Use of Submental Intubation in the Full-Face Makeover (Orthognathic Surgery, Facial Prosthesis Combined With Rhinoplasty).

BACKGROUND: Submental intubation is an intubation technique used for the management of airways in patients who suffered from complex maxillofacial trauma. Few studies focused on the role of submental intubation during Full-Face Makeover, like orthognathic surgery, facial prothesis, and rhinoplasty. METHODS: Authors describe a case series of 5 patients who underwent to Full-Face Makeover with submental intubation to manage the airways. The authors started with the Le Fort I subspinal osteotomy. The maxillary repositioning was guided through a 3D printed intermediate splint in all cases (previously simulated with Dolphin software).Subsequentially, the bilateral sagittal split osteotomy was performed. The mandibular repositioning was guided through a 3D printed final splint. The genioplasty was performed with a horizontal osteotomy after a labial mucosa incision. After the genioplasty, the authors used the incision previously used for the Le Fort I osteotomy to bluntly dissect the tissues in order to insert a custom-made polyether ether ketone zygomatic prosthesis. Lastly, an open rhinoplasty was performed. RESULTS: All the surgery lasted a mean less 6 hours. The submental intubation was removed in the operating room, at the end of the surgery. The patients were then discharged from the hospital 2 days after the surgery in all cases. CONCLUSIONS: Submental intubation is a valid method for the airway management in maxillofacial trauma and can be extended in case of Full-Face Makeover like orthognathic surgery combined with rhinoplasty. The absence of nasal traumatism during surgery leads to a more accurate rhinoplasty, with a greater satisfaction for the patient.

Captain America's Shield Genioplasty.

ABSTRACT: The chin represents one of the most important determinants of the facial aesthetics. Like many aesthetic parameters, the "ideal" chin has changed in history regarding projection and prominence. From the retrusive profiles of the Renaissance, stronger and more defined mandibular contour are nowadays desired both by masculine and feminine population.This change in the ideal references plays an important role in diagnosis and treatment planning. Various techniques for chin augmentation have been described, using both alloplastic materials and osteotomies.An interesting osteotomy variant, so-called chin shield osteotomy, has been described by Triaca et al to avoid a deep mentolabial fold. The authors describe herein the use of a shield plate, very similar in his form to Captain America's shield, that can at the same time provide bone fixation and soft tissues sustain in the mentolabial fold region, preventing the invasion of the gap between the bone fragments by the connective tissue, as it happens in a guided bone regeneration procedure.

The Pyramid Chin Augmentation: A New Technique.

ABSTRACT: The surgical approach to chin for esthetical purpose can be isolated or in a combination with other treatments like maxillomandibular surgery. Both possibilities include sliding genioplasty or implants of autologous or alloplastic materials. In this article, the authors present their new technique, the Pyramid Chin Augmentation.In January 2020, a 40-year-old male patient came to authors' observation asking for a great augmentation in the sagittal dimension of the chin, a better pronunciation of mandibular angles and of his cheekbones. The surgical treatment consisted in three different procedures at the same time: a chin wing osteotomy, a Pyramid Chin Augmentation and zygomatic PEEK custom-made malar implants. The pyramid was created on the body of the chin wing with a cortical bone graft from the oblique line of the ascending ramus of the mandible. The harvested bone was cut into strips of rectangular shape gradually shorter to be superimposed on the wing forming a pyramid. A fixation with 2 screws was performed and then was necessary to smoothen the edges of the bone layers.The result immediately after the end of the surgery was in line with the set goals. The mandibular angles were more prominent, the chin was more sagittal pronounced, and there was no evidence of depression in the symphysial region.The Pyramid Chin Augmentation Technique can be a valid tool in chin augmentation surgery and can also represent an effective procedure in the finishing touch of other facial surgery techniques.

Unilateral Condylar Hyperplasia: A Comparison With Two Open-Source Softwares.

