Ultrasound endoscopic bone cutting for rapid maxillary expansion.

PURPOSE: This study evaluated the feasibility and morbidity of ultrasound endoscopic rapid maxillary expansion. PATIENTS AND METHODS: Thirteen consecutive patients (7 women and 6 men; mean age at time of surgery, 22 yr 10 months; range, 15 yr 4 months to 26 yr 3 months) who required surgically assisted rapid palatal expansion were included in this study. Eight patients had Class III malocclusion and 5 had Class II malocclusion. All osteotomies were performed using ultrasound bone-cutting instruments under direct visualization with a rigid 30° 2.7-mm-diameter endoscope connected to a video system, with access through 3 small vertical incisions. RESULTS: Satisfactory maxillary expansion was achieved in all patients, with minimal postsurgical sequelae. The average operative time for the 13 cases was 74 minutes (standard deviation, 11 minutes) and was not dependent on the quality of bone. Postoperative pain was measured using a visual analog scale ranging from 0 to 10 and was found to be 1.5 ± 0.8 on the first postoperative day, which decreased to 0.9 ± 0.4 on the second day. Mucosal healing was excellent and none of the patients had excessive edema, hematoma formation, or nerve injury. CONCLUSION: The procedure described is minimally invasive and has advantages over the usual technique in providing direct vision, creation of a precise and safe osteotomy, minimal bleeding risk, and decreased dissection.

Immediate socket restoration after orbital trauma with globe loss: principles, timing, and our experience.

The literature-reported incidence of ophthalmic injuries occurring with facial fracture ranges widely from 0.8% to 30%. Ocular trauma necessitating enucleation or evisceration is less common, but it is not rare. The trauma and physical disability related to removal of the eye are extreme. Moreover, the loss of an eye causes severe changes to the anatomy and physiology of the orbit, resulting in deformities that affect the relationship between the socket and the prosthesis. Here, the authors present their own experience of 8 consecutive cases of trauma injuries with globe loss and emphasize the importance of accurate, early bone reconstruction involving evisceration and immediate socket restoration.

Ultrasonic aesthetic cranioplasty.

The management of frontal bone injury is an important issue, and inappropriate management of such injuries may give rise to serious complications. Piezosurgery is a technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. This instrument allows a safe method for osteotomy of the cranial vault in close proximity to extremely injury-sensitive tissue such as the brain. After a wide review of the literature, the authors present this technical report, introduce the use of piezosurgery to perform a safe "slim-osteotomies" for treatment of posttraumatic frontal bone deformities, and suggest the use of this instrument for aesthetic recontouring of the craniofacial skeleton.

Iliac flap versus fibula flap in mandibular reconstruction.

The mandible is one of the important parts of the body in terms of facial appearance and function. Vascularized free bone grafts have become the criterion standard in mandible reconstruction. With flap survival rates not too much distant to 100%, the focus is now on function and aesthetics. With the various free-flap options now available, reconstruction of the mandibular defect has achieved significant improvement in both functional and aesthetic results. However, few studies have compared the results of these options. The fibula is defined as the most popular flap in mandibular reconstruction, and only in few papers iliac flaps are preferred. However, quality of life and effectiveness data are not available to support this choice. Not any previous study prospectively compared these 2 flaps. Short- and long-term results of an outcome-research study were prospectively compared in microvascular mandibular reconstruction with fibular flap and iliac crest flaps. Mean functional and quality-of-life scores were higher following iliac crest reconstructions. Fibular flap was the flap of choice in total/subtotal mandibulectomy, but it does not appear preferable in hemimandibulectomy and/or in cases of segmental mandibulectomy, if compared with the iliac crest.

Bifunctional sculpturing of the bone graft for 3-dimensional augmentation of the atrophic posterior mandible.

