Late orbital radiotherapy combined with intravenous methylprednisolone in the management of long-lasting active graves' orbitopathy: a case report and literature review.

PURPOSE: To present a case and review the literature on Orbital Radiotherapy (OR) combined with intravenous methylprednisolone, focusing on its late application in patients with long-lasting active Graves' Orbitopathy (GO). Additionally, we suggest emerging perspective for future research in this context. METHOD: Relevant literature (randomized controlled studies, retrospective studies and reviews) was explored on PubMed from January 1973 to January 2024, searching "orbital radiotherapy" & "Graves disease". RESULTS: OR is a well-established second-line treatment for moderate-to-severe active GO, providing response rates comparable to glucocorticoids. Its anti-inflammatory effect makes OR particularly suitable for early active GO, and when combined with glucocorticoids, outcomes are synergistically improved. The emergence of the new Volumetric Modulated Arc Image-Guided Radiation Therapy (VMAT-IGRT) technique enables precise radiation delivery to the target, significantly reducing associated toxicity. This technological advancement enhances the feasibility of radiotherapy in benign diseases like GO. A retrospective study indicated that late OR in patients with long-lasting active GO may improve diplopia and visual acuity, decreasing disease activity. Our case report supports this conclusion. CONCLUSIONS: This report and literature review underscores the importance of considering late OR combined with intravenous methylprednisolone as a viable treatment option for GO patients with prolonged disease activity, emphasizing the crucial role of personalized therapy in managing GO. However, further investigations are warranted to validate this approach in cases of long-lasting active GO.

Temporomandibular joint involvement in psoriatic arthritis: a prospective clinical and ultrasonographic study.

OBJECTIVES: To evaluate the prevalence of temporomandibular disorders (TMD) in a monocentric cohort of patients affected by psoriatic arthritis (PsA), and to investigate the accuracy of temporomandibular joint (TMJ) ultrasound (US) compared with clinical evaluation and clinimetric composite index in assessing TMJ involvement. METHODS: We conducted a prospective cohort study of patients diagnosed with PsA who underwent at least one TMJ US examination and maxillofacial surgeon's evaluation between 2018 and 2021. The rheumatology physician's interpretation of each TMJ US exam (presence/absence of TMD) was compared with psoriatic arthritis disease activity indexes and maxillofacial surgeon's clinical judgement (presence/absence of TMD signs and/or symptoms). RESULTS: 142 psoriatic arthritis patients were included. 111 patients were totally asymptomatic for TMD, but 58.5% of them already showed TMJ US changes; moreover, 103 patients passed the maxillofacial surgeon's examination in the absence of any relevant findings but again, of these, 55.3% already presented US signs of TMD. Univariate analysis of subgroups with and without TMJ synovitis and with and without active power Doppler signal showed a significant prevalence of peripheral enthesitic involvement in patients affected by TMD (95.7% vs. 4.3%, p=0.001; and 72.2% vs. 27.3%, p=0.007, respectively). Multivariate regression analysis confirmed the results (p=0.01 and p=0.013, respectively). CONCLUSIONS: Peripheral enthesitic involvement may represent a potential risk factor for the development of TMJ synovitis in PsA patients. Since TMD often develops asymptomatically, TMJ US may detect early signs of TMD, ensuring precocious and adequate management.

The Role of Ultrasound in Temporomandibular Joint Disorders: An Update and Future Perspectives.

Temporomandibular joint (TMJ) disorder is the second most common chronic pain condition affecting the general population after back pain. It encompasses a complex set of conditions, manifesting with jaw pain and limitation in mouth opening, influencing chewing, eating, speaking, and facial expression. TMJ dysfunction could be related to mechanical abnormalities or underlying inflammatory arthropathies, such as rheumatoid arthritis (RA) or juvenile idiopathic arthritis (JIA). TMJ exhibits a complex anatomy, and thus a thorough investigation is required to detect the TMJ abnormalities. Importantly, TMJ involvement can be completely asymptomatic during the early stages of the disease, showing no clinically detectable signs, exposing patients to delayed diagnosis, and progressive irreversible condylar damage. For the prevention of JIA complications, early diagnosis is therefore essential. Currently, magnetic resonance imaging (MRI) is described in the literature as the gold standard method to evaluate TMJ. However, it is a high-cost procedure, not available in all centers, and requires a long time for image acquisition, which could represent a problem notably in the pediatric population. It also suffers restricted usage in patients with claustrophobia. Ultrasonography (US) has emerged in recent years as an alternative diagnostic method, as it is less expensive, not invasive, and does not demand special facilities. In this narrative review, we will investigate the power of US in TMJ disorders based on the most relevant literature data, from an early screening of TMJ changes to differential diagnosis and monitoring. We then propose a potential algorithm to optimize the management of TMJ pathology, questioning what would be the role of ultrasonographic study.

