Percutaneous Reduction of Isolated Zygomatic Arch Fractures: A 5-Year Experience.

PURPOSE: We evaluated the outcomes and differences in surgical time and hospitalization length for patients with an isolated zygomatic arch (ZA) fracture treated by percutaneous wire reduction with external fixation. PATIENTS AND METHODS: We designed and developed a retrospective study of patients with isolated ZA fractures treated from 2014 to 2019. The predictor variable was the operative treatment, represented by percutaneous reduction with external fixation. The primary outcome variables were the surgical time and hospitalization length. Other variables, including functional and esthetic results (evaluated by clinical and radiologic assessments) and the rate of immediate and delayed complications during a 6-month minimum follow-up period, were considered. Descriptive statistics were computed and compared with the international reported data. RESULTS: A total of 15 patients met specific inclusion and exclusion criteria. The 15 fractures were grouped using the classification reported by Kim et al as type 1A (n = 9) and type 1B (n = 6). No significant differences were found between the 2 groups, except for the fracture type. The operative treatment was performed with the patient under general anesthesia (n = 12) or local anesthesia with sedation (n = 3). Only 1 patient developed a complication (early hematoma). No other cases of early or delayed complications were reported. Two patients required a traditional surgical operation with the Gilles approach. The average hospitalization length and surgical time were 0.8 night and 18.4 minutes for the type 1A group and 0.7 night and 19.0 minutes for the type 1B group, respectively. Optimal esthetic and functional outcomes were obtained for all 15 patients. CONCLUSIONS: The results of the present study suggest that optimal esthetic and functional results can be obtained, minimizing the effect on soft tissues and patient discomfort, with a short surgical time and low rate of complications.

Dentoalveolar Fractures: New Orthodontic Protocol Proposal and Pilot Study.

The goal of fracture treatment that includes the dentoalveolar process is to obtain the anatomic bone healing and the pre-injury occlusion restoration with functional and aesthetic recovery, avoiding dental or periodontal lesions. Fractures activates, in the damaged tissue, the Regional Acceleratory Phenomenon, a physiological healing process that can also be activated during orthodontic overloads. Orthodontic treatment in the traumatized area could exploit this phenomenon in order to sustain the cellular activity.The aim of this study is to propose a treatment protocol for dentoalveolar fractures based on the use of orthodontics in order to sustain the physiological healing process known as Regional Acceleratory Phenomenon.The authors present 2 cases of an 18 year old woman and 23 year old man affected by dentoalveolar fracture. The operative protocol the authors applied foresaw three steps of treatment: orthodontic brackets application, surgery, orthodontic treatment.The patients showed complete healing at the 3 months follow-up and were treated up to 18 months for further orthodontic treatment.The operative protocol proposed by the Authors appears to be a rational choice since it allows a single orthodontic device to be an "active splinting system", with fast application time, good acceptance by the patient, low complications rate; moreover, it produces any planned dental movements for further orthodontic treatments.

Surgical Management of Large Odontogenic Cysts of the Mandible.

INTRODUCTION: Odontogenic cysts are defined as those cysts that arise from odontogenic epithelium and occur in the tooth-bearing regions of the jaws. Cystectomy, marsupialization, or decompression of odontogenic cyst are the most common treatments proposed for this pathology. The aim of this study is to retrospectively evaluate the result of decompression based on the volumetric reduction of the cystic cavity and new bone formation by cone beam computerized tomography (CBCT). METHODS: The 16 patients affected by a large odontogenic mandibular cyst were enrolled in the study. All the patients underwent a surgical decompression of the cyst followed by the enucleation after a follow-up ranging from 6 to 9 months according to the volume's reduction and new bone formation. All the patients were evaluated with a CBCT before and after the surgical decompression to measure and analyze the percentage of reduction of the cystic volume before proceeding with the enucleation. RESULTS: The decompression of the cyst showed a reduction of the cystic volume ranging from 38.2% to 54.4% proportionally to the treatment duration. The highest percentage of volume reduction observed was 54.4% in 1 patient followed-up for 9 months, before the surgical enucleation. CONCLUSION: In our experience, the decompression seems to be the most suitable technique for the primary treatment of large odontogenic cyst of the jaws followed by the enucleation after 6 to 9 months. The CBCT is an objective method to evaluate the cystic volume reduction after the decompression and helps the surgeon with the surgical planning.

