Use of surgical bone cement to increase the projection of the nasomaxillary buttress in a case of orthognathic surgery. Technical note.

The soft tissue outcome of the projection at the level of the nasomaxillary buttress is difficult to manage in cases of severe hypoprojection, being orthognathic surgery resolutive at the occlusal level but sometimes insufficient at the level of esthetic outcome. The literature describes the use of alloplastic prostheses and autologous bone grafts, but there are few documented cases of the use of premolded surgical cement for this purpose. The main advantage of the use of bone cement over the alternatives described is its ability to be premolded for customization, low cost, easy availability, speed of preparation and minimal comorbidity. This technical note describes the surgical steps and outcome of the use of surgical bone cement for projection augmentation at this level, including notes on preparation, premolding and fixation. Key words:Orthognathic surgery, maxillary surgery, surgical bone cement, nasomaxillary buttress.

A Quantitative and Qualitative Clinical Validation of Soft Tissue Simulation for Orthognathic Surgery Planning.

The purpose of this study was to perform a quantitative and qualitative validation of a soft tissue simulation pipeline for orthognathic surgery planning, necessary for clinical use. Simulation results were retrospectively obtained in 10 patients who underwent orthognathic surgery. Quantitatively, error was measured at 9 anatomical landmarks for each patient and different types of comparative analysis were performed considering two mesh resolutions, clinically accepted error, simulation time and error measured by means of percentage of the whole surface. Qualitatively, evaluation and binary questions were asked to two surgeons, both before and after seeing the actual surgical outcome, and their answers were compared. Finally, the quantitative and qualitative results were compared to check if these two types of validation are correlated. The quantitative results were accurate, with greater errors corresponding to gonions and lower lip. Qualitatively, surgeons answered similarly mostly and their evaluations improved when seeing the actual outcome of the surgery. The quantitative validation was not correlated to the qualitative validation. In this study, quantitative and qualitative validations were performed and compared, and the need to carry out both types of analysis in validation studies of soft tissue simulation software for orthognathic surgery planning was proved.

Comparison of the outcomes of unilateral orbital fracture repair with and without surgical navigation system: our experience in La Paz University Hospital / Comparación de los resultados en cirugía de fractura de órbita unilateral con y sin sistema de navegación quirúrgica: experiencia en el Hospital Universitario La Paz