Unilateral condylar hyperplasia (UCH) is a condyle disorder that arises due to osteoblastic hyperactivity, resulting in facial asymmetry, malocclusion and dysfunction. Authors, in this retrospective study, compared "gold standard" manual-segmentation with a "semi-manual one" using 2 kinds of open-source software (Horos and ITK-SNAP; Penn Image Computing and Science Laboratory) to calculate volume of 80 UCH condyles (40 patients). Moreover, volumetric differences between affected condyle and unaffected 1, between males and females, ages, and classification type were also analyzed. Fifteen patients (37.5%) were male and 25 (62.5%) were female. The gender ratio was 5:2, not far from the ratio 2:1 shown in literature. The mean age was 24 (SD 8.6) years; 22.9 (SD 6.6) for males and 24.6 (SD 9.6) for females according with the mean age derived from the Raijmakers et al meta-analysis and the Nitzan et al study. Right side (60%, 24 patients) was more often affected than the left side (40%, 16 patients). The 67.5% (27 patients) were classified as trasversal type, 25% (10 patients) as vertical types and 7.5% (3 patients) as combined. Despite Horos and ITK-SNAP values presenting some differences, the data follows the same tendency. The relationship is stronger for healthy condyles than affected condyles.

Synovial Chondromatosis and Calcium Pyrophosphate Deposition of the Temporomandibular Joint: Challenging Diagnosis.

BACKGROUND: The association between the synovial chondromatosis (SC) and the calcium pyrophosphate deposition (pseudogotta) in temporomandibular joint (TMJ) is very rare and has been described just 1 patient in the literature. CLINICAL PRESENTATION: A 64-year-old woman was referred to Dipartimento di Scienze Odontostomatologiche e Maxillo-Facciali, Sapienza Università di Roma after complaining about right temporomandibular pain, limitation in mandibular movements, and tumefaction in the right preauricular region. The patient was hospitalized for the surgery. The microscopic examination of the excised material revealed calcium pyrophosphate dihydrate (CPPD) deposits crystals associated with cartilaginous proliferation. CONCLUSION: The association between the SC and the calcium pyrophosphate deposition (pseudogotta) is a challenging diagnosis among TMJ neoplasms.

Mandibular Condylar Fractures in Children: Morphofunctional Results After Treatment With External Fixation.

Best treatment for paediatric patients with mandibular condylar fractures is still debated, and many approaches have been proposed. Closed treatment is the most used, but there is evidence showing long-term problems in patients with dislocated fractures. On the other hand, there are concerns on surgical treatment with open reduction internal fixation, particularly on the implanted hardware during growth. The aim of this study is to evaluate the long-term outcomes of paediatric patients treated surgically with external fixation. A total of 21 paediatric patients were treated. Diagnostic procedures included clinical and radiographic examinations. Of those 21 patients, 16 presented monocondylar fractures, 5 bicondylar fractures. They were treated surgically with open reduction and external fixation. Patients showed good recovery in maximal mouth opening, maximal lateral excursion and in vertical height of ramus, and all returned to preinjury occlusion. No patient presented permanent facial nerve palsy, and none referred pain or stiffness in the operated area. Minimal scars were visible. Just 1 patient referred clicking in the operated temporo-mandibular joint. Surgical approach using external fixation could be considered an option for treatment of mandibular condylar fractures in paediatric patient. Vertical height recovery, early mobilization, and good occlusion can be achieved, minimizing the risk of facial asymmetry.

Fast and Early Mandibular Osteodistraction: The Long-Term Follow-Up of Mandibular Distraction Osteogenesis on Teeth Position.

Pierre Robin Sequence is a congenital pathology defined by the triad micrognathia, glossoptosis and often a U-shaped cleft of soft palate. Newborns affected by airways obstruction may necessitate more invasive options: tongue-lip adhesion, tracheostomy and mandibular distraction osteogenesis. The authors analyzed the effect of fast and early mandibular osteodistraction on deciduous dental development in patients affected by Pierre Robin Sequence. Analysis of the patients treated for severe form was performed by a team composed by maxillofacial surgeons and dentists. Five patients were included for the analysis: before and long term clinical and radiological assessments were considered. All patients underwent fast and early mandibular osteodistraction; two years follow up computed tomography and panorex reconstructions showed bone consolidation, 33 of 35 teeth analyzed before ostedistraction are present after distraction protocol; no positional changes were detected at the follow up analysis either deciduous teeth and molar permanent buds. No deformities regarding molar buds were detected. In conclusion external mandibular distractor devices have been associated with dental injuries and facial scaring. Even though, the dental complications identified can not be unambiguously connected to the external distractor devices.

