Mandibular Distraction Osteogenesis in Children and Adolescents: A Clinical and Radiographic Research Using Cone-Beam Computed Tomography.

AIM: The aim of this cross-sectional study was to evaluate, via cone-beam computed tomography, the long-term postoperative outcome in children treated with mandibular distraction osteogenesis. MATERIALS AND METHODS: All young patients treated with mandibular distraction osteogenesis (MDO), during a 16-year period, at the University Department of Oral and Maxillofacial Surgery of a Pediatric Hospital, were recalled, and various clinical and radiographic parameters were recorded. RESULTS: Eleven patients were included: 5 with hemifacial microsomia (HFM) and 6 with mandibular micrognathia. In all cases, MDO had been successful in regular follow-up and decannulation, soon after MDO, was achieved in all tracheostomy cases. The long-term result in cases of HFM was found stable, functionally and esthetically accepted, although less satisfactory than in regular follow-up; in micrognathia patients, relapse of different degrees was registered in 4 of 6 cases, without any need for tracheostomy though. Detailed and accurate information was obtained by cone-beam computed tomography (CBCT). The shape of the regenerated bone was irregular in HFM cases and relatively normal in the micrognathia cases. Quality of the regenerated bone was normal in all patients. The irregular shape registered in HFM cases did not compromise a safe orthognathic operation. CONCLUSIONS: Distraction osteogenesis remains an early treatment choice in cases of mandibular deformities. Long-term findings showed that there is a degree of relapse with growth, which was more obvious in mandibular micrognathia cases. Computed tomography contributes to detailed evaluation of changes at the distraction site.

A novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography.

PURPOSE: Radiographic scales, based on plain radiographs, for the evaluation of alveolar cleft repair, have certain weaknesses and are thought to overestimate to some degree the success of the surgical intervention. The aim of this study was the presentation of a novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography (CBCT). MATERIALS AND METHODS: Patients treated with secondary osteoplasty for unilateral or bilateral alveolar cleft were evaluated using the Bergland and Enemark scales, as well as the novel success scale, which measures the bone height, the bone width and the level of the nasal floor. RESULTS: A total of 44 patients with a total of 53 alveolar cleft sites were included. According to the new scale, 60% of the cases were defined as successful, with moderate (kappa = 0.511) or substantial (kappa = 0.718) agreement, between the new scale and the Bergland or Enemark scale, respectively. Statistically significant correlation was reported between the new success scale and the closure of space of the lateral incisor, the patient's age at surgery, the graft revision and the presence of residual fistula. CONCLUSIONS: The novel success scale for evaluating alveolar cleft repair using CBCT takes into consideration all dimensions of the bony bridge. Future application is necessary for validation of its potential value.

Ewing's sarcoma of the maxillofacial region in Greek children: Report of 6 cases and literature review.

BACKGROUND: The rarity of Ewing's sarcoma (ES) in the maxillofacial region of children, coupled with the technical challenge of resection and associated functional and cosmetic impairment has resulted in deficient data regarding the optimal local control of the disease. OBJECTIVE: To describe our experience in the management of primary maxillofacial ES in children, focusing on the therapeutic modalities for local control of the disease. STUDY DESIGN: Single institution observational study. METHODS: This is a single institution review of patients, treated between 2007 and 2016. RESULTS: Six primary maxillofacial ES were treated according to the EURO-EWING 99 protocol, consisting of a uniform chemotherapy regimen, combined selectively with surgery and radiotherapy as local treatment. Patients' mean age was 9.42 years (range 6-12.5 years). One patient initially suffered from metastasis and succumbed to the disease; another refused further treatment following chemotherapy and was lost to follow-up. Four patients underwent surgery and adjuvant radiotherapy successfully. At a mean follow-up of 3.78 years relapse-free and overall survival rates were 60% and 80% respectively. The aesthetic and functional outcome was satisfactory in all treated patients. CONCLUSIONS: In eligible cases the combination of chemotherapy with surgery and adjuvant radiotherapy results in optimal oncological and functional outcome for children with ES of the maxillofacial region. Metastasis and poor response to chemotherapy are the most important adverse prognostic factors.

Rhabdomyosarcoma of the maxillofacial region in children and adolescents: Report of 9 cases and literature review.

