Bisphosphonate-Related Osteonecrosis and Metastasis Within the Same Site of the Jaw.

Osteonecrosis of the jaw (ONJ) is a well known complication in patients treated with bisphosphonates (BPs) for skeletal metastasis and multiple myeloma (MM). Few oncologic patients under treatment with BPs and with ONJ and metastasis or MM at the same site of the jaw have been described. We report here on a 54-year old white female who was treated with intra-venous zoledronic acid for skeletal metastasis of breast cancer who developed ONJ. Because of a fracture at the site of ONJ, resection of the affected segment was performed. Although metastasis was not suspected by pre-operative image analysis, histological examination revealed syncronous osteonecrosis and breast cancer metastasis in the resected mandibular segment. This case highlights that, in oncologic patients treated with BPs, ONJ may hide malignancy and that histology is the unique tool by which the diagnosis of either osteonecrosis or malignancy or both can be made definitely.

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.

Surgical treatment of congenital rhabdoid tumor in a 10-day-old newborn.

BACKGROUND: Malignant rhabdoid tumors are rare and aggressive tumors of pediatric age. The primary tumor can occur in different localizations, but it mainly involves kidney, soft tissue, or central nervous system. It has been associated to a poor diagnosis. METHODS: The authors present the case of a 10-day-old newborn affected by a bulky nasofronto-orbitary neoplasm. The patient underwent radical surgical treatment and further excision of a preauricular metastasis combined with postoperative chemotherapy treatment. RESULTS: The authors adopted a diagnostic and therapeutic protocol according to international guidelines, not without difficulty because the first histological report showed esthesioneuroblastoma. The rarity and aggresivity of rhabdoid tumor and the precocity of onset in our patient presented a difficulty to define prognostic factors and survival rates, as well as therapeutic plan of treatment. CONCLUSIONS: The authors underline the importance of a correct prenatal diagnosis and an early surgical treatment to reach the complete healing of the patient.

Dermoid cyst: unusual localization.

Dermoid cysts are embryonic lesions usually observed in the lateral eyebrow region and the midline nose and neck areas. Communication of these lesions with the central nervous system is rare and occurs in the nasal region. There are few clinical reports of temporal dermoid cysts presenting with intracranial extension, and we present a 15-year-old girl with a fronto-orbital dermoid cyst with intracranial extension and bone erosion. Her presenting symptom was a lacrimation reduction of the left eye. Excision of the cyst was done using a coronal approach because of its extension and localization.

Management of benign parotid tumors. What can we learn from our experience?

AIM: Parotid gland is the most common location for salivary gland tumors, more commonly pleomorphic adenoma and Warthin's tumor. Types of parotid surgery include superficial parotidectomy (SP), partial superficial parotidectomy (PSP), total conservative parotidectomy (TCP), enucleation (E), extracapsular dissection (ECD), and are related to different incidence of complications. The choice depends on tumors localization, dimension and histology. The aim was to compare complications rate such as facial and great auricular nerve impairment and Frey syndrome according to type of surgery performed. MATERIALS AND METHODS: We retrospectively review the management of 116 benign tumors of the parotid gland treated between January 2004 and January 2020 at our Department. RESULTS: Most frequent complication observed was a GAN deficiency (22.41%), permanent in 13% of cases. Post-operative facial nerve impairment was observed in 19 patients (persistent only in 1 case). Only Frey syndrome (4,31% of cases) seemed to be related to type of surgery (p<0.05) resulting more frequent in the group of patients that underwent "classical" parotidectomy, while facial nerve impairment, even if more frequent in this cases, did not statistically correlated with operative technique (p=0.054). CONCLUSIONS: Once experience is gained, in order to reduce post-operative morbidity extracapsular dissection is a reliable technique in the management of these neoplasms, even if attention has to be paid particularly in the removal of superficial masses "emerging" from the parenchyma. PSP is an alternative to SP, while CTP has to be reserved to selected cases ot tumors arising in the deep lobe. KEY WORDS: Benign tumor, Extracapsular dissection, Enucleation, Facial nerve Parotid gland, Parotidectomy, Superficial parotidectomy.

Open surgery versus endoscopic surgery in benign neoplasm involving the frontal sinus.

