Prospective study of nasal growth in bilateral cleft lip and palate patients after naso-alveolar moulding and primary columella lengthening compared to controls at 5, 10 and 20 years.

INTRODUCTION: A short columella, wide nostrils and a flat nasal tip are common features in patients with bilateral complete cleft lip and palate (BCLP). The objective of this study was to evaluate nasal morphology during growth in patients treated with naso-alveolar moulding (NAM) and primary surgical columella lengthening (PCL) compared with matched non-cleft individuals. STUDY DESIGN: Prospective longitudinal case-control study. PARTICIPANTS AND METHODS: Thirty-four consecutively treated BCLP patients at 5 and 10 years and at the end of growth (19.7 ± 2.0 years) were compared through normalized photogrammetry to a control of 34 age and sex-matched non-cleft individuals. Regression Models for Panel Data assessed how nasal measurements were influenced by surgery, age and gender. RESULTS: Nasal protrusion was equal to non-cleft controls at all ages. Length of the columella was also comparable to controls at 5 and 10 years, but significantly shorter at the end of growth. Inter-alar and nasal tip width and nasolabial angle were significantly wider than controls at all ages: More than 60% of the patients have asked for correction of the nasal width, but no early surgery for columella lengthening was needed. CONCLUSIONS: NAM and PCL have provided a nasal projection close to that of non-cleft individuals until adulthood, while length of the columella was physiological at 5 and 10, but shorter than controls at age 20. Width of the nasal tip and width of the alar bases were significantly wider than the controls and eventually required secondary nasal width correction in over two thirds of the sample.

Wide Range Applications of Spirulina: From Earth to Space Missions.

Spirulina is the most studied cyanobacterium species for both pharmacological applications and the food industry. The aim of the present review is to summarize the potential benefits of the use of Spirulina for improving healthcare both in space and on Earth. Regarding the first field of application, Spirulina could represent a new technology for the sustainment of long-duration manned missions to planets beyond the Lower Earth Orbit (e.g., Mars); furthermore, it could help astronauts stay healthy while exposed to a variety of stress factors that can have negative consequences even after years. As far as the second field of application, Spirulina could have an active role in various aspects of medicine, such as metabolism, oncology, ophthalmology, central and peripheral nervous systems, and nephrology. The recent findings of the capacity of Spirulina to improve stem cells mobility and to increase immune response have opened new intriguing scenarios in oncological and infectious diseases, respectively.

Photometric Evaluation of Adult Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening.

OBJECTIVE: The aim of this study was to assess the nasal shape of young adults with BCLP treated with primary surgical columella lengthening and nasoalveolar molding (NAM). SETTING AND PATIENTS: A group of 28 young adult patients with BCLP (mean age: 19.1±1.4 years) was compared through normalized photogrammetry to a control of 28 age- and sex-matched noncleft young adults. RESULTS: Nasal protrusion and length of the columella were not different from noncleft young adults. On the other hand, nasolabial angle, columellar width, interalar, and nasal tip width were significantly wider than the noncleft controls. Thus, 27% of the patients have requested at this time secondary correction of the excessive nasal width. CONCLUSIONS: Both NAM and primary rhinoplasty in patients with BCLP resulted in a near normal length of the columella and nasal projection until young adulthood. Nevertheless, width of all nasal features was significantly wider than the noncleft population and required secondary nasal correction in one-third of the sample.

Orthodontic Pre Grafting Closure of Large Alveolar Bony and Soft Tissue Gaps: A Novel Nonsurgical Protraction of the Lesser Segments in Growing Patients With Cleft Lip and Palate.

BACKGROUND: Closure of wide alveolar clefts with large soft tissue gaps and reconstruction of the dentoalveolar defect are challenging for the surgeon. Some authors successfully used interdental segmental distraction, which requires an additional surgical procedure. OBJECTIVE: This study evaluates the effectiveness of tooth borne devices utilized to orthopedically advance the lesser segments, with a complete approximation of the soft tissue of the alveolar stumps, allowing traditional simultaneous soft tissue closure and bone grafting, and avoiding the need for supplementary surgery. METHODS: Eight growing patients, 2 with unilateral complete cleft lip and palate (UCLP) and 6 with bilateral complete cleft lip and palate (BCLP), with large soft tissue and bony alveolar defects prior to bone grafting were prospectively selected. A banded rapid palatal expander (RPE) in BCLP and a modified RPE in UCLP combined with protraction face mask in younger patients or a modified Alt-Ramec in patients older than 12 years were applied. Radiographic and photographic records were available at T0, at the end of protraction (T1) and at least 1 year after bone grafting (T2). RESULTS: Patients with large gaps showed a significant reduction in the bony cleft area and approximation of the soft tissues at T1. All patients received bone grafting with good healing and ossification at T2. CONCLUSION: In growing patients with UCLP and BCLP with large gaps, presurgical orthodontic protraction seems to be an efficient method to reduce the cleft defect, minimizing the risk of post grafting fistulas, reducing the need for supplementary surgical procedures.

