Persistent Idiopathic Facial Pain (PIFP) in Patients Referred to a Multidisciplinary Centre in Italy: A Retrospective Observational Study.

BACKGROUND: Persistent Idiopathic Facial Pain (PIFP), previously named Atypical Facial Pain (AFP) is a poorly understood condition, often diagnosed after several inconclusive investigations. The aim of this retrospective study was to evaluate the demographic and clinical characteristics of patients with PIFP referred to a Facial Pain Center. METHODS: Between May 2011 and September 2014, data on 41 PIFP patients were analyzed regarding temporal, topographical and descriptive pain features, including onset, localization, pain descriptors and intensity. Pharmacological pain treatments were also registered. Finally, the presence and type of previous minor oro-surgery procedures in the painful area were investigated. RESULTS: Demographic and clinical characterization were similar to PIFP patients reported in literature. The presence of previous minor oro-surgery procedures in the painful area was reported in most of these patients, in particular endodontic treatments and tooth extractions. CONCLUSIONS: This retrospective analysis showed a high prevalence of minor oro-surgery procedures in our population, while its role in PIFP pathophysiology remains unknown. A new classification of PIFP built around the main discriminant factor of presence of these procedures in the painful area could be considered while available data were still insufficient to define specific diagnostic criteria.

Is post orthognathic maxillary sinusitis related to sino-nasal anatomical alterations?

Le Fort I osteotomies have been used for more than five decades, but their impact on nasal and paranasal cavities physiology, has not been studied deeply. In this paper we want to analyse the possible correlation between post-orthognathic findings and prevalence of sinusitis which require surgical treatment. A retrospective cohort study was designed in 2017; the study was designed and carried out in the Verona University maxillo-facial department, a referral centre for orthognathic surgery. The study population is made of 64 patients that underwent orthognathic surgery (To treat class II or III malocclusion) between 2010 and 2015. Inclusion criteria were the availability of a Cone Beam Computed Tomography (CBCT) before surgery and one between 12 and 24 months after orthognathic surgery. Exclusion criteria were smoking habit and previous orthognathic procedures. During follow-up time prevalence of sinusitis was 18.5% and some patients required a secondary surgery to treat sinusitis. Surgery induced anatomic alterations were frequent in patients with sinusitis, sings and symptoms of sinusitis show positive correlation with anatomic alterations.

Odontogenic orbital abscess: a case report and review of literature.

Odontogenic orbital abscess is a rare but well-documented complication of sinusitis and infections spreading from dental apical lesion. We report a case of orbital abscess with periorbital cellulitis, in a 35-year-old man with positive recent dental history of a periapical dental infection arising from the second upper left premolar spread into maxillary sinus. The patient has shown facial edema, ocular pain, ophthalmoplegia, proptosis, and initial visual symptoms. A surgical intervention to drain the abscess and a revision of the dental lesion and maxillary sinus were required. A review of literature is also reported focusing on etiology and treatment options dealing with odontogenic orbital abscess and cellulitis.

The Use of Double-Layer Collagen Membrane for the Improvement of Nasal Dorsum Skin Thickness and Texture in Primary Nose Surgery.

OBJECTIVES: To place a collagen membrane containing crushed nasal septal cartilage over the nasal dorsum to see how this graft can improve the results of visible postsurgical irregularities in thin skinned patients. METHODS: Fifty-seven patients were treated between 2006 and 2010 (26 males and 31 females) whose ages ranged between 31 and 55 years old. They were divided into group a, defect <1 mm, group b defect between 1 and 2 mm, group c defect >3 mm. These patients presented intraoperative nasal dorsum irregularities that were corrected with 57 cartilage grafts in conjunction with collagen membrane. RESULTS: All of our patients showed an initial over-correction. A dense network of collagen fiber bundles was observed running parallel to the surface of the membrane at the connective tissue-membrane interface. The clinical percentage of volume reabsorption was about 5% after 6 months, measured with clinical pictures and a clinical follow-up. No infection was noted, only 1 patient of dislocation was observed, and 5 patients required some refinements at the long-term follow-up. CONCLUSIONS: In the authors' experience the use of bilayered combined cartilage and collagen membrane grafts gives the best aesthetic results with balanced tip projection and dorsum fullness, and avoids thickness and texture modification of the skin above the graft. The use of Bio-gide membrane avoids all problems related to the donor site and shortens surgical time.

