Evaluation of homologous bone graft versus biomaterials in the aesthetic restoration of the middle third of the face.

BACKGROUND: Bone deficits of the midface can be observed following tumor surgery, facial traumas or malformations, and can determine aesthetic deformities requiring surgical corrections. The goal of this study is to illustrate the 23 years experience of the Maxillo-Facial Department of the "La Sapienza" University of Rome, in surgical correction of middle third bone loss for aesthetic improvement, and to compare postsurgical results from the use of biomaterials and homologous bone grafts. METHODS: From January 1977 to January 2000, 18 patients were surgically treated with bone grafts for bone deficit of the midface requiring aesthetic improvements, and 23 received biomaterial placement in the same district. A retrospective analysis regarding aesthetic improvements following corrective (reconstructive) surgery was carried out in order to compare long-term results obtained with bone grafts and biomaterials. RESULTS: Of the 19 implants of the zygomatic bone, 1 patient suffered from infection, observ-ed on the 8th day, following iliac bone graft in the maxillary area. Of the 32 prostheses, 7 became infected and in 1 case the material became exposed: Proplast(R) became infected 2 times, Gore-tex(R) 3 times and 1 time became exposed; 2 of the 24 Medpor(R) implants resulted in infection. The employment of bone graft obtained a good short term aesthetic result. Medpor(R) employment, was evaluated as an optimal aesthetic improvement. We cannot evaluate the results obtained with Gore-tex(R) and Proplast(R) because of the few cases treated. Anyway we consider unsatisfactory the corrections obtained with these 2 materials. CONCLUSIONS: Homologous bone grafts are still considered as the best choice when a further fixture positioning is planned for prosthetic rehabilitation of the alveolar ridge of the upper jaw or mandible. At the present time, some biomaterials are the definitive solution for restoring facial harmony in the 3 spatial dimensions.

Unusual vascular hamartoma of the hard palate. A case report.

Hamartomas are tumour-like malformations usually present since birth or which may develop during puberty. Hamartomas are related to anatomical development errors. Hamartomas are rarely found in the head and neck district. The case of an unusual vascular hamartoma localised in the hard palate of a 50-year-old female with no significant medical or family history is reported. Surgical treatment was performed by means of an excisional biopsy.

[Rhino-sinusal endoscopy as a diagnostic and therapeutic treatment in patients undergoing a bone marrow transplantation]. / Endoscopia rino-sinusale quale metodica diagnostica e terapeutica nei pazienti sottoposti a trapianto di midollo osseo.

Immunodepressed subjects appear to present as a common adverse event the infections complication of paranasal sinuses which can lead to an unfavourable clinical evolution spreading the infection to encephalic and endo-orbital tissues. The patients described by the authors present a common clinical history of neoplastic disorders concerning the haemopoietic tissue with an indication for bone marrow transplantation. These patients also demonstrated clinical-radiological evidence of rhino-sinusal impairment with specific maxillary sinus involvement. The clinical condition obliged us to reach a final diagnosis of the origin of rhino-sinusal involvement which clearly appeared by performing imaging diagnostic examinations in order to rapidly establish the correct therapy. The resolution of the rhino-sinus complication allows these patients to follow on the treatment for their own initial pathology. In fact, in order to resume the treatment against haemoblastic disorders, an essential step is to approach the paranasal sinus affection. Endoscopy, in the cases reported, permitted us to obtain a correct diagnosis and to develop a correct antimicrobic therapy, achieving the drainage of the maxillary sinus as well. Endoscopy achieved the same results as radical surgery of the maxillary sinus by the Caldwell-Luc approach, proving less aggressive and reducing operative timing, postoperative recovery timing and intra and post operative haemorrhagic complications. Moreover, endoscopy characteristics present a specific validity in patients with severe general conditions, which are described in the examined group, reducing time for diagnosis and therapy resulting specific to solve the rhino-sinus complication and also particularly important in order to interfere less with the delicate medical therapy for the primary pathology by the sample examined.

Posterior transpalatal distraction with pterygoid disjunction: a short-term model study.

