Surgical Navigation in Mandibular Reconstruction: Accuracy Evaluation of an Innovative Protocol.

Aim: the purpose of this work is to present an innovative protocol for virtual planning and surgical navigation in post-oncological mandibular reconstruction through fibula free flap. In order to analyze its applicability, an evaluation of accuracy for the surgical protocol has been performed. Methods: 21 patients surgically treated for mandibular neoplasm have been included in the analysis. The Brainlab Vector Vision 3.0® software for surgical navigation has been used for preoperative surgical planning and intra-operative navigation. A post-operative accuracy evaluation has been performed matching the position of mandibular landmarks between pre-operative and post-operative CT scans. Results: the maximal discrepancy observed was included between -3.4 mm and +3.2 mm, assuming negative values for under correction and positive values for overcorrection. An average grade of accuracy included between 0.06 ± 0.58 mm and 0.43 ± 0.68 mm has been observed for every mandibular landmark examined, except for mandibular angles that showed a mean discrepancy value included between 1.36 ± 1.73 mm and 1.46 ± 1.02 mm when compared to preoperative measurements. Conclusion: a satisfying level of accuracy has been observed in the protocol presented, which appears to be more versatile if compared to closed custom-made systems. The technique described may represent a valid option for selected patients, but it cannot be considered for routine activity because of the complexity of the method, the mobility of the jaw, the necessity of surgical navigator and the long surgical learning curve that is required.

"6 Anatomical Landmarks" Technique for Satisfactory Free-Hand Orbital Reconstruction With Standard Preformed Titanium Mesh.

Study Design: Retrospective study. Objective: Resolution of clinical signs and symptoms following orbital fractures depends on the accurate restoration of the orbital volume. Computer-Assisted procedures and Patient Specific Implants represent modern solutions, but they require additional resources. A more reproducible option is the use of standard preformed titanium meshes, widely available and cheaper; with their use quality of results is proportional to the accuracy with which they are positioned. This work identifies 6 reproducible and constant anatomical landmarks, as an intraoperative guide for the precise positioning of titanium preformed meshes. Methods: 90 patients treated at the Maxillofacial Surgery Department, Niguarda Trauma Center, Milan, for unilateral orbital reconstruction (January 2012 to December 2018), were studied. In all cases reconstruction was performed respecting the 6 proposed anatomical landmarks. The outcomes analyzed are: post-operative CT adherence to the 6 anatomical markers and symmetry achieved respect to controlateral orbit; number/year of re-interventions and duration of surgery; resolution of clinical defects (at least 12-months follow-up); incidence of complications. Results: Satisfactory results were obtained in terms of restoration of orbital size, shape and volume. Clinical defects early recovered with a low incidence of complications and re-interventions. Operating times and radiological accuracy have shown a progressive improvement during years of application of this technique. Conclusions: The proposed "6 anatomical landmarks" is an easy free-hand technique that allows everyone to obtain high levels of reconstructive accuracy and it should be a skill of all surgeons who deal with orbital reconstruction in daily clinical activity.

Extra-oral approach to lower third molar: a rare surgical indication.

The avulsion of the impacted lower third molar is one of the most common procedures in oral surgery. Even though it is characterized by possible complications due to the lesion of lingual and inferior alveolar nerves, the intra-oral surgical approach represents the first-choice strategy when planning surgery. However, in case of ectopic tooth in the mandibular basal bone, it is appropriate to consider an extra-oral transcutaneous surgical approach. The ectopia of the inferior wisdom tooth represents a very rare clinical condition and sometimes it is even unknown by patients and dentists: further evidence of this fact is represented by the paucity of paper related to the topic that can be found in the international scientific literature. The experience of the Department of Maxillofacial Surgery of San Gerardo Hospital in Monza (Italy) in management and treatment of ectopic impacted lower third molar is exposed through the presentation of three cases of ectopic third molar. Two out of three patients, aware of the risks related to the surgical procedure, refused the treatment proposed. One patient underwent surgical avulsion of the wisdom tooth through extra-oral transcervical approach. No early or late complications have been observed. Extra-oral surgical approach for ectopic lower third molar should be considered for selected cases. Given the rarity of the clinical condition and the procedure-related risks, accurate preoperative information has to be provided to the patient by physician and the procedure should only be performed by expert and competent surgeons.

