Polymorphous Adenocarcinoma: A Systematic Review of the Literature and Presentation of Two Cases in a Less-Considered Anatomical Site.

BACKGROUND: Polymorphous adenocarcinoma (PAC) is the second-most common malignant tumour of the minor salivary glands. Although PAC predominantly affects the palate, it can also involve the buccal mucosa. This systematic review aims to investigate the literature data about PAC. Furthermore, we report two cases of patients affected by PAC in an infrequently considered anatomical site. METHODS: According to PRISMA guidelines, a systematic review search was conducted on PubMed, Scopus, and Web of Science. Observational studies conducted on patients with a histological diagnosis of PAC were selected and analysed. Furthermore, two cases of patients with PAC affecting the buccal mucosa were reported. RESULTS: Twenty-nine studies were included, and 143 patients affected by PAC were analysed (62 males, 75 females, and 6 undefined, with a mean age of 57.4 ± 14.5 years). The palate was the most affected site (99/143, 69.2%), followed by the buccal mucosa (12/143, 8.4%). Moreover, we report two cases of patients with PAC affecting the buccal mucosa (one male and one female, with a mean age of 70.5 ± 2.5 years). CONCLUSIONS: The present study underscores the importance of considering the buccal mucosa as a possible location of minor salivary gland tumours; although it is a less-considered affliction, it is not uncommon.

MRONJ in breast cancer patients under bone modifying agents for cancer treatment-induced bone loss (CTIBL): a multi-hospital-based case series.

BACKGROUND: Cancer treatment-induced bone loss (CTIBL) is the most common adverse event experienced by patients affected by breast cancer (BC) patients, without bone metastases. Bone modifying agents (BMAs) therapy is prescribed for the prevention of CTIBL, but it exposes patients to the risk of MRONJ. METHODS: This multicentre hospital-based retrospective study included consecutive non-metastatic BC patients affected by MRONJ related to exposure to low-dose BMAs for CTIBL prevention. Patients' data were retrospectively collected from the clinical charts of seven recruiting Italian centres. RESULTS: MRONJ lesions were found in fifteen females (mean age 67.5 years), mainly in the mandible (73.3%). The mean duration of BMAs therapy at MRONJ presentation was 34.9 months. The more frequent BMAs was denosumab (53.3%). Ten patients (66.7%) showed the following local risk factors associated to MRONJ development: periodontal disease (PD) in three cases (20%) and the remaining six (40%) have undergone PD-related tooth extractions. One patient presented an implant presence-triggered MRONJ (6.7%). In five patients (33.3%) no local risk factors were observed. CONCLUSIONS: This is the first case series that investigated BC patients under BMAs for CTIBL prevention suffering from MRONJ. These patients seem to have similar probabilities of developing MRONJ as osteo-metabolic ones. Breast cancer patients under BMAs for CTIBL prevention need a regular prevention program for MRONJ, since they may develop bone metastases and be treated with higher doses of BMAs, potentially leading to a high-risk of MRONJ.

Comparison between Additive and Subtractive CAD-CAM Technique to Produce Orthognathic Surgical Splints: A Personalized Approach.

The present study aimed to evaluate the accuracy of digitally designed surgical splints generated with milling technology (material subtractive procedure) and with 3D printing technology (material additive procedure) through a customized approach in the planning of surgical orthognathic splints. Cone beam computed tomography (CBCT) examinations and scanned dental models of 10 subjects who had required surgical treatment of skeletal malocclusion were included. Simulation of the orthognathic surgery was performed according to dento-skeletal and aesthetic characteristics of the subjects and the visual treatment objective (VTO), using Dolphin3D software (Dolphin Imaging, version 11.0, Chatsworth, CA, USA). Afterward, the Appliance Designer software (3Shape A/S, Copenhagen, Denmark) was used to digitally design the surgical splints that were generated twice using laser stereolithography technology (DWS 0.29D, DWS, Vicenza, Italy) and milling technology (Sirona inLab MC X5). Finally, each physical splint was digitalized using a desktop scanner (D500 3D, 3Shape A/S, Copenhagen, Denmark) in order to perform deviation analysis using the original project as a reference. The relative percentage of matching (trueness) was calculated (Geomagic Control X software (3D Systems, version 2018.1.1, 3D Systems, Rock Hill, SC, USA). An Independent Student's t-test was used to statistically analyze the data. The milled splints showed a lower value of root to mean square (RMS) relative to the original project (0.20 mm ± 0.018) compared to the prototyped splints (0.31 ± 0.021) (p < 0.001). According to the present findings, surgical splints generated with milling technology present higher trueness compared with 3D printing technology.