Maxillo-Mandibular Reconstruction in Pediatric Patients: How To Do It?

Maxillo-mandibular reconstruction in pediatric patients involves particular functional and cosmetic implications. Attention is required for the craniofacial growth over time, involvement of the permanent dentition, facial symmetry, and donor site morbidity. Our aim is to identify the best reconstructive options for maxilla-mandibular defects in children (<18 years) based on our experience with 25 pediatric patients. We believe that reconstruction has to be performed at the same time as resection in pediatric patients. Local flaps should be reserved for cases of maxillary defects because of malignant neoplasms, which ultimately have poor prognosis. In cases of large mandibular defects, radiotherapy is eventually required. When the condition of the soft tissues is poor (because of previous surgery, etc), free flaps potentially represent the best options. Nevertheless, in patients younger than 5 years old (with no damaged tissues), reconstruction with rib grafts should be performed, and the use of titanium plates should be reserved for very select cases (such as temporary reconstruction in toddlers).

The Influence of Socioeconomic Factors on the Epidemiology of Maxillofacial Fractures in Southern Italy.

Maxillofacial fractures represent a serious public health problem. Their epidemiology is extremely variable and its analysis is crucial to establish effective treatment and prevention of these injuries. The aim of this multicentric retrospective study was to analyze causes, demographics, incidence, characteristics of 987 patients diagnosed with maxillofacial trauma between 2011 and 2015 at Complex Operative Unit of Maxillofacial Surgery of Federico II University of Naples and Magna Graecia University of Catanzaro, Italy; 657 male and 310 female patients were admitted in the study. The most frequently observed fracture involved the mandible (399 patients, 35.4%), followed by zygomatic complex (337 patients, 29.9%), orbital walls (160 patients, 14.2%), and nasal bones (129 patients, 11.4%). The most frequent cause of fracture was assaults (30.4%), followed by road traffic injuries (27.2%), falls (23.2%), sport accidents (15.4%), and others causes (2.6%). Significant variations of etiology have been detected between the 2 hospitals in relationship with different migration flow trends and cultural and socioeconomic features. Epidemiological analysis of maxillofacial fractures is crucial to identify the trauma burden and to help in developing a more efficient system to plan resource allocation and to deliver care and preventive measures establishing clinical and research priorities for effective treatment and prevention of these injuries.

Surgical evolution in the treatment of mandibular condyle fractures.

BACKGROUND: In Literature fractures of the mandible that involve the condyle ranges from 20% to 35% and various possible surgical options are described according to the varying pathological situations. Up to the present, numerous techniques have been used for the surgical treatment of condylar fractures. In this article we are proposing the combination of two surgical techniques as therapy for extra-capsular condylar fractures with dislocation. METHODS: From June 2003 to July 2007 30 patients were treated for condylar fractures with the application of a Rigid External Fixator under endoscopic assistance. This method includes a surgical reduction of the fracture with the aid of an endoscope, performing a transcutaneous insertion of a Rigid External Fixator to stabilize the fracture. RESULTS: Out of the total number of patients, 28 reached an optimal result without the need for temporary immobilization of the temporal mandibular joint and pre-auricular cutaneous access, thanks to the decisive aid of the video-endoscope. CONCLUSIONS: The endoscope allows perfect control over both the positioning of the external fixator and the surgical reduction, restoring the normal movement of the mandible with a return to full anatomical functioning of the temporo-mandibular joint. This approach avoids possible damages to the facial nerve branches. The rigid external fixation system is better than an internal one, because it is less restrictive in precise anatomical reduction, since with an REF the condylar fragment is kept in the correct anatomical position but is not obliged to maintain that exact position, and therefore it is possible to carry out all the repair mechanisms listed above. Endoscopic assistance allows a good positioning control of the REF although the endoscopy permits an optimal control of the condylemeniscal complex mobility after REF application.