Fast and early mandibular osteogenetic distraction in a 24-day-old female newborn with Larsen syndrome.

BACKGROUND: Larsen syndrome (LS) is a rare bone dysplasia characterized by multiple dislocations affecting large and small joints, progressive scoliosis, accessory and early ossifying carpal/tarsal bones, and characteristic craniofacial features. CASE PRESENTATION: A newborn with a clinical diagnosis of LS is presented. Shortly after birth, she had respiratory distress due to retrognathia. Such a life-threatening complication was resolved by mandibular distraction osteogenesis at 24 days of age. CONCLUSION: Fast and early mandibular osteogenetic distraction could represent an optimal tool to avoid tracheostomy and to improve oral feeding in patients with rare conditions, such as LS.

Tetris Genioplasty: A New Paradigm for Chin Asymmetries Correction.

The chin plays a crucial role as a fundamental structural component that contributes to the overall aesthetics and harmony of the face. Recognizing its central position, medical science has seen the evolution of numerous surgical techniques over the years, all aimed at correcting the range of structural irregularities that can affect the chin. In this contribution, the authors introduce an innovative osteotomy technique, aimed at cases of chin asymmetry in which the skeletal median diverges from the dental median. This technique, called "Tetris genioplasty", involves performing the classic rectangular osteotomy, but includes an additional vertical osteotomy in order to obtain two distinct segments. Finally, these segments are translocated and repositioned to obtain a realignment between the skeletal median and the dental median. The results were entirely satisfactory for the patients, aligning perfectly with the expected appearance after the operation. Furthermore, no complications were reported, proving the success and safety of the procedure. The Tetris genioplasty aligns itself with this progressive trend by offering a minimally invasive method that nevertheless is able to achieve excellent results with a high impact on the patient's quality of life, presenting a promising path in the pursuit of optimal aesthetic results with minimized patient morbidity and greater overall safety.

Is it necessary to use bone grafts to prevent defects at the lower border of the mandible after mandibular advancement?-a systematic review.

INTRODUCTION: Defects in the lower border of the mandible may represent an aesthetic problem after mandibular advancement in orthognathic surgery. The use of bone grafts has been reported in the literature as a possibility to reduce these defects in the postoperative period. OBJECTIVE: The objective of this systematic review is to answer the following research question: Is it necessary to use bone grafts to prevent defects at the lower border of the mandible after mandibular advancement? METHODS: The literature search was conducted on MEDLINE via PubMed, Scopus, Central Cochrane, Embase, LILACS, and Sigle via Open Gray up until December 2020. Five studies were eligible for this systematic review, considering the previously established inclusion and exclusion criteria. RESULTS: 1340 mandibular osteotomies were evaluated, with a mean advance of 8 mm, being 510 with bone graft (42 defects), 528 without graft (329 defects), and 302 with an alternative technique (32 defects). Regarding the type of bone graft used, three articles used xenogenous or biomaterial grafts and two allogenous bone grafts. The results of the meta-analysis showed a reduction in the presence of defects in the bone graft group: OR 0.04, 95% CI = 0.01, 0.19; p = 0.0005, (I2 = 87%; p < 0.0001). CONCLUSION: The use of bone grafts seems promising in reducing defects in the lower border of the mandible after mandibular advancement. New controlled prospective studies with a larger number of participants are needed to ensure the effectiveness of this procedure.

Le Fort III external midface distraction: surgical outcomes and skeletal stability.