The transpalatal distractor (TPD) allows for maxillary expansion according to the concepts of distraction osteogenesis. Unlike tooth-borne, surgically assisted rapid palatal expansion devices, the bone-borne TPD is designed to avoid periodontal ligament compression, buccal root resorption, fenestration, tooth tipping, and orthodontic relapse during and after the expansion. When the distractor is placed on the palate at the level of the second premolar and pterygomaxillary disjunction is not performed, more expansion occurs in the anterior part of the maxilla than it does in the posterior. The aim of this investigation was to test the hypothesis that pterygomaxillary disjunction and placement of the TPD on the palate at the level of the first molars result in more parallel expansion of the maxillary segments. Twenty consecutive patients were included in a prospective way, and their predistraction and postdistraction models were electronically analyzed. The change in resistance and force application resulted, on average, in parallel segment expansion. The results showed that pterygomaxillary disjunction and posterior placement of the TPD are indicated for patients having transverse maxillary deficiency with lateroposterior crossbite.

An unusual case of sub-condylar bilateral fracture and bilateral post-traumatic temporomandibular ankylosis.

A case of bilateral sub-condylar fracture with wide stump dislocation associated with a central facial trauma, fracture-intrusion of the rhino-orbital-maxillary complex and a parasymphyseal mandibular fracture, is reported. After surgery and inter-maxillary fixation an unusual temporo-mandibular ankylosis developed. Maximum mouth opening, lateral and protrusive movements were severely limited. Surgical treatment of ankylosis was requested and performed. The originality of this case lies in the atypical lateral dislocation of condylar neck fractured stumps to the zygomatic arches and in the later appearance of ankylosis between the glenoid fossa, zygomatic arch, condylar neck stump, and the condylar process displaced anteromedially. The ankylosed blocks were resected, displaced condyles were also removed due to the strong adhesion with the ankylotic tissue and the lack of any anatomical continuity or connection with the glenoid fossa. Functional therapy allowed the resolution of the functional limitation.

Comparative study on sensory recovery after oral cavity reconstruction by free flaps: preliminary results.

Anatomical restoration was once the only goal of reconstructive surgery, but now it represents only one step in the complete functional recovery process to allow resumption of physiological activity. Soft tissue and nerves play important roles in functional recovery, but the potential of these structures is not yet well known. Rehabilitation after oral cavity reconstruction by free flaps needs an interdisciplinary diagnostic and therapeutic approach, in which neurosensory recovery of transferred tissue is an important aspect. Previous studies have used clinical assessment to evaluate sensory recovery after oral reconstruction with free flaps, but these results have been subjective and not quantifiable. The aim of the present study is to evaluate the sensory recovery using objective and standardized electrophysiological data by recording the masseter inhibitory reflexes (MIR) following mental and lingual electrical stimulation. A group of 14 patients who underwent oral cavity reconstruction by transplantation of either forearm (9) or jejunal (5) noninnervated free flaps were investigated. We found that sensory recovery of fasciocutaneous radial forearm free flaps was better than that of jejunal free flaps. This could represent the starting point for further studies about sensory recovery of reconstructed anatomical structures based on standardized and objective electrophysiological data.

White cell apoptosis in platelet concentrates.

BACKGROUND: The aim of the present study was the evaluation of the apoptosis in residual white cells (WBCs) contained in platelet concentrates (PCs) and of the relationship of this apoptosis with the concentration of inflammatory cytokines in the medium and with platelet activation. STUDY DESIGN AND METHODS: Three independent methods were used to evaluated apoptosis in WBCs present in 9 PCs, either from single donors by apheresis (SD-PCs) or from pooled buffy coats (BC-PCs). All PCs were divided in two parts, one of which was irradiated. PCs were stored up to 4 days at room temperature, and samples were withdrawn daily for analysis of apoptosis, of platelet activation (surface and soluble CD62P), and of cytokine concentration (interleukin [IL]-1alpha, IL-1beta, IL-6, IL-8, and tumor necrosis factor alpha). RESULTS: Apoptosis was found to occur with storage in both irradiated and nonirradiated units. Platelet activation increased with storage time and was higher in BC-PCs. The amount of released cytokines was rather variable among PC units. Only IL-8 was consistently found to increase with storage time. CONCLUSIONS: Apoptosis of residual WBCs occurred in PC units as a function of storage time. The amount and the time course of apoptosis seem to correlate with IL-8 release rather than with platelet activation or with the occurrence of febrile nonhemolytic transfusion reactions.

[Surgical approach to benign primary tumors of the para-pharyngeal space]. / Approcci chirurgici per le neoplasie benigne primitive dello spazio parafaringeo.