INTRODUCTION: Restoration of normal orbital volume and globe position following traumatic injury is often difficult. Intraoperative navigation has emerged as a tool to allow the visualization of the implant position intraoperatively, by means of the planification in the preoperative computed-tomographic scan (CT scan). OBJECTIVES: The aim of this study was to compare the postoperative changes in orbital volume between two groups of study: one group that underwent surgical intervention before the implementation of intraoperative navigation (control group), and other group of patients which had undergone surgery with the aid of a navigation system (Software iPlan CMF version 3.0.5, Brainlab®, Feldkirchen, Germany) (navigation group). Another endpoint of our study was to determine it the presurgical planification and intraoperative navigation aided to position the implant. For that purpose, we determined the implant position with respect to the orbital floor and medial orbital wall and compared it between both groups of study. As secondary endpoints, we compared the rate of postoperative outcomes and reintervention rate between both groups. MATERIALS AND METHODS: A retrospective cohort study was designed. We selected a total of 35 consecutive orbital operations for unilateral orbital fractures performed between 2015 and 2018 at the Department of Oral and Maxillofacial Surgery in La Paz Hospital (Madrid), Spain. We collected information regarding: demographic data, cause of the fracture, time elapsed between diagnosis and surgical treatment, symptoms at diagnosis (diplopia, globe projection, ocular motility impairment), radiological findings (affected wall, muscular entrapment, herniation of the periorbital structures), and outcomes after surgical treatment (diplopia, globe position, ocular motility impairment, reintervention). By means of the iPlan CMF software, the orbital volume was determined in the preoperativeand postoperative CT scan. The plate position was determined by measuring the distance between the plate and the orbital rim,the distance between the plate and the residual posterior intact bony ledge and the distance between the plate and the medial orbital wall. Measurements were performed automatically in the three planes of space, although we used the sagital plane to measure the distance between the plate and the orbital rim and between the plate and the residual posterior intact bony ledge. To measure the distance between the plate and the medial orbital wall we used the axial plane. RESULTS: After surgery, we observed that abnormal globe position was significatively less frequent in the navigation group than in the control group (p = 0.029). The reoperation rate was 11 % in the navigation group and 35% in the control group (p = 0.071). Mean orbital volume of the unaffected orbit was 29.32 ± 2.64 cm3 in the navigation group and 28.64 ± 2.68 cm3 in the control group. Mean orbital volume of the affected orbit was 34.19 ± 3.67 cm3 in the navigation group and 32.78 ± 3.09 cm3 in the control group. Mean reconstructed orbital volume was 29.47 ± 2.75 cm3 in the navigation group and 28.88 ± 3.72 cm3 in the control group. Mean volume reduction and the mean difference in volume between unaffected and reconstructed side did not show significative differences between both groups. The mean distance from plate to orbital floor at the residual posterior intact bony ledge showed significative differences (p = 0.001), being inferior in the navigation group. CONCLUSIONS: The use of intraoperative navigation in orbital fractures is effective in improving plate positioning in the residual posterior intact bony ledge of the floor of the orbit, reducing complications such as enophthalmos compared to conventional surgery. Furthermore, the use of intraoperative navigation seems to decrease the rate of reintervention compared to conventional surgery. The restoration of orbital volume seems to be well addressed by both methods

INTRODUCCIÓN: La restauración del volumen orbitario normal y la posición del globo ocular después de una fractura orbitaria puede ser difícil. La navegación intraoperatoria ha surgido como una herramienta que permite visualizar la posición del implante intraoperatoriamente mediante la planificación en la tomografía computarizada (TC) preoperatoria. OBJETIVOS: El objetivo de este estudio fue comparar los cambios posoperatorios en el volumen orbitario entre dos grupos de estudio: un grupo que se sometió a intervención quirúrgica antes de la implementación de la navegación intraoperatoria (grupo de control), y otro grupo de pacientes que habían sido intervenidos con la ayuda de un sistema de navegación (Software iPlan CMF versión 3.0.5, Brainlab®, Feldkirchen, Alemania) (grupo de navegación). Otro criterio de valoración de nuestro estudio fue determinar si la planificación prequirúrgica y la navegación intraoperatoria facilitó a la hora de colocar la malla orbitaria. Para ello, determinamos la posición de la malla con respecto al suelo orbitario y la pared orbitaria medial y la comparamos entre ambos grupos de estudio. Como criterios de valoración secundarios, comparamos los síntomas oculares posoperatorios y la tasa de reintervención entre ambos grupos. MATERIALES Y MÉTODOS: Se diseñó un estudio de cohortes retrospectivo. Seleccionamos un total de 35 pacientes intervenidos por fracturas orbitarias unilaterales entre 2015 y 2018 en el Servicio de Cirugía Oral y Maxilofacial del Hospital Universitario La Paz (Madrid), España. Se recogió información sobre: datos demográficos, causa de la fractura, tiempo transcurrido entre el diagnóstico y la cirugía, síntomas al diagnóstico (diplopía, proyección del globo ocular, alteración de la motilidad ocular), hallazgos radiológicos (pared afectada, atrapamiento muscular, herniación grasa), y síntomas posquirúrgicos (diplopía, posición del globo ocular, alteración de la motilidad ocular), así como necesidad de reintervención. Mediante el software iPlan CMF se determinó el volumen orbitario en el TC preoperatorio y posoperatorio. La posición de la malla se determinó midiendo la distancia entre la malla y el borde orbitario, la distancia entre la malla y el reborde óseo intacto posterior residual y la distancia entre la malla y la pared orbitaria medial. Las mediciones se realizaron de forma automática en los tres planos del espacio, aunque utilizamos el plano sagital para medir la distancia entre la malla y el borde orbitario y entre la malla y el reborde óseo posterior. Para medir la distancia entre la malla y la pared orbitaria medial utilizamos el plano axial. RESULTADOS: Después de la cirugía, observamos que la posición anormal del globo ocular fue significativamente menos frecuente en el grupo de navegación que en el grupo control (p = 0,029). La tasa de reintervención fue del 11 % en el grupo de navegación y del 35 % en el grupo de control. El volumen orbitario medio de la órbita sana fue 29,32 ± 2,64 cm3 en el grupo de navegación y 28,64 ± 2,68 cm3 en el grupo control. El volumen orbitario medio de la órbita afectada fue 34,19 ± 3,67 cm3 en el grupo de navegación y 32,78 ± 3,09 cm3 en el grupo control. El volumen orbitario reconstruido medio fue de 29,47 ± 2,75 cm3 en el grupo de navegación y 28,88 ± 3,72 cm3 en el grupo control. La reducción media del volumen y la diferencia media de volumen entre el lado sano y el reconstruido no mostraron diferencias significativas entre ambos grupos. La distancia media de la placa al suelo orbitario en el reborde óseo posterior residual mostró diferencias significativas (p = 0,001), siendo inferior en el grupo de navegación. CONCLUSIONES: El uso de la navegación intraoperatoria en fracturas orbitarias es eficaz para mejorar el posicionamiento de la placa en el reborde óseo residual posterior del suelo orbitario, reduciendo complicaciones como el enoftalmos, en comparación con la cirugía convencional. Además, el uso de la navegación intraoperatoria parece disminuir la tasa de reintervención en comparación con la cirugía convencional. La restauración del volumen orbitario parece ser adecuada a través de ambos métodos