Short implant procedures may suffer from fixture instability, if incorrectly planned and performed, and from an esthetically compromised rehabilitation, due to increased interarch distance and increased crown-implant ratio. Several procedures have been proposed to achieve alveolar ridge augmentation with different success and complication rates: onlay grafts, alveolar sandwich osteotomies, titanium micromesh, alveolar distraction, and alveolar nerve transposition. The edentulous posterior mandible suffers from the presence of a compact cortical layer, which tends to limit graft osteogenesis, because of a low permeability to the osteogenic elements (microvessels and cells). This report introduces a variant to the endochondral onlay bone graft, in which an external cortical layer is placed above a biologically active core of cancellous bone and platelet-rich plasma. This solution provides easy 3-dimensional conformation of the graft, enhancing its mechanical stability. The presence of the biologically active core provides better vascular support and a valid interface between graft and the osteogenetic cell lines.

Extracapsular lumpectomy and SMAS flap for benign parotid tumours: an early outcome in a small number of cases on Frey's syndrome and facial nerve dysfunction.

Parotidectomy is the most common approach for benign salivary neoplasms. The aim of the present study was to retrospectively analyse no. 34 extracapsular lumpectomies (ELs) performed with superficial musculoaponeurotic system (SMAS) flaps on 32 patients for benign parotid tumours. Based on the extent of the surgical defect the surgical resection was associated with sternocleidomastoid (SCM) muscle rotation flap in 8 patients, superficial temporal artery fascial flap (STAFF) in 2, and temporalis muscle rotation flap in 2. None of the patients affected by pleomorphic adenoma or Warthin's tumour had a complete facial palsy. Only 1 patient (2.9%) had a postoperative transient partial facial paralysis with incomplete eye closure. Neither haematoma formation, nor wound infection was observed, while seroma formation occurred in only 1 patient (2.9%). No cases of Frey's syndrome occurred. An SMAS flap should be performed in primary postparotidectomy reconstruction; a temporoparietal fascia flap (TPFF) if a major defect is anticipated, or when the SMAS has to be resected; an SCM muscle flap covered by an SMAS flap is the method of choice in more extensive rare defects.

Simultaneous functional endoscopic sinus surgery and esthetic rhinoplasty in orthognathic patients.

PURPOSE: Patients treated for dentofacial deformities may be predisposed to aggravated sinonasal disease postoperatively, particularly if concurrent rhinoplasty is performed. The authors present their experience with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and functional endoscopic sinus surgery (FESS). PATIENTS AND METHODS: Thirteen patients were treated with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and FESS from January 2002 to December 2005. An operative algorithm for patients with dentofacial deformities requiring rhinoplasty was developed. The surgical procedure was performed under general anesthesia with nasotracheal intubation and maxillary/mandibular osteotomies first. Nasotracheal intubation was then converted to orotracheal intubation and FESS was performed. The third step was correction of the esthetic deformities of the nose through an open approach. RESULTS: In all cases, it was possible to successfully complete the combined operation. Median operation time was: 2 hours and 18 minutes for orthognathic bimaxillary surgery, 54 minutes for rhinoplastic surgery; and 23 minutes for FESS. All the patients had good esthetic and functional results and were free from symptoms consistent with previous rhinosinusitis. CONCLUSION: The combination of orthognathic surgery, rhinoplasty, and FESS in selected cases is safe and effective.

Conscious analgesia and sedation during orthognathic surgery: preliminary results of a method of preventing condylar displacement.

A patient who is unconscious and paralysed has a condyle that is different from what it would be were he awake and the same force applied. The occlusion may relapse as a result of changes in condylar position immediately after the removal of intermaxillary fixation (IMF). Examination of the occlusion and an understanding of the changes secondary to a condylar displacement can identify it reliably during the operation. A study group (n=78) and a control group (n=74) were chosen randomly from patients listed for bimaxillary orthognathic surgery. No local anaesthetic was infiltrated so as not to disturb proprioception. In the study group, the IMF was removed immediately after the fixation and the occlusions were checked with light digital pressure on the chin. The patients were then woken rapidly (maintaining the intubation) in a state of conscious analgesia and sedation and invited to open and close their mouths and to move the mandible laterally. If clinical examination of the passive and active movements of the mandible were suitable, the anaesthetics were topped up and the operation completed. "Conscious" analgesia and sedation is certainly a valid aid during orthognathic surgery.