The burden of facial trauma on mortality in patients with multiple injuries: A single-center analysis of 1862 motorcycle accidents.

The study aims to assess the influence on mortality of motorcycle road accidents, caused by injuries to the head, chest, abdomen, face, skin, pelvis and extremities. Road motorcycle accidents consecutively admitted to Level I Trauma Center were retrospectively analyzed. Each body site involvement was classified through Abbreviated Injury Score (AIS-98), and Comprehensive Facial Injury (CFI) score; Injury Severity Score (ISS) was also calculated. The data collected were subjected to a descriptive analysis and inferential statistic, with uni- and multivariate analysis; mortality was the main outcome examined. 1862 patients were studied. Limbs (53.9%) and Head (53.8%) are the most involved body site, facial trauma regards 19.4% of the sample. Only 4.4% of Facial injuries occurred as isolated, 71.6% were associated to Head involvement. The overall mortality was 4.6% and 80.0% of dead patients were affected by Head injury. Multivariate analysis shows that head (OR=3.06, p <0.0001), thoracic (OR=1.82, p <0.0001) and abdominal trauma (OR=1.41, p =0.019) are predicting the risk of death. Facial trauma does not directly influence mortality and, however severe and distracting it may be, becomes secondary to the management of frequently associated brain injuries. Severity scores targeted to the risk of death, such as AIS and AIS-derived, are ineffective in describing the true characteristics of facial injuries. The CFI score has been shown to predict the weight of surgical treatment and the outcome of the hospital stay, therefore its use is recommended.

Epidemiology of Maxillo-Facial Trauma During COVID-19 Lockdown: Reports From the Hub Trauma Center in Milan.

STUDY DESIGN: Retrospective study. OBJECTIVE: Following SARS-CoV-2 pandemic break-out a lockdown period for the population and a reorganization of the Health System were needed. Hub-function Centers for time-dependent diseases were identified and Niguarda Hospital (Milan) was selected as main Regional Trauma Center. The purpose of our study is to report the experience of Niguarda Maxillofacial Trauma Team during this period, pointing out epidemiological changes in the presentation of trauma in comparison to the previous 3 years. METHODS: Two hundred and sixteen patients were admitted to the Emergency Department from 8th March 2020 to 8th May 2020. One hundred and eighty-one had a diagnosis of Major Trauma and 36 had also facial fractures; 35 patients had isolated facial fractures. Data were compared to the activity during the same period in 2017-2019 and statistical analysis was carried out concerning demographic and clinical characteristics, trauma dynamics and positivity to COVID-19. RESULTS: Cumulative curves of patients admitted because of Major Trauma describe a superimposable linear trend in years 2017-2019, while 2020 shows an increase from April 16th. Average age and number of more severe patients were higher than previous years. Epidemiological changes concerned road accidents, accidents involving pedestrians and cyclists, interpersonal violence, suicide attempts and domestic accidents. The incidence of facial fractures was confirmed through years and, according to its measured severity, 75% of patients required management. COVID-19 positivity without systemic symptoms didn't influence the type of treatment. CONCLUSION: The COVID-19 lockdown offers a unique opportunity to study the reversal epidemiological effects on trauma.

Analysis of Different Safety Devices in the Prevention of Motorcycle-Related Craniofacial Trauma - A Retrospective Study.

