Tetris Genioplasty: A New Paradigm for Chin Asymmetries Correction.

The chin plays a crucial role as a fundamental structural component that contributes to the overall aesthetics and harmony of the face. Recognizing its central position, medical science has seen the evolution of numerous surgical techniques over the years, all aimed at correcting the range of structural irregularities that can affect the chin. In this contribution, the authors introduce an innovative osteotomy technique, aimed at cases of chin asymmetry in which the skeletal median diverges from the dental median. This technique, called "Tetris genioplasty", involves performing the classic rectangular osteotomy, but includes an additional vertical osteotomy in order to obtain two distinct segments. Finally, these segments are translocated and repositioned to obtain a realignment between the skeletal median and the dental median. The results were entirely satisfactory for the patients, aligning perfectly with the expected appearance after the operation. Furthermore, no complications were reported, proving the success and safety of the procedure. The Tetris genioplasty aligns itself with this progressive trend by offering a minimally invasive method that nevertheless is able to achieve excellent results with a high impact on the patient's quality of life, presenting a promising path in the pursuit of optimal aesthetic results with minimized patient morbidity and greater overall safety.

The use of inter-alar ligaments flap for tip and supra-tip contouring in primary open structural rhinoplasty.

BACKGROUND: Precise tip contouring is paramount to achieve pleasant cosmetic results in rhinoplasty. Loss of tip projection or rotation, supra-tip deformities, as well as long-lasting edema, may jeopardize the outcome, thus leading to patient's dissatisfaction or re-intervention. Several approaches were previously reported, sometimes with considerable drawbacks or conclusions mainly supported by experience. The aim of this study is to describe the inter-alar ligaments flap for tip and supra-tip contouring and to comparatively assess its efficacy and safety. METHODS: The study included 147 patients who underwent primary structured open rhinoplasty and divided into 2 groups: group 1 underwent harvesting and repositioning of the inter-alar ligaments flap, group 2 underwent conventional tip dissection. Tip edema, supra-tip definition and fullness were blindly scored at 2-, 6- and 12-month post-operative follow-up. Naso-labial angle was measured at 2 and 12 months post-operatively. Univariate analysis and and multivariable regression model were performed. RESULTS: Supra-tip definition was significantly higher in group 1 at 2-, 6- and 12-months post-operative follow up (p<0.05, p<0.01 and p<0.01, respectively). Tip edema and supratip fullness were significantly lower in group 1 at each time point (p<0.01). Naso-labial angle, as well as its modification between 2- and 12-months post-intervention, did not differ in the 2 groups. All findings were confirmed when controlled for eventual confounders. CONCLUSIONS: The inter-alar ligaments flap proved to be versatile, effective and consistently reliable in reducing tip edema and improving supra-tip definition. It may be tailored to the patient, partially folded to improve tip projection or used to camouflage tip grafts.

Numbers of Beauty: An Innovative Aesthetic Analysis for Orthognathic Surgery Treatment Planning.

The aim of this study was to validate a new aesthetic analysis and establish the sagittal position of the maxilla on an ideal group of reference. We want to demonstrate the usefulness of these findings in the treatment planning of patients undergoing orthognathic surgery. We took a reference group of 81 Italian women participating in a national beauty contest in 2011 on which we performed Arnett's soft tissues cephalometric analysis and our new "Vertical Planning Line" analysis. We used the ideal values to elaborate the surgical treatment planning of a second group of 60 consecutive female patients affected by skeletal class III malocclusion. Finally we compared both pre- and postoperative pictures with the reference values of the ideal group. The ideal group of reference does not perfectly fit in Arnett's proposed norms. From the descriptive statistical comparison of the patients' values before and after orthognathic surgery with the reference values we observed how all parameters considered got closer to the ideal population. We consider our "Vertical Planning Line" a useful help for orthodontist and surgeon in the treatment planning of patients with skeletal malocclusions, in combination with the clinical facial examination and the classical cephalometric analysis of bone structures.

J-Graft for Correction of Vertical and Horizontal Maxillary Bone Defects.

INTRODUCTION: This prospective study aims to evaluate the reliability of a reconstructive technique, which uses autologous J-shaped graft (J-graft) harvested from the mandibular ramus. MATERIALS AND METHODS: Thirty-six maxillary defects among 32 patients (20 women and 12 men) were treated. All patients presented enough bone volume at the donor site to perform the harvesting procedures needed for the autologous reconstruction. All patients underwent clinical and radiographical evaluations through standardized radiographs taken before the intervention, immediately after the bone grafting, 6 to 7 months, and 1 year later. The loss of tooth vitality, the alterations of skin and mucosa sensibility, and the patients' subjective perception of discomfort related to the surgical procedure were investigated. RESULTS: We found an overall success rate of 91.66% with a mean bone gain of 4.8 mm vertically and 5.6 mm horizontally, assessed through computed tomography. According to clinical examinations, 35 sites completely recovered with proper incorporation of the graft, whereas 33 sites reached enough bone volume to allow the implant placement. CONCLUSION: The described technique explains how to harvest and shape a J-graft. It achieves the simultaneous restoration of the horizontal and vertical bone loss with a single bone block.

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.

The "beauty arch: " a new aesthetic analysis for malar augmentation planning.