Open reduction and internal fixation of extracapsular mandibular condyle fractures: a long-term clinical and radiological follow-up of 25 patients.

BACKGROUND: During the last 2 decades, many studies on the treatment of mandibular condyle fracture have been published. The incidence of mandibular condyle fractures is variable, ranging from 17.5% to 52% of all mandibular fractures. This retrospective study evaluated the long-term clinical and radiological outcomes after surgical treatment of 25 patients with a total of 26 extracapsular condyle fractures. METHODS: We used 2 types of surgical approaches, the retromandibular retroparotid or preauricular approach. Three kinds of rigid internal fixation plates were used-single plate, double plate, and trapezoidal plate. The following post-operative clinical parameters were evaluated: dental occlusion, facial nerve functionality, skin scarring, and temporomandibular joint functionality. All patients underwent post-operative orthopanoramic radiography and computed tomography. The patients were also monitored for complications such as Frey's syndrome, infection, salivary fistula, plate fracture, and permanent paralysis of the facial nerve; the patient's satisfaction was also recorded. RESULTS: Of the 25 patients, 80% showed occlusion recovery, 88% had no facial nerve injury, and 88% presented good surgical skin scarring. The patients showed early complete recovery of temporomandibular joint functionality and 72% of them were found to be asymptomatic. The postoperative radiographs of all patients indicated good recovery of the anatomical condylar region, and 80% of them had no postoperative complications. The average degree of patient satisfaction was 8.32 out of 10. Our results confirm that the technique of open reduction and internal fixation in association with postoperative functional rehabilitation therapy should be considered for treating patients with extracapsular condylar fractures. CONCLUSION: The topic of condylar injury has generated more discussion and controversy than any other topic in the field of maxillofacial trauma. We confirm that open reduction and internal fixation is the treatment of choice for patients with neck and sub-condylar mandibular fractures.

Superficial ulnar artery perforator flap.

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

Submental intubation in complex maxillofacial trauma: Pilot balloon protection.

AIMS: This study aims to describe our refined technique of submental intubation to avoid the recorded intraoperative complications related to tube passage and pilot balloon rupture. CASE SERIES: This is a retrospective case series of 21 patients with complex maxillofacial trauma who underwent submental intubation from January 2019 to January 2023. All the patients underwent to the same procedure with a new technique of pilot balloon protection: the pilot balloon was not deflated because, once the connector was removed, only the tube was curved and passed through the incision extraorally while the cuff remained inflated. The wire of the pilot balloon was passed behind the last tooth so as not to interfere with the maxillary-mandibular fixation, remaining extraorally under the anesthetist's view. DISCUSSION: Only 2 patients (9.5%) reported complications related to submental intubation: in particular a patient (4.8%) reported oral floor infection, and in another patient (4.8%) an unesthetic skin scar was observed. No patients reported intraoperative complications related to the procedure. CONCLUSION: The technique of pilot balloon protection that we have proposed seems to be effective in reducing the intraoperative complications related to the passage of the pilot balloon, such as rupture, damage or early extubation.

Mandibular reconstruction after post-traumatic complex fracture: Comparison analysis between traditional and virtually planned surgery.