Introduction: Motorcycle accidents are one of the most frequent causes of trauma. Safety devices and helmets can influence the severity of injuries. Our retrospective study wants to evaluate the different effectiveness of Open-face and Full-face helmets in the prevention of craniofacial trauma. Materials and Methods: The sample consists of 440 patients admitted to two Level I Trauma Centres in Northern Italy, between January 2002 and February 2019, because of motorcycle-related craniofacial trauma. For each patient personal data were collected, as well as type and site of fractures, type of helmet, if worn, Comprehensive Facial Injury (CFI) score and Abbreviated Injury Score (AIS-Head) for head injuries. Inferential statistical analysis was then conducted. Results: Two hundred and eighty-eight patients wore Open-face helmets (69.7%) and 125 patients wore Full-face ones (30.3%). Mean CFI score (Standard deviation - SD) observed in patients with Open-face helmets was 7.0 (SD: 6.8) and surgery was required in 149 cases (51.7%); while it was 4.9 (SD: 6.0) in patients with Full-face helmets for whom surgery was required in 43 cases (34.4%) (P < 0.0001 and P = 0.002, respectively). Multivariate analysis shows that severity of facial trauma is a significant risk factor for head injury severity with OR 1.90 (95% confidence interval: 1.43 - 2.51) and P < 0.0001. Discussion: Full-face helmets are definitely considered to be more protective for facial trauma, which is also a significant risk factor for the severity of head injuries. The type of helmet chosen influences the need of surgical treatment in case of craniofacial trauma.

Circummaxillary Sutures in Patients With Apert, Crouzon, and Pfeiffer Syndromes Compared to Nonsyndromic Children: Growth, Orthodontic, and Surgical Implications.

OBJECTIVE: To evaluate patency of circummaxillary sutures in children with Apert, Crouzon, and Pfeiffer Syndromes and to compare it to a nonsyndromic matched control group. DESIGN: Case-control study. SETTING: Tertiary care public hospital. MATERIALS AND METHODS: Thirty-eight computed tomography (CT) scans of patients affected by syndromic craniofacial synostosis (13 patients with Apert syndrome, 20 patients with Crouzon syndrome, and 5 patients with Pfeiffer syndrome), average age 5 ± 2.8 years, range 1.9 to 12 years, were compared to age- and sex-matched control CTs of 38 nonsyndromic children. Computed tomography scans of the study group had to be performed prior to any midfacial surgery. MAIN OUTCOME MEASURES: Midpalatal suture, zygomaticomaxillary sutures, and pterigomaxillary sutures were evaluated and scored. RESULTS: The syndromic group showed a significant earlier ossification of all sutures compared to the nonsyndromic group. Significant differences were already present in early childhood and continued through adolescence. CONCLUSIONS: Based on the differences in terms of maxillary sutural ossification identified, midfacial hypoplasia does not seem to be only secondary to premature cranial base ossification, but also to primary synostosis of facial sutures, thus providing new insights into the pathogenesis of midface deficiency in children with craniofacial-synostosis. Care should be taken when planning any maxillary orthopedics, such as expansion or maxillary protraction, given the high frequency of early fusion of circummaxillary sutures.

Understanding the relevance of comprehensive facial injury (CFI) score: Statistical analysis of overall surgical time and length of stay outcomes.

Comprehensive facial injury (CFI) score is a powerful and extremely simple scale used to grade the clinical severity of all facial injuries, and is expressed in terms of the overall surgical time needed for definitive treatment. Its statistical validation was previously reported in 2019. The aim of this study was to investigate further the link with duration of surgery, applying the score to a larger sample of patients, and to evaluate the relationship between CFI score and other extremely relevant dependent variables: length of stay (LOS) in high care units (HCU) and in intensive care units (ICU). 1406 patients with diagnosis of at least one facial bone fracture, and treated by the same team in two highly specialized trauma centers, were studied. For each patient a specific CFI score is assigned and overall surgical time, length of stay, and presence of associated injuries were recorded. Data were divided into six clusters according to CFI score: (1) 0-5, (2) 6-10, (3) 11-15, (4) 16-20, (5) 21-25, and (6) >25. Regressions between CFI clusters and duration of surgery (minutes), LOS in ICU (days), and in HCU (days) were established. In addition, the presence of associated head and/or somatovisceral injuries was analyzed and related to CFI score. Statistical analysis confirmed linear regression existing between each CFI cluster and overall surgical time (p < 0.00001), with improved significance of the results using median values of surgical duration for each cluster (p = 0.0001). It also demonstrated the existence of linear regression between all CFI clusters and LOS in HCU (p = 0.0001) and between CFI clusters 3-6 and median values of LOS in ICU (p = 0.0001). Finally, associated injuries were observed to be more frequent in high CFI score clusters, occurring in around 90% of patients with a CFI score >25 (p < 0.00001). Association of head and facial injuries play a major role in high LOS in ICU values, whereas coexistence of facial, head and somatovisceral involvement increases LOS in ICU to over twice that for single association. Surgical time and length of stay are outcomes traditionally used to assess the statistical significance of many new proposed trauma score. The strong correlation demonstrated between CFI score and each of these variables confirms its value and reliability. CFI score is proven to be an ideal, simple, informative, and reproducible tool for measuring severity of facial injuries and their clinical impact. It allows correlation with associated head and somatovisceral injuries, focusing attention on the interesting field of reciprocal influences in simultaneous, multidistrectual involvement. None of the previously proposed facial injury severity scales have offered such informative and statistically significant features.

