The Management of Iatrogenic Obstructive Sleep Apnoea Syndrome Following Bimaxillary Surgery in a Patient with Cleft Lip and Palate.

A 26-year-old man presented with a 6-year history of severe obstructive sleep apnoea syndrome followed a bimaxillary osteotomy procedure for a class III skeletal pattern. The patient was born with a unilateral cleft lip and palate and underwent primary lip and palate repair and later a pharyngeal flap for severe velopharyngeal insufficiency. Surgical management of obstructive sleep apnoea syndrome with conventional osteotomy, in cleft lip and palate patients, is a difficult problem. Distraction osteogenesis may provide a safer alternative. The authors describe and discuss the indications and the technical challenge of a multistage treatment protocol with distraction osteogenesis.

The Le Fort I osteotomy as surgical approach of an extensive pleomorphic adenoma of the palate.

Pleomorphic adenoma (PA) is the most common benign mixed salivary gland tumor. We describe here a peculiar case of a 72-year-old woman with a PA of the palate resected with palatal approach combined with Le Fort I osteotomy, adding to the currently limited scientific literature on intraoral approach for removal of extensive tumors of the midface. The Le Fort I osteotomy approach allows direct visualization of the tumor and ensures a wide excision, increasing safety and minimizing the possibility of recurrence.

Unilateral mandibular hypoplasia in adult patients: distraction osteogenesis and conventional osteotomies in a standardized sequence.

INTRODUCTION: This study analyzed the outcomes of nongrowing patients with unilateral mandibular hypoplasia treated according to a specific protocol, which combines distraction osteogenesis, orthodontic treatment, and conventional osteotomies. MATERIALS AND METHODS: The patients treated were objectively evaluated. Patient's satisfaction was assessed by questionnaire. Surgical changes were analyzed using cephalometry and three-dimensional facial surface data before surgery (T0) and at long-term (T1) follow-up. RESULTS: Four patients were included in this study. The normalization of facial proportion and a high increase in symmetry were evident. Residual defects were documented in the postoperative symmetry of the chin. In the questionnaire, all patients gave favorable responses to their facial changes; for most of the objective parameters, all patients improved. CONCLUSIONS: A multistage treatment protocol for the correction of facial deformities in patients with unilateral mandibular hypoplasia is a valid procedure for skeletal and occlusal stability. An evident improvement of the facial appearance is also achieved.

Single-step resection and reconstruction using patient-specific implants in the treatment of benign cranio-orbital tumors.

PURPOSE: The aim of this study was to evaluate surgical outcomes using patient-specific prostheses produced by computer-aided design and manufacturing for primary reconstruction in patients with benign cranio-orbital tumors. Polyetheretherketone was used to manufacture the implants. MATERIALS AND METHODS: The present study included 3 patients who underwent fronto-orbito-pterional craniotomy using individual custom-made surgical guides. Patient-specific polyetheretherketone prostheses were used for reconstruction during the same surgery. All patients underwent esthetic examination (facial and orbital symmetry, globe projection and position), ophthalmologic examination (diplopia with the Hess-Lancaster test, visual field and acuity), and radiologic evaluations (computed tomography and magnetic resonance imaging) during the preoperative and follow-up periods. Operating time and short- and long-term complications were recorded. RESULTS: The immediate and long-term morphologic results were satisfactory; in particular, ocular globe position and projection were correct. After 25 to 31 months, none of the patients developed implant-related complications, such as infection, extrusion, or malposition. Two-year postoperative computed tomograms and magnetic resonance images showed no recurrences. CONCLUSION: Single-step resection and reconstruction with computer-aided designed and manufactured implants is a challenging new technique that decreases operative time and morbidity. The implants adequately restore an anatomically complex area with satisfactory cosmetic results.

Changes in hospital admissions for facial fractures during and after COVID 19 pandemic: national multicentric epidemiological analysis on 2938 patients.

PURPOSE: The objective of this multicenter study was to examine the differences in maxillo-facial fractures epidemiology across the various phases of the SARS-CoV-2 pandemic. METHODS: This is a retrospective study on patients who underwent surgery for facial bone fractures in 18 maxillo-facial surgery departments in Italy, spanning from June 23, 2019, to February 23, 2022. Based on the admission date, the data were classified into four chronological periods reflecting distinct periods of restrictions in Italy: pre-pandemic, first wave, partial restrictions, and post-pandemic. Epidemiological differences across the groups were analysed. RESULTS: The study included 2938 patients. A statistically significant difference in hospitalization causes was detected between the pre-pandemic and first wave groups (p = 0.005) and between the pre-pandemic and partial restriction groups (p = 0.002). The differences between the pre- and post-pandemic groups were instead not significant (p = 0.106). Compared to the pre-pandemic period, the number of patients of African origin was significantly higher during the first wave and the post-pandemic period. No statistically significant differences were found across the periods concerning gender, age, fracture type, treatment approach, and hospital stay duration CONCLUSIONS: The COVID-19 pandemic brought about significant changes in fracture epidemiology, influenced by the restrictive measures enforced by the government in Italy. Upon the pandemic's conclusion, the fracture epidemiology returned to the patterns observed in the pre-pandemic period.