Have There Been any Changes in the Epidemiology and Etiology of Maxillofacial Trauma During the COVID-19 Pandemic? An Italian Multicenter Study.

ABSTRACT: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a significant impact on people's behavior. The aim of this study has been to evaluate how the SARS-CoV-2 pandemic has impacted the incidence and the features of maxillofacial fractures presented at 6 Italian tertiary centers. Clinical records of all the patients diagnosed for facial fractures between February 23 and May 23, 2019 and 2020 were retrospectively reviewed. Any differences in patient number and characteristics and fracture etiology and site between the 2 groups were then statistically analyzed.There has been a 69.1% decrease in the number of incoming patients during the pandemic. The number of foreign patients has decreased significantly (23.3% versus 9.6%, P = 0.011) while the average age has increased (38.6 versus 45.6 years old, P = 0.01). Specific statistical significant differences for accidental falls (31.8% versus 50.1%, P = 0.005) and sports injuries (16.9% versus 1.4%, P < 0.001) were found. Concerning fracture sites, significant differences have been found in relation to nasal (22.5% versus 11.4%, P = 0.009) and frontal sinus (0.9% versus 4.4%, P = 0.037) fractures. In conclusion, SARS-CoV-2 pandemic has significantly changed the epidemiology and the etiology of facial traumas.

Quantification of heterogeneity to classify benign parotid tumors: a feasibility study on most frequent histotypes.

Aim: To differentiate Warthin tumors (WTs) and pleomorphic adenomas (PAs) measuring heterogeneity of intravoxel incoherent motion (IVIM) and dynamic-contrast enhanced-magnetic resonance imaging biomarkers. Methods: Volumes of interest were traced on 18 WT and 18 PA in 25 patients. For each IVIM and dynamic-contrast enhanced biomarker, histogram parameters were calculated and then compared using the Wilcoxon-signed-rank test. Receiver operating characteristic curves and multivariate analysis were employed to identify the parameters and their pairs with the best accuracy. Results: Most of the biomarkers exhibited significant difference (p < 0.05) between PA and WT for histogram parameters. Time to peak median and skewness, and D* median and entropy showed the highest area under the curve. No meaningful improvement of accuracy was obtained using two features. Conclusion: IVIM and dynamic-contrast enhanced histogram descriptors may help in the classification of WT and PA.

Costochondral graft in growing patients with hemifacial microsomia case series: Long-term results compared with non-treated patients.

OBJECTIVE(S): The aim of this study was to evaluate the long-term effectiveness of costochondral graft in hemifacial microsomia (HFM) type III patients. SETTINGS AND SAMPLE POPULATION: A sample of 10 patients affected by HFM type III treated during growth in the same Centre with costochondral graft (CCG patients group) is compared with a control group (CG) sample of 10 non-treated patients affected by the same malformation in order to understand whether surgery during growth provides advantages in terms of bony and facial symmetry after an 8-year follow-up. MATERIALS AND METHODS: The growth of the CCG was assessed on panoramic X-rays. To assess facial symmetry, a photometric evaluation on the frontal view was carried out. RESULTS: In CCG patients group the graft grown in mean less than the healthy ramus, a good facial symmetry was achieved after surgery, but was lost in the majority of the cases at the most recent control. In CG, occlusal canting slightly increased and facial asymmetry was relatively stable during the years. CONCLUSION: In patients with a congenital deformity, restoring the height of the ramus leads to an immediate restitution of facial symmetry, but in the long term, there is a return to the asymmetrical pattern. In CG, the asymmetry is stable during years with no increase of the facial deformity.

SECg Staging System: A New Approach to the Management of Arteriovenous Malformations of the Head and Neck.