The CFI score: Validation of a new comprehensive severity scoring system for facial injuries.

At the time of writing there is no measuring scale for the severity of facial trauma that can effectively summarize its clinical relevance, and can therefore be proposed as a definitive tool in trauma center decision making. This paper introduces a new, simple, comprehensive, and reproducible score for facial trauma, in which its severity is expressed in relation to the surgical duration necessary for definitive treatment. This parameter is identified as the most significant in expressing the commitment of care required. Statistical validation of this comprehensive facial injury (CFI) score involved a sample of 1050 patients, treated by the same team in two highly specialized trauma centers. It demonstrated a linear regression between CFI score and surgical duration, and a high degree of accuracy in forecasting overall surgical time for each type of facial injury. The descriptive capacity of CFI score, and its extremely simple use, make it a perfect tool for widespread application and for facilitating communication inside trauma centers. It also allows the classification of homogeneous groups of patients - a prerequisite for benchmarking and effective analysis of results. The CFI model is definitively proposed for the classification of facial injuries, and therefore for the integration of maxillofacial skills, within the trauma team.

Extensive Dural Ossification After Decompressive Posttraumatic Craniectomy: A Case Report and Review of the Literature.

BACKGROUND: We present a case of almost complete bifrontal dural ossification after decompressive craniectomy for severe traumatic brain injury. CASE DESCRIPTION: A 6-year-old boy was brought to the emergency room after a severe traumatic brain injury (Glasgow Coma Scale/Score 7). Due to rapidly increasing intracranial pressure values (>20 mm Hg) refractory to conservative therapy and in the absence of focal lesions justifying the neurological status, a bicoronal decompressive craniectomy was performed. The patient underwent reconstructive bifrontal cranioplasty with autologous bone 110 days after surgery. Preoperative computed tomography scans showed an abnormal hyperdense layer surrounding both frontal lobes. During the procedure, widespread islets of eggshell-shaped bony tissue were found covering the pericranium and the dura mater. They were laboriously removed from the underlying tissues. Two months later computed tomography scans did not show evidence of calcification at the level of the frontal lobes or signs of bone reabsorption or epidural collections. CONCLUSIONS: We focus on the clinical implications of this phenomenon, in terms of its surgical management and how it may influence the timing of cranioplasty. Furthermore, we discuss the main pathophysiologic models described in the literature.

Assessing the precision of posttraumatic orbital reconstruction through "mirror" orbital superimposition: A novel approach for testing the anatomical accuracy.

Orbital reconstruction in cases of trauma is usually performed using the unaffected side orbital volume as a reference, but this measurement does not fully consider the anatomical characteristics of orbital surfaces. We propose a novel procedure based on the registration of 3D orbital segmented surfaces. Reconstructed orbits from 20 patients and healthy orbits from 13 control subjects were segmented from the post-operative CT-scans. The 3D orbital model from the unaffected orbit was "mirrored" according to the sagittal plane and superimposed onto the reconstructed one, with calculation of volumes, asymmetry index and point-to-point RMS (root mean square) distances. Inter- and intra-observer errors were tested through Bland-Altman plot. Differences in volume, asymmetry index and RMS value between the control group and the treated patients were assessed through two-way ANOVA and Student's t-test (p < 0.05). According to Bland-Altman test, intra- and inter-operator repeatability was respectively 87% and 89%. No significant differences in volume or asymmetry index between the control group and the treated patients were observed (p > 0.05), but the RMS value was significantly larger in the latter ones (on average, 0.90 ± 0.26 mm vs. 0.67 ± 0.17 mm, p < 0.05). Results show that the reconstructed orbits present a morphologically different surface from the unaffected ones.