Unilateral Sinus Disease: Not Just Odontogenic! - A Retrospective Study.

INTRODUCTION: Unilateral sinus disease (USD), and especially unilateral maxillary sinusitis (UMS), is an increasingly common finding in the ear, nose, and throat and maxillofacial practice. The aim of this retrospective study was to describe the clinical features of a series of patients affected by USD and, in particular, UMS due to sinonasal anatomic anomalies and of odontogenic origin. MATERIALS AND METHODS: A total of 292 patients affected by UMS were reviewed. Medical charts, radiological images, and surgical notes were all reviewed, particularly including data on UMS due to sinonasal anatomic anomalies and on UMS of odontogenic origin. RESULTS: A total of 66 patients have been excluded due to a diagnosis of malignant disease or other benign-defined etiology. Forty-eight patients (21.2%) affected by UMS due to sinonasal anatomic anomalies, whereas 178 (78.8%) patients affected by an odontogenic sinusitis. All patients were surgically treated by functional endoscopic sinus surgery, often in combination with a maxillofacial approach. DISCUSSION: UMS of odontogenic origin represented the greater group of USD. Computed tomography scans are always recommended to define UMS etiology (in particular excluding a malignant origin) and also to plan the most adequate surgical treatment.

Novel design of miniplate for fixation of fractures at transition zone of parasymphysis-body region of mandible - A clinical randomised study.

Fractures through the mandible at the level of the parasymphysis extending obliquely and traversing through the transitional zone to body region are relatively common. Therefore, a surgeon should have an appropriate understanding of the biomechanics of different plating techniques to fix these fractures. There is always a dilemma for the surgeon as to whether to fix these mandibular segments with one or two miniplates, and the presence of mental neurovascular bundle makes it more challenging. A study was planned in the Department of Oral and Maxillofacial Surgery to evaluate a novel twin-fork design of a miniplate used for fracture fixation at the transition zone of parasymphysis and body region of mandible after an in-vitro study of same design, and provided encouraging results. A total of 30 patients (10 patients in three groups each) were included in the study. All patients were evaluated preoperatively and postoperatively for operating time, ease of placement of miniplate, occlusion, reduction of fracture, neurosensory disturbances and infection. The novel design of twin-fork-shaped miniplate proved to be superior to the conventional miniplate in terms of neurosensory (Fisher exact test 17.40; p = 0.003) and functional outcome. There was statistically significant difference (χ2 = 13.895, p = 0.031) in postoperative reduction of fracture at week 4, indicating superiority of the twin-fork miniplate among the other conventional designs. The study concludes that the use of newly designed twin-fork-shaped miniplate should be encouraged in the fractures of transitional zone of parasymphysis-body region involving mental neurovascular bundle.

The arrhinias: Proboscis lateralis literature review and surgical update.

Proboscis lateralis (PL) is a rare malformation, reported for the first time in 1861 by Forster in his monograph on congenital malformations of the human body. The abnormal side of the nose is represented by a tube-like rudimentary nasal structure, attached at any point along the embryonic fusion line between the anterior maxilla and the frontonasal processes. As clefts of the lip (and alveolus) are bilateral or unilateral, an arrhinia can be bilateral (total) or unilateral. In this case it is a 'hemi-arrhinia' (or heminasal agenesis. The arrhinias represent three groups of anomalies, each with different levels of clinical severity, some involving association with the labio-palatal cleft or agenesia of the premaxilla (1). In PL the nasal cavity on the affected side is replaced by a tubular appendage located off-center from the midline of the face, arising commonly from the medial aspect of the roof of the orbit (2). It is usually associated with heminasal aplasia or hypoplasia, microphthalmia, and - less commonly - with midline clefting. Associated brain and cranial vault anomalies are seen in 19% of these patients. PL is usually unilateral, with very few symmetrical/bilateral cases being reported (3). Morpho-aesthetic and psychological problems are frequent concerns for the patients and their families. In this study, the authors describe a clinical case and the chosen surgical technique, as well as reviewing the alternative techniques present in the literature.

Autologous Fat Transfer for Facial Augmentation: Surgery and Regeneration.

