Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome: Long-Term Results of Respiratory Function and Reverse Face-Lift.

PURPOSE: Scientific literature considers maxillomandibular advancement (MMA) as the most effective surgical treatment for the management of adult obstructive sleep apnea syndrome (OSAS). Maxillomandibular advancement enlarges the pharyngeal space by expanding the skeletal framework. Moreover, it projects the soft tissue of the cheeks, the mouth, and the nose in the aging face, which is characterized by multiple signs affecting the middle third and the lower third. The potential of orthognathic surgery (double jaw surgical advancement) of expanding the skeletal foundation to increase the facial drape support and to rejuvenate the face by a "reverse face-lift" is now recognized. The aim of this study was to review the surgical outcomes after MMA in terms of respiratory function and assessment of facial esthetics. METHODS: We retrospectively reviewed the charts of all patients affected by OSAS who underwent maxillomandibular advancement between January 2010 and December 2015 in 2 tertiary hospitals (IRCCS Policlinico San Martino of Genoa and IRCCS Policlinico Ca' Granda of Milan). During the postoperative follow-up examination, all patients underwent polysomnographic examination and esthetic assessment to evaluate the respiratory function and facial rejuvenation after double jaw surgical advancement. RESULTS: The final study sample included 25 patients (5 females, 20 males). The overall success rate of the surgical treatment (apnea/hypopnea index, AHI <20) was 79%; the overall rate of surgical cure (AHI <5) was 47%. Twenty-three patients (92%) showed a degree of rejuvenation after MMA. CONCLUSIONS: Maxillomandibular advancement is currently the most effective surgical treatment for the management of OSAS in adult patients who are not responders to medical treatment. "Reverse face-lift" is the consequence of the double jaw surgical advancement.

Analysis of the High Submandibular Approach: A Critical Reapprasail of a Transfacial Access to the Mandibular Skeleton.

AIM: In 2006 following the development of dedicated osteosynthesis plates, Meyer and colleagues reported a successful clinical study of condylar fractures treated by a modified submandibular approach; it was called high submandibular approach or "Strasbourg approach." The aim of this study is to describe the high submandibular approach step by step. CASE SERIES: Between January 2010 and December 2015 at the Maxillofacial Unit of the Hospital "Policlinico San Martino" 13 patients affected by subcondylar fracture underwent open reduction and internal with high submandibular approach. Surgery was uneventful in all patients; no infections occurred in any of the cases; the mean procedure duration was 89 minutes, ranging from 66 to 125 minutes. The mean hospital stay was 2.9 days, ranging from 2 to 6 days. At the 1-year follow-up, all patients had stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. CONCLUSIONS: The morbidity is negligible in terms of damage to the facial nerve, vascular injuries, and aesthetic deformity. The authors think that further prospective clinical trials are necessary to assess and eventually develop this approach.

Orbital Floor Fractures Comparing Different Kinds of Reconstruction: A Proposal for Restoration of Physiological Anatomy.

ABSTRACT: The most effective treatment for orbital fractures is still under debate and different strategies are proposed in the literature. All such strategies focus on reconstruction of the orbital structure, neglecting the main function of the medial and inferior walls, these latter being constructed so as to break during high energy trauma. The aim of the authors is to highlight the difference between different reconstructive techniques in an orbital fracture restoration, being inclined to favor repair over reconstruction of the orbital floor, assuming that a second trauma could happen and reconstructive material left in the orbit may damage the visual apparatus in such a scenario. Following this theme, the authors propose a reconstruction strategy using a custom made stereolithographic model and resorbable plate made of polylactic acid mesh molded onto it. The mesh is used alone or in combination with bone graft, to obtain a better reparative result. At present, this approach is best suited to sports people and the young. Even if a deeper evaluation of the method would be useful, the series of case studies presented could be of stimulus for future discussion.

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.

A rare isolated unilateral myositis ossificans traumatica of the lateral pterygoid muscle: a case report.

