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OBJECTIVES: Transitioning from non-outpatient orthognathic surgery to outpatient surgery is a new challenge, and it is essential to target the eligible population as precisely as possible. Several authors describe series of outpatient orthognathic surgery but do not include the reasons for their success or failure. The main aim of this study was to identify the factors significantly associated with "successful" outpatient orthognathic treatment. The secondary objective was to determine the factors significantly associated with prolonged hospital stays (≥ 2 nights). MATERIALS AND METHODS: A prospective cohort study including patients undergoing orthognathic surgery was conducted over a period of 1 year. We recorded the prognostic factors that contributed to successful outpatient treatment and prolonged hospital stays. These factors were evaluated by bivariate and multivariate analysis. RESULTS: A total of 102 patients were included, and the success rate of treatment was 65%. The variables that were isolated by multivariate analysis were: patients over the age of 22, procedures ending before 1 pm, brief operations, the absence of both postoperative vomiting and the administration of morphine. CONCLUSION: Patient selection, organisation of outpatient facilities and anaesthetic protocols contribute to the development of outpatient orthognathic surgery. These initial considerations provide a framework for our practice, but the considerations that predict the failure of outpatient surgery will need to be clarified. CLINICAL RELEVANCE: Orthognathic surgery can be performed on outpatient basis in selected cases. Age, the operative time, procedure end time, postoperative vomiting and the administration of morphine are associated with the success of outpatient care.
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Cirurgia Ortognática , Procedimentos Cirúrgicos Ortognáticos , Humanos , Tempo de Internação , Estudos Prospectivos , Procedimentos Cirúrgicos Ambulatórios , Procedimentos Cirúrgicos Ortognáticos/métodos , Náusea e Vômito Pós-Operatórios , Pacientes Ambulatoriais , Derivados da Morfina , Estudos RetrospectivosRESUMO
PURPOSE: To investigate morbidity related to harversting of bilateral fibula free flap for head and neck reconstruction using subjective and functional tests. METHODS: Patients were retrospectively evaluated using point evaluation system (PES) and balance evaluation systems test (BESTest) questionnaires to assess morbidity related to surgery. RESULTS: Five patients were enrolled in the study. Mean PES scores was 22.2 over 24. Mean overall function assessed with BESTest was 77.6%, and the results were poorest for section I. Sections V and VI had scores of 88% and 83%, respectively, indicating that the sensory balance and gait stability of the patients were compromised only minimally. CONCLUSION: Bilateral harvesting of the fibula free flap is not associated with an increase in long-term morbidity and does not lead to significant functional impairments. Therefore, this procedure should be considered safe, and can be performed without concern regarding morbidity, when bone reconstruction with a fibula free flap is indicated.
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Fíbula/cirurgia , Retalhos de Tecido Biológico/efeitos adversos , Reconstrução Mandibular/efeitos adversos , Complicações Pós-Operatórias/etiologia , Coleta de Tecidos e Órgãos/efeitos adversos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Estudos Retrospectivos , Sítio Doador de Transplante , Adulto JovemRESUMO
Iatrogenic injury in oral surgery is the most frequent cause of sensory disturbance in the distribution of the inferior alveolar nerve (IAN) and mental nerve.Inferior alveolar nerve damage can occur during third molar extraction, implant location, orthognathic surgery, preprosthetic surgery, salivary gland surgery, local anesthetic injections or during the resection of benign or malignant tumors.Injuries to the IAN can be caused also by endodontic treatment of mandibular molars and premolars when filling material is forced into the tooth and mandibular canal.The sensory disturbances that could follow a damage of the IAN could be hypoesthesia, dysesthesia, hyperesthesia, anesthesia, and sometimes a painful anesthesia that strike ipsilateral lower lip, chin, and teeth. These can undermine life quality by affecting speech, chewing, and social interaction.Treatment of these complications is sometimes difficult and could consist in observation or in surgical decompression of the involved nerve to relieve the patient's symptoms and improve sensory recovery. The most debated points are the timing of intervention and the effective role of decompression in clinical outcome-improvement.The purpose of this article is to show authors' experience with 2 patients treated with microsurgical nerve decompression to remove endodontic material from the mandibular canal and providing also a comprehensive review of the literature.