OBJECTIVES: Arteriovenous malformations (AVM) are the most troublesome vascular malformations to deal with. They tend to behave like low-grade malignancies with infiltrative and disruptive growth. Crucially, the clinical course of an AVM that has been improperly managed is usually characterized by a recurrence that is much more aggressive than the original disease. As in oncology, a comprehensive staging system is highly desirable and is to date lacking in the literature. The authors present a new comprehensive staging system. METHODS: A multicentric multidisciplinary team of experts in the field of vascular anomalies has created this new staging system. The SECg staging system defines the local extension of the disease (S1-S4), the vascular architecture of the malformation (E1, E2, E3), the severity of the symptoms (C0-C3) and the presence or absence of growth of the AVM (g+, g-). RESULTS: This staging system allows to address all the aspects of AVMs and, more importantly, to help building an appropriate, individualized treatment plan for affected patients. After being staged an AVM can be defined as (a) healable, (b) healable with predicted sequelae, or (c) unhealable. Then, the SECg system allows to outline (a) absolute indications, (b) relative indications, and (c) no indications for treatment. The purpose of the treatment (radical, palliative) is furthermore taken into consideration. CONCLUSIONS: This multicentric, the SECg staging system that this multidisciplinary group of Authors has defined allows for a comprehensive staging of the disease which in turn has enabled to outline an algorithm to properly manage AVMs.

Odontogenic rhinosinusitis and sinonasal complications of dental disease or treatment: prospective validation of a classification and treatment protocol.

PURPOSE: Odontogenic sinusitis and sinonasal complications of dental disease or treatment (SCDDT) represent a heterogeneous group of conditions that often require multidisciplinary care. The present study aims to prospectively validate a classification and treatment protocol for SCDDT patients. METHODS: One hundred twenty-eight consecutive patients (73 females and 45 males, mean age 52.4 years) affected by SCDDT not responding to dental and medical therapy were classified and surgically treated according to the proposed protocol. The protocol classified patients into three aetiology-based groups (preimplantologic, implantologic, and related to traditional dental diseases and procedures, respectively). The groups were further divided into classes according to the presence of oro-antral communications and/or dislocated dental hardware. Each condition was treated according to the class-related, protocol-defined treatment, by either a transnasal or combined transnasal/transoral approach. All patients were successfully classified according to our protocol. None of the proposed classes were redundant, and no condition fell outside the definitions. RESULTS: The surgical treatment protocol proved to be adequate and effective, in that 125 of the 128 patients completely recovered after surgical treatment. CONCLUSIONS: The term SCDDT and the consequent classification proposed by the authors appear, therefore, to be nosologically correct. Furthermore, the protocol-related proposed treatment appears to be clinically sound, with a success rate nearing 98%.

A multiparametric analysis combining DCE-MRI- and IVIM -derived parameters to improve differentiation of parotid tumors: a pilot study.

AIM: To evaluate dynamic contrast-enhanced (DCE)-MRI and diffusion weighted (DW)-MRI diagnostic value to differentiate Warthin tumors (WT) by pleomorphic adenomas (PA). MATERIALS & METHODS: Seven WT and seven PA were examined. DCE- and  DW-MRI parameters were extracted from volumes of interest; volume of interest-based averages and standard deviations were calculated. Statistical analysis included: linear discriminant analysis, receiver operating characteristic curves, sensitivity and specificity. RESULTS: No single feature was able to differentiate WT by PA (p > 0.05); linear discriminant analysis analysis showed that a combination of all features or combinations of feature pairs (namely: Ktrans(std) & f(std), Ktrans(std) & D(std), kep(std) & D(std), MRE(av) & TTP(av)) might achieve sensitivity (SENS), specificity (SPEC) = 100%, with a slight reduction after cross-validation analysis (SENS = 0.875; SPEC = 1). CONCLUSION: Although preliminary and not conclusive, our results suggest that differentiation between WT and PA is possible through a multiparametric approach based on combination of DCE- and DW-MRI parameters.

Objective Assessment of Lingual Nerve Microsurgical Reconstruction.

Lingual nerve (LN) injury is one of the most serious consequences of oral surgery. Prompt microsurgical reconstruction of the nerve can alleviate most of those symptoms leading to satisfactory functional recovery.Thirty-five patients with partial to complete LN injury underwent surgery in the period between January 2006 and May 2015. All patients underwent a preoperative clinical and neurological evaluation with the assessment of lingual tactile and pain sensory thresholds and masseteric inhibitory reflex.All patients underwent explorative surgery and direct microneurorrhaphy of distal and proximal stumps in case of complete lesion, while the removal of traumatic neuroma and the following microneurorrhaphy of distal and proximal stumps of the injured nerve was performed in case of incomplete lesion. Nerve grafting has always been avoided because of distal stump mobilization obtained by severing the submandibular branch of the LN.All patients but 1 exhibited good recovery of tongue sensation, never complete, both clinically and electrophysiologically: recovery of the excitability of masseteric inhibitory reflex suppression components SP1 and SP2 was observed, often with increased latencies but consistent with a functional recovery.All patients feeling pain preoperatively experienced complete relief of algic symptoms.The early microsurgical approach is the most suitable choice for the treatment of LN injuries.