Modified technique for endoscopic endonasal reduction of medial orbital wall fracture using an absorbable packing.

PURPOSE: The purpose of this study was to describe a modified technique using only biological dura substitute (Lyoplant®) associated or not to a sheet of Medpore® (porous polyethylene plate) avoiding the use of Silastic® or Merocel® packing for endoscopic endonasal reduction of medial orbital wall fracture. METHODS: An interventional case report was used involving two patients with medial orbital wall fracture that were treated with the modified technique. Postoperatively, the patients were evaluated for visual acuity, enophthalmos, extraocular motility, and diplopia. RESULT: Twelve months after surgery, patients recovered completely without any residual eye symptoms or complications, and postoperative CT showed a completely corrected medial orbital wall fractures. CONCLUSION: The reported technique proved itself to be safe and effective, and it may be expected to have advantages over the conventional endoscopic approach using a non-absorbable packing, avoiding the need for long-term nasal packing and a secondary removal procedure.

Odontogenic Orofacial Infections.

Acute dental abscess is a frequent and sometimes underestimated disease of the oral cavity. The acute dental abscess usually occurs secondary to caries, trauma, or failed endodontic treatment. After the intact pulp chamber is opened, colonization of the root canals takes place with a variable set of anaerobic bacteria, which colonize the walls of the necrotic root canals forming a specialized mixed anaerobic biofilm. Asymptomatic necrosis is common. However, abscess formation occurs when these bacteria and their toxic products breach into the periapical tissues through the apical foramen and induce acute inflammation and pus formation. The main signs and symptoms of the acute dental abscess (often referred to as a periapical abscess or infection) are pain, swelling, erythema, and suppuration usually localized to the affected tooth, even if the abscess can eventually spread causing a severe odontogenic infection which is characterized by local and systemic involvement culminating in sepsis syndrome. The vast majority of dental abscesses respond to antibiotic treatment, however, in some patients surgical management of the infection may be indicated. In the present work, a retrospective analysis of the patients with dental orofacial infections referred to the Unit of Dentistry and Maxillofacial Surgery of the University of Verona from 1991 to 2011 has been performed.

Is the Retromandibular Transparotid Approach a Reliable Option for the Surgical Treatment of Condylar Fractures?

PURPOSE: This study evaluated the outcomes and complications of the surgical treatment of condylar fractures by the retromandibular transparotid approach. The authors hypothesized that such an approach would be safe and reliable for the treatment of most condylar fractures. MATERIALS AND METHODS: A retrospective evaluation of patients who underwent surgical reduction of a condylar fracture from January 2012 to December 2014 at the Clinic of Dentistry and Maxillofacial Surgery of the University Hospital of Verona (Verona, Italy) was performed. Inclusion criteria were having undergone surgical treatment of condylar fractures with a retromandibular transparotid approach and the availability of computed tomograms of the preoperative and postoperative facial skeleton with a minimum follow-up of 1 year. Static and dynamic occlusal function, temporomandibular joint health status, presence of neurologic impairments, and esthetic outcomes were evaluated in all patients. RESULTS: The sample was composed of 25 patients. Preinjury occlusion and temporomandibular joint health were restored in most patients. Esthetic outcomes were deemed satisfactory by clinicians and patients. Neither permanent neurologic impairments nor major postoperative complications were observed. CONCLUSIONS: According to the results of the present study, the retromandibular transparotid approach is a viable and safe approach for the surgical treatment of condylar fractures.

The "Anatomical Balance Correction" for Secondary Cleft Lip Nasal Deformities.

Secondary cleft lip nasal deformities corrective procedures are still a major concern for the maxillofacial surgeons.

Rehabilitation of a complex midfacial defect by means of a zygoma-implant-supported prosthesis and nasal epithesis: a novel technique.