Iliac flap versus fibula flap in mandibular reconstruction.

The mandible is one of the important parts of the body in terms of facial appearance and function. Vascularized free bone grafts have become the criterion standard in mandible reconstruction. With flap survival rates not too much distant to 100%, the focus is now on function and aesthetics. With the various free-flap options now available, reconstruction of the mandibular defect has achieved significant improvement in both functional and aesthetic results. However, few studies have compared the results of these options. The fibula is defined as the most popular flap in mandibular reconstruction, and only in few papers iliac flaps are preferred. However, quality of life and effectiveness data are not available to support this choice. Not any previous study prospectively compared these 2 flaps. Short- and long-term results of an outcome-research study were prospectively compared in microvascular mandibular reconstruction with fibular flap and iliac crest flaps. Mean functional and quality-of-life scores were higher following iliac crest reconstructions. Fibular flap was the flap of choice in total/subtotal mandibulectomy, but it does not appear preferable in hemimandibulectomy and/or in cases of segmental mandibulectomy, if compared with the iliac crest.

A Rare Cause for Cervical Pain: Eagle's Syndrome.

Patients with pharyngodynia and neck pain symptoms can lead to an extensive differential diagnosis. Eagle's syndrome must be taken in account. Eagle defined "stylalgia" as an autonomous entity related to abnormal length of the styloid process or to mineralization of the stylohyoid ligament complex. The stylohyoid complex derives from Reichert's cartilage of the second branchial arch. The styloyd process is an elongated conical projection of the temporal bone that lies anteriorly to the mastoid process. The incidence of Eagle's syndrome varies among population. Usually asymptomatic, it occurs in adult patients. It is characterized by pharyngodynia localized in the tonsillar fossa and sometimes accompanied by disphagia, odynophagia, foreign body sensation, and temporary voice changes. In some cases, the stylohyoid apparatus compresses the internal and/or the external carotid arteries and their perivascular sympathetic fibers, resulting in a persistent pain irradiating in the carotid territory. The pathogenesis of the syndrome is still under discussion.

Simultaneous functional endoscopic sinus surgery and esthetic rhinoplasty in orthognathic patients.

PURPOSE: Patients treated for dentofacial deformities may be predisposed to aggravated sinonasal disease postoperatively, particularly if concurrent rhinoplasty is performed. The authors present their experience with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and functional endoscopic sinus surgery (FESS). PATIENTS AND METHODS: Thirteen patients were treated with simultaneous rhinoplasty, maxillary/mandibular osteotomies, and FESS from January 2002 to December 2005. An operative algorithm for patients with dentofacial deformities requiring rhinoplasty was developed. The surgical procedure was performed under general anesthesia with nasotracheal intubation and maxillary/mandibular osteotomies first. Nasotracheal intubation was then converted to orotracheal intubation and FESS was performed. The third step was correction of the esthetic deformities of the nose through an open approach. RESULTS: In all cases, it was possible to successfully complete the combined operation. Median operation time was: 2 hours and 18 minutes for orthognathic bimaxillary surgery, 54 minutes for rhinoplastic surgery; and 23 minutes for FESS. All the patients had good esthetic and functional results and were free from symptoms consistent with previous rhinosinusitis. CONCLUSION: The combination of orthognathic surgery, rhinoplasty, and FESS in selected cases is safe and effective.

Condylar positioning devices for orthognathic surgery: a literature review.

In the past few years, many devices have been proposed for preserving the preoperative position of the mandibular condyle during bilateral sagittal split osteotomy. Accurate mandibular condyle repositioning is considered important to obtain a stable skeletal and occlusal result, and to prevent the onset of temporomandibular disorders (TMD). Condylar positioning devices (CPDs) have led to longer operating times, the need to keep intermaxillary fixation as stable as possible during their application, and the need for precision in the construction of the splint or intraoperative wax bite. This study reviews the literature concerning the use of CPDs in orthognathic surgery since 1990 and their application to prevent skeletal instability and contain TMD since 1995. From the studies reviewed, we can conclude that there is no scientific evidence to support the routine use of CPDs in orthognathic surgery.