OBJECTIVE: To review clinical presentation, histology, treatment and survival for pediatric maxillofacial rhabdomyosarcoma (RMS) and evaluate the role of surgical treatment. STUDY DESIGN: Retrospective analysis of medical charts. METHODS: Files of patients, treated for primary maxillofacial RMS from 1997 to 2016, were examined for clinical presentation, staging, histology, treatment protocol and complications, recurrence and final outcome. RESULTS: Our cohort included 4 male and 5 female patients (mean age 8.47 years). One tumor, occupying the infratemporal space, was parameningeal; the other 8, located at the mandible (4) or the maxilla/zygomatic bone (4) were non-parameningeal. All patients received chemotherapy preoperatively. Surgery was performed in 7 patients, of whom 4 received postoperative radiotherapy. The histological type was alveolar (5) or embryonal (4). Overall survival hitherto was 66,6%, depending on histology (40% and 100% for the alveolar and embryonal type respectively). CONCLUSIONS: Pediatric maxillofacial RMS originated mostly from the facial skeleton and most tumors were non-parameningeal. The alveolar type was slightly more common. An individualized multidisciplinary approach combining chemotherapy and local control mostly with surgery and selectively with radiotherapy has proven successful for the treatment of non-orbital, non-parameningeal maxillofacial RMS. Histology was a major treatment determinant and the most important prognostic factor.

Evaluation of Dentoalveolar Trauma in Children and Adolescents: a Modified Classification System and Surgical Treatment Strategies for Its Management.

OBJECTIVE: To retrospectively analyze dentoalveolar trauma in pediatric patients, propose a modified classification, and delineate an approach for its urgent care from the surgeon's perspective. PATIENTS AND METHODS: Clinical records of patients, attended at the 'A. and P. Kyriakou' Children's Hospital Department of Oral and Maxillofacial Surgery from 2000 to 2015, were retrieved and data were analyzed. RESULTS: A total of 365 cases of dentoalveolar trauma, affecting 363 children and adolescents (221 males and 142 females), with an age range from 1 to 15 years, were treated in the authors' department. The most common injury mechanism was falls. The trauma was graded as class II in most patients (41.65%). The anterior maxilla was injured in the majority of the patients (78.35%). In 230 patients (63%) the trauma involved the primary dentition. Two hundred eighty-nine of the patients were treated with local anesthesia on an emergency basis, while in the rest 76 patients general anesthesia was considered mandatory. CONCLUSIONS: Accurate diagnosis, timely treatment, and follow-up are critical for the management of dentoalveolar trauma in pediatric patients. A modified more detailed and severity-specific classification and guidelines for its surgical management may assist practitioners in decision making and effective treatment planning.

Complications of Zygomatic Implants: Our Clinical Experience with 4 Cases.

Zygomatic implants have been used for rehabilitation of the edentulous atrophic maxilla as an alternative to bone grafting for almost two decades resulting in satisfactory clinical outcomes. However, the patients with edentulous atrophic maxilla treated using this technique may present serious complications that could put the prosthetic restoration at risk. Four cases are reported in this paper, one case with a cutaneous fistula in the left zygomatic-orbital area caused by aseptic necrosis at the apical part of the implant, which was treated with the surgical removal of this part, a second case with loss of the right zygomatic implant due to failure of osseointegration and two cases of periimplantitis that resulted in partial and complete removal of the implant, respectively. All patients who had complications were treated without compromising the restoration which remained functional after appropriately modified treatment.

Tufted angioma of the maxilla: a rare case with unique clinical presentation.

Tufted angioma is an uncommon benign vascular tumor usually presenting in early childhood and affecting mainly the skin. It has been associated with Kasabach-Merritt syndrome, a severe coagulopathy of poor prognosis. There have been very few published cases of oral tufted angiomas, and maxillary bone involvement has not been hitherto reported. We present a case of a 10-year-old Caucasian boy with an erythematous left maxillary gingival mass accompanied by subjacent hard tissue swelling. Radiologic evaluation revealed an irregular mixed radiolucent and radiopaque area in the left maxilla, accompanied by alveolar ridge erosion, cortical plate expansion, and displacement and divergence of the premolars. The histopathologic examination showed scattered irregular tufted lobules of variably sized vascular spaces inside the subepithelial connective tissue and among the underlying bone trabeculae, exhibiting a "cannonball" appearance. Immunohistochemical evaluation found positivity for CD31, CD34, and smooth muscle actin, and a final diagnosis of tufted angioma with osseous involvement was rendered. A thorough review of the pertinent literature revealed only 9 previously published intraoral tufted angioma cases, the salient demographic and clinicopathologic features of which are summarized.