PURPOSE: Several authors have described zygoma implants as a reliable surgical option to rehabilitate severe maxillary defects in case of extreme atrophy or oncological resections. The aim of this study is to report a new technical approach to the rehabilitation of a complex oronasal defect by means of a zygoma-implant-supported full-arch dental prosthesis combined with a nasal epithesis. PATIENTS AND METHODS: The patient presented with a subtotal bilateral maxillectomy and total rhinectomy defect because of a squamous cell carcinoma of the nose. No reconstructive surgery was performed because of the high risk of recurrence; moreover, the patient refused any secondary procedure. After surgery, the patient presented a wide palatal defect associated to the absence of the nasal pyramid. Zygoma-retained prostheses are well documented, and they offer good anchorage in rehabilitating wide defects after oncological surgery and a good chance for patients to improve their quality of life. We hereby describe two prosthetic devices rehabilitating two iatrogenic defects by means of a single intraoral implant-supported bar extending throughout the oronasal communication, thus offering nasal epithesis anchorage. RESULTS: At 1-year follow-up after functional prosthetic loading, no implant failure has been reported. Clinical and radiological follow-up showed no sign of nasal infection or peri-implantitis. The patient reported a sensitive improvement of his quality of life. CONCLUSIONS: Simultaneous oral and nasal rehabilitation of complex oronasal defects with zygoma-implant-supported dental prosthesis and nasal epithesis represents a reliable surgical technique. According to this clinical report, the above-mentioned technique seems to be a valuable treatment option as it is safe, reliable and easy to handle for both surgeon and patient.

Extraordinary sneeze: Spontaneous transmaxillary-transnasal discharge of a migrated dental implant.

This case report describes an extraordinary case of the spontaneous transmaxillary-transnasal discharge of a dental implant, which occurred during a sneeze. The patient was complained of symptoms of acute sinusitis. She underwent a computed tomography scan that revealed a dental implant dislocated in the maxillary sinus. Medical treatment based on antibiotics and mucolytics was administered to the patient in order to prepare her for endoscopic endonasal surgery. The implant was spontaneously discharged two days after during a sneeze. Mucociliary clearance in combination with a local osteolytic inflammatory process and mucolytics therapy are the likely causes of this unusual discharge.

Surgical Treatment of Oroantral Communications.

BACKGROUND: Oroantral communication (OAC) can be defined as a pathologic space created between the maxillary sinus and the oral cavity.This communication and subsequent formation of a chronic oroantral fistula is a common complication often encountered by oral and maxillofacial surgeons.Although various techniques have been proposed in published studies, long-term successful closure of oroantral fistulas is still one of the most difficult problems confronting the surgeon working in the oral and maxillofacial region.The decision of which treatment modality to use is influenced by many factors, such as the amount and condition of tissue available for repair, the size and location of the defect, the presence of infection, the time to the diagnosis of the fistula. OBJECTIVE: To evaluate an alternative technique for the treatment of oro-antral fistula, using a combined therapeutic ear nose and throat/intraoral approach. METHODS: Twelve consecutive patients affected by complicated OAC were included in this study.The protocol consisted of: clinical, endoscopic, and radiological preoperative evaluation (panoramic tomogram and computed tomography); systemic antibiotic and steroid therapy for 2 weeks before surgery; one-stage surgical procedure consisting of Functional Endoscopic Sinus Surgery technique associated with the closure of the OAC by a titanium mesh and a mucoperiosteal flap; postoperative antibiotic and cortisone-based therapy.A titanium mesh was used to obtain an optimal support and stabilization of soft tissues.Follow-up consisted of weekly clinical evaluation during the first month, a clinical evaluation at 1, 3, 6, 12, 24 months and a nasal endoscopy at 3, 8, 24 weeks after surgery. A second surgical step took place to remove the mesh, after a period of healing, which went from 6 to 18 months. Samples were harvested from the surgical site after mesh removal for histological analysis. RESULTS: At 1 month follow-up, in 10 patients of 12, the Valsalva manoeuvre was negative, same result at the 3rd month follow-up, although in 11 of 12 patients. In 5 of 12 patients, the mesh was exposed. The histological analysis confirmed the formation of a pseudo-periosteum layer.One patient failed because the mesh lost its stability. The patient was operated again 8 months later and new mesh was fixed into place. CONCLUSION: The current study showed that one-stage, combined endoscopic and intraoral approach represents a feasible and minimally invasive procedure for the long-term effective treatment of chronic complicated OACs.The main advantage of the use of a titanium mesh to guide the regeneration is that it assures a predictable healing, mechanic scaffold, tissues stability and allows a possible following oral rehabilitation.

Are Zygomatic Implants Associated With Maxillary Sinusitis?