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Descompressão Cirúrgica/métodos , Nervo Mandibular/cirurgia , Microcirurgia/métodos , Tratamento do Canal Radicular/efeitos adversos , Traumatismos do Nervo Trigêmeo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias , Distúrbios Somatossensoriais/etiologia , Traumatismos do Nervo Trigêmeo/etiologiaRESUMO
BACKGROUND: Recently, the scapular tip free flap has been popularized as a valuable option for bone reconstruction of the head and neck area. Analyses of perioperative and long-time morbidity are crucial to enable complete comprehension of this technique and will be presented in this paper. METHODS: Perioperative and long-term morbidity of scapular tip flaps harvesting were analyzed in a cohort of 19 patients. Local complications and ambulation-time were used to assess perioperative results, while Constant-Murley and DASH scores were used to evaluate long-term morbidity on shoulder functions. RESULTS: Local perioperative complications were minimal (three cases of seroma and two wound dehiscence). Ambulation time ranged between 2 and 4 days (mean 2.7 days). Constant-Murley scores ranged between 66 and 100 (mean 92.2). The DASH score ranged between 39 and 85 (mean 48.6). CONCLUSION: Harvesting a scapular tip free flap resulted in very low shoulder morbidity, without interfering the patient's daily activities. © 2015 Wiley Periodicals, Inc. Microsurgery 35:447-450, 2015.
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Retalhos de Tecido Biológico/transplante , Mandíbula/cirurgia , Maxila/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/epidemiologia , Escápula/transplante , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos , Seroma/diagnóstico , Seroma/epidemiologia , Seroma/etiologia , Deiscência da Ferida Operatória/diagnóstico , Deiscência da Ferida Operatória/epidemiologiaRESUMO
Medical photography is an essential tool in orthognathic surgery to facilitate diagnosis, preoperative planning, and follow-up. Photographic documentation has clinical, research, teaching and legal applications. An accurate diagnostic approach and surgical planning of dentofacial deformity requires the ability to work with reproducible and measurable photographic images. It must also respect certain legislative rules for its use within a health institution and the dissemination of images in the educational and scientific framework. We propose through this narrative review a standardized protocol to obtain reproducible images in the different planes of space. We also review and discuss fundamental points for setting up a photographic room dedicated to photography in orthognathic surgery.
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Cirurgia Ortognática , Humanos , Ossos Faciais , Fotografação/métodos , Literatura de Revisão como AssuntoRESUMO
PURPOSE: After maxillary osteotomy in orthognathic surgery, patients report nasal breathing discomfort in early postoperative period. Topical hyaluronic acid (HA) has been proven to have beneficial effects on the upper airway tract mucosa. This prospective randomized controlled study was designed to analyze the effect on nasal obstruction of nebulized HA during the recovery process after maxillary osteotomy. METHODS: Patients were randomized to control and treatment groups. The postoperative treatment differed only for additional nebulized HA provided to the treatment group. The level of nasal obstruction, and its impact on quality of life, was assessed every 3 days for the first 15 days postoperatively using a questionnaire. Demographic and other variables (maxillary osteotomy type and surgical movements) were analyzed. Differences in quantitative data were tested using Student's t-test, the Mann-Whitney U test, and mixed repeated measures ANOVA. RESULTS: Twenty-four subjects were included in each group; differences in age, sex, type of maxillary osteotomy, and movements were non-statistically significative. At the beginning of treatment (T0), the two groups had comparable questionnaire scores regarding nasal breathing discomfort (p >0.05), whereas statistically significant differences were found at days 3, 6, 9, and 12 (p <0.05). A significant decrease in nasal breathing discomfort over time was observed in both groups, with trends that differed between the two, indicating faster improvement in the treatment group. CONCLUSION: Nebulized HA can be a useful additional treatment in early postoperative period after orthognathic surgery. Patients reported more rapid improvement of nasal respiratory symptoms, indicating a potential role for HA in reducing recovery time and patient discomfort after maxillary surgery.