Homologous Banked Bone Grafts for the Reconstruction of Large Cranial Defects in Pediatric Patients.

PURPOSE: Autogenous bone represents the best material in pediatric reconstructive cranioplasty because of its compatibility with growth; however, its availability is limited. Alternative use of alloplastic materials would have the advantage of unlimited amount, but shows an increased risk of complications and incompatibility with growth. Fresh frozen banked cadaveric bones could be ideal for the reconstruction of large cranial defects in growing patients, because it offers unlimited amount of structural grafts with biomechanics properties quite similar to the autologous bones. RESULTS: The authors report 2 cases of growing patients (13 months female and 9 years old male) undergoing the reconstruction of large (about 70 cm and 50 cm respectively) cranial vault defects, by using structural homologous banked bone grafts.Analytic main reconstruction materials risks/benefits evaluation, literature review of few previously reported pediatric cranioplasty with homologous bone, and both clinical cases satisfactory radiologic long-term results (beyond 4 years of F.U.) are reported. CONCLUSION: Structural homologous banked bone grafts appear as a valid solution for pediatric canioplasty reconstruction of wide defects, entailing the advantages of available without limitations and compatibility with future growth. The risk of transmissible infections seems minimal and is totally counterbalanced by the stability of long-term results.

Negative pressure wound therapy in complex cranio-maxillofacial and cervical wounds.

The care and the management of the healing of difficult wounds at the level of the skull-facial face many problems related to patient compliance and the need to perform multiple dressings, with long periods of healing and, occasionally, a very long hospitalisation period. The introduction and evolution of negative pressure wound therapy (NPWT) in the treatment of difficult wounds has resulted in better healing, with a drastic reduction in terms of time and biological costs to the patient and cost to the health care system. The main aim of this study is to describe and discuss, using out our experience, the usefulness of NPWT in the cranial-facial-cervical region. We studied 16 patients with complex wounds of the cranial-facial-cervical region treated with NPWT. We divided clinical cases in four groups: cervicofacial infectious disease, healing complications in oncological-reconstructive surgery, healing complications of injury with exposure of bone and/or internal fixations and healing complications in traumatic injury with loss of substance. We evaluated complete or incomplete wound healing; application time, related also to hospitalisation time; days of intensive care unit (ICU) stay; management of the upper airways; timing of medication renewal; and patient comfort and compliance (on a scale of 1-5). Depression values were always between -75 and -125 mmHg in a continuous aspiration pattern. For every patient, we used the ActiVAC Therapy Unit, derived from the vacuum-assisted closure system (Kinetic Concepts Inc., San Antonio, TX). Medication renewals were performed every 48-72 hours. The NPWT application time ranged from 4 to 22 days (mean of 11·57 day). Therapy was effective to gain a complete restitutio ad integrum in every patient included in the group of cervicofacial infectious disease. Therapy has, however, been well tolerated in our series; this is probably due to the decreased number of applications, the ease of use and the comfort of the system relative to traditional dressing. Results were satisfactory for most of cases treated; faster and more effective wound healing was achieved. The lower number of NPWT applications, relating to standard dressings, led to an increase in patient comfort and compliance and a decrease in the use of medical, and in some cases economic, resources according to international literature.

An atypical case of craniometaphyseal dysplasia. Case report and surgical treatment.