Arthroscopy with open surgery for treatment of synovial chondromatosis of the temporomandibular joint.

We report a case of synovial chondromatosis of the temporomandibular joint in which both joint compartments were affected. Because of the important involvement of the medial aspect of the joint, arthrotomy was done with arthroscopic assistance.

Is there a role for arthrocentesis in recapturing the displaced disc in patients with closed lock of the temporomandibular joint?

OBJECTIVE: The aim of this study was to evaluate the effectiveness of arthrocentesis in releasing acute and chronic closed lock of the temporomandibular joint, improving function, reducing pain and recapturing the displaced disc. STUDY DESIGN: We performed arthrocentesis and mandibular manipulation (MM) as an initial treatment in 33 patients (unilateral involvement) with a variable duration of closed lock and magnetic resonance imaging (MRI) evidence of anterior disc displacement without reduction (ADDWR). Duration of locking ranged from 1 week to 2 years. After the procedure, soft diet, physiotherapy, and an interocclusal appliance (IA) were prescribed. Postoperative MRI images were obtained at 1 month. A clinical examination with analysis of maximal mouth opening (MMO), a visual analog scale (VAS), and a self-administered questionnaire were used for evaluation of pain, jaw dysfunction, and activities of daily living (ADL). The follow-up period was 1 year. RESULTS: At 1-year follow-up, MMO had increased significantly from a mean of 24.7 +/- 5.9 mm to 39.6 +/- 6.2 mm (P < .05). Functional improvement was associated with a significant reduction in VAS (from 6.2 +/- 2.3 to 2.8 +/- 3.4), pain (from 11.7 +/- 7.1 to 4 +/- 3.8), dysfunction (from 8.6 +/- 4.9 to 3.2 +/- 2.8), and ADL scores (from 13.9 +/- 12 to 4.4 +/- 5), with P < .05. The overall success rate was 72.7%; it was higher in acute patients (87.5%) than in chronic patients (68.0%). The disc was recaptured (the disc was interposed between the condyle and the eminence on closed and open MRI images) in 3 cases in which the duration of locking was less than 1 month (acute patients). CONCLUSIONS: The results indicate that arthrocentesis, in association with MM and IA, could be effective in improving function and reducing pain in patients with closed lock. Better results were obtained in terms of MMO, VAS, and questionnaire scores in acute closed lock cases than in chronic ones. Recapturing the anteriorly displaced disc is possible only in patients with acute closed lock.

Piezosurgery: a new method for osteotomies in rhinoplasty.

Two basic techniques for lateral osteotomy have been developed to date; the internal (endonasal) continuous technique and the external (percutaneous) perforating method. Numerous investigators have subjectively reported that the application of the two techniques results in less postoperative ecchymosis and edema compared to the use of other techniques, but an alternative and gentle method for performing lateral osteotomy or bony hump removal has not been proposed yet. The authors present a new soft technique to perform nasal osteotomy in rhinoplasty using piezoelectric ultrasonic vibrations, and emphasize the advantages of this method.

Surgical treatment of Aspergillus mycetomas of the maxillary sinus: review of the literature.

The present study reviews the literature concerning the surgical treatment of Aspergillus mycetoma (AM) in the last 20 years to identify a gold standard surgical technique. Aspergillus mycetoma of the maxillary sinus, or mycetoma (fungus ball), is a noninvasive or extramucosal mycotic infection. Surgical removal of the sinus fungal masses to ensure drainage and aeration is performed using the traditional Caldwell-Luc (CL) procedure or endoscopic sinus surgery (ESS). Results of this review suggest that the gold standard surgical technique for AM is ESS with middle meatal antrostomy. General or local antifungal drugs are not indicated. Combined approach with an intraoral surgical access from the anterolateral wall of the maxillary sinus has to be reserved for selected cases in which ESS doesn't permit complete extraction of all fungal concretions or foreign bodies. The CL procedure should be avoided, because it has detrimental consequences for sinus physiology.

Feasibility of preoperative planning using anatomical facsimile models for mandibular reconstruction.