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Obstrução Nasal , Cirurgia Ortognática , Humanos , Ácido Hialurônico/uso terapêutico , Obstrução Nasal/tratamento farmacológico , Obstrução Nasal/cirurgia , Estudos Prospectivos , Qualidade de Vida , Osteotomia de Le FortRESUMO
Our study aimed to compare the biomechanical behaviour of mandibles with or without titanium miniplates when subjected to an impact after bone healing using a finite element model (FEM) of the human mandible. We simulated mandibular trauma on an FEM of a human mandible carrying or not two parasymphyseal miniplates and applying a concentrated force of 2000 N to four different areas, including the insertion area, the area straddling the edge of the miniplates and the adjacent bone, at a distance from the miniplates on the symphysis, and on the basilar border of the mandible below the miniplates. Then, we compared the Von Mises stress distributions between the two models. In the case of an impact on the miniplates, the maximum Von Mises stress occurred in two specific areas, on the cortical bone at the posterior border of the two miniplates at a distance from the impact, while in the model without miniplates, the Von Mises stresses were homogenously distributed in the impact area. The presence of titanium miniplates in the case of trauma affects the biomechanical behaviour of the mandible and could cause more complex fractures. We recommend informing patients of this potential risk.
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Major defects of the facial structures cause severe functional and esthetic impairment. Difficulty in head and neck reconstruction lies in cases of secondary, tertiary, or further reconstruction. This is not a rare situation for patients who had cancer of the upper airways, since the rate of recurrence, second location, or osteoradionecrosis is high. Multiple surgeries and radiation therapy cause significant fibrosis and scar tissues, making any further reconstruction a major challenge for the surgeon when operating patients with vessel- depleted neck. We report our experience with a clinical case of a patient to whom we performed a double free flap reconstruction anastomosed on a vascular loop in a context of vascular cervical desert. In our case, the use of an arteriovenous loop proved to be a reliable approach for a vessel-depleted free tissue reconstruction. This technique has received insufficient attention, yet it provides a means to establish dependable vascular alternatives.
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Neoplasias de Cabeça e Pescoço , Reconstrução Mandibular , Procedimentos de Cirurgia Plástica , Humanos , Neoplasias de Cabeça e Pescoço/diagnóstico , Neoplasias de Cabeça e Pescoço/cirurgia , Pescoço/cirurgia , Lábio/cirurgiaRESUMO
INTRODUCTION: We hypothesize that the removal of mandibular third molars (M3) 6 months prior to a bilateral sagittal split osteotomy (BSSO) could allow the displacement of the inferior alveolar nerve (IAN) in a favorable lingual position. This study aimed to radiographically compare the position of IAN before and after M3 removal in patients with Class II malocclusion. MATERIALS AND METHOD: The CBCT images of 30 randomly selected patients (mean age 15.5 years, 19 females and 11 males) were segmented regarding the mandibular bone and the IAN canal. Mandibles were then superimposed and compared using 3D slicer (www.slicer.org). An orthonormal system was constructed, and the coordinates of IAN were assessed in the x- (horizontal axis), y- (depth axis), and z- (vertical axis) directions. RESULTS: The mean changes in x- and z-values were 0.37 %, -0.09 % for the right IAN, 0.07 %, and -0.10 % for the left IAN, respectively. Y-axis was the dimension the most impacted by the M3 removal with a mean variation of -11.96 % for the right IAN, and 0.45 % for the left nerve (p1=0.74 and p2=0.04, respectively). Three patients presented a change in the IAN position superior to 1 mm on at least one coordinate axis. We observed a more important change in x-values of the right IAN in male than in female (p = 0.04), and no significant modifications regarding the other dimensions. Finally, there was no correlation between the age of the patients and the changes in IAN position. CONCLUSION: This study confirms the absence of influence of mandibular third molar removal on the inferior alveolar nerve route prior to BSSO.