BACKGROUND: Jaw reconstruction after complex post-traumatic fracture is still a challenge for surgeons using traditional surgery. Virtual surgical planning has proven to be a valid tool for managing these fractures. The aim of this study is to quantitatively evaluate the VSP effectiveness compared to traditional surgery in the management of complex mandibular fractures. METHODS: 30 patients with diagnosis of complex mandibular fracture were enrolled and divided in two groups: Group A (virtually planned surgery), The plate was pre-modeled and employed during the surgery; Group B (traditional surgery), the plate was shaped directly during the surgery. Virtually planned and post-operative Computer Tomography were after compared for both the groups to highlight discrepancies in mm. RESULTS: Fracture surgical reduction was successful without intraoperative complications. In Group A, all the mean discrepancies' values were <1 mm while in Group B the values were included between 1.36 and 1.94 mm. The mean operative time was 69 min for Group A, while 106 min for Group B. CONCLUSIONS: Fracture virtual reduction and realization of pre-modeled plate are able to guarantee a more anatomically correct reduction and a decrease in operating times. These outcomes translate into a decrease in both short and long-term complications.

New perspectives in the differential diagnosis of jaw lesions: Machine learning and inflammatory biomarkers.

This study aimed to assess the diagnostic performance of a machine learning approach that utilized radiomic features extracted from Cone Beam Computer Tomography (CBCT) images and inflammatory biomarkers for distinguishing between Dentigerous Cysts (DCs), Odontogenic Keratocysts (OKCs), and Unicystic Ameloblastomas (UAs). This retrospective study involves 103 patients who underwent jaw lesion surgery in the Maxillofacial Surgery Unit of Federico II University Of Naples between January 2018 and January 2023. Nonparametric Wilcoxon-Mann-Whitney and Kruskal Wallis tests were used for continuous variables. Linear and non-logistic regression models (LRM and NLRM) were employed, along with machine learning techniques such as decision tree (DT), k-nearest neighbor (KNN), and support vector machine (SVM), to predict the outcomes. When individual inflammatory biomarkers were considered alone, their ability to differentiate between OKCs, UAs, and DCs was below 50 % accuracy. However, a linear regression model combining four inflammatory biomarkers achieved an accuracy of 95 % and an AUC of 0.96. The accuracy of single radiomics predictors was lower than that of inflammatory biomarkers, with an AUC of 0.83. The Fine Tree model, utilizing NLR, SII, and one radiomic feature, achieved an accuracy of 94.3 % (AUC = 0.95) on the training and testing sets, and a validation set accuracy of 100 %. The Fine Tree model demonstrated the capability to discriminate between OKCs, UAs, and DCs. However, the LRM utilizing four inflammatory biomarkers proved to be the most effective algorithm for distinguishing between OKCs, UAs, and DCs.

Full Digital Workflow for Mandibular Ameloblastoma Management: Showcase for Technical Description.

This is a showcase for technical description of a full digital workflow aimed to reconstruct and prosthetically rehabilitate the mandible after surgical resection. The surgery was performed following a computer-aided design and computer-aided manufacturing (CAD-CAM) guided workflow, using 3D reconstruction of the mandible and the fibula. After 2 years, when the ossification of the flap was reached and verified by a computed tomography (CT) scan, surgery was performed using a two-step implant rehabilitation, with successful outcomes.

Bifocal mandibular fractures: which should be treated first?

Fractures of the mandible have been reported to account between 40% and 62% of all facial fractures. Most surveys show that just under 50% are isolated, the same amount are doubly fractured. This study aims to clarify, according to our experience, the correct surgical sequence which should be followed in order to treat bifocal mandibular fractures. From January 2004 to January 2009, we have conducted a retrospective study on a sample of patients operated on in our department because of bifocal mandibular fractures. We include only those cases in which the jaw was fractured in 2 places, in particular patients who suffer a fracture in tooth-bearing areas (symphysis, parasymphysis, and anterior body) and also contralaterally in non-tooth-bearing areas (posterior body, angle, ramus, and condyle). The sample was divided into 2 groups based on the fracture sequence of reduction. At 1-year follow-up, the group of patients who received first the tooth-bearing fractured areas treatment, followed by treatment of non-tooth-bearing fractured area on bifocal mandibular fracture, showed less postoperative complications and reduced surgical time and costs. It is recommended from this study that reduction of the tooth-bearing fragment be prior to that of the tooth-free fragment for the bifocal mandible.