Surgical access to tumors of the parapharyngeal space can be performed by transoral or trancervical approaches. Risk of intraoperative bleeding and difficulties in radical enucleation represent the disadvantages of transoral approach. This approach must be performed for small and inferomedial lesions, or for preoperative biopsy when necessary. Transcervical approaches can be distinguished in transparotid or transmandibular, or submandibular. Before the late '70s all parapharyngeal masses were approached by transparotid access, with facial nerve manipulation in all cases. CT and MR techniques now allow the right presumptive preoperative diagnosis in 90% of patients. To avoid the risk of injury of the facial nerve when possible, transparotid approach is now limited to the lesions with parotid origin. Transmandibular and submandibular approaches allow an adequate exposure and a direct access to the parapharyngeal space. Personal experience with 6 patients presenting primitive tumors of the parapharyngeal space is reported and surgical approaches proposed in the literature are reviewed.

[Radial forearm free cutaneous flap. Evaluation of the level of damage to the donor site]. / Lembo libero fascio-cutaneo di radiale. Valutazione degli esiti a livello del sito donatore.

BACKGROUND: After more than a decade of experiences, the radial forearm fasciocutaneous free flap has proven to be a well standardized surgical technique, widely used for its easy application and versatility. The review of the literature shows that most of the contraindications to the use of this flap concern mainly the donor site morbidity. Aim of this work is to evaluate the complications of this surgical technique, to study the functional impairment and the scars secondary to the harvesting of the flap, in order to point out which techniques can contribute to their reduction. METHODS: Seventeen patients submitted consecutively to oral cavity reconstruction using a radial forearm flap, whose donor site has been reconstructed with a full-thickness skin graft have been studied. The postoperative complications have been examined, the functional and aesthetic alteration at the donor site analyzed, with a medium follow-up of 17.5 months. RESULTS: The study of this series has pointed out not relevant early and middle term postoperative complications, no significant hand or finger motility and sensorial deficiencies associated with a percentage of full aesthetic and functional satisfaction of patients for this treatment higher than 80%. CONCLUSIONS: On the basis of personal clinical experience, even if on a small series of cases, the conclusion is drawn that the functional and aesthetic outcomes depend significantly on the surgical techniques used to harvest the flap and to cover the donor site.

[Maxillo-mandibular fixation by mono-cortical screws. Clinical indications and surgical methods]. / Il bloccaggio intermascellare con viti transfisse monocorticali. Indicazioni cliniche e note di tecnica chirurgica.

BACKGROUND: Intermaxillary fixation is one of the most reknown and widely used techniques in maxillofacial traumatology. It's carried out usually by means of direct criss-cross teeth wiring or through the wiring of a metallic archbar on the upper and lower jaws. These techniques are time-consuming operations, they can produce dental or periodontal damages, and are not well tolerated by the patient, even under local anesthesia. Recent experiences in oral implantology and in the use of miniscrews for rigid internal fixation suggest the experimentation of new, easy to use and better tolerated systems for bone-anchored intermaxillary fixation. METHODS: 1-0 stainless steel wires and titanium monocortical screws, 2 mm of diameter and 12 and 15 mm of length, have been used as alveolar-bone anchorages for the intermaxillary fixation of 10 mandibular fractures. The fixations have been performed either under general or local anesthesia, with 2, 4 or 6 points of alveolar bone anchorage, maintaining the fixation for 15 days in condylar fractures and for 40 days in all the other cases. RESULTS: A really good compliance of the patient towards all the procedures performed under local anesthesia, with a clear reduction of postoperative discomfort has been observed. Infection or rejection of the implanted screws did not occur as well as cases of alveolar or dentoparodontal damages. CONCLUSIONS: This preliminary report on a new intermaxillary fixation technique didn't point out any significant complication of the procedure, showing at the same time that this technique can be easily performed under local anesthesia on out-patients with a better compliance, lower postoperative discomfort and good skeletal stability.

[Differential diagnosis in a case of brown tumor caused by primary hyperparathyroidism]. / Diagnosi differenziale in un caso di tumore bruno da iperparatiroidismo primitivo.