Autologous fat transfer (AFT) is a well-established and safe surgical technique in which autologous fat tissue is injected at a defective site directly after its harvesting and centrifugation. Initially used as an excellent filler for facial enhancement and rejuvenation, AFT has evolved over the years into more complex reconstructive procedures. Autologous fat transfer is now additionally used for correcting and restoring cranial and maxillofacial volume defects resulting from traumas, tumors, or congenital disorders. Apart from being a natural filler, human adipose tissue represents a rich source of mesenchymal stem cells, called adipose-derived stem cells, that exhibit multilineage differentiation potential and secrete several angiogenic and antiapoptotic factors.In this work, the authors will discuss different aspects influencing the final outcome of AFT, on the basis of the major clinical outcomes obtained using this surgical procedure. Starting from preoperative evaluation and planning, donor-recipient sites, and type of anesthesia and infiltration, the discussion will continue by analyzing the methods of adipose tissue harvesting, purification, and processing. Finally, an overview of the type of placement, clinical application, postoperative care, possible complications, fat graft take, longevity, volume maintenance, and future perspectives will be provided.

Orbital Fractures in Childhood.

Pediatric orbital floor fractures exhibit distinctive features that distinguish them from orbital injuries seen in the adult population. This is mainly due to different anatomy and mechanical properties of the orbital bones in children. The management of pediatric orbital floor fractures requires consideration of these factors, including the age of the patient and therefore child's growth potential, using, if possible, a minimally invasive surgical approach. The aim of this paper is to report a case of a 1-year-old male child with a surgically treated blowout fracture of the orbital floor. To enable early diagnosis and treatment, accurate physical examination is mandatory, but a computed tomographic examination is important, especially in younger patients because of their inability to fully express their symptoms and poor compliance. We discuss the specific presentation and diagnostics of orbital floor fractures in early childhood and the related surgical planning and treatment.

Transnasal Endoscopic Approach for the Treatment of Medial Orbital Wall Fractures.

The aim of this study is to report a case series of blowout fractures of the medial orbital wall that were treated endoscopically. Isolated fractures of the medial orbital wall are uncommon and can be asymptomatic. Various surgical methods for repairing medial orbital wall fractures have been described. The standard approach for the treatment of medial orbital wall fractures is the transcutaneous approach or the transconjunctival with retrocaruncular approach. In the last years, the attention on the use of minimally invasive techniques such as transnasal endoscopic approach is growing. This was a retrospective study of six cases completely managed endoscopically. In the presented case series, the endoscopic endonasal approach represented a safe and effective procedure for the reduction of medial wall orbital fractures.

Mandibular Condyle Osteoma.

BACKGROUND: Osteoma is a benign tumor composed of both cortical and cancellous bones that increase in size with continuous formation of bone. The pathogenesis is unknown. Osteomas can cause symptoms depending on their location and size. They can be asymptomatic or symptomatic, with trismus, limitation of mouth opening, and progressive malocclusion with facial asymmetry and can be painful. AIM: The aim of this paper is to report an unusual case of osteoma in the mandibular condylar neck and review the cases of mandibular condyle osteomas that have been reported in the last 15 years. CONCLUSIONS: Only a few cases involving the temporomandibular joint have been reported. We report an unusual case of osteoma in the mandibular condylar neck causing restricted mouth opening in addition to pain. Complete surgical excision in symptomatic cases is the therapy of choice with a low recurrence rate.

An in-vitro evaluation of a novel design of miniplate for fixation of fracture segments in the transition zone of parasymphysis-body region of mandible using finite element analysis.

The mandibular parasymphysis and body regions are highly dynamic areas. They are constantly subjected to both occlusal and muscular forces. Fractures at this transition zone of the parasymphysis and body region thus represent a special pattern that creates a dilemma for the surgeons - whether to use one miniplate fixation or two miniplates as per Champy's guidelines. Mental nerve paresthesia is a very common complication due to dissection and stretching of the mental nerve in this region. Hence, an in-vitro research study of a novel twin fork design of miniplate is performed, which evaluates the biomechanical behavior using computerized finite element analysis. A comparison is carried out with the conventional design. The results show that the twin fork miniplate produces the lowest stresses - 23.821 MPa - and the least total structural deformation after applying the maximum occlusal bite force. This study concludes that the newly designed miniplate is superior in terms of stability because it shows the least structural deformation, and produces the lowest equivalent stresses on application of maximal occlusal forces. An additional advantage is the preservation of the mental nerve during the plating procedure because the broad end of the Y shape allows atraumatic positioning of the miniplate and hence the fixation of fractured segments.