Midface is a critical area for the aesthetics of the face. Despite malar hypoplasia is often combined with a class III malocclusion, there are few studies focusing on the results of a combined approach of malar implants and Le Fort I. We describe a new aesthetic analysis, named "beauty arch" analysis, for the assessment of sagittal projection of the malar region. We took a reference group of 74 Italian women participating in a national beauty contest in 2011 on which we performed our analysis. We used the ideal values to elaborate the surgical treatment planning of a second group of 45 consecutive female patients affected by skeletal class III malocclusion.Twenty-three patients undergo simultaneous Le Fort I osteotomy and malar implants. From the descriptive statistical comparison of the patients' values before and after orthognathic surgery and malar implants with the reference values, we observed how all parameters considered got closer to the ideal population. We consider our beauty arch a useful help for surgeon in the treatment planning of patients with skeletal malocclusions and malar implants.

Mandibular reconstruction with different techniques.

Traumas, malformative or dysplastic pathologies, atrophy, osteoradionecrosis, and benign or malignant neoplasm can cause bone deficits in the mandible. Consequent mandibular defects can determine aesthetic and functional problems; therefore, being able to perform a good reconstruction is of critical importance.Several techniques have been proposed for mandibular reconstruction over the years. In this article, we present and discuss the evolution during the time of the methods of mandible reconstruction as well as pros and cons of each procedure on the basis of experience of 10 years in the maxillofacial department of the Catholic University of Sacred Heart of Rome.Free flaps represent the gold standard method of reconstruction of large mandibular defects: the fibula bone flap represents the best choice for large defects involving the arch and the mandibular ramus, whereas the deep circumflex iliac artery represents a valid alternative for mandibular defects involving the posterior region.In cases where free flap reconstructions are contraindicated, the use of regional pedicle flap combined with autologous bone grafts still represents a valid choice. Patients who are not deemed suitable for long and demanding surgery can still be treated using alloplastic materials in association with regional pedicle flap or, when adjuvant radiation therapy is needed, by simple locoregional pedicle flap. Finally, in selected cases, the bone transporting technique should be considered as a valid alternative to the more "traditional" reconstructive methods because of the extraordinary potential and its favorable cost-benefit ratio.

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.

Bilateral condylar resorption in down syndrome.

Asymptomatic idiopathic condylar resorption is a rare disease of difficult diagnosis and treatment. We review the literature about this rare condition and report a case of a patient, affected by Down syndrome, who underwent a complete untreated bilateral condylar resorption in adolescence and then developed pain on chewing only 20 years later. Despite a precise orthodontic and surgical therapeutic plan, treatment had to be discontinued because of patient lack of compliance. This case is the first of its kind to be reported and emphasizes the need for special attention in patients with disability.

Transnasal endoscopic approach to the impacted maxillary canine.

The inclusion of maxillary canines is a very common condition. The intraoral approach to the canine extraction can be buccal or palatal depending on the position of the tooth. However, in some cases, the proximity to the nasal floor or the side wall of the nose makes the transoral approach rather invasive. The aim of this article was to describe a novel transnasal endoscopically assisted approach for the extraction of high palatal/paranasal impacted canines. Thirty-seven maxillary canines have been extracted in 29 patients. The surgical approaches were buccal in 5 cases, palatal in 24 cases, and transnasal endoscopically assisted in 8 cases. Patients treated with the transnasal approach required the least amount of pain killers in the postoperative period, and the average of the operative time was shorter than that of the transoral extraction. In our opinion, the transnasal endoscopically assisted approach is a safe and effective procedure for the extraction of highly impacted maxillary canines located within 2 cm from the piriform aperture.

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.

Equine pericardium membrane to prevent dorsal irregularities in rhinoplasty.

Even after a well-executed rhinoplasty, small dorsal irregularities are not uncommon. Many materials have been used for camouflage, including autologous, homologous, and alloplastic materials. We used an equine pericardium membrane in 33 postrhinoplasty patients to prevent or correct nasal dorsal irregularities. The membrane promotes a local fibrous reaction, which leaves a uniform connective layer. In our hands, equine pericardium membrane seems to be a useful material for rhinoplasty refinements.

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.

Mandibular alterations and facial lower third asymmetries in unicoronal synostosis.

PURPOSE: Maxillary and mandibular alterations in children affected by anterior synostotic plagiocephaly have, until today, received only scarce attention. The goal of this paper is to focus on the mandibular alterations, persisting after the early correction of anterior plagiocephaly during the first year of life. METHODS: Maxillary and mandibular metric measurements were performed on high resolution, thin slices CT scans; all images were reconstructed into 3D models which were used to perform the metrical assessments. RESULTS: Twelve patients were selected; all of them had been treated in early age with a neurosurgical intervention and had reached the end of maxillo-mandibular growth at the time of the evaluation. Significant discrepancies were documented between the two affected sides, with all measured distances being shorter on the synostotic side than the nonsynostotic one, the only exception being the vertical dimension of the mandibular ramus. DISCUSSION: Mandibular alterations resulted to be characterized by lower jaw hypoplasia on the side of the affected suture and anterior displacement of the glenoid fossa; these two entities compensated each other uncompletely, ending in a rotation of the mandibula towards the synostotic side.

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.

Giant neglected desmoplastic ameloblastoma: reconstruction with free fibula flap.

The desmoplastic ameloblastoma (DA) is a rare variant of the conventional ameloblastoma. It accounts for only 4% to 13% of all ameloblastomas. In this article, we describe the case of a young child affected by a giant neglected DA of the jaw. Preoperative biopsy demonstrated the extremely rare osteoplastic variant of DA. The patient was submitted to segmental mandibulectomy and immediate reconstruction with a free fibula osseous flap. The postoperative period was uneventful. The patient was very satisfied with the functional and aesthetic results of the procedure. In case of such rare variants of ameloblastoma, it is mandatory to preoperatively recognize them to allow the adequate treatment modality to be provided.