Surgical Approaches in Odontogenic Orbital Cellulitis (OOC): Our Experience and Review of Literature.

Aims Odontogenic orbital cellulitis represents a complication of root infections of upper pre-molars and molars. The severity depends on the orbital structure involved. The treatment is based on antibiotic therapy associated or not to surgery. Through the presentation of three cases and a review of literature, we purpose as aim of our study to underline the necessity of a timely diagnosis and to provide the correct surgical approach in each different types and stages of orbital infections. Methods We present three patients that were affected by dental infection evolved in orbital cellulitis. In two cases the disease was solved with the extraction of infected tooth and a surgical endoscopic drainage of the abscess through antrostomy of maxillary sinus. In the third patient the disease had already induced a bulbar perforation and endophthalmitis, so an orbit evisceration was necessary. Results Review of literature showed that the standard treatment of orbital cellulitis is the transnasal approach associated or not by a transoral and/or transcutaneous procedure depending on the stage of the disease and on the causes. In our 3 cases these indications were followed without relapses of the disease. Conclusion An early diagnosis is mandatory in odontogenic orbital cellulitis specially to avoid serious complications. Surgical treatment can be simple and effective mostly in early-stage infection: it is based on extraction of infected tooth and on the drainage of abscess. Surgical approach consists in transnasal procedure flanked or not by transoral and transcutaneous procedures based on the stage of the infection considering involved structures.

Condylar Reshape in Orthognathic Surgery: Morphovolumetric and Densitometric Analysis Based on 3D Imaging and Digital Workflow.

Background: Condylar remodelling (CR) is a complex of phenomena that generates in response of the temporo-mandibular joint to forces and stress to maintain a morphological, functional and occlusal homeostasis. The most worrying aspect of the condylar reshape is the condylar resorption which implies fast loss of vertical dimension (>6% of pre-surgical value), mandibular retraction and open bite with preserved articular function. Materials and Methods: Six parameters were analysed to study the condyles of twelve patients that underwent orthognathic surgery. The digital workflow was then described to make it reproducible enabling a more in-depth study of the reshaping processes that involving the condyle after a great stress like the surgery. Results: The results of our study showed many statistically significant variations of the studied parameters. In all patients, it was noticed a decreased bone density (p = 0,002 per side). Objectives: The aim of our study, with the aid of the contemporary 3D imaging and digital modelling and workflow technologies, is to investigate and analyse quantitatively and qualitatively the adaptative processes occurring in CR following bimaxillary repositioning. To the best of our knowledge, this is the only paper that investigates the CR considering six different variables at once.

Nasal Septal Deviation After Surgically Assisted Rapid Maxillary Expansion.

Background and Aim: Surgically assisted rapid maxillary expansion (SARME) is a surgical technique widely used to correct deficiency of the transverse maxillary dimension. Although some studies investigated the effect of SARME on nasal and facial alterations, there is no evidence that correlates nasal septal deviation (NSD) to SARME as a possible postoperative sequel. The aim of this study is to address and quantify possible variations in the position of the nasal bony septum after SARME and identify any NSD as a postoperative outcome of this surgical technique. Patients and Methods: This is a retrospective study, conducted at the Department of Oral and Maxillofacial Surgery of the University Hospital of Araraquara (Unesp, faculty of dentistry), SP, Brazil. Twenty-nine patients who underwent SARME were studied; every patient was evaluated by cone-beam computerized tomography (CBCT) before (T0) and six months after surgery (T1), and we collected the variation of nasal septal position by measuring the distance between the bony septum and the nasal lateral wall. Our measurements were carried out at the level of the head, midpoint and tail of the inferior turbinate. Results: A mean NSD ranging from 0.4 to 1.2 mm was measured, and it is more pronounced at the anterior part of the bony septum. Twenty-seven patients (93.1%) presented minor changes in bony septum position; in 2 cases (6.8%), a significant NSD was found (p < 0.05). Conclusion: A variation of bony nasal septum position can be expected in any direction after SARME, and it is more pronounced at anterior portion.