Evaluation of a Sample of Patients With Unilateral Cleft Lip and Palate Treated With a Two-Stage Protocol.

The aim of this paper was to assess growth, speech, and aesthetic results at the completion of growth in patients with unilateral cleft lip and palate treated with the 2 stages Milan surgical protocol.Craniofacial growth was evaluated with cephalometric analysis and a theoretical need for orthognathic surgery.Nasolabial appearance was qualitatively assessed using the Asher McDade Aesthetic Index.Speech was assessed using the Gos.Sp.Ass '98 modified for Italian language scoring system.Burden of care was recorded in terms of number of secondary surgical procedures. All of the patients were treated and evaluated at San Paolo Hospital, Smile House, Milan.Fifty-two consecutive patients treated by the same surgeon were recalled, 12 patients did not come for assessment.The first surgical step (average age of 6 months) was cheilorhinoplasty (Millard modified Delaire technique) and soft palate rapair (Pigott). The second step (average age of 35 months) was hard palate and alveolar repair performed simultaneously with an early secondary gengivo alveolo plasty. Fifty-six percent of the patients did not need further surgery after the 2-stage surgery protocol.The 2-stage surgical protocol of Milano, Smile House, seems to be effective for treatment of unilateral cleft lip and palate, with good results in terms of speech, labial appearance, and alveolar cleft management. Nevertheless, maxillary growth was moderately impaired by the protocol.

A Shift in the Orbit: Immediate Endoscopic Reconstruction After Transnasal Orbital Tumors Resection.

Endoscopic endonasal resection of orbital lesions is a safe and common approach. Nevertheless, medial orbital wall defects following the procedure are not routinely addressed, potentially leading to diplopia and enophthalmos. In this article, the authors propose a new technique for purely endoscopic endonasal reconstruction of orbital wall defects following endoscopic endonasal resection of orbital lesions.The patient, a 43-year-old male, suffering from right exophthalmos and diplopia due to a venous malformation of the right orbit underwent endoscopic endonasal resection of the mass. Excision was followed by immediate transnasal endoscopic reconstruction with a commercially available porous polyethylene mesh (Medpor).The postoperative course was uneventful. The patient did not report any residual orbital asymmetry or diplopia. No recurrence of the venous malformation, mesh infection, or reconstruction instability was reported during the follow-up.The authors believe that this new technique could spur head and neck surgeons in strategically rethinking their approach to orbital tumors, proposing reconstruction to patients on a routine basis, and developing even more reliable and manageable solutions.

Use of Buccinator Myomucosal Flap in Tongue Reconstruction.

The myomucosal buccinator flap, first described by Bozola in 1989, has become an important tool for intraoral defects reconstruction. In the literature, there is a variety of proposed myomucosal cheek flaps, both pedicled and island, based on the buccal or the facial arteries. From January 2007 to December 2011, the authors used a pedicled buccinator flap based posteriorly on the buccal artery to reconstruct partial lingual defects following tumor resection in 27 patients. The buccal fat pad was translated to cover the donor site defect. After 3 to 4 weeks from the original surgery, a second procedure under local anesthesia was performed to detach the pedicle and remodel the flap. The morphological and functional outcomes of the procedures were evaluated by the surgeons and a speech and language therapist. All patients presented satisfactory results. The authors consider the use of the described technique as the gold standard in the reconstruction of partial tongue defects after tumor resection.

Stereophotogrammetric Evaluation of Labial Symmetry After Surgical Treatment of a Lymphatic Malformation.

Lymphatic malformations (LMs) are rare, nonmalignant masses, frequently involving the head and neck, potentially causing impairment to the surrounding anatomical structures. Major LMs frequently cause facial disfigurement with obvious consequences on self-esteem and social functioning. The attempt to restore symmetry is thus one of the main goals of treatment. In this study, the authors present a not-invasive method to objectively quantify the symmetry of the labial area before and after surgical treatment of a LM, affecting a 16-year-old woman. This was done with sequential three-dimensional stereophotogrammetric imaging and morphometric measurements. The method showed a high reproducibility and supplied quantitative indicators of the local degree of symmetry, helping clinicians in its objective assessment, and facilitating treatment planning and evaluation. A quantitative appraisal of the results can additionally improve patient adherence to a usually multistage therapy.

An easy access to retrieve dental implants displaced into the maxillary sinus: the bony window technique.