Soft tissue changes after orthodontic surgical correction of jaws asymmetry evaluated by three-dimensional surface laser scanner.

Aesthetic improvement is an essential goal of treatment of facial asymmetry, and it is often difficult to achieve. Reliable three-dimensional measurements are required to support outcome studies. In this study, 15 white adult subjects, 9 females and 6 males, with maxillomandibular asymmetry and malocclusion were studied. The patients were treated with orthodontics and different surgical procedures in single or multiple steps. All patients received double-jaw surgery, except 1 patient who underwent only maxillary osteotomy. Nine of the 15 patients received additional procedures (genioplasty and rhinoplasty) to achieve better symmetry. Posterior-anterior and lateral cephalometry and three-dimensional facial surface data were obtained before (T0) and 1 year (T1) after surgery. Scan data at T0 and T1 were pooled by electronic surface averaging to obtain the mean pretreatment and posttreatment facial model. A symmetric model was constructed by averaging the actual T0 scans and their mirrored models to obtain the virtual optimal symmetric face. Different linear and angular measurements were then calculated for comparison of the mean T0 and T1 models. The normalization of facial proportion and a high increase in symmetry were evident. Residual defects were documented in the postoperative symmetry of the chin. Treatment of facial asymmetry, combined with dental occlusion problems, is still a challenge for maxillofacial surgeons. Orthognathic surgery provides an important improvement of symmetry, but further refinements of technique are still required. Three-dimensional evaluation results in an effective method to support outcome studies on the surgical correction of complex facial deformities.

Etiology and patterns of facial lacerations and their possible association with underlying maxillofacial fractures.

BACKGROUND: This study was designed to analyze the etiology and patterns of soft-tissue facial lacerations associated with maxillofacial fractures and to identify associations between facial lacerations and underlying fractures. METHODS: Of 1960 patients who had been admitted for maxillofacial fractures between 2001 and 2010, only patients with complete clinical records presenting with facial lacerations were considered for this study. Facial lacerations were classified according to the MCFONTZL system. RESULTS: Of the 1960 patients admitted with maxillofacial fractures, 637 had 836 associated facial lacerations. Motor vehicle accidents and falls were responsible for most injuries to patients with facial lacerations. According to etiology, fractures resulting from work-related accidents more frequently produced associated lacerations.For all causes of injury, more facial lacerations were observed over the "T" area formed by the upper orbit and forehead, nose, upper and lower lips, and chin. Lacerations and maxillofacial fractures were more frequently localized to the middle third of the face, followed by the inferior third.There was a strong association between lacerations and fractures in the chin region, considering both symphyseal and parasymphyseal fractures (direct trauma) and condylar fractures (indirect trauma). CONCLUSIONS: An association between facial lacerations and underlying maxillofacial fractures was observed, particularly in the inferior orbital area and over the zygoma, mandible, and chin.

Surgical treatment of odontogenic myxoma.

BACKGROUND: There is no consensus about the surgical treatment of odontogenic myxoma. The aim of the current study was to present our experience and discuss the surgical management and outcome in 10 patients diagnosed with odontogenic myxoma. METHODS: A retrospective review of charts of patients who were surgically treated for odontogenic myxoma was performed. Patients were recalled, and eventual recurrences were investigated. RESULTS: Eight lesions were mandibular, whereas 2 were maxillary. In 3 patients, enucleation and curettage was performed. Instead, in the remaining 7 patients, segmental resection and immediate reconstruction were decided. At follow-up, no patient showed recurrence of the lesion. CONCLUSIONS: Our protocol is to perform conservative surgery by enucleation and curettage when lesions were smaller than 3 cm, whereas a segmental resection with immediate reconstruction is preferred in patients affected by bigger tumors. Long-term follow-up is required, in particular when conservative surgery is preferred.

Facial mobility after bimaxillary surgery in class III patients: a three-dimensional study.