The frontal sinus, because of its proper anatomic features, has a particular relation with nasal cavities. Indeed, its anatomic opening (ostium) is strictly related to a complex ethmoidal structure prechamber mainly composed of the frontal recess.This constitutional feature makes the endoscopic approach more complex in comparison with other major sinuses treatment.In the following work, we present a systematization of surgical approach in relation to different pathologies, analyzing differences and results throughout the comparison of 2 groups: one treated with the endoscopic approach, and the other with open surgery.From these observations, we can assess that surgical approach choice must consider several parameters such as neoplasm localization, extension, dimension, and frontal recess anatomic features.

Isolated sphenoid sinus mucocele: etiology and management.

Sphenoid isolated lesions are rare; they occur in 2% to 3% out of all paranasal sinus lesions. Diagnosis is based on the endoscopic examination and computed tomography scan or magnetic resonance imaging of the maxillofacial area. In this study, we present patients with sphenoid mucocele in the Maxillo-facial Surgery Department, University of Rome La Sapienza, treated with the endoscopic technique. Moreover, a literature review is performed, dealing with the evolution of approaches to the sphenoid sinus. From January 2001 to January 2007, we treated 75 patients affected by paranasal sinus mucocele. Out of this number, 8 patients (11%) presented an isolated localization in the sphenoid sinus. These patients were divided as follows: 5 involved the right sphenoid sinus and 3 involved the left sphenoid sinus. Isolated sphenoid sinus disease is a rare entity that can result in serious sequelae if diagnosis and treatment are inappropriately delayed. In our study, we highlighted how the endoscopic approach allows the removal of even large mucocele with the use of 45-degree angle optic and if it is possible to control and remove lateral walls of the sphenoid sinus. In our experience, we shifted from a traditional approach to the endoscopic approach. At the present time, the endoscopic approach represents the gold standard for sphenoid sinus mucocele treatment because it allows the best view of the sphenoid sinus and grants a better restoring of respiratory function and a higher compliance from the patient.

Management and treatment of sinonasal inverted papilloma.

AIMS: The aim of this paper is to describe the surgical experience of 35 patients with Inverted Papilloma (IP) of paranasal sinuses and its recurrence rate after a year of follow-up. MATERIALS: A retrospective chart review was performed on patients presenting with IP of paranasal sinuses. Thirty-five patients comprised the focus of this study. For all patients was performed a pre-surgery TC, and for more 5 patients it was necessary to perform a Magnetic Resonance (MR) with gadolinium. RESULTS: Among 35 patients selected, 18 patients underwent to open surgery, 4 patients had a combined approach with endoscopy and open surgery, while 13 patients were managed only with an endoscopic approach, with a minimum of 1 year of follow-up. Our results highlighted that the global percentage of success 12 months after the treatment was 93% and it not vary according to the tipology of the approach used if a radical excision of the lesion is achieved. More in depth, among 35 cases, only 2 patients were found to have recurrences and were treated with coronal and endoscopic approach. CONCLUSION: It is fundamental to underline that surgery must be carried on in a radical manner to treat these tend to recur. A complete removal of the lesion and bone peripheral border filing are essential to perform a correct and definitive treatment. Also, endoscopic approach can be taken into account when tumors are localized median to a sagittal plan crossing the orbit median wall and when they did not massively compromised paranasal sinus walls.

Aesthetic restoration in maxillo-mandibular malformations: the role of genioplasty.

AIM: The aim of this study was to determinate how orthognatic surgery aids to cure many skull and face abnormalities and to help re-establishing the correct occlusive relation thanks to the repositioning of the maxillo-mandibular skeleton basis. METHODS: The study included 183 male patients and 338 female patients, with an average age of 23 years. The sample series was divided according to specific pathologies. All patients underwent surgical procedures and the therapeutic strategy was determined based on the anomalies presented. RESULTS: 113 patients had a II class dental skeletal occlusion, 180 patients had a III class dental-skeletal occlusion and 222 patients had skull-facial abnormalities. 5 patients underwent only a genioplasty, 82 patients underwent a genioplasty associated with BSSO, 175 patients underwent a genioplasty associated with Le Fort I osteotomy and the remaining 253 patients underwent a genioplasty associated with BSSO and Le Fort I osteotomy. CONCLUSION: The experience shows that genioplasty has been successfully introduced in orthognathic surgical therapeutic procedures, for dental-skeleton abnormalities and mandibular asymmetries treatment. In recent years, the evolution of computer systems has allowed an accurate assessment and programming, by means of the three-dimensional display, which are of great help in the course of diagnosis and evaluation of the displacements to be carried out, in order to obtain optimal aesthetic results.