Epithelial-myoepithelial carcinoma of the parotid gland: Clinicopathological aspect, diagnosis and surgical consideration.

The present paper describes the clinical and pathological features of epithelial-myoepithelial carcinoma (EMC) of the parotid gland. This rare tumor represents <1% of all salivary gland tumors and arises most commonly in the parotid gland, but it has also been described in the submandibular gland, minor salivary glands and palate. EMC is considered to be a low-grade malignant tumor that may commonly recur locally after resection in 23-50% of cases. The complex and varied morphological expression of this neoplasm has attracted numerous investigators, who have presented valuable but often contradictory data. After an in-depth analysis of the clinicopathological aspects of EMC, we speculate that adequate resection with negative soft-tissue margins is the minimum recommended and necessary therapy.

A Rare Cause for Cervical Pain: Eagle's Syndrome.

Patients with pharyngodynia and neck pain symptoms can lead to an extensive differential diagnosis. Eagle's syndrome must be taken in account. Eagle defined "stylalgia" as an autonomous entity related to abnormal length of the styloid process or to mineralization of the stylohyoid ligament complex. The stylohyoid complex derives from Reichert's cartilage of the second branchial arch. The styloyd process is an elongated conical projection of the temporal bone that lies anteriorly to the mastoid process. The incidence of Eagle's syndrome varies among population. Usually asymptomatic, it occurs in adult patients. It is characterized by pharyngodynia localized in the tonsillar fossa and sometimes accompanied by disphagia, odynophagia, foreign body sensation, and temporary voice changes. In some cases, the stylohyoid apparatus compresses the internal and/or the external carotid arteries and their perivascular sympathetic fibers, resulting in a persistent pain irradiating in the carotid territory. The pathogenesis of the syndrome is still under discussion.

Endoscopically assisted enucleation and curettage of large mandibular odontogenic keratocyst.

This article reports a case of a mandibular multilocular keratocyst treated with endoscopically assisted enucleation and curettage. An ectopic third molar displaced in the coronoid process area was also removed.Odontogenic keratocysts (OKCs) are known for their propensity to recur. The incomplete removal of the cyst is one of the mechanisms for which it is thought that the keratocyst recurs. The endoscopic assistance allowed us to explore accurately the operative field and the areas of difficult access, improving the complete removal of the cystic lesion. Moreover, it allowed us to monitor closely the separation of the cyst lining from the inferior alveolar nerve and limit the extension of the surgical approach. At 3-year follow-up no evidence of recurrence was evidenced by radiological and clinical controls.

Arthroscopy with open surgery for treatment of synovial chondromatosis of the temporomandibular joint.

We report a case of synovial chondromatosis of the temporomandibular joint in which both joint compartments were affected. Because of the important involvement of the medial aspect of the joint, arthrotomy was done with arthroscopic assistance.

Endoscopic treatment of maxillary sinus disease before grafting.

We present our experience of the treatment of four patients with maxillary sinus disease by endoscopic sinus surgery to restore the normal physiology of the sinus before grafting.

Is there a role for arthrocentesis in recapturing the displaced disc in patients with closed lock of the temporomandibular joint?