Quantifying soft tissue changes after orthognathic surgery is increasingly important in surgical planning, but little is actually known about the changes in facial mobility after surgery. In the current study, we investigated facial mimics in patients before and after orthognathic surgery. Eleven patients with jaw discrepancy requiring maxillary and/or mandibular surgery were considered. Facial landmarks were applied, and facial surface data were acquired using a three-dimensional laser scanner before surgery and after 3, 6, and 12 months. The facial movements were frowning, eye closure, grimace, smiling, and lip purse. They were described in terms of surface and landmark displacements. Mean and SD were calculated for the right and left sides of the face and compared with normal values previously obtained in control subjects. We compared the results in 4 groups of patients: all the patients together (group A), bimaxillary surgery (group B), basal surgery without ancillary procedures (group C), and basal surgery plus rhinoplasty and/or genioplasty (group D). After surgery, modifications of symmetry were evident in many subjects, but after 1 year, facial movements were statistically similar to presurgical registrations. In smiling, the single case observations revealed a postsurgical improvement of amplitude in 8 subjects. In conclusion, orthognathic surgery did not significantly modify facial mobility in the long term. On the contrary, the amplitude of movement during smiling seems to increase in the majority of subjects. Our evaluation of three-dimensional laser scanning of facial movement showed that it can detect small posttreatment changes on soft tissues.

Surgical management of orbital trapdoor fracture in a pediatric population.

PURPOSE: Orbital trapdoor fractures are pure orbital floor fractures with herniation and entrapment of the orbital contents, leading to restricted eye movement and diplopia. Trapdoor fractures in children have been discussed widely in published reports; however, the treatment policy and outcome remain controversial, although early treatment has been advocated. Our retrospective study analyzed the long-term results of pediatric patients undergoing surgery for trapdoor fractures to determine the outcome in relation to the type of fracture and the timing and technique of intervention. PATIENTS AND METHODS: The present study included 24 patients (age range 6 to 16 years) who underwent surgery for trapdoor fractures from 1998 to 2007. The demographic, etiologic, radiologic, and surgical findings, interval between trauma and surgery, surgical techniques, and complications were recorded. Diplopia, ocular motility, dysesthesia, and scar quality were recorded at follow-up. RESULTS: The follow-up duration averaged 36 months. At follow-up, 1 (8.3%) of 12 patients who underwent surgery within 24 hours (urgent treatment) had residual diplopia. In contrast, 3 (37.5%) of 8 patients who underwent surgery 24 to 96 hours (early treatment) and 4 (100%) of 4 who underwent surgery after 96 hours (late treatment) had diplopia. No sensory deficit of the skin or unesthetic eyelid scar was noted. CONCLUSIONS: We found a correlation between the outcome and the timing of surgery for trapdoor fractures in the pediatric population. The success rate was significantly better when the fractures were treated within 24 hours of the injury. The results of the present study have strengthened the assertion that trapdoor orbital fractures pose a true surgical emergency.

Mucoepidermoid carcinoma of the lacrimal sac masquerading as dacryocystitis.

Tumors originating from the lacrimal sac are exceedingly rare. They may mimic chronic inflammation and be misdiagnosed, delaying treatment and allowing the tumor to devastate the visual system. Mucoepidermoid carcinoma has been described only occasionally. We report a case that presented with unusual diagnostic and treatment aspects. A 33-year-old Italian man had tearing in his right eye. The initial presentation mimicked dacryocystitis, and the patient had been treated with antibiotics and steroids, without results. Consequently, an external dacryocystorhinostomy was performed, during which an open biopsy specimen was taken; it suggested the presence of a basocellular epithelioma. Computed tomography, magnetic resonance imaging, and further biopsies led to the diagnosis of squamous carcinoma of the lacrimal sac. On this basis, the patient underwent preoperative radiation (41.4 Gy) and conservative surgical resection of the tumor, with preservation of the eye and extraocular muscles. The histopathologic examination of the gross surgical specimen led to a final diagnosis of primary mucoepidermoid carcinoma of the lacrimal sac and revealed clear resection margins. The clinical evaluation and positron emission tomography at 6 months showed complete functional recovery and no evidence of the disease. This report highlights the clinicopathologic characteristics and therapeutic uncertainty of this rare tumor.

Juvenile Facial Growth and Mimicry: A Preliminary 3D Study.

