Patient-Specific Facial Implants in Polyetheretherketone and Their Stability: A Preliminary Study.

BACKGROUND: Polyetheretherketone (PEEK) is a synthetic material with many favorable characteristics; PEEK implants are increasingly used for a variety of applications ranging from cranioplasty to orthopedic surgery and facial implants. METHODS: This study is a retrospective review of patients who underwent PEEK implant placement in our department over the last 5 years. Polyetheretherketone computer-aided design and manufacture facial implants were designed from high-resolution computed tomography (CT) scans of each patient. The implants placed were onlay implants used for facial rehabilitation purposes to correct malformative and posttraumatic malformations. RESULTS: Twenty-eight consecutive patients (11 males and 17 females) underwent PEEK implant positioning between January 2015 and December 2020. Common indications were anterior plagiocephaly, hemifacial microsomia, and residual facial imbalance after orthognathic surgery. No complications of implant breakdown, exposure, infection, or displacement were noticed during the follow-up period. During routine controls on 3 patients, we requested a craniomaxillofacial CT scan for reasons unrelated to the implanted prostheses. The CT scans were all high resolution (<1-mm slices). The CT images indicated that bone was starting to form around the implant in all 3 patients as well as in the penetrating holes that were planned in the implants. CONCLUSIONS: In our experience, computer-designed, patient-specific PEEK onlay implants are a valid option for the treatment of malformative and posttraumatic malformations. This is, to the best of our knowledge, the first clinical report on bone reaction to PEEK implantation in the maxillofacial field. Moreover, based on the signs of bone regrowth that we observed in CT controls we can presume that the design of this type of prosthesis can probably take advantage of some technical stratagems not yet codified and fully exploited. Despite our preliminary favorable results, further multicentric and comparative studies are necessary to evaluate outcomes and better understand the behavior of this promising material and thus optimize its use in craniomaxillofacial surgery.

Our problems and observations in 3D facial implant planning.

BACKGROUND: Three-dimensional renderings of two-dimensional computed tomography data have allowed for more precise analysis in the craniofacial field. Design, engineering, architecture, and other industries have paved the way for the manipulation and printing of three-dimensional objects. The usual planning is only carried out based on the bony structures, often without taking into consideration the presence of soft tissues and soft structures. During our practice, we have found ourselves facing the challenge posed by these structures; the aim of this article is to discuss our experience in designing implants presenting our tips and tricks for a better planning leading to an easy and reliable positioning. CASE PRESENTATION: We have retrieved all patients in 5 years among those who underwent computer-aided design/computer-aided manufacturing implant placement in the last 5 years in order to review the eventual problems and the solutions found. A total number of 25 patients were retrieved and, among them, 10 patients were selected, in which planning inaccuracy caused difficulties during implant placement and which then led to induced changes during the planning of similar cases or in which the problems were noted before or during the planning which led to changes in the plan to address those problems. Six of the selected cases were polyetheretherketone facial implants for the correction of residual deformities in malformed or deformed patients. One case was a delayed orbital reconstruction with a titanium implant. Two cases were titanium functional and anatomical reconstruction of the mandible in patients with failed post-oncological reconstructions. There was 1 case with a mandibular ramus complex and hard-to-treat fracture. CONCLUSIONS: The planning of the implant mostly relies on hard tissue three-dimensional reconstruction, but it should not be limited at what is immediately evident. A surgeon's clinical experience should always guide the process, with knowledge of the patient's anatomy and evaluation of the quality and of the soft tissue response being taken into consideration. The implant should always be tailored not only based on the bone defect and evaluations but also using the patient's previewed and actual anatomy, evaluating eventual interferences and pitfalls.

Functional Upper Airway Space Endoscopy: A Prognostic Indicator in Obstructive Sleep Apnea Treatment with Mandibular Advancement Devices.