Disseminated necrotic mediastinitis spread from odontogenic abscess: our experience.

AIMS: Deep neck infections are rare but potentially fatal complication of pulpal abscess of the teeth. If an infection can progress rapidly from a toothache to a life threatening infection, then it is critical that dentists be able to recognize the danger signs and identify the patients who are at risk. Mediastinitis is a severe inflammatory process involving the connective tissues that fills the intracellular spaces and surrounds the organs in the middle of the chest. This pathology has both an acute and a chronic form and, in most cases, it has an infectious etiology. This study want to expose the experience acquired in the Oral and Maxillo-facial Sciences Department, Policlinico Umberto I, "Sapienza" University of Rome, regarding two clinical cases of disseminated necrotizing mediastinitis starting from an odontogenic abscess. METHODS: We report two clinical cases of disseminated necrotic mediastinitis with two different medical and surgical approaches. The radiographic and photographic documentation of the patients was collected in the pre-and post-operatively. All patients underwent a CT scan and MRI. RESULTS: Mediastinitis can result from a serious odontogenic abscess, and the extent of its inflammation process must be never underestimated. Dental surgeons play a key role as a correct diagnosis can prevent further increasing of the inflammation process. CONCLUSIONS: A late diagnosis and an inadequate draining represent the major causes of the elevated mortality rate of disseminated necrotizing mediastinitis.

Variation of the upper airways in pediatric patients with OSAS and retrusion of the midface.

In pediatric patients, the incidence of Sleep-Disorder breathing (SDB) is 2% for OSAS and 7-8% for snoring. Snoring, sleep apnea and the development of neurocognitive and behavioral disorders represent the main symptoms. In these children, snoring is noisy and is present for the greater part of sleep. Accurate diagnosis and treatment protocol is critical for a child with OSAS as it is associated to complications as: pulmonary hypertension, chronic pulmonary heart disease, low height-weight development, behavioral problems, reduced school performance, bedwetting and daytime sleepiness or irritability. For this reason, over the years different surgical techniques were developed to solve the clinical symptoms evident on the polysomnographic test. In this paper, the authors report the experience at the Department of Cranio-Maxillo-Facial Surgery, Policlinico Umberto I, "Sapienza" Università di Roma, in the treatment of pediatric patients with OSAS and midface retrusion.

Fronto-ethmoidal osteoma. Open treatment.

INTRODUCTION: Osteoma is a benign tumour, composed of mature compact or cancellous bone, which can arise in any facial bone. Among the paranasal sinuses, the frontal and ethmoid sinuses are most frequently involved. Osteoma grows very slowly and small lesions are often not symptomatic. On the other hand, sometimes patients present with symptoms such as sinusitis, headache or ophtalmologic manifestations. These findings are secondary to obstruction of the involved sinus cavity with secondary mucocele formation or occasionally an expansile lesion with distortion of the facial contour. MATERIALS AND METHODS: From 2005 to 2010, twenty-one (21) patients affected with non-syndromic fronto-ethmoidalosteomas were evaluated in our Department. Collected data include patients' age at the time of disorders, gender, presenting signs and symptoms, primary diagnosis, type and characteristics of the treatment performed, radiological findings and post-treatment results. All patients were investigated by CT scans in axial and coronal planes. The treatment and outcomes of this group were reviewed. RESULTS: All patients of the study underwent surgery and had a follow-up of at least 5 years. Surgical excision of the tumour was undertaken. Postoperative CT scans in axial and coronal planes showed complete removal of the tumour in all cases. No complications or recurrences were observed. DISCUSSION: Small, asymptomatic osteomas probably do not need to be treated but should be observed periodically. Surgical management remains the mainstay of treatment for these tumours. It requires total excision via an adequate approach, depending upon the site of presentation. CONCLUSION: A purely endoscopic endonasal approach has the risk of incomplete excision. In our experience open technique provides a wide exposure and better control. Even frontal osteomas can be safely removed by careful open surgery KEY WORDS: Ethmoidal sinus, Frontal sinus, Open treatment, Osteoma, Paranasal sinuses.