Nonsurgical management of condylar fractures in children: A 15-year clinical retrospective study.

PURPOSE: To present the 15 years of experience after closed treatment of condylar fractures in children, by evaluating the short- and long-term results and propose treatment modalities. MATERIAL AND METHODS: Data were retrieved for all young patients with condylar fractures who were treated from 2000 to 2014. Gender, age of patient, date of injury, type of fracture, treatment provided, and follow-up were registered. RESULTS: A total of 84 patients (mean age: 8.9 years) with 106 condylar fracture sites were included in the study. In 80 cases (95.2%), treatment was nonsurgical, with or without intermaxillary fixation, followed by kinesiotherapy. An intraocclusal block was additionally placed in 19 cases. Open reduction was selected in 4 cases. All condylar fractures healed without functional or esthetic complications, with the exception of 2 patients (2/80, 2.5%). Therefore, in late follow-up, no subjective symptoms were recorded, and a functional well-contoured condylar process was observed in all X-rays. Slight asymptomatic mandibular deviation was recorded in wide mouth opening in 29.1% of the patients. CONCLUSIONS: Conservative treatment of condylar fractures is the treatment of choice in children. However, the child's age, adequacy of function of the mandible, degree of displacement or dislocation of the condylar fragment, and need for active kinesiotherapy should be considered in all cases.

Management of Intraosseous Vascular Malformations of the Jaws in Children and Adolescents: Report of 6 Cases and Literature Review.

BACKGROUND: Intraosseous vascular malformations represent a rare clinical entity of the facial skeleton. The purpose of the current study was to present our experience in a Greek paediatric population and propose guidelines for the treatment of these jaws anomalies in children and adolescents. METHODS: A retrospective study (from 2009 to 2014) was performed to investigate the features and management of the intraosseous vascular anomalies in a Greek paediatric population. RESULTS: Six patients aged between 6 and 14 years were treated for intraosseous vascular malformations (4 venous and 2 arteriovenous) of the jaws. Five lesions were located in the mandible and one in the maxilla. In four lesions with pronounced vascularity superselective angiography, followed by embolization was performed. Individualized surgical treatment, depending on the size and vascularity of the lesions was applied in 4 patients. CONCLUSIONS: The intraosseous vascular malformations of the jaws may escape diagnosis in paediatric patients. A multidisciplinary approach is important for their safe and efficient treatment. Embolization is recommended for extended high-flow lesions, either preoperatively or as a first-line treatment, when surgery is not feasible without significant morbidity.

Internal fixation of mandibular angle fractures using one miniplate in Greek children: a 5-year retrospective study.

UNLABELLED: Treatment modalities of mandibular angle fractures (MAFs) have been analyzed in several studies mainly referring to adult populations. AIM: The aim of this study was to retrospectively present and discuss our experience and literature findings regarding the treatment of MAFs in children. PATIENTS AND METHODS: Data were retrieved from the files of the Oral and Maxillofacial department, at the Children's Hospital ''P. & A. Kyriakou'' of Athens, during a 5 years period (2009-2013). Demographic features, treatment methods, outcome and follow-up of all patients with mandibular angle fractures were recorded. RESULTS: 6 boys, 5-14 years old (mean age 10 years), were included in the study. They were all treated intraorally with open reduction and fixation via one monocortical titanium plate osteosynthesis at the external oblique line of the mandible, followed by 1 week of intermaxillary fixation (IMF). Plates were removed 3-12 months post-operatively. Follow-up period ranged from 12 to 18 months (mean 14.7 months). All fractures healed uneventfully and the patients tolerated well both the operation and the post-operative period. CONCLUSION: Osteosynthesis via intraoral approach combined with short duration IMF is adequate in treating MAFs in children.

Surgical treatment of oral and facial soft tissue cystic lesions in children. A retrospective analysis of 60 consecutive cases with literature review.