Fibrous-cystic osteitis is a bone metabolic disorder related to hyperparathyroidism. This pathological condition shows a bone catabolism enhancement, due to increased level of PTH. Brown tumour is a uni- or multi-focal bone lesion, which represents the terminal stage of the hyperparathyroidism-dependent bone pathology. This focal lesion is not a real neoplasm showing itself as a cellular reparative process, mainly interesting the jaws, specially the mandible. Because of the similar radiological features (cyst-like radiolucency) showed by other lesions, the diagnosis can be difficult. Histology cannot guarantee a certain diagnosis, some lesions, such as giant cell tumour, giant cell granuloma, aneurysmal bone cyst and cherubism, show a similar macroscopical and microscopical features. Differential diagnosis is possible only by comparative evaluation of clinical, radiological and biochemical evidences. Personal experience with a patient affected by maxillary expansive lesion previously diagnosed as GCT is reported. Radiological examinations showed another cyst-like lesion involving the mandible. Clinical history and multifocality of lesions were suggestive for the presence of a systemic disease, laboratory data allowed a primary hyperparathyroidism diagnosis. Parathyroid scintigraphy was performed and detected a parathyroid adenoma. In first instance the patient underwent to surgical operation on the jaws in order to stop the rapid progression of bone lesions, and then another operation for the removal of parathyroid adenoma was performed.

[Dissection of the cranial base en bloc with the infratemporal fossa]. / Dissezione della base cranica in monoblocco con la fossa infratemporale.

A high incidence of morbidity and mortality was related with skull-base neoplasm surgery. Several advances have permitted, in recent years, the total excision of such neoplasms with minimal patient morbidity. Due to an improved understanding of the surgical anatomy of the skull-base and to the collaboration of the neurosurgeon and maxillofacial surgeon and, moreover, to the improvements of imaging (CT and MR) in the past decades new combined approaches were planned and performed to allow en bloc resections of extensive lesions. Extensive exposure of the tumor, improved management of the internal carotid artery, preservation of cranial nerves not involved by tumors and improved cranial base reconstruction techniques (by free flaps) have resulted from this progress. The aim of the present work is to show the main anatomical landmarks of infratemporal fossa and medium skull base that help the surgeon to achieve an en bloc resection.

Schwannoma of the mandible.

Schwannoma is a benign neoplasm originating from Schwann's cell. It involves neurons and axons of peripheral nerves. This tumor has a predilection for the head and neck region, and often occurs as soft tissue lesion. Intraosseous sheath tumors are rare, comprising less than 1% of all bone tumors; the mandible is the most common site. The literature reports only 30 acceptable cases of schwannoma of the mandible. We report a new case of schwannoma that is unusual in its intraosseous localization and the patient's comparatively young age.

[The role of SMAS in the prevention of Frey's syndrome]. / Ruolo dello SMAS nella prevenzione della sindrome di Frey.

Frey's syndrome is the most common postoperative complication in the parotid gland surgery. The authors report their own experience with 80 patients who underwent surgical operation of superficial or total parotidectomy. In 45 of them was performed the SMAS flap, no SMAS flap performed in the remaining 35 patients. The follow-up was performed by interviewing the patients about their symptoms. The purpose of this work is to show the role of SMAS flap, that minimize the frequency and the intensity of symptoms of the Frey's syndrome.

[Perioperative drug management in surgery using revascularized flaps]. / Presidi farmacologici perioperatori nella chirurgia mediante lembi rivascolarizzati.

The success of free flap tissue transfer firstly depends on the correct surgical technique. Taking off from the donor site tissue for the reconstruction provokes a chain of physiopathological events that could evolve in truly pathological phenomena. The pharmacological treatment is aimed to miss and control the eventual local complication, and also to support the general conditions of the patient. Numerous pharmacological protocols have been proposed on experimental studies, and also on clinical practice to control local complications. It is necessary to eliminate the reactive vasospasm present in the vessels during anastomosis, and to reduce the risk of vascular pedicle thrombosis and to maintain rheological qualities of blood so to reactivate and sustain microcirculation functionality. Many authors have proposed anticoagulant and antiplatelet therapy, associated with vasodilatator drugs and drugs acting on blood viscosity and tissue metabolism, even if the latter have been primarily studied in experimental applications. The authors report their own experience on 29 patients that underwent 31 free flap tissue transfers from January 1992 to January 1995. The pharmacological therapy activated on the test can be divided into two different periods, one intraoperative and one postoperative. ASA is administered one hour before anastomosis, and vessels are irrigated with heparin or lidocaine solutions during the adventectomy and anastomosis. Antiplatelet therapy together with administration of low molecular dextran is performed in the first 3 to 4 postoperative days; afterwards, the dextran-40 administration is stopped while the ASA therapy is continued in smaller dose.

[Complications of reconstructive surgery using free flaps in the maxillofacial region]. / Complicanze della chirurgia ricostruttiva mediante lembi liberi del distretto maxillo-facciale.