Studies focused on facial development during childhood have been conducted by means of 3D technology to provide modifications of anthropometric parameters. Facial mobility was also considered. This study proposed a 3D approach to facial growth changes. Facial surface data of 6 subjects were acquired in T1 (age 7-14 years) and after 7 years (T2), in rest position, and during voluntary movements, by a 3D laser scanner. Linear and angular measurements on rest position scans at T1 and T2 were compared. Each mimic scan was superimposed with the corresponding rest scan. Displacement of significant anthropometric points was measured for each facial gesture and at T1 and T2 statistically compared. Vertical measurements were those most influenced by aging. Some measurements of central facial area were consistent over time. The pattern of soft tissues displacement for each expression was consistent in T1 and T2. These results may be helpful for missing children identification.

Soft, hard-tissues and pharyngeal airway volume changes following maxillomandibular transverse osteodistraction: Computed tomography and three-dimensional laser scanner evaluation.

INTRODUCTION: Maxillomandibular transverse osteodistraction (MMTOD) is an alternative approach to the traditional treatment for transverse maxillary and mandibular deficiencies and crowding. The aim was to report soft and hard-tissues changes and airway volume variation. METHODS: In this study, skeletally mature, non-syndromic patients with transverse maxillary and mandibular hypoplasia, who underwent a MMTOD between 2010 and 2012, were included. Surgical changes were analysed using clinical evaluation, three-dimensional facial surface data and computed tomography analysis before (T0) and after the completion of post-op orthodontic treatment (T1). RESULTS: Nineteen patients (eight males and eleven females; average age: 26.3 years) were enrolled. MMTOD produces facial changes in the cheek, paranasal areas, nasal base and chin. Facial changes are mostly explained by the underlying skeletal movements, which are essentially represented by the transverse enlargement of both the maxilla and the mandible. Following MMTOD, the airway volume and the lateral dimension of the cross-sectional airway increased significantly. CONCLUSIONS: MMTOD is a technique that allows an increase in airway volume and in both maxillary and mandibular arch perimeters simultaneously by increasing skeletal width. Facial appearance is improved and a stable occlusion is obtained.

Facial Mobility after Maxilla-Mandibular Advancement in Patients with Severe Obstructive Sleep Apnea Syndrome: A Three-Dimensional Study.

Introduction. The functional results of surgery in terms of facial mobility are key elements in the treatment of patients. Little is actually known about changes in facial mobility following surgical treatment with maxillomandibular advancement (MMA). Objectives. The three-dimensional (3D) methods study of basic facial movements in typical OSAS patients treated with MMA was the topic of the present research. Materials and Methods. Ten patients affected by severe obstructive sleep apnea syndrome (OSAS) were engaged for the study. Their facial surface data was acquired using a 3D laser scanner one week before (T1) and 12 months after (T2) orthognathic surgery. The facial movements were frowning, grimace, smiling, and lip purse. They were described in terms of surface and landmark displacements (mm). The mean landmark displacement was calculated for right and left sides of the face, at T1 and at T2. Results. One year after surgery, facial movements were similar to presurgical registrations. No modifications of symmetry were present. Conclusions. Despite the skeletal maxilla-mandible expansion, orthognathic surgical treatment (MMA) of OSAS patients does not seem to modify facial mobility. Only an enhancement of amplitude in smiling and knitting brows was observed. These results could have reliable medical and surgical applications.

The effect of closed septorhinoplasty on nasal functions and on external and internal nasal valves: A prospective study.

BACKGROUND: Because nasal function and shape are so closely intertwined, quantitative assessments can better define their relationship and how they are affected by septorhinoplasty. OBJECTIVE: The aim of this prospective study was to perform an analysis of the nasal airflow resistances and a three-dimensional (3D) evaluation of the soft-tissue changes after closed septorhinoplasty. METHODS: Before surgery (T0) and 6 months after closed septorhinoplasty (T1), 30 patients underwent symptoms evaluation by means of the Italian version of the Nasal Obstruction Symptom Evaluation scale, endoscopic fiberoptic nasal examination, and visual analog scale for subjective assessment of nasal obstruction. Nasal airflow resistances were investigated with active anterior active rhinomanometry. A 3D laser scanner was used to evaluate facial soft-tissues, with specific nasal points and angles. RESULTS: Subjective nasal obstruction decreased. Anterior active rhinomanometry demonstrated a reduction in total inspiratory and expiratory resistances between T0 and T1 but without statistical significance. The significance was still absent after decongestion, excluding turbinate hypertrophy as a cause of failed objective amelioration of nasal resistance. Facial laser scanning showed statistically significant reduction of the superior nasal width and superior alar angle, and a weak negative correlation between the superior alar angle and nasal resistances. CONCLUSION: The absence of objective reduction of nasal airflow resistances could be the result of concurrent surgery on nasal septum and nasal valve. In particular, the ameliorating effect on nasal airflow resistances is counterbalanced by the worsening effect of the narrowing of nasal valve.

