Sagittal split osteotomy of the fibula for modeling the new mandibular angle.

Fibula modeling techniques for mandible reconstruction carry a high risk of bone perfusion impairment and low predictability of osteotomy angles. To restore the parabolic shape of the mandible, the number of osteotomies should be as small as possible to preserve both periosteal and endosteal perfusion. We report our approach with sagittal split osteotomy (SSO) technique for mandibular angle reconstruction.Obwegeser-Dal Pont SSO of fibula flaps was performed on 10 patients who underwent mandibular angle reconstruction. Bone segments were tilted according to stereolithographic template and fixed with 3 bicortical screws in triangular fashion. Fibula-gonial angle at 15 days and 6 months from surgery was compared with the contralateral-mandibular-gonial angle using Kruskal-Wallis test with a P < 0.05 considered significant.Mean bone length and skin paddle size were 15.6 cm (range, 13-18 cm) and 22.5 cm (range, 3 × 4 cm to 11 × 5 cm). Bone unions occurred at 12 months (mean follow-up, 39 months). No differences (P > 0.05) between fibula-gonial angle at 15 days (mean, 122.88 ± 0.55 degrees; range, 122.49-123.27 degrees) and 6 months (mean, 123.36 ± 0.88 degrees; range, 122.73-123.99 degrees) and contralateral-mandibular-gonial angle (mean, 123.20 ± 0.80 degrees; range, 122.62-123.77 degrees) were observed.Fibula SSO allows for new-mandible angle shaping, reducing risk of pedicle and endosteal vascular impairment. Triangular bone fixation thereby emerges as a reliable technique, enhancing functional and aesthetic long-term outcomes.

Ameloblastic carcinoma: rare localization of a rare neoplasm.

Ameloblastic carcinoma (AC) is a rare neoplasm of the maxillofacial district. It usually occurs in the posterior region of the jaw. In one third of cases, it occurs in the maxilla, usually in the posterior portion. From a review of international literature, we found 60 cases described. A 77-year-old patient presented to our division of maxillofacial surgery after the onset of a vegetans lesion of the maxilla. He had already been subjected to a first histologic examination that detected an AC. Surgery consisted of removal of a trapezoidal flap of the maxillary bone containing the mass. Histologic examination confirmed preoperative biopsy findings. Because of the low compliance, we did not plan for surgical reconstruction.Surgical resection is the treatment of choice for this kind of lesion, leaving at least a 2-cm free margin. Neoadjuvant radiotherapy may be useful for tumor debulking.

Retroauricular transmeatal approach to manage mandibular condylar head fractures.

BACKGROUND: There is a multitude of reported surgical approaches and technical variants with some unresolved technical problems to gain direct access to mandibular condylar head fractures; they can be divided into 2 groups: intraoral and extraoral. In 2005, Neff et al (Mund Kiefer Gesichtschir 2005;9:80), supported by a previous experimental work, reported a successful clinical study of condylar head fractures treated by a retroauricular approach; this article is in German, and the later English-language literature does not mention about this approach to open reduction and internal fixation of mandibular condylar fractures. The retroauricular transmeatal access, selected and performed by the senior author to treat 14 patients affected by highly located condylar head fracture, is illustrated in details. METHODS: We collected data of 14 consecutive adult patients who, after the discussion about all options, had consented to have 16 mandibular condylar head fractures treated with open reduction and internal fixation by miniplates and screws via a retroauricular transmeatal approach. We exposed the temporomandibular joint area easily and better by dissecting via a retroauricular route with identification, ligation, and transection of the retromandibular vein; because of the posterior access, the frontal branch of the facial nerve and the auriculotemporal nerve are located and protected within the substance of the anteriorly retracted flap, superficial to the retromandibular vein. The follow-up clinical examination showed temporary weakness of the frontal branch of the facial nerve in 1 case with a recovery to normal function of 1.6 months; no patients had permanent weakness of the facial nerve or injury of the auriculotemporal nerve. There was absence of any salivary fistula, sialocele, and Frey syndrome; hearing was preserved in all cases, without any auditory stenosis or aesthetic deformity, and there was absence of any infections, hematoma, or scarring. CONCLUSIONS: Retroauricular approach provides good exposure of the temporomandibular joint and satisfactory protection from nerve injuries and vascular lesions, allowing an adequate osteosynthesis. The scar is hidden behind the ear, and the morbidity is low in terms of auditory stenosis, aesthetic deformity, and salivary fistulas.