PURPOSE: The use of a mandibular advancement device (MAD) in the treatment of obstructive sleep apnea (OSA) is a consolidated therapy. This study aimed to evaluate the predictive value of awake upper airways (UA) functional endoscopy in identifying the outcome of MAD therapy. METHODS: This observational prospective study included 30 adult OSA patients, all patients underwent pre-treatment awake UA functional endoscopy, during the exam subjects were instructed to advance their mandible maximally, and they were divided into three different groups according to the response of the soft tissue, group A (expansion), group B (stretch), group C (unchanged). The results of this test were used in combination with other noninvasive indexes to predict the treatment outcome in terms of apnea-hypopnea index (AHI) reduction. RESULTS: We found that a substantial AHI reduction occurred in group A and group B while e slight AHI reduction was measured in group C. CONCLUSION: Based on our experience the awake UA endoscopy is a valid prognostic exam for discriminating responder and non-responder patients; in addition our results indicate the possibility of predicting a range of post-treatment AHI index values.

Use of an Oral Device in the Stabilization of Facial Advancement after Early Removal of the Osteodistraction Device for Postoperative Sequelae.

The aim of this study is to present an oral device that improves splanchnocranium stability after osteodistraction in children treated for correction of craniofacial malformations. When removal of the distraction device before the end of the treatment is necessary, the reposition of a new fixation system might not be possible. In these cases, regrown bone is immature, and relapse of malformation occurs frequently. We have been treating these cases by the application of an oral device named Maxillary Advancement Contention (MAC). MAC is used in every patient when any complication interrupts the protocol of osteodistraction before the end of the stabilization time. The device is placed immediately after the removal of the distraction device and left in place for at least three months. We used MAC in six children surgically treated for correction of craniosynostosis with facial or craniofacial advancement. To establish the relapse of malformation we analyzed relations Sella-Nasion-Orbitale (SNOr) and Sella-Nasion-A point (SNA) angles before application of the MAC and after one year. The analysis of stability was excellent in every patient. This device might help, with a minimally invasive procedure, to maintain the obtained advancement allowing stabilization of the regrown bone.

The Use of Ropivacaine in Therapeutic Treatment of Oral Aphthosis.

The use of anaesthetic drugs in the treatment of oral aphthosis is one of the pharmaceutical possibilities that a doctor can use for the most painful forms. Normally, Lidocaine or Diclofenac is used to treat this disease, but they can be used for a very limited time and so they are of little practical use. In this study, the authors have used Ropivacaine whose pharmaceutical kinetics allows the analgesic effect to be active for 60 to 90 minutes. In our research, we compared 8 groups of patients who have been given 3 principal pharmaceutical products: one group was given an anaesthetic drug, one had a topical medication administered which is often used for the treatment of aphthous lesions, and the last group was given a multivitamin. These pharmaceutical products were used alone and in various possible combinations in the 8 groups. The results of this study are very interesting and show that in all the groups that used anaesthetics there was more satisfaction on the patients' part because their pain level became more manageable right after the first application of the drug and the patients could carry on with their normal lives.

Alveolar Ridge Split Technique Using Piezosurgery with Specially Designed Tips.

The treatment of patients with atrophic ridge who need prosthetic rehabilitation is a common problem in oral and maxillofacial surgery. Among the various techniques introduced for the expansion of alveolar ridges with a horizontal bone deficit is the alveolar ridge split technique. The aim of this article is to give a description of some new tips that have been specifically designed for the treatment of atrophic ridges with transversal bone deficit. A two-step piezosurgical split technique is also described, based on specific osteotomies of the vestibular cortex and the use of a mandibular ramus graft as interpositional graft. A total of 15 patients were treated with the proposed new tips by our department. All the expanded areas were successful in providing an adequate width and height to insert implants according to the prosthetic plan and the proposed tips allowed obtaining the most from the alveolar ridge split technique and piezosurgery. These tips have made alveolar ridge split technique simple, safe, and effective for the treatment of horizontal and vertical bone defects. Furthermore the proposed piezosurgical split technique allows obtaining horizontal and vertical bone augmentation.

The Medical Legal Aspects of Surgery First and a New Model of Consent Form.

