Linear and angular measurements confirmed these differences. CONCLUSION: Early secondary GAP results in satisfactory maxillary shape, with significant but limited differences relative to controls.

Transthoracic hernia after harvesting a costal and latissimus dorsi flap.

Ribs are one of the most widely used grafts in craniofacial surgery. Harvesting a costochondral graft is easy and safe. The main complications are related to pneumothorax and chest-wall deformity in children. A complication is described in a patient who underwent an orbito-zygomatic reconstruction with two contiguous ribs and a latissimus dorsi free flap, and who subsequently developed a transthoracic hernia that required reconstruction with polypropylene mesh.

Ossification of vascular pedicle in fibular free flaps: a report of four cases.

The fibular free flap is the most widely used flap for jaw reconstruction. Flap contouring requires removal of bone excess in the proximal segment by a subperiosteal dissection, preserving vascular connections between the pedicle and the bone and leaving well vascularized periosteum attached to the vascular pedicle. Among about 100 reconstructions with fibular flaps, 4 cases were observed of abnormal ossification along the vascular pedicle. Periosteum preserves its osteogenic capability after transposition, especially in a revascularized flap; this characteristic, together with the direct contact with the bone, allows the possibility of new bone formation along the pedicle. It would appear necessary to change the technique of reducing fibular excess, with removal of periosteum together with the bone, in order to avoid the complication described.

Pericranium graft in reconstructive surgery of atrophied maxillary bones.

In preprosthetic surgery the autologous bone is universally considered the gold standard. Calvaria is, among many options, one of the preferred for its unique characteristics of hardness, easy of harvest and very low morbidity at donor site. Moreover, it gives the possibility of harvesting the pericranium. This technique, recently introduced in common practice in Milan, allows to harvest a large quantity of periosteum to cover bone grafts perioperativly. Periosteal tissue is used to cover bone grafts for two reasons. First, it would provide a layer of tissue that, thanks to its osteogenic potential, would prevent bone resorption. Second, this would interpose a layer of soft tissue to act as a cushion between the bone and mucosal flap to minimize the risk of wound dehiscence, that would bring to bone exposure and consequent failure of reconstruction. Five jaw reconstructions were performed with autologous bone and pericranium. In all cases the outcome was good, the grafts took with correct bone volume preservation. Implants were positioned according to prosthetic needs. In one case a vascular necrosis of a mucosal flap occurred. Bone exposure was prevented by the periosteum, which was revascularized after few days, allowing bone integration. Considering its potential protective capability towards bone grafts and the lack of donor site morbidity, this technique should be considered as a standard procedure in preprosthetic reconstructive surgery.

Surgical treatment of bifid mental nerve damaged by root canal therapy. A case report.

This article describes the successful surgical treatment of a case of damage to the inferior alveolar nerve, due to inadvertent extrusion of endodontic material into the mandibular canal. The accident was favoured by an anatomical variant of the nerve canal ending with a double mental foramen, already described in the literature. The complex surgical operation of uncertain outcome was dictated by neuralgia refractory to medical treatment, rather than hypoesthesia associated with compression of the nerve trunk. Problems related to loss of sensitivity and possible causes of nerve damage (traumatic, pathological and iatrogenic) are discussed.

The free fibula flap for treating benign mandibular lesions.

UNLABELLED: A variety of benign lesions that are typically treated conservatively can affect the mandible. The treatment must be radical when these lesions are locally aggressive and involve the perimandibular soft tissues or involve most of the thickness of the mandible. The main treatment is mandibular resection and reconstruction with bone grafts, mainly iliac crest bone grafts for segmental mandibulectomy or a calvaria bone graft for resection without interruption of the mandible body. These grafts are limited due to the possibility of infection and the unpredictable long-term resorption. Free flap surgery, particularly with fibula free flaps, represents a new era in mandibular reconstruction. This technique has similar donor site morbidity, while the transferred bone resists infection and bone resorption. These advantages are achieved at the cost of a procedure that is about 1 h longer when performed by an experienced microsurgical team. We report our experience with mandibular reconstruction following the surgical resection of benign lesions in 7 patients. All the reconstructions had good RESULTS: After reconstruction, the facial morphology showed restored symmetry of the lower third profile in all patients. The functional results were satisfactory, with restored mandibular function in all cases. No signs of recurrence have appeared in any patient after a mean follow-up of 24 months.

Prevention of bisphosphonate-related mandibular fractures.

Mandibular fracture is usually the clinical end of bisphosphonate-related osteonecrosis of the jaw. This is a painful complication and patients cannot feed as usual, with a worsening of their quality of life. The goal of treatment in bisphosphonate related osteonecrosis of jaw (BRONJ) patients is to slow progression of bone necrosis. We present a novel technique for treatment of severe mandibular BRONJ in stage 3 patients that present with a high risk to develop fracture, since they have a residual unaffected mandibular bone height less than 6 mm. We treated 10 patients in this clinical situation with an extra-oral application of a reconstructive plate superficial to the platysma, to keep the plate separated from the infected site to avoid contamination and consequent need of removal, followed by an intraoral approach for active curettage of mandibular necrosis. The preservation of blood supply to the mandible and avoidance of direct contact of the infected site with the reconstructive plate are some advantages of this technique. This plate allows enhancement of mandibular strength, allowing proper treatment of the BRONJ site on the oral side without fear of causing a mandibular fracture when the residual mandible is thin. This technical solution guarantees these patients an extended disease-free period since it is effective in preventing mandibular fractures in patients with low mandibular residual height left after the BRONJ onset.

Technical refinements in mandibular reconstruction with free fibula flaps: outcome-oriented retrospective review of 99 cases.

Congenital disease, major trauma, tumour resection and biphosphonate-related osteonecrosis can lead to partial, subtotal, or total loss of the mandibular bone. Minor defects can be easily reconstructed using bone grafts, whereas microvascular free tissue transfer may be unavoidable in the case of major bone loss or poor quality of soft tissue. Simple bone or composite osteocutaneous fibula free flaps have proven invaluable and remain the workhorse for microvascular mandibular reconstruction in daily practice. Our experience with 99 consecutive fibular free flaps confirms the available data in terms of high success rate. In these cases, 90% had total success, while 7 had complete flap failures. Three of our patients showed skin paddle necrosis with bony conservation. This report focuses on the technical refinements used by the authors that can prove valuable in obtaining predictable and precise results: in particular, we discuss surgical techniques that avoid vascular pedicle ossification by removing the fibular periosteum from the vascular pedicle itself and reduce donor site morbidity and aid in management of the position in the new condylar fossa. Finally, new technologies such as intraoperative CT and custom premodelled fixation plates may also increase the predictability of morpho-functional results.