BACKGROUND: Functional and aesthetic mandibular reconstruction after ablative tumor surgery continues to be a challenge even after the introduction of microvascular bone transfer. Complex microvascular reconstruction of the resection site requires accurate preoperative planning. In the recent past, bone graft and fixation plates had to be reshaped during the operation by trial and error, often a time-consuming procedure. This paper outlines the possibilities and advantages of the clinical application of anatomical facsimile models in the preoperative planning of complex mandibular reconstructions after tumor resections. METHODS: From 2003 to 2005, in the Department of Maxillofacial Surgery of the University of Udine, a protocol was applied with the preoperative realization of stereolithographic models for all the patients who underwent mandibular reconstruction with microvascular flaps. 24 stereolithographic models were realized prior to surgery before emimandibulectomy or segmental mandibulectomy. The titanium plates to be used for fixation were chosen and bent on the model preoperatively. The geometrical information of the virtual mandibular resections and of the stereolithographic models were used to choose the ideal flap and to contour the flap into an ideal neomandible when it was still pedicled before harvesting. RESULTS: Good functional and aesthetic results were achieved. The surgical time was decreased on average by about 1.5 hours compared to the same surgical kind of procedures performed, in the same institution by the same surgical team, without the aforesaid protocol of planning. CONCLUSION: Producing virtual and stereolithographic models, and using them for preoperative planning substantially reduces operative time and difficulty of the operation during microvascular reconstruction of the mandible.

Septic arthritis of the temporomandibular joint successfully treated with arthroscopic lysis and lavage: case report and review of the literature.

Septic arthritis of the temporomandibular joint (TMJ) is infrequently reported. We present a case of septic arthritis of the TMJ following the extraction of the left upper second molar that occurred 1 week before beginning of symptoms. No evident predisposing factors were detected. Arthroscopic diagnosis of septic arthritis, lysis and lavage, and capsular stretch were performed. Cultures taken from the TMJ space grew Streptococcus sp. After 1 month of antimicrobial therapy the patient was asymptomatic and mandibular function was normal. Literature related to septic arthritis of TMJ and its treatment was reviewed. Different surgical procedures are available to treat this condition. Arthroscopy should be preferred as initial treatment on account of the possibility of drainage and accurate lavage under direct visualization of joint space, at the same time allowing confirmation of diagnostic hypotheses. Improving joint mobility with lysis of adhesions and capsular stretch in an early stage of disease may be helpful in stopping the fibrosis process.

High condylectomy and disc repositioning compared to arthroscopic lysis, lavage, and capsular stretch for the treatment of chronic closed lock of the temporomandibular joint.

OBJECTIVE: The article shows the 1-yr results comparing the efficacy of open-surgery high condylectomy and disc repositioning and the arthroscopic procedure of lysis, lavage and capsular stretch in patients with chronic closed lock of the temporomandibular joint (TMJ). STUDY DESIGN: Twenty patients with a clinical and radiologic diagnosis of chronic closed lock were randomly chosen to be treated with either open surgery or arthroscopy. Each patient was evaluated with a visual analog scale (VAS) for pain and a mandibular functional impairment questionnaire (MFIQ). The evaluation also included a clinical examination. Each patient was recorded at baseline before surgery and at 1-yr follow-up. Statistical analysis was made to evaluate whether differences in MFIQ, VAS, maximum opening and protrusion, lateral joint tenderness, muscle tenderness, crepitation, and clicking at 1-yr follow-up from baseline were significant. Results were considered statistically significant when P < .05. RESULTS: Both open surgery and arthroscopic surgery reduced pain and improved mandibular function. The severity of pain was significantly reduced in both groups (P = .005). In both the open and arthroscopy groups mandibular function improved significantly (P = .005). The clinical examination showed similar good results for the 2 surgical procedures. At 1-yr follow-up a majority of patients from both the open (80% of the patients) and the arthroscopy (70% of the patients) groups fulfilled the criterion of a cutoff point for maximum interincisal opening of equal or more than 35 mm (P = 0.005); all the patients in both groups fulfilled the criterion of the cutoff point for maximum protrusion of more than 5 mm (P = .007). At 1-yr follow-up, clicking was the same as before surgical procedures; no patient in the open group showed crepitation, but crepitation was found in patients in the arthroscopy group. Joint tenderness and pain on lateral palpation as well as muscle tenderness and pain were reduced in all the cases, disappearing in some of them, but the difference was significant only regarding joint tenderness (open surgery, P = .016; arthroscopy, P = .031). CONCLUSIONS: Open-surgery high condylectomy and disc repositioning and the arthroscopic procedure of lysis, lavage and capsular stretch are both effective surgical methods to treat symptomatic patients with a diagnosis of chronic closed lock of the TMJ. Because of the minimally invasive character of the arthroscopic procedure, it should be considered as the first choice in the surgical treatment of the TMJ.