INTRODUCTION: Craniometaphyseal dysplasia is a rare hereditary bone disease presenting metaphyseal widening of the tubular bones, sclerosis of craniofacial bones and bony overgrowth of the facial and skull bones. Craniometaphyseal dysplasia occurs in an autosomal dominant (AD) and an autosomal recessive (AR) form. CASE REPORT: We present a 32-year-old patient arrived at our unit in May 2009. His main discomfort was a major limitation of the mouth opening, in the context of a craniofacial deformity. Relying on patient's medical history and the performed diagnostic tests, the diagnosis of craniometaphyseal dysplasia was made. CONCLUSION: After careful evaluation of the clinical case, in accordance with the requirements of the patient, we opted for a surgical treatment aimed at correction of functional limitation of temporomandibular joint and aesthetic improvement of the facial bones. The stability of the clinical results led us to suggest and to undertake the surgical path, also due to the lack of safe and consolidated non-surgical treatments for the specific case.

Orbital Osteoblastoma: Technical Innovations in Resection and Reconstruction Using Virtual Surgery Simulation.

Osteoblastoma is a benign tumor of bone, representing less than 1% of bone tumors. Craniomaxillofacial localizations account for up to 15% of the total and frequently involve the posterior mandible. Endo-orbital localization is very rare, with most occurring in young patients. Very few of these tumors become malignant. Orbital localization requires radical removal of the tumor followed by careful surgical reconstruction of the orbit to avoid subsequent aesthetic or functional problems. Here, we present a clinical case of this condition and describe a surgical protocol that uses and integrates state-of-the art technologies to achieve orbital reconstruction.

Photometric evaluation of cranial and facial symmetry in hemicoronal single suture synostosis treated with surgical fronto-orbital remodeling.

OBJECTIVE: Evaluation of frontal vault symmetry and progressive facial symmetrization in a cohort of patients with hemicoronal single suture synostosis treated with a standardized cranioplasty and rigid fixation. PATIENTS AND METHODS: Fifty-four patients with hemicoronal synostosis operated between 1999 and 2014 were reviewed retrospectively. Pre, immediately postoperative and yearly photographs from the top of the skull and frontal views of the face were taken with the same head position and projection. A photogrammetric method was applied to quantify the pre and postoperative contour changes. The anterior skull hemispheres were traced, divided into two equal parts and the areas were compared. Angular measurements obtained by the intersection of the interpupillary line and the glabella perpendicular vertical line were calculated. The average photographic follow-up was 6.8 years. Range 1-14 years. RESULTS: The average advancement on the affected side was 18 mm (range: 16-23 mm). The pre-surgical cranial area on the affected side was increased on average 14.6 + 2.4% (range: 10-18%). The angular measurements documented the frontal symmetry obtained and the progressive improvement of facial symmetry. CONCLUSION: Cranioplasty with rigid fixation achieved a stable correction of anterior plagiocephaly leading to subsequent symmetrical facial growth. Photogrammetry allowed fora quantitative long-term validation.

Temporomandibular joint ankylosis as part of the clinical spectrum of Carey-Fineman-Ziter syndrome?

The Carey-Finema-Ziter syndrome (CFZS, MIM 254940) is an apparently autosomal recessively inherited disorder consisting of the combination of non-progressive congenital myopathy with Moebius and Pierre Robin sequence, facial anomalies and growth delay. Mental development has been described as normal or delayed. Temporomandibular joint (TMJ) ankylosis is the immobility of the joint caused by ankylotic fusion of the mandible to the cranial base or zygoma. It is a serious and disabling condition that may cause problems in mastication, digestion, speech, appearance, and oral hygiene. Most often is a true ankylosis of the TMJ but other pathological mechanisms are described (i.e., the fusion of the coronoid process to temporal bone or with the zygoma, or a variety of soft tissues disorders like Fibrodysplasia Ossificans Progressiva). Here we report a 2-year-old girl fitting with a clinical diagnosis of CFZS associated with a limited mouth opening in which temporomandibular joint ankylosis was suspected. Because it has been postulated that many clinical features in CFZS may only be secondary effects of brainstem anomalies and muscle weakness during development, the limited opening of the mouth observed in our patient could represent a rare clinical feature of CFZS itself. © 2016 Wiley Periodicals, Inc.

Primary Intraosseous Squamous Cell Carcinoma of the Jaws: 6 New Cases, Experience, and Literature Comparison.