A retrospective study on the stability of Le Fort III midface advancement with distraction in craniofacial dysostosis. Twenty-six surgical procedures for midface advancement were performed between 2000 and 2009. Subjects were 14 consecutive patients who underwent Le Fort III osteotomy with midface advancement using a rigid external distraction device (Synthes) in the Dep of Maxillo-Facial Surgery of the University "Sapienza" of Rome. In this study, 8 patients (n = 3 females, n = 5 males) affected by craniofacial dysostosis (Crouzon, n = 5; Apert, n = 3; Pfeiffer syndrome, n = 1; and other, n = 1) were selected on the basis of age and radiologic documentation. The mean age at the time of the procedure was 8.6 years, and all the patients had at least 1 year of follow-up after distraction.The radiologic documentation of each case was composed of posteroanterior and lateral cephalograms preoperatively (T1), at the time of removal of the distractor device (T2), and at follow-up (T3).The average latency period before activation of the distractor was 5 days. The device was activated on an average of 15 mm (range, 7-22 mm) as recorded on the device at a rate of 1 mm/d. Activation period ranged from 7 to 15 days, and the consolidation period was 8 to 12 weeks.Seven anatomic landmarks and 5 cephalometric measurements were identified on the lateral cephalograms at each of the 3 time periods. The cephalograms underwent digital analysis via Dolphin imaging digitalization software by 2 operators independently. The displacement of each identified landmark was recorded and examined in relation to their position at each time point.Cephalometric analysis revealed stability of Le Fort III midface advancement during follow-up. However, bone growth after midface advancement is limited, and as reported in the literature, almost no spontaneous growth is present because of the intrinsic nature of malformations. Patients treated in the growing age benefit from midface advancement, with resolution of exophthalmos, ocular bulb exposure, airway impairment, and good aesthetic outcome.

Assessment of maxillary canting on cone beam computed tomography and digital models: A retrospective study and proposal of a method.

OBJECTIVES: The mounting of the plaster casts on articulator procedure is routinely performed in orthognathic surgery to assess canting of the maxillary occlusal plane, but the currently used protocols and reference plane could be source of errors which affect reliability. Nowadays the assessment of canting of the maxillary occlusal plane could be also performed with an entirely digital protocol. Aim of the study was to propose a method to evaluate canting in patients affected by Unilateral Condylar Hyperplasia, comparing the measurements performed on digital models matched on CBCT with those made on traditional articulator. MATERIALS AND METHODS: A retrospective cross-sectional study was designed on 20 patients affected by vertical Unilateral Condylar Hyperplasia treated in the Units of Orthodontics and Maxillo-Facial Surgery. The canting of the maxillary occlusal plane was measured on plaster casts mounted on the conventional articulator and the measures were compared with those made on digital models matched on CBCT, according the protocol developed in our Unit. Molar, canine and basal difference were measured. To compare the two protocols and to test the agreement, we performed descriptive statistics, comparison between means and Bland Altman analysis. P value was set at 0.05. RESULTS: Statistic comparison demonstrated agreement between measurements performed with the digital protocol and conventional physical method. CONCLUSION: Measurements of canting with digital protocol are comparable to the physical standard method. A total digital protocol allows faster availability and storage of patient's data and better communication between orthodontist and maxillo-facial surgeon, especially in patients affected by three-dimensional malocclusions.

Microdeletion 3q syndrome.

The authors present the clinical case of a 5-month-old boy, affected by multimalformative syndrome with features of microdeletion 3q syndrome. In the literature so far, the real incidence is unknown because of its rarity. The goal of this study was to describe the salient findings of this rare malformative syndrome, which needs a multidisciplinary approach. The patient had 3q interstitial chromosome deletion (q22.1-q25.2). He showed the following clinical features: microcephaly, microphthalmia, epicantus inversus, blepharophimosis, palpebral ptosis, short neck with pterygium, brachycephaly, round face, hypotelorism, broad nasal bridge, beaked nose, large and low-set ears, soft cleft palate, retromicrognathia with large mouth, arthrogryposis of the superior limbs and knees in association with clinodactyly, overlapping of second and third digits of both hands and feet, and gastroesophageal reflux. The patient developed physical and motor development delay. He was affected by Dandy-walker malformation, characterized by cerebellum vermis hypoplasia. The placement of the patient in contiguous gene syndrome (Dandy walker syndrome, Pierre-Robin sequence, and Seckel syndrome) was carried out by a multidisciplinary team to have a holistic evaluation of clinical findings. Thanks to this approach, it was possible to establish a complete diagnostic and therapeutic course. The genetic analysis enables to arrange an assistive program. Surgeons' attention was focused on the malformations, which represented an obstacle for normal development and social life.