Intraoperative awakening of the patient during orthognathic surgery: a method to prevent the condylar sag.

PURPOSE: The intraoperative diagnosis, during orthognathic procedures, of an unfavorable condylar position is highly desirable. A simple technique that can reliably identify a malpositioned condyle intraoperatively has obvious advantages. The manual positioning of the condyle is easier, but it requires the utmost care and an experienced operator. Muscle tone is described as maintaining contact across the temporomandibular joint. The anesthetized and curarized patient has a condylar position posterior to that in the same patient when he is awake, with the same seating force applied. Under general anesthesia, the condyle may be inferior and might not feel stable until it moves posteriorly and has adequate compression of the retrodiscal tissues on the posterior wall. Relapse of the occlusion as a result of changes in the condylar position may occur immediately after the removal of the temporary intermaxillary fixation (IMF). The surgeon needs to understand the mechanism of condylar sag and the specific patterns of malocclusion that it may produce. This will enable him to make a diagnosis and to implement the appropriate corrective measures, providing the opportunity for immediate correction of condylar position, thereby obviating the need for a second operation or orthodontic compromise. MATERIALS AND METHODS: A study group (group A, 76 patients) and a control group (group B, 73 patients) were randomly formed from the dysgnathic patients scheduled for bimaxillary orthognathic surgery (Le Fort I osteotomy and bilateral sagittal split osteotomy). The free mandibular proximal segment was gently and manually positioned in the glenoid fossa. All the mandibles were fixed with bicortical screws. In group A, immediately after the fixation, IMFs were removed and the occlusions were checked with light digital pressure on the chin, then the patients were rapidly awakened (maintaining the intubation) in a state of conscious analgo-sedation and asked to open and close, and to laterally move the mandible. If clinical examination of the passive and active movements of the mandible was suitable, the anesthesia was reinforced and the operation was concluded. RESULTS: In 11 of the 76 patients of group A, malocclusion was noted, after the rigid fixation, with the method of digital pressure on the chin; the intraoperative awakening of the patients confirmed the clinical appearance and it provided further clinical signs to identify the offending condyle and to favor appropriate corrections. In 8 of the group A patients, malocclusions were not noted with manipulation of the mandible, but they were pointed out during the intraoperative awakening, and then they were appropriately corrected. In 2 of the group B patients, malocclusion was noted, after the rigid fixation, with the method of digital pressure on the chin, and it was immediately corrected. In 7 of the group B patients, malocclusion was not noted during the operation with the method of digital pressure on the chin, but it was noted at the end of the surgical procedure (12-24 hours after). CONCLUSION: Muscle tone, muscular activity, and proprioception appear to have important roles in the clinical evidence of a postoperative malocclusion during the intraoperative awakening; they can reliably implement the accuracy of the diagnosis of condylar sag, and they can favor its correction.

Conscious analgesia and sedation during orthognathic surgery: preliminary results of a method of preventing condylar displacement.

A patient who is unconscious and paralysed has a condyle that is different from what it would be were he awake and the same force applied. The occlusion may relapse as a result of changes in condylar position immediately after the removal of intermaxillary fixation (IMF). Examination of the occlusion and an understanding of the changes secondary to a condylar displacement can identify it reliably during the operation. A study group (n=78) and a control group (n=74) were chosen randomly from patients listed for bimaxillary orthognathic surgery. No local anaesthetic was infiltrated so as not to disturb proprioception. In the study group, the IMF was removed immediately after the fixation and the occlusions were checked with light digital pressure on the chin. The patients were then woken rapidly (maintaining the intubation) in a state of conscious analgesia and sedation and invited to open and close their mouths and to move the mandible laterally. If clinical examination of the passive and active movements of the mandible were suitable, the anaesthetics were topped up and the operation completed. "Conscious" analgesia and sedation is certainly a valid aid during orthognathic surgery.