Management of an exposed mandibular plate after fibula free flap with vacuum-assisted closure system.

INTRODUCTION: In 1997, Morykwas et al introduced negative pressure dressings to manage complicated wounds; since its introduction, the vacuum-assisted closure (VAC) system has been successfully used in the fields of general surgery, orthopedic surgery, plastic surgery, and gynecology. Recently, some authors described this technique to manage complex wounds in the craniomaxillofacial region; we introduce the case of exposed peroneal bone and mandibular reconstruction plate after a fibula osteomyocutaneous free flap managed with this method. CLINICAL REPORT: A 41-year-old man presented an advanced mandibular osteoradionecrosis with an extensive composite three-dimensional defect of the lower jaw involving the oral mucosa, the mandibular bone, the external skin, and the soft tissue, with a clear communication between the oral cavity and the exterior. A subtotal mandibulectomy and a fibula osteomyocutaneous free flap to reconstruct the defect was performed; 1 month after surgery, the patient presented an exposition of a segment of the fibula and reconstruction plate. The patient was put on VAC for 20 days before a pedicle pectoralis major musculocutaneous flap was performed as definitive reconstruction. DISCUSSION: The advantages of the VAC device in the management of complicated craniofacial wounds have been discussed by a multitude of experimental and clinical studies. This method removes fluids and infectious materials and helps draw together wound edges, increasing blood flow and promoting wound healing. Of the 2 proposed mechanisms (fluid-based and mechanical), it seems that the latter is of greater importance in the production of new tissue. Up-to-date adequate surgical debridement, wet-to-dry dressing changes, and appropriate antibiotic treatment remain the mainstay in treating complex craniofacial wounds; however, in selected cases, the VAC system can be used to achieve a primary closure or to provide a transitory coverage preparing the wound bed until a definitive reconstruction is planned and/or performed. CONCLUSIONS: This therapy is a safe, innovative, and useful tool and can be of great assistance especially in complex craniofacial wounds, but it poses some problems such as intricate contours and orifices of the head and neck region, painful dressing changes, and remarkable costs.

Canine fossa puncture in endoscopic sinus surgery: report of two cases / Punção da fossa canina em cirurgia endoscópica sinusal: relato de dois casos

Abstract Introduction: Chronic rhinosinusitis with nasal polyposis is a common chronic disease that often affects maxillary sinus. Endoscopic sinus surgery is the most common procedure for treating the majority of maxillary sinus lesions. Objective: To demonstrate the role of canine fossa puncture during endoscopic sinus surgery procedure in patients with severe maxillary sinus disease. Methods: We present 2 cases where canine fossa puncture has been performed as method to obtain a complete access to the maxillary antrum. Results: According our experience, 2 cases on 296 endoscopic sinus surgery (0.6%) where antrostomy and used of angled microdebrider were not sufficient, canine fossa puncture has been performed as an alternative method to obtain a complete access to the maxillary antrum. Conclusion: Although the advent of endoscopic sinus surgery, our cases support the fact that actually canine fossa puncture is a minimally invasive technique useful in selected cases.

Resumo Introdução: A rinossinusite crônica com polipose nasal é uma doença crônica comum que frequentemente afeta o seio maxilar. A cirurgia endoscópica sinusal é o procedimento mais comum para tratar a maioria das lesões do seio maxilar. Objetivo: Demonstrar o papel da punção da fossa canina durante o procedimento de cirurgia endoscópica sinusal em pacientes com doença grave do seio maxilar. Método: Apresentamos dois casos em que a punção da fossa canina foi feita como método para obter acesso completo ao antro maxilar. Resultados: De acordo com nossa experiência, dois casos em 296 cirurgias endoscópicas sinusais (0,6%) nos quais a antrostomia e o uso de microdebridador angular não foram suficientes, a punção da fossa canina foi feita como um método opcional para obter acesso completo ao antro maxilar. Conclusão: Apesar do advento da cirurgia endoscópica sinusal, os nossos casos apoiam o fato de que a punção da fossa canina é uma técnica minimamente invasiva útil em casos selecionados.