OBJECTIVE: The aim of this study was to evaluate the effectiveness of arthrocentesis in releasing acute and chronic closed lock of the temporomandibular joint, improving function, reducing pain and recapturing the displaced disc. STUDY DESIGN: We performed arthrocentesis and mandibular manipulation (MM) as an initial treatment in 33 patients (unilateral involvement) with a variable duration of closed lock and magnetic resonance imaging (MRI) evidence of anterior disc displacement without reduction (ADDWR). Duration of locking ranged from 1 week to 2 years. After the procedure, soft diet, physiotherapy, and an interocclusal appliance (IA) were prescribed. Postoperative MRI images were obtained at 1 month. A clinical examination with analysis of maximal mouth opening (MMO), a visual analog scale (VAS), and a self-administered questionnaire were used for evaluation of pain, jaw dysfunction, and activities of daily living (ADL). The follow-up period was 1 year. RESULTS: At 1-year follow-up, MMO had increased significantly from a mean of 24.7 +/- 5.9 mm to 39.6 +/- 6.2 mm (P < .05). Functional improvement was associated with a significant reduction in VAS (from 6.2 +/- 2.3 to 2.8 +/- 3.4), pain (from 11.7 +/- 7.1 to 4 +/- 3.8), dysfunction (from 8.6 +/- 4.9 to 3.2 +/- 2.8), and ADL scores (from 13.9 +/- 12 to 4.4 +/- 5), with P < .05. The overall success rate was 72.7%; it was higher in acute patients (87.5%) than in chronic patients (68.0%). The disc was recaptured (the disc was interposed between the condyle and the eminence on closed and open MRI images) in 3 cases in which the duration of locking was less than 1 month (acute patients). CONCLUSIONS: The results indicate that arthrocentesis, in association with MM and IA, could be effective in improving function and reducing pain in patients with closed lock. Better results were obtained in terms of MMO, VAS, and questionnaire scores in acute closed lock cases than in chronic ones. Recapturing the anteriorly displaced disc is possible only in patients with acute closed lock.

Accuracy of virtual reality and stereolithographic models in maxillo-facial surgical planning.

Computed tomography is a medical instrument that can be useful not only for diagnostic purposes, but also for surgical planning, thanks to the fact that it offers volumetric information which can be translated in three dimensional models. These models can be visualized, but also exported to Rapid Prototyping (RP) systems, that can produce these structures thanks to the rapidity and versatility of the technologies involved. The literature reports various cases of stereolithographic models used in orthopedic, neurological, and maxillo-facial surgery. In these contexts, the availability of a copy of the real anatomy allows not only planning, but also the practical execution of surgical operations, within the limitations of the materials. Nevertheless, the Rapid Prototyping model also presents some disadvantages that can be reduced if practical simulation is accompanied by virtual simulation, performed on a digital model. The purpose of this work is to examine and present the use of Virtual Reality (VR) and Rapid Prototyping for surgical planning in Maxillo-Facial surgery.

Condylar positioning devices for orthognathic surgery: a literature review.

In the past few years, many devices have been proposed for preserving the preoperative position of the mandibular condyle during bilateral sagittal split osteotomy. Accurate mandibular condyle repositioning is considered important to obtain a stable skeletal and occlusal result, and to prevent the onset of temporomandibular disorders (TMD). Condylar positioning devices (CPDs) have led to longer operating times, the need to keep intermaxillary fixation as stable as possible during their application, and the need for precision in the construction of the splint or intraoperative wax bite. This study reviews the literature concerning the use of CPDs in orthognathic surgery since 1990 and their application to prevent skeletal instability and contain TMD since 1995. From the studies reviewed, we can conclude that there is no scientific evidence to support the routine use of CPDs in orthognathic surgery.

Management of the orbit in malignant sinonasal tumors.

Malignant ethmoid and maxillary sinus tumors frequently involve the orbit. Orbital involvement is an important prognostic predictor of recurrence-free, disease-specific, and overall survival. Most authors agree that orbital preservation as opposed to orbital exenteration or clearance does not result in significant differences in local recurrence or actuarial survival. The eye can be safely preserved in most patients with ethmoid or maxillary sinus cancer invading the orbital wall, including malignancies that invade the orbital soft tissues with penetration through the periorbita provided that they can be completely dissected away from the orbital fat. Malposition of the globe and nonfunctional eyes frequently result when patients have not had adequate rigid reconstruction of the orbital floor, particularly if they have received postoperative radiotherapy. This underscores the importance of such reconstruction. Isolated defects following orbital exenteration may be reconstructed with a temporalis muscle flap. Microvascular free-tissue transfer is the best option for repair of defects following orbital exenteration and total maxillectomy, although an obturator still has a role in selected patients.