OBJECTIVES: To present the experience in the treatment of soft tissue cysts of the orofacial region in children treated at the Department of Oral and Maxillofacial Surgery at Children's Hospital "A. and P. Kyriakou", Dental School, University of Athens. STUDY DESIGN: This is a retrospective study including 60 young individuals, 4 months to 14 years old. Surgical treatment was provided under general anaesthesia, during a 13-year period from 2000 to 2012. RESULTS: The majority of cysts were mucoceles (n = 36, 60.0%), followed by ranulas (n = 15 or 25.0%), dermoid cysts (n = 4 or 6.6%), branchial cysts (n = 2 or 3.3%), thyroglossal duct cysts (n = 2, 3.3%) and one case of cystic hygroma (n = 1 or 1.6%). The primary method of treatment was enucleation and secondary marsupialization. CONCLUSION: It is very important to appreciate that although soft tissue cysts are benign lesions, some of them may grow to a large size and become a major threat, especially in developing orofacial regions in children. In addition, as some types of soft tissue cysts such as cystic hygroma show a tendency to recur, early examination and follow-up is required for the young population.

Development of surgical techniques of secondary osteoplasty in cleft patients following 12 years experience.

PURPOSE: To evaluate the results of secondary osteoplasty in cleft patients, over a 12 years period, and to propose certain modifications and improvements of the cleft repair technique. MATERIALS AND METHODS: Data were retrieved for all young patients treated from 2000 to 2011. Patients were divided in 3 groups, of 4 years duration each; parameters registered among others included peri-operative orthodontics, type of graft used, techniques applied and revisions required until final repair. RESULTS: 65 patients (mean age 11.6 years) were included in the study. 80 cleft sites were treated. All clefts were finally repaired and bone continuity was achieved. Peri-operative orthodontics was applied in 84.6% of the cases. Bone grafts were harvested 60 times (84.5%) from the left anterior iliac crest and 11 times (15.5%) from the genial region of the mandible. During the 12 years period ameliorations and changes were made at the recipient site, regarding the technique applied and the type of the graft. Revision operations for additional bone grafting were required in 6 cases in all (6/80 or 7.5% of the cleft sites). A gradual reduction of the number of revision osteoplasties was recorded in the 3 time periods, attributed to the improvements afore mentioned. CONCLUSIONS: Cleft bone repair, even in difficult bilateral cases, may be achieved with standardised preparation of the recipient site, adequate graft from the iliac crest, used in the form of both particulate bone and cortical plate on top, as well as full coverage of the graft.

Surgical management of head and neck vascular anomalies in children: a retrospective analysis of 42 patients.

OBJECTIVE: This article aimed to present a series of surgically treated head and neck vascular anomalies during a 12-year period, highlighting the epidemiology, diagnostic approach, indications for surgery, and final clinical outcome. STUDY DESIGN: The medical records of all patients with head and neck vascular anomalies, surgically treated at our department from 1998 to 2010, were reviewed retrospectively. RESULTS: A total of 42 patients with 46 vascular anomalies were identified. Patients' diagnoses included vascular tumors, hemangiomas mainly (18 cases), and various vascular malformations (26 cases). All patients were submitted to surgical treatment (excision-resection) to resolve main clinical symptoms (ulceration, bleeding, impaired mastication and feeding, airway obstruction) and/or esthetic issues. Recurrence was noted in 3 patients. CONCLUSION: Accurate differential diagnosis based on history, physical examination, and imaging, is the key to optimal treatment. Surgical intervention is warranted for small to moderately extended lesions to avoid complications and/or esthetic concerns and psychosocial distress.

An algorithm for the management of Staphylococcus aureus carriage within patients with recurrent staphylococcal skin infections.