Posttraumatic Glabellar Mucocele: Case Report.

Mucoceles are benign, expansile cystic masses covered by respiratory epithelium filled with mucus secreted by goblet cells interspersed in the ciliated mucosa. Mucoceles result from the accumulation and retention of the products of secretion, desquamation, and inflammation in cases where the drainage is obstructed. We present a case of a nasal mucocele that developed in a 50-year-old man, possibly related to a craniofacial trauma that had occurred 24 years earlier. This is an unusual case of posttraumatic glabellar mucocele with subcutaneous extension and nasal bone erosion without any neurologic or ophthalmologic involvement.

Craniomaxillofacial Fibrous Dysplasia: Conservative Treatment and Maxillary Osteotomy Using the Schuchardt-Kufner Technique.

Fibrous dysplasia (FD) is a disturbance of the mesenchymal tissue that accounts for 2.5% of all bone tumors and more than 7% of nonmalignant bone tumors. In the craniomaxillofacial region, FD affects the calvaria, skull base, zygoma, and jaws, the prevalent site being the maxilla (50% of cases). Therapy for craniomaxillofacial FD is surgical. The goals of surgery are to prevent functional disorders and restore facial symmetry, volume, and contour. In this article, we present a case of a young female patient affected by right orbital-zygomatic-maxillary FD. She had developed facial asymmetry and malocclusion that were corrected using the Schuchardt-Kufner osteotomy technique.

Temporomandibular Joint Ankylosis After Early Mandibular Distraction Osteogenesis: A New Syndrome?

Distraction osteogenesis (DO) has been one of the most innovative concepts in cranio-maxillofacial syndromology and surgery over the last 25 years.Early mandibular distraction in severe micrognathia has recently been recognized as an effective treatment option to safely relieve upper airway obstruction associated with mandibular deficiency.An increased incidence in temporomandibular joint complications during DO in neonates has recently been reported, especially in syndromic patients.The authors report 2 children affected by severe micrognathia and severe respiratory distress at birth.Early DO was performed during the first 2 months of the life in another institution with the aim of increasing mandibular length and upper airway size.Both the patients had severe restricted jaw opening after DO and mandibular abnormalities.Temporomandibular joint ankylosis after early mandibular distraction could be a considered a new pathological entity.

Piezosurgery: A new and safe technique for distraction osteogenesis in Pierre Robin sequence review of the literature and case report.

INTRODUCTION: Pierre Robin sequence (PRS) is characterized by microgenia and retrognathia. Cleft palate and glossoptosis are frequently associated with airway obstruction and difficulty in swallowing. Distraction osteogenesis with micro-distractors has recently been considered as a surgical option during the neonatal age. CASE PRESENTATION: A 6-week-old female with PRS underwent mandibular lengthening in neonatal age. Mandibular osteotomies were performed with the piezoelectric scalpel. DISCUSSION: Piezosurgery represents an innovative technique as it offers the maxillofacial surgeon the opportunity to make precise bone cuts without damaging the soft tissue, minimizing the invasiveness of the surgical procedure, and the opportunity of working in a field which is almost totally blood free. CONCLUSION: The use of a piezoelectric device to perform this kind of surgery provides clinical and surgical results which would be difficult with traditional instruments, not only for the patient's benefit but also for the surgeon's. Preservation of the original bony structure, especially of the cancellous bone, will benefit the bone healing process due to its high estrogenic potential.

Selective augmentation of stem cell populations in structural fat grafts for maxillofacial surgery.

Structural fat grafting utilizes the centrifugation of liposuction aspirates to create a graded density of adipose tissue. This study was performed to qualitatively investigate the effects of centrifugation on stem cells present in adipose tissue. Liposuction aspirates were obtained from healthy donors and either not centrifuged or centrifuged at 1,800 rpm for 3 minutes. The obtained fat volumes were divided into three layers and then analyzed. The results demonstrate that centrifugation induces a different distribution of stem cells in the three layers. The high-density layer displays the highest expression of mesenchymal stem cell and endothelial markers. The low-density layer exhibits an enrichment of multipotent stem cells. We conclude that appropriate centrifugation concentrates stem cells. This finding may influence the clinical practice of liposuction aspirate centrifugation and enhance graft uptake.

Three-dimensional volumetric restoration by structural fat grafting.