The introduction of "surgery first" has resulted in a new requirement to compare and resolve medical legal problems which previously did not exist in traditional orthognathic surgery. The first issue relates to the relationship between the doctor and the patient and, in particular, the need to create a new informed consent form for surgery first. The second problem that has arisen with the arrival of surgery first concerns the relationship between health workers, namely the surgeon, and the orthodontist. The authors of this article propose a new template for informed consent specifically created for surgery first and also a model for the new working relationship between surgeons and orthodontists which will facilitate and improve co-operation between them. This will improve results, and guarantee a greater level of protection for the surgeon. It will also enable the identification the individual responsibilities of each person.

Trancutaneous Versus Intraoral Approach to Isolated Zygomatic Arch Fractures: A Comparison of Two Techniques.

Zygomatic arch fractures are caused by a vector force orthogonal to the bone segment that causes the collapse of the arch through depression of the bone fragments. Reduction of isolated zygomatic arch fractures are usually only of esthetic interest, with the exception of those cases where the fracture causes an impingement with the underlying mandibular coronoid process, causing limitation of mandibular movements. Reduction is usually performed with an extraoral approach, more rarely through a transoral approach. In this article, authors compare the traditional transcutaneous technique with the intraoral approach in 2 groups for a total number of 42 patients.For what concerns the correct alignment of the fragments, the 2 techniques have shown being equivalent. Although the intraoral approach has shown being a faster surgical procedure leaving no visible incision, allowing faster recovering and reduced postoperative pain.

Ameloblastic carcinoma of the maxilla: A case report and an updated review of the literature.

Ameloblastic carcinoma (AC) is an uncommon malignant odontogenic tumor that can be difficult to differentiate from ameloblastoma and can arise directly as an undifferentiated lesion or from a pre-existing benign lesion. The current study presents a novel case of primary maxillary AC and review the literature on AC of the maxilla. The review of the literature indicates that secondary tumors and posterior localization are associated with a higher tendency for recurrence and, often, multiple recurrences. Surgical therapy, eventually followed by radiotherapy, is the treatment modality most frequently applied, while the role of chemotherapy remains unclear. Several new cases of maxillary AC have been recently described in literature, making this pathology more frequent than previously considered; this is perhaps an indication of an increased diagnostic sensibility, rather than a real increase in the incidence of the disease itself.

Diagnostic Accuracy of Obstructive Airway Adult Test for Diagnosis of Obstructive Sleep Apnea.

RATIONALE: The gold standard for the diagnosis of Obstructive Sleep Apnea (OSA) is polysomnography, whose access is however reduced by costs and limited availability, so that additional diagnostic tests are needed. OBJECTIVES: To analyze the diagnostic accuracy of the Obstructive Airway Adult Test (OAAT) compared to polysomnography for the diagnosis of OSA in adult patients. METHODS: Ninety patients affected by OSA verified with polysomnography (AHI ≥ 5) and ten healthy patients, randomly selected, were included and all were interviewed by one blind examiner with OAAT questions. MEASUREMENTS AND MAIN RESULTS: The Spearman rho, evaluated to measure the correlation between OAAT and polysomnography, was 0.72 (p < 0.01). The area under the ROC curve (95% CI) was the parameter to evaluate the accuracy of the OAAT: it was 0.91 (0.81-1.00) for the diagnosis of OSA (AHI ≥ 5), 0.90 (0.82-0.98) for moderate OSA (AHI ≥ 15), and 0.84 (0.76-0.92) for severe OSA (AHI ≥ 30). CONCLUSIONS: The OAAT has shown a high correlation with polysomnography and also a high diagnostic accuracy for the diagnosis of OSA. It has also been shown to be able to discriminate among the different degrees of severity of OSA. Additional large studies aiming to validate this questionnaire as a screening or diagnostic test are needed.

Use of N-Butyl-2-Cyanoacrylate (Glubran2(®)) in Fractures of Orbital-Maxillo-Zygomatic Complex.