AIM OF THE STUDY: To present the authors' experience concerning the removal of dental implants displaced in the maxillary sinus via an intraoral approach consisting of the creation of a bony window pedicled to the maxillary sinus membrane. MATERIALS AND METHODS: Thirty-six systemically healthy patients, presenting with oral implants displaced into the maxillary sinus, but with no signs of acute or chronic sinusitis, were consecutively treated between 2002 and 2012 via an intraoral approach with the bony window technique. RESULTS: Removal of oral implants from the maxillary sinus was achieved in all patients, and postoperative recovery was uneventful in all of them. Computed tomographies performed after surgery showed no signs of residual sinus infection in all patients and a complete ossification of the bony window margins. Twelve of the 36 treated patients were treated with a sinus grafting procedure 12-18 months after in the same areas previously treated with the bone lid technique. Seventeen implants were placed in the grafted areas 6-9 months later and, after a further waiting period needed for osseointegration, the treated patients were rehabilitated with implant-supported prostheses. The survival rate of implants was 100%, and no complications related to the sinuses and implants were recorded. CONCLUSION: Results from this study seem to demonstrate that the bony window technique is a safe and easy way to remove oral implants from the maxillary sinus under local anesthesia. The surgical access is hardly visible 6-12 months after surgery, and maxillary sinuses appeared free from residual pathology in all treated patients. Finally, this procedure allows a second-stage sinus grafting procedure via a lateral approach as in a previously untreated maxillary sinus, thus allowing an implant-supported prosthetic restoration.

Comprehensive surgical management of cocaine-induced midline destructive lesions.

PURPOSE: This article presents a review of the literature and proposes a protocol for managing acute and chronic midfacial cocaine-induced injuries. MATERIALS AND METHODS: This report describes a series of 4 patients affected by cocaine-induced midline destructive lesions. Three patients came to the authors' attention after 18 months of drug withdrawal and underwent surgical treatments to restore nasal and palatal morphology and function, and the fourth patient was referred because of acute cocaine-induced destructive lesions and was treated by aggressive debridement. An 18-month drug-free period is planned before beginning any reconstructive procedures in this latter patient. RESULTS: Long-term follow-up showed stable results without relapse of palatal fistulas and good esthetic nasal appearance in all 3 patients undergoing reconstruction. The fourth patient did not show any disease progression and will be monitored for drug withdrawal. CONCLUSION: Chronic cocaine consumption may cause multiple types of damage to the soft and hard tissues of the midface. Acute lesions must be addressed with aggressive debridement. As a result of chronic injury, the palate and nose are deformed in a very complex way and the vascularity of the remaining local tissues may be compromised or inadequate for flap harvesting. Palatal and nasal reconstructions are very delicate operations and should be addressed separately to maximize the predictability of the result.

Surgical treatment of vascular malformations of the facial bones.

PURPOSE: To characterize intraosseous vascular malformations and describe the most appropriate approach for treatment according to clinical experience and a review of the published data. MATERIALS AND METHODS: We performed a retrospective review of 11 vascular malformations (7 venous and 4 arteriovenous) of the facial bones treated during a 10-year period using en bloc resection or intraoral aggressive curettage alone or preceded by endovascular embolization. Corrective surgery was planned to address any residual bone deformities. The cases were reviewed at a mean follow-up point of 6 years. RESULTS: Facial symmetry was restored in the cases requiring reconstruction. Tooth sparing was possible in the case of jaw and/or maxillary localization. Recanalization occurred in 14% of the venous and 33% of the arteriovenous malformations. CONCLUSIONS: Facial intraosseous venous malformations can be successfully treated using surgery alone. Facial intraosseous arteriovenous malformations will be better addressed using combined approaches. Aggressive curettage will obviate the need for extensive surgical resection in selected cases.

Is pre-operative electromyography a reliable tool in differentiating acute and chronic facial palsy? A preliminary evaluation in patients treated with triple innervation facial reanimation.

Electromyographic evaluation is a reliable tool for confirming facial palsy and assessing its severity. It allows differentiating facial paresis and paralysis, and further distinguishes acute palsies, still showing muscle fibrillations, from chronic cases. This article aims to show that EMG fibrillations might represent a better criterion to differentiate acute and chronic palsies than the standard 18-24 months' cut-off usually employed for classification and treatment purposes. We performed a cohort study using the eFACE tool for comparing triple innervation facial reanimation results in patients with EMG fibrillation treated <12 months, 12-18 months, and >18 months from paralysis onset. Patients showed a statistically significant post-operative improvement in all eFACE items, both in the whole sample and in the three groups. Only the deviation from the optimal score for the gentle eye closure item in group 2 didn't reach statistical significance (p = 0.173). The post-operative results were comparable in the three groups, as the Kruskal-Wallis test showed a difference only for the platysmal synkinesis item scores, which were significantly lower in group 3 (p = 0.025).