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Dente Impactado , Traumatismos do Nervo Trigêmeo , Adolescente , Feminino , Humanos , Masculino , Mandíbula/diagnóstico por imagem , Mandíbula/cirurgia , Nervo Mandibular/diagnóstico por imagem , Dente Serotino/diagnóstico por imagem , Dente Serotino/cirurgia , Osteotomia , Dente Impactado/diagnóstico por imagem , Dente Impactado/cirurgia , Traumatismos do Nervo Trigêmeo/diagnóstico , Traumatismos do Nervo Trigêmeo/etiologia , Estudos RetrospectivosRESUMO
Central giant cell granulomas (CGCG) are rare intraosseous osteolytic lesions of uncertain aetiology. Despite the benign nature of this neoplasia, the lesions can rapidly grow and become large, painful, invasive, and destructive. The identification of molecular drivers could help in the selection of targeted therapies for specific cases. TRPV4, KRAS and FGFR1 mutations have been associated with these lesions but no correlation between the mutations and patient features was observed so far. In this study, we analysed 17 CGCG cases of an Italian cohort and identified an interesting and significant (p=0.0021) correlation between FGFR1 mutations and age. In detail, FGFR1 mutations were observed frequently and exclusively in CGCG from young (<18 years old) patients (4/5 lesions, 80%). Furthermore, the combination between ours and previously published data confirmed a significant difference in the frequency of FGFR1 mutations in CGCG from patients younger than 18 years at the time of diagnosis (9/23 lesions, 39%) when compared to older patients (1/31 lesions, 0.03%; p=0.0011), thus corroborating our observation in a cohort of 54 patients. FGFR1 variants in young CGCG patients could favour fast lesion growth, implying that they seek medical attention earlier. Our observation might help prioritise candidates for FGFR1 testing, thus opening treatment options with FGFR inhibitors.
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Granuloma de Células Gigantes , Humanos , Adolescente , Granuloma de Células Gigantes/genética , Granuloma de Células Gigantes/diagnóstico , Granuloma de Células Gigantes/patologia , Taxa de Mutação , Mutação , Receptor Tipo 1 de Fator de Crescimento de Fibroblastos/genéticaRESUMO
BACKGROUND: Severe microretrognathia with the absence of ascending mandibular ramus is a challenging deformity and treatment must aim to avoid tracheostomy or remove it as soon as possible. Although it is not often reported, mandibular distraction osteogenesis represents a valid treatment option in infants affected by hypoplastic mandible Pruzansky-Kaban type IIb and III. CASE PRESENTATION: The authors describe 3 cases of infants affected by severe respiratory insufficiency due to congenital mandibular hypoplasia, with follow up ranging from 4 to 8 years. Clinical and technical considerations on treatment choices and outcomes are discussed starting from review of the literature and direct clinical experience. CONCLUSION: Early mandibular distraction, specifically bidirectional distraction, is an effective and repeatable technique that leads to mandible lengthening with counterclockwise rotation, pogonion projection increase, anteropositioning of the tongue base, and expansion of oropharyngeal volume with positive effect on the respiratory problems of the infant. Even in Treacher Collins patients, known to have a low decannulation rate, all of these elements are essential for effective speech and swallowing therapy and for a subsequent attempt of decannulation.
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Obstrução das Vias Respiratórias , Disostose Mandibulofacial , Micrognatismo , Osteogênese por Distração , Obstrução das Vias Respiratórias/cirurgia , Humanos , Lactente , Mandíbula/diagnóstico por imagem , Mandíbula/cirurgia , Disostose Mandibulofacial/cirurgia , Traqueostomia , Resultado do TratamentoRESUMO
OBJECTIVES: This prospective study evaluated the accuracy of mandibular reconstruction using free fibular flaps (by comparing virtual plans to the three-dimensional postoperative results), and the extent of bone-to-bone contact after computer-assisted surgery. METHODS: We included 65 patients who underwent partial-continuity mandibular resections from February 2013 to January 2017, and evaluated virtual planning, surgical techniques, and accuracy. RESULTS: Forty-seven patients were analysed. A total of 112 fibular segments received 54 implants. We measured 227 distances between landmarks to assess the accuracy of reconstruction. Postoperative reconstruction accuracy ranged from 0.5 to 3 mm. CONCLUSION: Virtual surgical planning very accurately translated simulation into reality, particularly in patients requiring large, complex mandibular reconstructions using multiple fibular segments. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2169-E2175, 2021.