Traqueotomías en pacientes críticos durante la pandemia por COVID-19. Estudio preliminar de nuestra experiencia en el Hospital Universitario La Paz de Madrid / Tracheotomies in critical patients during the COVID-19 pandemia. Preliminary study of our experiences at La Paz University Hospital of Madrid

El brote epidémico causado por el virus SARS-CoV-2 se encuentra plenamente activo en España. Alrededor del 10-15 % de los pacientes ingresados precisan cuidados en unidades de críticos, siendo intubados de forma prolongada y precisando la realización de traqueotomías. Se realiza un estudio observacional de las traqueotomías realizadas por nuestro Servicio de Cirugía Oral y Maxilofacial a pacientes COVID-19 de unidades de cuidados intensivos realizadas entre el 17 de marzo y el 17 de abril de 2020. El estudio analiza aspectos epidemiológicos y clínicos de los pacientes, el tipo de técnica quirúrgica empleada, el tiempo quirúrgico, el tipo de cánula empleada, las complicaciones postquirúrgicas y el seguimiento clínico de los pacientes. Un total de 22 pacientes fueron sometidos a traquetomía reglada abierta. Fueron dieciocho hombres y cuatro mujeres de edades entre 40 y 77 años (64,9 años de media). En todos los casos la realización de traqueotomía fue como consecuencia del proceso pulmonar por la neumonia bilateral COVID-19. Dos pacientes presentaron un neumotórax en el postoperatorio inmediato como complicación, un paciente falleció durante la realización del procedimiento y otro tras su llegada a la Unidad de Cuidados Intensivos tras la realización de la traqueotomía. A pesar de que la traqueotomía es una técnica quirúrgica reglada, las características especiales de los pacientes COVID-19 hacen de este procedimiento una situación crítica por la inestabilidad pulmonar y la rápida desaturación del paciente. Todo ello obliga a la realización del procedimiento por facultativos con experiencia para disminuir el tiempo quirúrgico y poder enfrentarse a cualquier eventualidad