Recurrent skin infections of staphylococcal origin raise the question of probable skin colonization by Staphylococcus aureus and the need for eradication. Available evidence does not exist for such settings. A management algorithm was developed by a group of experts that was implemented prospectively in 125 patients admitted for recurrent staphylococcal skin infections. Patients were tested for skin carriage of S. aureus in seven body surfaces. In the event of carriage, therapy was administered consisting of hair and body washing with antiseptics for 60 days and parallel oral treatment according to the antibiogram for 30 days. Patients were followed up for 3 years. Seventy-nine patients were colonized by S. aureus, 49 by methicillin-susceptible (MSSA) and 30 by methicillin-resistant (MRSA) isolates. The eradication rate following the algorithm was 83.7% for patients colonized by MSSA and 90.0% for patients colonized by MRSA. The greater eradication rates were achieved after treatment with one antistaphylococcal penicillin or clindamycin in the case of MSSA carriage and with clindamycin or a fluoroquinolone in the case of MRSA carriage. Of the 79 treated cases, 18 relapsed. Time to relapse did not differ between MSSA carriers and MRSA carriers. It is concluded that the suggested algorithm may be clinically efficacious and achieve high decolonization and low relapse within patients with recurrent staphylococcal skin infections colonized by either MSSA or MRSA.

Benign fibro-osseous lesions of the jaws in children. A 12-year retrospective study.

INTRODUCTION: Fibro-osseous lesions, a diverse group of bone disorders including developmental, reactive or dysplastic diseases and neoplasms, share overlapping clinical, radiographic and histopathologic features and demonstrate a wide range of biological behaviour. AIM: To evaluate the characteristics, treatment and outcome of benign fibro-osseous lesions of the jaws in children. PATIENTS AND METHOD: All patients with fibro-osseous lesions of the jaws treated at the department of Oral and Maxillofacial Surgery of the «A & P Kyriakou¼ Children's Hospital of Athens from 2000 to 2011 were included in this study. Data were retrieved from patients' files and their present situation was registered. RESULTS: Sixteen males and 10 females (mean age 8.5 years) were treated. Fibrous dysplasia was most often encountered (26.9%), and the mandible was the most frequent location (76.9%). All cases were surgically treated and histopathologically confirmed. Marginal ostectomy was performed in 7 cases, partial ostectomy in 4, enucleation and curettage in 10 and trimming-remodelling in 5 cases. Mean follow-up was of 5.5 years with no recurrence, except in one case of fibrous dysplasia. CONCLUSIONS: Fibro-osseous lesions, although sharing similar microscopic features, exhibit a variety of clinical behaviour rendering their treatment highly individualized.

Lymphatic malformations in children and adolescents.

PURPOSE: This article aimed to present a series of surgically treated lymphatic malformations of the cervicofacial region in a population of children and adolescents during a 13-year period. METHODS: The medical records of all children and adolescents with cervicofacial lymphatic malformations, treated surgically at our department from 1998 to 2011, were reviewed retrospectively. RESULTS: Eighteen patients with 20 lymphatic malformations located within the soft tissues of the cervicofacial region were identified. All patients were submitted to surgical treatment (excision or resection with conventional scalpel or radiosurgery) to address complications (ulceration, bleeding, impaired mastication and feeding, airway obstruction) and/or aesthetic issues. Recurrence was noted in 2 of our patients. CONCLUSIONS: Accurate diagnosis based on history, clinical examination, and adequate imaging techniques is the key to the optimal treatment of cervicofacial lymphatic malformations; surgical intervention remains the treatment of choice for these lesions.

Hybrid odontogenic ghost cell tumor and cutaneous pilomatrixoma: a highly unusual coexistence.

This article describes the first published case of coexistence in a child of a rare hybrid odontogenic ghost cell tumor and a solitary cutaneous pilomatrixoma. An 11-year-old boy presented with a large well-defined unilocular radiolucent lesion in the right posterior mandible. Marsupialization followed by enucleation of the remaining lesion at a later period was the treatment of choice. Histopathologic analysis revealed a hybrid tumor demonstrating areas identical to calcifying cystic odontogenic tumor, ameloblastoma, ameloblastic fibro-odontoma, ameloblastic fibromyxoma, and adenoid odontogenic tumor. A cutaneous nodule was also removed from the facial area and demonstrated classic features of pilomatrixoma on histopathology. Sixteen cases of hybrid calcifying cystic odontogenic tumor associated with odontogenic tumors other than ameloblastomas and odontomas are referred in the literature to date. Young males are frequently affected, and the mandible is the most common site of involvement. The occurrence in the same patient of 2 distinctive entities, which both demonstrate ghost/shadow cells, may be a coincidental finding or suggest a common origin regarding the histogenesis of these cells. Alternatively, future molecular studies may clarify possible genetic or/and predisposing factors for the development of these lesions.