Upper airway volume after Le Fort III advancement in subjects with craniofacial malformation.

AIM: There are no quantitative standards for the volumetric measurements of the airway space after Le Fort III advancement. Computed tomographic (CT) scans have provided the opportunity to compare with the accuracy of real anatomic changes, thus the functional improvements, resulting after a surgical treatment. MATERIALS AND METHODS: Three-dimensional CT scans processed by Digital Imaging and Communications in Medicine files in Dolphin 3D software were used to assess the airway space volume in 4 subjects affected by craniofacial syndromic malformations treated with Le Fort III advancement. The preoperative (T0) and postoperative (T1: 6 mo after surgery) three-dimensional craniofacial CT scans of the subjects were collected and retrospectively analyzed. Image segmentation of the anatomic structures of interest and the three-dimensional graphic rendering were done by using the Dolphin Imaging Plus 11.0 software. RESULTS: The airway space volume was significantly increased after surgery (mean [SD]: from 9166.57 [1861.48] mm to 15,300.45 [5114.09] mm; P < 0.01). The sagittal surfaces had an expansion from 798.92 (74.88) to 1151.45 (218.47) mm. The coronal surfaces grew from 226.75 (62.85) to 390.42 (102.21) mm, and axial surfaces increased 473.32 (62.34) to 676.00 (151.07) mm from T0 to T1. CONCLUSIONS: In conclusion, this study showed an increase in the upper airway space volume in white subjects after Le Fort III advancement.

Role of a new orthognathic surgery in maxillomandibular reconstruction by free flaps.

PURPOSE: The objective of this study was to describe the orthognathic surgery techniques for the treatment of occlusal anomalies in those patients who underwent complex maxillomandibular reconstruction with bony free flap. MATERIALS AND METHODS: The authors describe their personal technique developed over years of experience with reconstruction of mandibular defects with bony free flaps. RESULTS: The outcomes in these patients who were treated according to our surgical planning were completely satisfying, with a 100% stability of the treated bones. CONCLUSIONS: Orthognathic procedure on bony free flaps for the reconstruction of mandibular defects is nowadays accepted. Patients who underwent major mandibular destruction due to oncologic disease or trauma outcomes can now benefit from this technique.

Cleft lip and palate: technical strategies for the primary palatoplasty.

Surgical procedures in cleft lip and palate repair are continuously evolving. In the international literature, many guidelines exist dealing with different timings and surgical approaches. The authors present a technical strategy on primary palatoplasty and the guidelines for the surgical management of cleft lip and palate adopted by the Department of Maxillo-Facial Surgery of the Università "La Sapienza" of Rome. This approach has been developed to allow a physiological facial growth and to preserve the essential main features of the stomatognathic system enclosing phonation and swallowing. Moreover, the authors present their own surgical technique for primary palate repair at 24 to 48 months with the galea-pericranium free flap.

Early secondary alveoloplasty in cleft lip and palate.