PURPOSE: To analyze the clinical, histologic, radiologic, therapeutic, and prognostic aspects of 6 cases of an uncommon head and neck malignancy and compare these results with data in the literature. MATERIALS AND METHODS: The medical histories of all patients treated in the Maxillofacial Surgery Unit in San Gerardo Hospital (Monza, Italy) for primitive intraosseous squamous cell carcinoma (PIOSCC) of the jaw were reviewed. All patients were considered suitable for inclusion in the study, specifically those whose oral mucosa had not been compromised and who did not have distant metastases. RESULTS: Six patients were included (4 male, 2 female). The odontogenic origin was histologically shown in only 2 patients. The male-to-female ratio was 2:1, and the malignancy occurred in the posterior mandible in 50% of cases. The most common symptoms were swelling and pain, but no sensory disturbances were observed. Radiologic findings indicated considerable variation in presentation, including small cystic lesions, which might complicate a pathologic diagnosis. All patients in the study were treated with surgery, and 2 patients received adjuvant radiotherapy. Cervical node metastases were present in 33% of patients. All patients are currently alive and free of disease. CONCLUSION: PIOSCC is a rare malignancy of the head and neck. Diagnosis can be difficult during the early stages of disease owing to a lack of clinical symptoms or radiologic presentation. Treatment is surgical and, like every other cancer, must be adequate to cure the cancer.

Posttraumatic Delayed Enophthalmos: Analogies with Silent Sinus Syndrome? Case Report and Literature Review.

Acute posttraumatic enophthalmos is a well-known symptom occurring in orbital blowout fractures. Its late onset in the absence of radiologic evidence of displaced fractures is rare and traditionally attributed to ischemic liponecrosis or fibrotic scarring of endo-orbital soft tissues. In this article, we describe a case of facial trauma, diagnosed and treated at the Maxillo-Facial Surgical Department of Hospital Ca' Granda Niguarda of Milan, in which delayed monolateral enophthalmos is associated with CT evidence of remodeling of orbital walls attributed to atelectasis of the maxillary sinus, as occurs spontaneously in patients suffering from silent sinus syndrome (SSS). Despite that classic criteria exclude traumatic etiology of SSS, recent literature suggests the possibility to include it. Our case is the first reported in literature supported by complete clinical and radiological documentation obtained before and after the condition established itself. The analogy with cases of spontaneous obstacle of aeration allows us to choose "two-step" surgical treatment with endoscopic uncinectomy and antrostomy and a delayed surgical correction of orbital volume to improve aesthetic results. The case described in this article and the review of the literature may focus physicians' attention on evaluating the possible traumatic changes in the physiologic sinus drainage system.

Long-term follow-up of large maxillary advancements with distraction osteogenesis in growing and non-growing cleft lip and palate patients.

BACKGROUND: Maxillary distraction osteogenesis (DO) in cleft lip and palate patients has been described by several authors, but most studies have a relatively short follow-up and do not clearly separate growing patients from non-growing patients. METHOD: The records of 22 consecutive patients affected by cleft lip and palate, who underwent Le Fort I osteotomy and maxillary distraction with a rigid external distractor (RED), were reviewed. The sample was subdivided into a growing and a non-growing group. All patients had pre-DO cephalometric records, immediately post DO, 12 months post DO and long-term records with a long-term follow-up of >5 years (range 5-13 years). As a control sample for the growing group, cleft children with a negative overjet not subjected to distraction or any protraction treatment during growth were followed up until the completion of growth. RESULTS: The average maxillary advancement in the growing group was 22.2 ± 5.5 mm (range: 15-32 mm); in the non-growing group, it was 17.7 ± 6.6 mm (range: 6-25 mm). Excellent post-surgical stability was recorded in the adult sample. On the other hand, growing children had an average 16% relapse in the first year post DO and an additional 26% relapse in the long-term follow-up. CONCLUSIONS: This study seems to point out that early Le Fort I DO allows for the correction of very severe deformities. It is followed by a relatively high amount of true skeletal relapse in children with cleft lip and palate. Prognosis should be discussed in depth with the family and true aesthetic and psychological needs assessed.