Benign Paroxysmal Positional Vertigo After Oral and Maxillofacial Surgery: Our Experience and Review of Literature.

OBJECTIVES: The aim of our study is to evaluate the influence of patient risk factors and the length of surgical time on the onset of BPPV (benign paroxysmal positional vertigo) and suggest surgical and clinical strategies to prevent this rare complication. METHOD: Our retrospective study analyzes that, in 2 years, 281 patients, divided into three groups, underwent wisdom teeth extraction, sinus lift elevation and orthognathic surgery, at the Oral and Maxillofacial Department of the University of Naples "Federico II." RESULTS: Twenty-one patients presented postoperative BPPV. Some comorbidities, like dyslipidemia, high cholesterol levels, vascular problems, endocrinological disorders, perimenopausal age, female gender, cranial trauma, neurologic disorders, migraine, hypovitaminosis D, autoimmune disease, flogosis of inner ear, can be risk factors to the occurrence of postoperative vertigo. CONCLUSION: Our statistical analysis revealed a relationship between surgical time and comorbidity and onset of vertigo for each group of patients.

Low-cost, self-made CAD/CAM-guiding system for mandibular reconstruction.

Facial symmetry, as well as function, remains the big challenge for surgeons who attempt mandibular reconstruction. Nowadays several studies recommend the use of computer aided surgery (CAS) and CAD/CAM technology to guide mandibular segmental osteotomies and reconstruction using free fibula flap. Although these systems have radically changed the way of doing mandibular reconstructive surgery, they are expensive and require extended periods of time for prototypation. This may be an important limitation in case of malignant neoplasms which require short-term treatment. The aim of our study is to investigate the reliability and efficiency of a protocol to obtain cutting guides produced in a "homemade" way. This study includes four consecutive patients who underwent a segmental mandibulectomy and fibula osteo-cutaneous free flap reconstruction for oral squamous cell carcinoma between January and September 2016. The CAD/CAM system algorithm proposed was based on the use of free open source software for digital planning and 3D layer plastic deposition printer. A cost of about 3 Euro for each case was estimated. An average mean distance between 3D preoperative and postoperative mesh points of 1.631 mm and a standard deviation of 5.496 mm has been demonstrated by 3D volume overlay analysis. Overlapping results with much shorter prototyping time was required with the in-house procedure described as compared to the available commercial system. In conclusion, we expect that this technique will reduce operative time and cost however further study and large series are needed to confirm our results and better define the applicability in everyday surgical practice.

The epidemiological analysis of maxillofacial fractures in Italy: The experience of a single tertiary center with 1720 patients.

PURPOSE: Maxillofacial fractures represent a serious public health problem. Their epidemiology is extremely variable, and its analysis is crucial to establish effective treatment and prevention of these injuries. However only two works have been published about maxillofacial fracture epidemiology in Italy. MATERIALS AND METHODS: The records of 1720 patients diagnosed with maxillofacial fractures in a 15-years period (2001-2015) in our department were retrospectively reviewed. RESULTS: A total of 1108 male and 612 female patients were included in the study. The most frequent aetiology of fracture was road traffic injuries (57.1%), followed by assault (21.7%), falls (14.2%), work accidents (3.5%), sport accidents (3.3%) and other causes (0.2%). Significant variations of aetiology were detected between males and females and between Italians and individuals from other countries. The most frequently observed fracture involved the mandible (861 cases, 36%), followed by zygoma (489 cases, 20.4%), orbital walls (386 cases, 16.1%) and maxilla (282 cases, 11.8%). CONCLUSION: Road traffic legislation enforcement and continuous public education regarding the use of security devices remain an ongoing problem in our region and should be encouraged. In the same way, as migration flows influence and change the epidemiology of facial traumas, it is crucial to establish social support programs that avoid these disadvantaged categories of victims of violence and crime.