The aims of this study were to present a personal surgical technique throughout the review of international literature concerning surgical techniques, objectives, and outcomes in early secondary alveoloplasty and to describe our personal surgical techniques in alveolar bone defect repair in cleft lip and palate.Throughout a literature analysis, it is now settled that early secondary alveoloplasty could reestablish the continuity of alveolar bone and prevent upper dental arch collapse after presurgical orthopedic upper maxilla expansion; it also might give a good bone support for teeth facing the cleft and allow the eruption of permanent elements with the bone graft and rebalance the symmetry of dental arch, improve facial aesthetic, guarantee an adequate amount of bone tissue for a further prosthetic reconstruction with implant, and finally close the eventual oronasal fistula.The surgical technique we are presenting permitted a total number of 35 early secondary alveoloplasty on which a long-term follow-up is still taking place.We can assess that early secondary alveoloplasty must be performed before permanent canine eruption. Iliac crest is the suggested donor site for bone grafting; orthopedic and orthodontic treatments must be performed in association with surgery, and if there is the dental element agenesia, an implantation treatment must be considered.

Reconstruction of the Adult Hemifacial Microsomia Patient with Temporomandibular Joint Total Joint Prosthesis and Orthognathic Surgery.

BACKGROUND: HFM patients' reconstruction has always been a challenge for maxillofacial surgeons, and numerous reconstructive techniques have been described. Surgical treatment depends on the patient's age and contemplates Temporomandibular Joint (TMJ) reconstruction in conjunction with orthognathic surgery, usually necessary following completion of growth to maximize the functional and esthetic results. Distraction osteogenesis had gained popularity as valid alternative in growing patients, but the two primary methods to reconstruct the TMJs involve the use of autogenous, using free or microvascular bone grafts, or alloplastic graft, but there is no widely accepted method. METHODS: The increasing use of temporomandibular prosthesis for temporomandibular problems has led us to use them even in HFM. A case of female nongrowing patients with HFM type IIb treated with temporomandibular prosthesis in an all-in-one protocol is presented. RESULTS: Incisal opening, measured with BioPAK system (Bioresearch Inc., Milwaukee, USA), was 21.4 mm in the presurgical period and 32.2 mm after all-in-one procedure, for an increase of 50.5%. Excursive movement to the right side was 2.2 mm in the presurgical period and was 1.5 mm after surgery, for a decrease of 31.8%. Left excursion movement changed from 5 mm to 6.1 mm, for an increase of 22.0%. CONCLUSIONS: The TMJ Concepts patient-fitted TJP in conjunction with orthognathic surgery for TMJ and jaw reconstruction is a valid option for patients with HFM.

Histological findings in TMJ treated with high condilectomy for internal derangement.

Intra-Articular Temporo-Mandibular Disorders (TMD) are characterized by displacement of the disc that causes the condyles to slip back over the disc thus resulting in TMJ discal damage and erosion of the condyle's bone. The etiology of temporomandibular disorder (TMD) is multidimensional: biomechanical, neuromuscular, bio-psychosocial and biological factors may contribute to the disorder. The study involved 46 joints in 27 patients with a diagnosis of Intra-Articular Temporo-Mandibular Disorders (TMD) according to Axis I of Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications and underwent surgery between 2011 and 2014. Patients were divided into three groups. Group 1 were included patients with Disc Displacement (DD) without reduction without limited opening, Group 2 patients with DD without reduction with limited opening. Finally, Group 3 included patients with Degenerative Joint Disease (DJD) TMD. In all cases, diagnosis of Intra-Articular Temporo-Mandibular Disorders (TMD) was confirmed by pre-operative examination (clinical, MRI and/or CT scan). Tissue specimens were obtained from all 50 joints for histopathology. The aim of this study was to analyse histological features of the surgical specimens obtained from patients with Intra-Articular Temporo-Mandibular Disorders who underwent surgery and assess the association with clinical findings and imaging. Preliminary results show in Group 1, fibrocartilage is preserved and regular, there are isolated outbreaks of bone resorption and focal sclerosis. In Groups 2 and 3 fibrocartilages are irregular and thickness varies widely and sclerosis is more pronounced. In early stages of TMD, the disc antero-medial displacement might play a fundamental role in the etiopathogenesis that can became an irreversible joint damage thus leading to a wide spectrum of articular symptoms and signs in TMD (Cohen et al., 2014; Hagandora and Almarza, 2012; Nah, 2012).