Primary and secondary reconstruction of complex craniofacial defects using polyetheretherketone custom-made implants.

PURPOSE: The aim of this study was to evaluate the surgical outcomes using polyetheretherketone (PEEK) patient-specific prostheses produced by computer-aided design and manufacturing for primary and secondary reconstruction in patients with craniofacial defects. MATERIAL AND METHODS: The study included 13 patients who underwent reconstruction for craniofacial defects using PEEK patient-specific implants (PSI). Eight patients underwent single-step primary reconstruction using individual custom-made surgical guides and custom-made prostheses during the same surgery; five patients underwent delayed reconstruction. The material used to manufacture the implants was PEEK in 13 cases. All patients underwent esthetic examination, ophthalmological examination, and radiological evaluation during the preoperative and follow-up periods. The operation duration and short- and long-term complications were recorded. RESULTS: The shape and global position of the implants were satisfactory in each case. Fitting of the implant during surgery required extensive adaptation in 1 case and minor in 11 cases. Of 13 implants, 11 adequately restored a morphological complex area with satisfactory cosmetic results. No complications related to the implants were reported. CONCLUSION: Reconstruction for cranio-facial defects using PEEK computer-aided designed and manufactured implants is a promising new technique that allows for accurate restoration of the complex 3D anatomy of the craniofacial region.

Three-dimensional laser scanner evaluation of facial soft tissue changes after LeFort I advancement and rhinoplasty surgery: patients with cleft lip and palate vs patients with nonclefted maxillary retrognathic dysplasia (control group).

OBJECTIVE: The aim of this study was to analyze the differences in facial soft tissue changes, despite the same extent of upper jaw forward movement, between patients with unilateral cleft lip and palate (uCLP) and those without, after LeFort I osteotomy and secondary rhinoplasty. STUDY DESIGN: Twelve patients with maxillary retrognathic dysplasia and nose deformity were divided in 2 groups, A (uCLP) and B (control), and compared on the basis of the same maxillary advancement. Cephalometry and 3D mean facial model of groups A and B were obtained before and after surgery. Linear and angular measurements were calculated. RESULTS: Upper vermilion and alar base remained unchanged in group A but increased in group B. In both groups, symmetry of the nasal base was improved, and an increase of the sagittal projection of the lips was observed. CONCLUSIONS: 3D analysis showed that surgical procedures for uCLP can provide a satisfactory aesthetic outcome, but some differences are evident in comparison with the control group.

Soft tissue changes after maxillo-mandibular advancement in OSAS patients: a three-dimensional study.

INTRODUCTION: Maxillo-mandibular advancement (MMA) is the most successful surgical treatment for OSAS. This study prospectively evaluated soft tissue changes in typical OSAS patient before and after MMA. MATERIAL AND METHODS: Ten patients with severe OSAS, who underwent MMA, were considered. Age, BMI, polysomnographic recordings and cephalometric data were examined. Facial surface data acquired using a 3D laser scanner before (T0) and 1 year (T1) after surgery were pooled by electronic surface averaging to obtain the mean T0 and T1 facial model. A virtual optimal face (V) was used as control group. Mean T0, T1 and V models were compared. RESULTS: The mean AHI improved from 69.8 ± 35.2 to 17.3 ± 16.7. The mean maxillary advancement was 9.2 mm ± 1.2 and the mean mandibular advancement was 10.4 mm ± 2.2. The comparison between T0 and T1 showed an overall increase of the sagittal projection of the cheeks, lips and of the chin. The comparison between T1 and V showed a transversal increase of the cheeks at the cross section through ch (cheilon). CONCLUSION: MMA is a highly effective treatment for OSAS. The evaluations of 3D laser scanning showed that surgery in OSAS patients didn't cause an impairment of the facial appearance.

Progressive midfacial bone erosion and necrosis: case report and differential diagnosis.

A 31-year-old woman presented with a large oro-nasal communication (ONC), loss of vomer and significant nasal cartilage and nose deformity. Physical examination of the patient revealed a typical midline destructive lesion (MDL) with nasal septum and hard/soft palate perforation with a friable granular surface and a large amount of necrotic tissues. Medical history was unremarkable and the patient denied previous local trauma, including surgical procedures or drug assumption. Pathological examination revealed the presence of necrosis and chronic inflammation. MDLs have numerous etiologies. Signs and symptoms of MDLs can be similar and an accurate diagnosis may be elusive. We hereby present detailed clinicopathological findings.