The use of adipose tissue transfer for correction of maxillofacial defects was reported for the first time at the end of the 19th century. Structural fat grafting (SFG) was introduced as a way to improve facial esthetics and in recent years has evolved into applications in craniomaxillofacial reconstructive surgery. Several techniques have been proposed for harvesting and grafting the fat. However, owing to the damage of many adipocytes during these maneuvers, the results have not been satisfactory and have required several fat injection procedures for small corrections. The author's (L.C.) overview the application of SFG in the management of volumetric deficit in the craniomaxillofacial in patients treated with a long-term follow-up.

Management of temporomandibular joint reankylosis in syndromic patients corrected with joint prostheses: surgical and rehabilitation protocols.

Temporomandibular joint ankylosis (TMJA) is a severe disorder described as an intracapsular union of the disc-condyle complex to the temporal articular surface with bony fusion. The management of this disability is challenging and rarely based on surgical and rehabilitation protocols. We describe the treatment in two young adults affected by Goldenhar syndrome and Pierre Robin sequence with reankylosis after previous surgical treatments. There are three main surgical procedures for the treatment of TMJA: gap arthroplasty, interpositional arthroplasty, and joint reconstruction. Various authors have described reankylosis as a frequent event after treatment. Treatment failure could be associated with surgical errors and/or inadequate intensive postoperative physiotherapy. Surgical treatment should be individually tailored and adequate postoperative physiotherapy protocol is mandatory for success.

Craniofacial surgical strategies for the correction of pneumosinus dilatans frontalis.

INTRODUCTION: Pneumosinus dilatans is a rare condition and different techniques have been proposed for its management and correction. The abnormally expanded, aerated frontal sinus has been described in the literature as: frontal sinus hypertrophy, pneumosinus dilatans, pneumosinus frontalis, aerocele, pneumocele, sinus ectasia, hyperpneumatization and others. The precise aetiology and pathogenesis of the condition is unknown, although several basic hypotheses have been proposed MATERIAL AND METHODS: The authors report two cases of frontal bossing and supraorbital ridge deformity correction using craniofacial surgical principles. DISCUSSION: Functional and morphological results are discussed and compared with other open procedures. CONCLUSION: A variety of surgical procedures have been proposed for the correction of the pneumosinus dilatans frontalis. The craniofacial approach is advocated to reproduce the normal anatomy of the forehead in the upper part, the supraorbital rim and glabellar area.

Surgical decompression in endocrine orbitopathy. Visual evoked potential evaluation and effect on the optic nerve.

Endocrine orbitopathy (EO) represents the most frequent and important extrathyroidal stigma of Graves disease. This chronic autoimmune condition involves the orbital contents, including extraocular muscles, periorbital connective-fatty tissue and lacrimal gland. The increase of fat tissue and the enlargement of extraocular muscles within the bony confines of the orbit leads to proptosis, and in the most severe cases optic neuropathy, caused by compression and stretching of the optic nerve. The congestion and the pressure of the enlarged muscles, constrict the nerve and can lead to reduced sight or loss of vision with the so called "orbital apex syndrome". Generally surgical treatment of EO, based on fat and/or orbital wall expansion, is possible and effective in improving exophthalmos and diplopia. Since there are limited reports focussing on optic neuropathy recovery after fat and/or orbital walls decompression the Authors decided to perform a retrospective analysis on a series of patients affected by EO. The study population was composed of 10 patients affected by EO and presenting to the Unit of Cranio Maxillofacial Surgery, Center for Craniofacial Deformities & Orbital Surgery St. Anna Hospital and University, Ferrara, Italy, for evaluation and treatment. A complete Visual Evoked Potentials (VEP) evaluation was performed. There were seven women and three men with a median age of 55 years. Optic nerve VEP amplitude and latency were recorded as normal or pathological. Abnormal results were scored as moderate, mild and severe. Differences in VEP pre and post-operatively were recorded as present or absent (i.e. VEP Delta). Pearson chi square test was applied. There were 20 operated orbits. The first VEP evaluation was performed 3.2 months before surgery and post-operative VEP control was done after a mean of 18.7 months. Fat decompression was performed in all cases and eight patients had also bony decompression. VEP amplitude and latency were affected in 10 and 15 cases before operation and six and nine after surgery, respectively. VEP amplitude and latency significantly improved after orbital decompression. Fat and orbital wall decompression are of paramount importance not only to improve exophthalmos and diplopia in patients affected by EO but also as rescue surgery for severe cases where optic neuropathy caused by stretching of the optical nerve is detected by VEP. Imaging and functional nerve evaluation are mandatory in all cases of EO.