The subject of our investigation was a group of twenty-nine patients with cervico-facial malignant neoplasms. The 29 patients, whose ages ranged from 12 to 68, with a mean age of 40, underwent surgery between January 1992 and January 1995. Cranial base and/or maxillo-facial defects were restored by free flap tissue transfer. Thirty-one micro-surgical free flaps were performed and post-operative monitoring was carried out for about 15-20 days. The aim of the present study is to show the importance of clinical semeiology which permits an early diagnosis of post-operative complications. Furthermore, post-operative monitoring of microsurgical free tissue transfer enables an etiological diagnosis and surgical vascular salvage of the flap to be made at the most opportune time. Many Authors report microsurgical transfer success at 95%-96% because timely detection and resolution of complication can minimize flap failure. We report our experience with 31 free flaps performed in 29 patients. Three of the patients needed a second transfer due to the failure of the first. Two underwent free flap transfers, while a pedicle flap was carried out on the other. In fourteen, latissimus dorsi free flaps were used (in 2 cases the procedure had to be performed twice), the forearm and the jejunum were employed in eight patients and the rectus abdominis in one.

[Diagnostic and surgical problems in a case of post-traumatic retention of a foreign body in the submandibular gland]. / Problemi diagnostici e chirurgici in un caso di ritenzione metatraumatica di corpo estraneo nella ghiandola sottomandibolare.

We report a particular case of a traumatically introduced foreign body in the sub-mandibular gland. A breaking object (plastic pen) penetrated, through the anterior oral floor, the submandibular gland. Such foreign bodies should be removed before suturing the wounds, as they can disturb healing and cause problems long after the accident. An adequate history, clinical and imaging studies should reveal the possibility of foreign body penetration and its localization, when it isn't previously removed. We compare the use of ultrasound detection of foreign bodies in soft tissue and conventional plain radiography, computed tomography, and magnetic resonance imaging. The usefulness of US in this kind of research does not justify TC or RM studies and allows a less invasive surgical operation.

[Indications for mandibular periosteotomy in the treatment of cancer of the oral cavity]. / Indicazioni alla corticotomia nel trattamento del carcinoma del cavo orale.

Marginal mandibulectomy is a compromise between preserving the mandibular structure and radical oncological surgery. In order to evaluate the correctness of the indications for this operation, a group of 47 patients with oral carcinoma underwent direct surgery or associated chemoradiotherapy and surgery. Surgery was programmed on the basis of clinical and radiological examinations and the specific evaluation of the distance of the tumour mass from the mandibular surface. This approach was justified by the lack of correlation, in anatomic and clinical terms, between tumoral infiltration of the mandible and metastatic recurrence in the cervical lymph nodes. Lastly, the varying pattern of tumoral invasion of the various mandibular regions (thickness of cortical bone, presence of foramen) induced the authors to distinguish the indications for conservative treatment by segments. According to international literature and on the basis of the authors' past experience, marginal mandibulectomy represents an extremely interesting method since it associates a satisfactory aesthetic-functional level with a radical oncological approach, in particular with regard to the symphyseal and parasymphyseal region owing its structural characteristics and reconstructive importance. The indications for this type of surgery are therefore in theory based primarily on oncological aspects, and subsequently on the various anatomic and reconstructive aspects of the various mandibular segments.

[Reconstruction of the oral cavity: the free radial forearm flap versus the free jejunal flap]. / Ricostruzione del cavo orale: lembo libero di radiale versus lembo libero di digiuno.

The concentration in a restricted area such as the oral cavity of the essential anatomic structures for mastication, deglutition, speech, salivary drainage and respiration makes it indispensable to ensure not only the structural reconstruction of the region but also, and above all, a functional reconstruction of the anatomic unit affected by resection. The use of revascularised flaps has extended both the quantity and quality of reconstructive methods available. In the context of the oral cavity the most widely used flaps are the radial forearm free flap and jejunum free flap. In this paper the authors report their personal experience in a group of 13 patients (6 radial forearm and 7 jejunum) undergoing oral cavity reconstruction using free flap. For each flap the authors describe the microsurgical procedure, the clinical characteristics of the post-operative period, the locoregional complications, the donor site and lastly the long-term clinical, anatomopathological and functional modifications 6-12 months after primary treatment. Moreover, they highlight the varying characteristics of the two flaps and make a critical assessment of the advantages and disadvantages of using one or other method. Lastly, in the light of their experience and a review of international literature, the authors underline the importance of making a careful choice and personalized reconstruction, and finally outline their own criteria of choice.