Treatment of central giant-cell granulomas of the jaws in children: conservative or radical surgical approach?

INTRODUCTION: Although central giant-cell granulomas of the jaws (CGCG) tend to appear more often in children and young adults, most studies include patients of all ages. AIM: Aim of this study was to present and discuss the characteristics, the selected treatment pattern and the outcome of central giant-cell granulomas of the jaws exclusively in children up to 13 years old, during a 10 years period. MATERIAL AND METHOD: Twelve young patients, 5-13 years old were included in the study. CGCGs were surgically removed in toto by enucleation followed by curettage of the bone. Repair of the remaining bone defect was performed at the same operation in five cases. RESULTS: All patients healed uneventfully and had prosthetic and/or orthodontic rehabilitation applied post-operatively. Regular long-lasting follow-ups were scheduled. Recurrence occurred in two cases (16.7%), it was small in size and was surgically treated again. CONCLUSIONS: Conservative surgery, without extensive bone removal, for CGCGs of the jaws in children was successful in our cases. Additional repair of the osseous defect when needed and teeth rehabilitation as soon as possible are essential in children population. Follow-up needs to be long-lasting, to secure bone healing and unaffected jaw growth. Findings in children population of the present study were similar to those of adults or adolescent populations, although a rather low recurrence rate has been noticed.

Surgical management of primary chronic osteomyelitis of the jaws in children: a prospective analysis of five cases and review of the literature.

INTRODUCTION: Primary chronic osteomyelitis (PCO) of the jaws is an uncommon non-suppurative inflammatory disease of unknown origin. Although the disease is not age-specific, only sparse cases with onset during childhood or adolescence have been reported in the literature. PURPOSE: This study seeks to present five cases of maxillofacial PCO in children and to evaluate the effectiveness of the applied therapeutic protocol. A review of the literature concerning diagnosis and treatment of PCO with special emphasis on surgical therapy is also performed. PATIENTS AND METHODS: Demographic data, clinical, radiographic and histopathologic findings, blood tests results, and the treatment protocol applied to five young patients suffering from PCO and referred to the Department of Oral and Maxillofacial Surgery at "A. & P. Kyriakou Children's Hospital" over the past 5 years are presented. Decortication and contouring of the affected bone were performed; antibiotics were administered for a short period of time and the patients remained under follow-up evaluation. RESULTS: The posterior mandible was affected in four cases and the maxilla-zygomatic bone in one case. All patients showed remission of signs and symptoms after surgical treatment. The postsurgical clinical course was uneventful in all cases. However, recurrences have been noted, as reported in the literature. CONCLUSION: PCO of the jaws is a complex clinical entity, presenting both a diagnostic and therapeutic challenge, especially in young patients. Surgical treatment in conjunction with antibiotics and non-steroid anti-inflammatory drugs proved to be beneficial and to improve considerably the patients' quality of life. Nevertheless, exacerbation of the disease may appear and regular follow-up of the patients is required.

A retrospective analysis of the characteristics, treatment and follow-up of 26 odontomas in Greek children.

Odontomas represent the most common type of odontogenic jaw tumors among patients younger than 20 years of age. Clinically, they are often associated with eruption failure of adjacent permanent teeth, and are classified as compound and complex. The aim of the present retrospective study was to present the characteristics, treatment approach and outcome of odontomas in Greek children, over a ten-year period. Twenty six patients, 2 to 14 years of age (mean 9.3 years), with odontomas treated during the years 1999-2008 at the Department of Oral & Maxillofacial Surgery of a Children's Hospital, were included in the study. Data from patients' files were retrieved and they were recalled for review. Odontomas were equally distributed in the maxilla and mandible and 42.3% of them were located in the anterior maxilla. Of the odontomas, 80.7% were related to disturbances in tooth eruption. Bone expansion was observed in 65.3% of the cases. All odontomas were surgically removed, and related impacted permanent teeth were either left to erupt spontaneously, orthodontically guided into occlusion or were removed. Orthodontic intervention appeared to be necessary in older children, while in younger children spontaneous eruption was frequent. In the present study, odontomas were associated with unerupted or impacted teeth. Radiographic examination was essential to verify the presence of the tumor and early removal prevented tooth eruption failure and disturbances in a majority of the cases.