INTRODUCTION: Myositis ossificans traumatica is a pathological condition characterized by the extraskeletal formation of bony tissue, induced by violent or repeated trauma. CASE PRESENTATION: A 30-year-old Italian man, after surgical treatment for multiple facial fractures, presented with a progressive limitation of mouth opening. A computed tomography scan showed a significant calcification of the fibers of the left lateral pterygoid muscle. The working diagnosis was myositis ossificans traumatica of the left lateral pterygoid muscle. Surgical excision was suggested but not performed. Our patient underwent physiotherapy treatment resulting not in a complete restoration of mandibular movements but in an acceptable recovery of mouth opening. CONCLUSIONS: Myositis ossificans is a rare complication that can be caused by muscle trauma. Therefore, special attention should be paid to surgical trauma. In the present case, surgical excision was considered, in accordance with the literature, and suggested to our patient, but he declined due to the absence of any pain or any significant limitation to his daily life activities. He therefore underwent physiotherapy treatment, in line with our unit's guidelines, resulting not in a complete restoration of mandibular movements but in an acceptable recovery of mouth opening.

Reconstruction of small orbital floor fractures with resorbable collagen membranes.

Orbital floor fractures are the most common facial fractures. The goals of orbital floor fracture repair are to free incarcerated or prolapsed orbital tissue from the fracture defect and to span the defect with an implant to restore the correct anatomy of the orbital floor and the pretrauma orbital volume. No consensus exists on the choice of implants to be used for orbital floor reconstruction, and several implant materials are available.Our study intended to evaluate, for the first time, the effectiveness and complications related to the use of a resorbable collagen membrane in the reconstruction of small pure blow-out fractures. From October 2008 to November 2010, 23 patients who underwent reconstruction of the orbital floor using a resorbable collagen membrane following fracture were included in this study. At the 6-month follow-up, only 2 patients (9%) reported postoperative complications secondary to the operative procedure (surgical approach, orbital floor dissection), but these were not directly related to the use of the membrane. In 12 cases, a computed tomography scan revealed new bone formation beneath the membrane.On the basis of this data, we believe that the use of a resorbable collagen membrane is a safe and effective alternative for reconstruction of small (<3 cm(2)) pure orbital floor fractures.

Repair of orbital floor fractures: our experience and new technical findings.

We report our experience with the repair of the orbital floor fractures and present new technical findings. We evaluated 30 subjects with pure blowout fractures treated at the Department of Maxillofacial Surgery of the Federico II University of Naples, Italy, between 2005 and 2007. A preoperative examination by computed tomography scans provided classification of the orbital floor fractures into small and large fractures by measurement of the bone defect to choose the appropriate reconstructive implant materials, resorbable or nonresorbable. The clinical follow-up has been performed at 1 week, 1 month, 3 months, and 6 months. We observed a resolution of preoperative symptoms. The scar was not evident, and there was an absence of postoperative complications. We concluded that the use of resorbable materials for small orbital floor fractures and nonresorbable materials for large orbital floor fractures offers satisfactory results in both functional and aesthetic considerations. Furthermore, the new technical findings allow standardization of the surgical technique to be more accurate, also reducing the economic costs.

Two load sharing plates fixation in mandibular condylar fractures: biomechanical basis.

Mandibular condylar fractures have a high incidence but there is no consensus regarding the best choice of osteosynthesis. From a review of the literature, it is evident that the technique used most frequently for fixation is the positioning of a single plate despite complications concerning plate fracture or screw loosening have been reported by various authors. Different studies have highlighted that the stability of osteosynthesis is correlated with the mechanical strains occurring in the condylar region, generated by the muscles of mastication. The aim of our study was, through a mandibular finite element model (FEM), to confirm this correlation and to analyse the behaviour of single and double elements of union in the fixation of mandibular subcondylar fractures. We concluded that the use of two plates provides greater stability compared with the single plate, reducing the possibility of displacement of the condylar fragment. Therefore we recommend that this technique should be adopted whenever possible.