INTRODUCTION: Fractures of the orbital-maxillo-zygomatic complex are among the most common fractures affecting the facial skeleton. Goal of surgical treatment is the realignment of fracture lines for a complete functional and aesthetic rehabilitation. MATERIALS AND METHODS: From January 2008 to January 2011 in the Department of Maxillofacial Surgery of Complesso Integrato Columbus of the Università Cattolica del Sacro Cuore in Rome, 25 patients, affected by comminute fractures of the anterior wall of the maxillary sinus associated with fractures of the orbital-maxillary complex were selected. The synthesis of the larger fracture fragments was performed by plates and screws (1.5 mm) while a biocompatible glue (N-Butyl-2-Cyanoacrylate-Glubran2(®)) was applied to treat the comminute fractures of the anterior wall of the maxillary sinus. RESULTS AND CONCLUSION: The aim of our article is to report our experience and a review of the literature on application of-Butyl-2-Cyanoacrylate for treatment of comminute fractures of the anterior wall of the maxillary sinus. According to the results achieved in our study the N-Butyl-2-Cyanoacrylate can be indicated to treat comminuted fractures of the anterior wall of the maxillary sinus which could not easily be treated with internal rigid fixation.

OSAS surgery and postoperative discomfort: phase I surgery versus phase II surgery.

INTRODUCTION: This study aims to investigate the reasons that discourage the patients affected by OSAS to undergo orthognathic surgery and compares the postoperative discomfort of phase I (soft tissue surgery) and phase II (orthognathic surgery) procedures for treatment of OSAS. MATERIAL AND METHODS: A pool of 46 patients affected by OSAS was divided into two groups: "surgery patients" who accepted surgical treatments of their condition and "no surgery patients" who refused surgical procedures. The "surgery patients" group was further subdivided into two arms: patients who accepted phase I procedures (IP) and those who accepted phase II (IIP). To better understand the motivations behind the refusal of II phase procedures, we asked the patients belonging to both the IP group and "no surgery" group to indicate the main reason that influenced their decision to avoid II phase procedures. We also monitored and compared five parameters of postoperative discomfort: pain, painkiller assumption, length of hospitalization, foreign body sensation, and diet assumption following IP and IIP procedures. RESULTS: The main reason to avoid IIP procedures was the concern of a more severe postoperative discomfort. Comparison of the postoperative discomfort following IP versus IIP procedures showed that the former scored worse in 4 out of 5 parameters analyzed. CONCLUSION: IIP procedures produce less postoperative discomfort. IIP procedures, namely, orthognathic surgery, should be the first choice intervention in patients affected by OSAS and dentoskeletal malformation.

Anterior retrograde approach to the myofascial temporalis muscle for orbital reconstruction: series of 9 consecutive cases.

BACKGROUND: Among the reconstructive options after orbital exenteration, the temporalis myofascial flap (TMF) has been widely recognized as the one of the best available solutions. We think that the hemicoronal approach to harvest the TMF represents a disadvantage so we adopted a modified approach that we named the anterior retrograde approach to the TMF. METHODS: Nine patients with malignant orbital tumors underwent orbital exenteration and primary reconstruction with TMF harvested with the anterior retrograde approach. The temporalis muscle was widely exposed through the anterior incision used to perform the orbital exenteration. The harvested flap was then rotated and insetted to fill the orbital cavity. RESULTS: Neither cases of total/partial flap failure nor local/regional recurrence of tumor were recorded. The technique showed a significant reduction of morbidity, surgical time, and blood loss compared with the traditional technique. CONCLUSIONS: We think that the anterior retrograde approach should be considered as a valid alternative to the traditional hemicoronal approach.

The Use of a Superiorly Based Melolabial Interpolated Flap for Reconstruction of Anterior Oronasal Fistulas: An Easy and Practical Solution.