PURPOSE: The purpose of the present study was to analyze the relation between zygomatic implants and symptomatic and radiologic modifications of the maxillary sinuses. MATERIALS AND METHODS: A retrospective cohort study of patients who underwent zygomatic implant rehabilitation at the Clinic of Dentistry and Maxillofacial Surgery of the University of Verona from January 2005 through May 2014 was designed. The primary predictor variable was time (pre- vs postoperative). Concerning outcome variables, radiologic findings of thickened mucosa or opacification of the maxillary sinuses were evaluated on computed tomograms using the Lund-Mackay Staging System. Clinical symptoms were evaluated using the Sino-Nasal Outcome Test-20 (SNOT-20). The parameters assessed underwent descriptive statistical analysis. RESULTS: The sample was composed of 41 patients (mean age, 54 yr; 61% women). Preoperatively, 12% had sinus findings. Postoperatively, 46% had sinus findings (P = .0001 by McNemar paired test). Preoperatively, 12% had a SNOT-20 score higher than 11. Postoperatively, 15% had a SNOT-20 score higher than 11 (P = 1 by McNemar paired test). CONCLUSIONS: In accordance with data in the literature data, placement of zygomatic implants does not seem to be associated with severe rhinosinusitis complications. However, in a considerable number of patients, asymptomatic radiologic alterations of the paranasal sinuses were observed. Therefore, it is important to plan assessments of the prosthetic and peri-implant components of the procedure and the postoperative homeostasis of the maxillary sinuses.

Quadruple zygomatic implants supported rehabilitation in failed maxillary bone reconstruction.

Extreme atrophy of the jaws constitutes a challenge for maxillofacial surgeons. The technique involving Le Fort I osteotomy, bone grafting, and endosseous implants remains the gold standard treatment for class V and class VI atrophy of the maxilla. As severe maxillary atrophy is associated to impaired microvascularization of overlying soft tissues, reconstruction using vascularized free fibula flaps together with endosseous implants is one of the possible treatment plans. When this approach fails, however, retreating these patients using traditional techniques often proves unsatisfactory. This study outlines our clinical experience with full-arch zygoma implant-supported prosthetic rehabilitation to treat severe atrophic maxilla following failure of strategies including multiple Le Fort I procedures or vascularized free fibular flaps.

Is Le Fort I Osteotomy Associated With Maxillary Sinusitis?

PURPOSE: The purpose of the present study was to investigate the association between Le Fort I osteotomy and the anatomic, radiologic, and symptomatic modifications of the maxillary sinus. MATERIALS AND METHODS: Subjects who had undergone Le Fort I osteotomy from January 2008 to December 2013 were enrolled in a retrospective cohort study. The eligibility criteria were the availability of a cone beam computed tomography (CBCT) scan taken before and 12 to 24 months after the procedure. The exclusion criteria were the unavailability of CBCT scans, the use of tobacco, and previous orthognathic procedures. The primary predictor variable was time (pre-vs postoperative). The primary outcome variables were the sinus volume, mucosal thickening, iatrogenic alterations in the sinus anatomy, and rhinosinusitis symptoms, evaluated using the Sino-Nasal Outcome 20-item Test (SNOT-20). Descriptive statistics were computed for each variable, and paired analyses were used to compare the pre- and postoperative values. RESULTS: The data from 64 subjects (mean age 27; 59.4% were female; median follow-up 32.4 months, range 13 to 66 months) were studied. Postoperatively, 1.6% of the sample (0% preoperatively) had moderate-to-severe and 15.6% (3.1% preoperatively) had mild-to-moderate sinusitis symptoms. The rest of the sample presented with mild to no symptoms. The increase in the SNOT scores after surgery was statistically significant (P = .016). Radiologic evidence of postoperative inflammatory processes affecting the paranasal sinuses was found in 27.3% of the sinuses (9.4% preoperatively). The postoperative Lund-Mackay scores were significantly greater (P = .0005). A 19% decrease was found in the mean postoperative sinus volume, with a 37% incidence of iatrogenic injury. CONCLUSIONS: The study results indicate that Le Fort I osteotomies can have an important impact on sinus health. The postoperative radiologic evidence of maxillary sinus inflammatory processes and the incidence of rhinosinusitis symptoms and iatrogenic damage in these patients have led us to conclude that CBCT scans and the SNOT-20 questionnaire should be used routinely during postoperative monitoring. Larger long-term studies are warranted to clarify the postoperative outcomes and complications.