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Desenho Assistido por Computador , Retalhos de Tecido Biológico , Reconstrução Mandibular/métodos , Modelagem Computacional Específica para o Paciente , Cirurgia Assistida por Computador/métodos , Adulto , Pontos de Referência Anatômicos/diagnóstico por imagem , Feminino , Fíbula/diagnóstico por imagem , Fíbula/cirurgia , Humanos , Imageamento Tridimensional , Masculino , Pessoa de Meia-Idade , Planejamento de Assistência ao Paciente , Estudos ProspectivosRESUMO
BACKGROUND: Buccinator myomucosal flaps are routinely used for oral cavity reconstruction and are indicated mainly in patients classified as having stage N0 cancer. This purpose of this study was to investigate whether preservation of the vascular pedicle of the flap (facial artery and vein) during stadiative neck dissection alters the oncologic safety in these patients. METHODS: Fifty patients underwent resection of T1 to 3, N0 squamous cell carcinoma of the tongue or floor of the mouth, stadiative neck dissection, and reconstruction with a facial artery musculomucosal (FAMM) flap were retrospectively analyzed concerning rate of occult neck metastasis and recurrences. RESULTS: Occult metastasis was detected in 10 patients. Mean follow-up was 41 months. The overall survival rate was 88%, and the disease-specific survival rate was 92%. CONCLUSION: Neck dissection with preservation of the facial artery and vein does not alter the rate of regional recurrences, confirming the oncologic safety of myomucosal flaps in oral cavity reconstruction. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1200-E1202, 2016.
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Carcinoma de Células Escamosas/cirurgia , Neoplasias Bucais/cirurgia , Procedimentos de Cirurgia Plástica , Retalhos Cirúrgicos/transplante , Adulto , Idoso , Idoso de 80 Anos ou mais , Artérias , Músculos Faciais/irrigação sanguínea , Músculos Faciais/transplante , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mucosa Bucal/irrigação sanguínea , Mucosa Bucal/transplante , Esvaziamento Cervical , Recidiva Local de Neoplasia , Estudos Retrospectivos , Retalhos Cirúrgicos/irrigação sanguínea , VeiasRESUMO
PURPOSE: Gracilis muscle reinnervated by the contralateral facial nerve via cross-graft technique is nowadays considered to be a first-line procedure for facial animation in unilateral palsies. Despite the wide number of papers published analyzing technical aspects, refinements, functional results, and cosmetic outcomes, only a few authors have focused their publications on the patient's perspective and impact on QOL of these procedures. MATERIAL AND METHODS: Changes in quality of life in 42 patients treated with gracilis muscle transplant reinnervated via cross-face graft were analyzed through a comparison of preoperative and postoperative items on the Facial Disability Index questionnaire. Statistical evaluation with a paired t-test was performed concerning overall results and specific items modifications. RESULTS: Overall improvement of QOL was found to be highly significant (p = 0.001). Mouth and eye functions were the most improved (p = 0.001), whereas isolation (p = 0.004) and feeling calm and peaceful (p = 0.001) were the most improved among the social functions. CONCLUSIONS: Facial animation with gracilis neuromuscular transplantation reinnervated with contralateral healthy facial nerve via a cross-graft procedure has been demonstrated to be a safe and reliable procedure in the treatment of congenital or established facial palsies. Our results on quality of life impact support that these operations are not only reliable and safe but also of primary relevance to patients' everyday lives.