PURPOSE: This study aimed to propose the use of a superiorly based melolabial interpolated flap for reconstruction of anteriorly located oronasal fistulas maxillary defects. MATERIALS AND METHODS: Using a prospective study design, we evaluated indications and outcomes of the reconstructive technique using the interpolated melolabial flap in 6 patients affected by anteriorly located maxillary defects with naso-sinonasal communication. The cases differed in demographic characteristics and etiology of the defect. The outcome variables were flap vitality/failure and persistent/recurrent oronasal fistula. Both the outcomes were clinically evaluated. RESULTS: No partial or total flap failures were recorded. Two patients experienced recurrent oronasal fistula after previous attempts of correction that required second surgery repair; in both cases, the melolabial flap was available and functional for the secondary procedure. CONCLUSIONS: In selected cases, the superiorly based interpolated melolabial flap could represent a valuable choice for repairing of anteriorly located maxillary defects with oronasal fistulas.

Long term follow-up in inferior alveolar nerve transposition: our experience.

INTRODUCTION: Inferior alveolar nerve transposition (IANT) is a surgical technique used in implantoprosthetic rehabilitation of the atrophic lower jaw which has not been well embraced because of the high risk of damage to the inferior alveolar nerve (IAN). There are cases in which this method is essential to obtain good morphologic and functional rebalancing of the jaw. In this paper, the authors present their experience with IANT, analyzing the various situations in which IANT is the only surgical preprosthetic option. METHODS: Between 2003 and 2011, 35 patients underwent surgical IANT at our center. Thermal and physical sensitivity were evaluated in each patient during follow-up. The follow-up ranged from 14 to 101 months. RESULTS AND CONCLUSION: Based on our experience, absolute indications of IANT are as follows: (1) class IV, V, or VI of Cawood and Howell with extrusion of the antagonist tooth and reduced prosthetic free space; (2) class V or VI of Cawood and Howell with presence of interforaminal teeth; (3) class V or VI of Cawood and Howell if patient desires fast implantoprosthetic rehabilitation with predictable outcomes; (4) class VI of Cawood and Howell when mandibular height increase with inlay grafts is advisable.

Pleomorphic adenoma and benign parotid tumors: extracapsular dissection vs superficial parotidectomy--review of literature and meta-analysis.

OBJECTIVE: This study compared extracapsular dissection (ED) vs superficial parotidectomy (SP) in the treatment of pleomorphic adenoma and benign parotid tumors. STUDY DESIGN: The research covered the years 1950-2011 in PubMed, Ovid MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus. Of 1152 articles screened, 123 studies met the inclusion criteria. A review of the nomenclature of the different parotid surgery techniques was done. Recurrence rate, permanent facial nerve paralysis, and Frey syndrome of patients who underwent ED vs those who underwent SP were compared by meta-analysis. RESULTS: Our meta-analysis data comparing ED and SP found that: (1) the recurrence rate is higher in patients treated with SP; (2) SP has a higher incidence of cranial nerve VII paralysis; and (3) Frey syndrome is more common after SP. CONCLUSIONS: ED may be a viable option in the treatment of unilateral benign parotid tumors of the superficial lobe, sized less than 4 cm, without involvement of the facial nerve.

Autologous fat transplantation for the temporalis muscle flap donor site: our experience with 45 cases.

BACKGROUND: Temporal depression after temporalis muscle flap transposition is characterized by a concavity of the soft tissue and associated with the relief of the orbital rim and zygomatic arch. The purpose of this study was to describe the use of autologous fat grafting for the treatment of postsurgical temporal contour deformities. METHODS: Between March 2008 and April 2011, 45 patients were treated with lipofilling. A virtual 3-dimensional preoperative assessment was used to objectively quantify the loss of volume of the affected side. Two different methods were used to evaluate the surgical outcomes. RESULTS: A noticeable soft tissue augmentation of the temporal region was noted in all cases. In 35 patients, a second procedure was required and in 1 patient, a third procedure was required. The final result was assessed as fully satisfactory by 39 patients (86.6%), as satisfactory by 5 patients (11.1%), and as unsatisfactory by 1 patient (2.2%). CONCLUSION: We believe that structural fat grafting at the temporalis muscle flap donor site is an effective technique that provides a high satisfaction rate and only a few complications.

Vertical distraction osteogenesis combined with bilateral 2-step osteotomy for preprosthetic rehabilitation of edentulous mandible.