Bisphosphonate therapy and osteonecrosis of the jaw complicated with a temporal abscess in an elderly woman with rheumatoid arthritis: a case report.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an adverse drug reaction described as the progressive destruction and death of bone tissue of the mandible or maxilla, in the course of bisphosphonate therapy. Orally administered bisphosphonates, widely used for the treatment of osteoporosis, are rarely associated with BRONJ. Instead, the risk greatly increases whether the patient is concomitantly taking steroid and/or immunosuppressant agents. The aims of this paper are to briefly discuss the evidence of the associations between bisphosphonate therapy and BRONJ, and the effects of co-occurring factors such as the presence of rheumatoid arthritis, dental surgery, and concomitant corticosteroid therapy. In particular, we present the case of an elderly woman with BRONJ suffering from rheumatoid arthritis, with a recent dental extraction and with a very unusual complication: a temporal abscess, who was successfully treated.

Staging of osteonecrosis of the jaw requires computed tomography for accurate definition of the extent of bony disease.

Management of osteonecrosis of the jaw associated with antiresorptive agents is challenging, and outcomes are unpredictable. The severity of disease is the main guide to management, and can help to predict prognosis. Most available staging systems for osteonecrosis, including the widely-used American Association of Oral and Maxillofacial Surgeons (AAOMS) system, classify severity on the basis of clinical and radiographic findings. However, clinical inspection and radiography are limited in their ability to identify the extent of necrotic bone disease compared with computed tomography (CT). We have organised a large multicentre retrospective study (known as MISSION) to investigate the agreement between the AAOMS staging system and the extent of osteonecrosis of the jaw (focal compared with diffuse involvement of bone) as detected on CT. We studied 799 patients with detailed clinical phenotyping who had CT images taken. Features of diffuse bone disease were identified on CT within all AAOMS stages (20%, 8%, 48%, and 24% of patients in stages 0, 1, 2, and 3, respectively). Of the patients classified as stage 0, 110/192 (57%) had diffuse disease on CT, and about 1 in 3 with CT evidence of diffuse bone disease was misclassified by the AAOMS system as having stages 0 and 1 osteonecrosis. In addition, more than a third of patients with AAOMS stage 2 (142/405, 35%) had focal bone disease on CT. We conclude that the AAOMS staging system does not correctly identify the extent of bony disease in patients with osteonecrosis of the jaw.

Endoscopic approach to maxillo-facial trauma.

AIM: This article reviews the application of endoscope-assisted techniques to the treatment of maxillofacial trauma and discusses some aspects of these techniques and reporting our experience. INTRODUCTION: In the last decades, diagnostical imaging, surgical techniques and surgical instrument development allowed a great progress in management of facial fractures. In recent years, to some Authors, endoscopic approach to maxillofacial trauma has become common for reducing zygomatic arch, orbital blow-out, medial orbital wall, frontal sinus and subcondylar mandibular fractures. The endoscopic reduction of facial fractures as an alternative to open reduction allowed to manage patients with less unwanted complications. In fact, endoscopic approach permit to decrease perisurgical morbidity and offers to surgeons to reach good results. DISCUSSION: Indications to endoscopic reduction are represented by dimension, extension and site of the fracture and to the surgeon's experience. CONCLUSIONS: The use of endoscopy in maxillo-facial surgery represents one of the main realities of modern medicine together with advanced sectors of biomedical engineering research. In this way, not only time of hospitalization will be reduced but also morbidity in maxillofacial surgery.

A new surgical approach for the treatment of chronic recurrent temporomandibular joint dislocation.

Chronic recurrent temporomandibular joint (TMJ) dislocation is defined as the complete loss of articular relationships, during mouth-wide opening, between the articular fossa of the temporal bone and the condyle-disk complex. The most frequent pathogenetic factors involved in chronic recurrent dislocation of the TMJ are supposed to be trauma, abnormal chewing movements, TMJ ligaments, capsule laxity, and masticatory muscles disorders. In fact, TMJ dislocation occurs more frequently in people with general joint laxity and in patients with internal derangement of the TMJ or with occlusal disturbance. Management of TMJ dislocation remains a challenge. Eminectomy, whose validity has been demonstrated by several authors, acts on the bony obstacle, preventing condylar locking, but does not have a therapeutic effect on TMJ ligament and capsular laxity or masticatory muscle incoordination, which seem to be the real cause of TMJ dislocation in most cases. The authors present a mini-invasive modified technique of eminectomy, which aims to act on both the obstacle and the cause with respect and restoration of TMJ biomechanical constraints.