Blunt maxillary fracture and cheek bite: two rare causes of traumatic pneumomediastinum.

Subcutaneous facial emphysema is a well-known consequence of oral and maxillofacial traumatic injury. In some rare cases, the subcutaneous air collection could spread through the retropharyngeal and paralatero-cervical spaces, reaching the mediastinum. This clinical entity is known as pneumomediastinum and represents a severe and, sometimes, life-threatening condition. Other reported causes of pneumomediastinum are esophageal and tracheal traumatic or iatrogenic rupture. Finally, the so-called spontaneous pneumomediastinum is caused by a sudden increase in alveolar pressure and is usually seen in young men. We present two cases of pneumomediastinum as a consequence of unusual traumatic damage of orofacial tissues, followed by repeated sneezing and Valsalva maneuver.

Traumatic Intraconal Foreign Body: Report of an Injury Corrected With Combined Surgical and Endoscopic Treatment.

BACKGROUND: Management of penetrating ocular splinter injuries is very controversial. Penetrating wounds of the orbit represent a complex therapeutic problem that requires a multidisciplinary approach. Endoscopic approaches to the orbit are currently performed through the lamina papyracea to access the medial part, or through large orbitotomies to access the lateral part. OBJECTIVE: To describe a novel combined approach to the lateral part of the orbit. METHODS: Clinical and surgical findings of intraorbital foreign body removal are presented. A minimal supraorbital osteotomy was performed, combined with endoscopic intraorbital dissection. RESULTS: The foreign body was removed, no postoperative complications were reported, and visual acuity increased from 2/10 preoperatively, to 8/10 one month after surgery. CONCLUSION: The present technique can be considered a safe and novel surgical approach to access the retrobulbar space and to treat the pathology of this anatomic region.

Simultaneous Le Fort I osteotomy and zygomatic implants placement with delayed prosthetic rehabilitation.

Patients affected by severe maxillary atrophy and skeletal malocclusion have been widely treated by simultaneous orthognathic surgical procedures, interpositional bone insertion and immediate or delayed implant placement. Although several authors have described that the "quad" technique using 4 zygomatic fixtures as an effective way to fully rehabilitate the severe atrophic maxilla, there are still no experiences relative to the use of zygomatic fixtures associated to maxillary osteotomies in case of large skeletal discrepancy. The aim of this study is to report a 1-step surgical rehabilitation of severe atrophic maxilla by means of Le Fort I osteotomy for maxillary forward repositioning and simultaneous insertion of 4 zygomatic implants with immediate prosthetic loading.

A dental implant in the infratemporal fossa: case report.

This case report describes a rare displacement of a dental implant in the infratemporal fossa, which occurred during placement of the implant into the pterygoid process with computer-assisted technology. The implant was immediately removed by means of an intraoral approach to prevent any neurologic complications. Although computer-aided systems in implant surgery represent a reliable and effective tool, the surgeon should always instruct the patient on the necessary behavior during implant placement and the risks associated with a lack of adherence to these recommendations.

Zygoma implant-supported prosthetic rehabilitation of a patient after subtotal bilateral maxillectomy.

This clinical report describes the successful implant-supported prosthetic rehabilitation of a patient who underwent subtotal bilateral maxillectomy for an oral squamous cell carcinoma with a consequent wide defect interesting the whole hard palate and most of the soft palate, causing a large opening that directly connects the oral cavity to the nasal fossa bilaterally. The innovative aspect of this case is represented by the realization of an obturator prosthesis supported by just 3 zygoma implants.The maxillary bone had been largely excised by radical surgery. Despite the resection had a complete oncological success and the patient was free of disease after 24 months' follow-up, the patient experienced severe speech and deglutition deficit due to the iatrogenic large oro-antral communication. Three zygoma implants have been positioned, 2 through the right maxillary bone and, owing the wide lack of bone, just 1 on the left side. No mucogingival surgery was necessary around the zygoma implants. The obturator prosthesis was stabilized by the 3 implants and the patient's oral function as well as quality of life widely improved.The results show that zygoma implants could represent a viable surgical option to obtain a satisfactory oral function rehabilitation even in case of extensive maxillary defect.