The outbreak caused by the SARS-CoV-2 virus is currently very active in Spain. Many infected people still require to be hospitalized. Around 10-15 % of hospitalized patients require intensive care, where they are intubated for a prolonged period, needing tracheotomies some weeks after the intubation. We will be conducting an observational study of the tracheotomies performed by our oral and maxillofacial Department to COVID-19 patients on intensive care units between March 17th and April 17th, 2020. This study will be analyzing the patients' epidemiological and clinical aspects, surgical technique employed, surgical time, type of cannula used, postoperative complications and the patients' clinical monitoring. A total of 22 patients underwent open elective tracheotomy. There were twenty-two males and three females aged between 40 and 77 (mean: 64,9 years-old). In all cases tracheotomy was carried out due to pulmonary process caused by COVID-19 bilateral pneumonia. Two patients presented pneumothorax in the immediate postoperatory care as a complication, one perished during the procedure and another did so after arriving to the Intensive Care Unit after the tracheotomy surgery. Even though tracheotomy is a ruled surgical technique, the special characteristics of COVID-19 patients make of this procedure a critical situation, mainly due to lung instability and quick desaturation of the patients. This requires the surgery to be carried out by experienced physicians in order to reduce operative time and to be able to react to any eventualities that may arise

Predictable dental rehabilitation in maxillomandibular reconstruction with free flaps. The role of implant guided surgery

The reconstruction of maxillomandibular defects secondary to oral cancer surgery, represent a great challenge for Maxillofacial surgeons. During the last decades the reconstructive surgery has experimented a big advance due to the development of the microsurgical techniques. At present, we are able to reconstruct complex defects using free flaps that provide both soft and bone tissue. Fibula, iliac crest and scapula free flaps have been the three classic options for the maxillomandibular reconstruction owing to the amount of bone that this flaps provide, allowing the posterior dental rehabilitation with implants. Today, our objective it is not only the aesthetic reconstruction, but also the functional reconstruction of the patients enhancing their life quality. Guided implant surgery in free flap reconstructed patients has become an essential tool, helping to define the exact position of the dental implant in the flap. In this way it is possible to look for the areas with better bone conditions, avoiding the osteosynthesis material used to fixate the flap with the native bone and deciding the best biomechanical option, in terms of number and situation of the implants, for the future dental prostheses. In summary, using the guided implant surgery, it is possible to design an exact and predictable dental implant rehabilitation in patients with oral cancer who are reconstructed with free microvascular flap, resulting in an optimal aesthetic and functional result

Predictable dental rehabilitation in maxillomandibular reconstruction with free flaps. The role of implant guided surgery.

The reconstruction of maxillomandibular defects secondary to oral cancer surgery, represent a great challenge for Maxillofacial surgeons. During the last decades the reconstructive surgery has experimented a big advance due to the development of the microsurgical techniques. At present, we are able to reconstruct complex defects using free flaps that provide both soft and bone tissue. Fibula, iliac crest and scapula free flaps have been the three classic options for the maxillomandibular reconstruction owing to the amount of bone that this flaps provide, allowing the posterior dental rehabilitation with implants. Today, our objective it is not only the aesthetic reconstruction, but also the functional reconstruction of the patients enhancing their life quality. Guided implant surgery in free flap reconstructed patients has become an essential tool, helping to define the exact position of the dental implant in the flap. In this way it is possible to look for the areas with better bone conditions, avoiding the osteosynthesis material used to fixate the flap with the native bone and deciding the best biomechanical option, in terms of number and situation of the implants, for the future dental prostheses. In summary, using the guided implant surgery, it is possible to design an exact and predictable dental implant rehabilitation in patients with oral cancer who are reconstructed with free microvascular flap, resulting in an optimal aesthetic and functional result.

Síndrome de Sjögren: criterios diagnósticos mediante resonancia magnética / Sjögren's syndrome: Magnetic resonance diagnosis criteria

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