The aim of the current study was to appraise the effectiveness of distraction osteogenesis combined with bilateral 2-step osteotomy for the vertical augmentation of atrophic edentulous mandibles. To verify the predictability of this technique, we evaluated bone density and vertical bone gain of a cohort of 27 patients. The intraoral alveolar distractor was placed in the symphyseal area; then, it was left in situ for 2 months after surgery to consolidate the newly formed bone. A total of 189 implants were inserted. The main complications' issue was tied up to the neurosensory disturbances of the inferior alveolar nerve, which disappeared few months after the surgery.At the end of the distraction osteogenesis, a mean vertical bone gain of 10.5 mm evaluated by comparing preoperative and postoperative computed tomography was reached. Three months after the surgery, the radiologic data indicated that the difference in the mean bone density, recorded in Hounsfield units (HU), between the distracted bone and the preexisting mandibular bone was not statistically significant (P > 0.05). The last measurements done showed that the osseous density in the distraction chamber was higher than the original medullary bone density: the regenerated bones were more dense (876.8 [205.9] HU) than the preexisting medullary bone (312.1 [142.3] HU) and less dense than the preexisting cortical bone (1721.1 [170.4] HU) at the ninth month.In conclusion, this approach appeared to be a viable solution for the improvement of vertical volume in atrophic mandibles.

Intracortical versus anteromedial approach for iliac crest bone harvesting in preprosthetic surgery: a randomized prospective clinical trial.

PURPOSE: The aim of this study was evaluate the morbidity after anterior iliac crest bone harvesting by comparison of 2 approaches: medial and intracortical. PATIENTS AND METHODS: Between April 2006 and February 2010, 73 consecutive subjects underwent anterior iliac crest bone harvesting. The sample was divided in 2 groups: 37 subjects treated with the medial approach and 36 with the intracortical approach. Patients were monitored during their hospital stay, considering the postoperative complications, the analgesic requirements, resumption of the ambulation, and length of stay. Postoperative controls were performed at 7, 14, and 30 days 6 and 12 months after surgery. A questionnaire on patient's satisfaction and complaints was released. RESULTS: The 2 approaches resulted in significant statistical differences in 3 areas: the average time of operation, recovery of gait capabilities, and duration of the postsurgical pain were lower when intracortical approach was used. DISCUSSION AND CONCLUSION: The low postsurgical morbidity can be related to the minimal muscular detachment, and the risk of fracture is reduced. Bone wax is not necessary for the hemostasis. We consider intracortical approach to be ideal in the case of selected transversal maxillary atrophies.

Evaluation of obstructive sleep apnea in pediatric patients with facio-craniostenosis: a brief communication.

PURPOSE: This study aimed to evaluate our experience in treating cranio-maxillo-mandibular malformations with hypoplasia of the upper and middle third of the face. We wished to determine a new diagnostic path involving a new clinical questionnaire for obstructive sleep apnea (OSA) evaluation, which we have developed by merging existing tests, literature findings, and our clinical experience to obtain a high level of information with minimal cost. This questionnaire is an improvement of the other anamnestic tests in the literature. METHODS: The study was carried out on 17 pediatric patients affected by syndromic craniofacial malformations and treated with surgical advancement of the middle third of the face, associated with or without upper third advancement, through osteodistraction. We used the obstructive airway child test (OACT) for clinical evaluation. The OACT is an OSA assessment test based on questions proposed to the patient's relatives. All patients underwent polysomnography for instrumental assessment of OSA. These patients were also required to have a computed tomography scan for surgical planning. At the start of the treatment, 11 patients had severe OSA, 4 patients had moderate OSA, and 2 patients had slight OSA. RESULTS: At the end of the treatment, 6 patients had slight OSA and 11 patients had no OSA; these data were confirmed with OACT and polysomnography. CONCLUSIONS: Based on our results, we suggest the following flowchart: OACT for OSA clinical evaluation; CT scan for evaluation of the volume of the rhinoropharyngeal air column, anatomical obstruction detection, and surgical planning; and polysomnography for diagnostic confirmation.