Custom made onlay implants in peek in maxillofacial surgery: a volumetric study.

PURPOSE: Facially malformed patients often present a variable degree of facial imbalance even after basal bone correction, and resolution of the residual hard- and soft-tissue deficiencies and asymmetries of the face are of great importance for achieving a satisfactory post-implant procedure result. The use of polyether ether ketone (PEEK) implants for maxillofacial reconstruction has been documented in the literature, but the number of patients who have received them is limited. The aim of this study was to evaluate the overall volumetric results in patients with facial imbalance after onlay custom implant positioning for mandible and fronto-orbital reconstructions. Analysis was performed by confronting volumes with the use of three-dimensional (3D) photogrammetry. METHODS: Fifteen patients were eligible for PEEK implant placements, eight for mandibular angle reconstruction, and seven for fronto-orbital reconstruction. Pre- and post-surgical 3D images of each patient's face were acquired. Facial asymmetry was analyzed by comparing each face with its mirrored copy. RESULTS: Three-dimensional analyses have shown that some degree of volume imbalance was still present in the patients with only 1.32 ± 1.02 mm residual discrepancy after treatment. CONCLUSION: Results of the study were found to fall within clinically acceptable limits since an asymmetry rate of < 3 mm is considered to fall into the norm.

Reconstruction of severe atrophic jaws with Fresh Frized Bone Allografts: clinical histologic and histomorphometric evaluation.

OBJECTIVES: Rehabilitation of maxillary edentulism with implant-supported prostheses has come into common clinical practice. Although autologous bone has osteoinductive, osteoconductive and osteogenetic properties, its use is subject to certain disadvantages such as: Increased morbidity Limited amount of bone harvested from each donor site. AIM: The aim of this study is to analyze clinical, histological and histomorphometric results of homologous bone for implantoprosthetic rehabilitation in severe atrophic jaws. PATIENTS AND METHODS: Twenty consecutive patients, 14 female and 6 males, were treated with homologous bone bank. Treatment protocol consist of: first surgycal step, trasversal and vertical volume restore, second surgycal step: screw remove, specimen biopsy and insert implant fixtures. RESULTS: Data show that Fresh Frozen Bone Allografts (FFBA) could be a valuable substitute for autologous bone, in as much as histological and histomorphometric results are widely overlapping. CONCLUSIONS: Homologous bone is a valuable option for its large availability with a low cost, good versatility, no morbidity at the donor site, shorter surgical time and hospital stay.

Case report of oligodontia: long term stability of orthognatic surgery and prosthetic rehabilitation.

Oligodontia may compromise the harmonious development of the masticatory system. The quantity and quality of agenesis determines the type of approach and the complexity of rehabilitative therapy. We present a case of a patient affected by oligodontia and maxillo-mandibular skeletal alterations, corrected by orthodontic and orthognatic surgical treatment, assisted by prosthetic-presurgical rehabilitation of the lower arch. After surgery the occlusion was finally restored by a definitive prosthesis modeled on the presurgical one and supported by the same residual dental elements. Photographic and cephalometric analysis have shown the stability of the results at 20 years follow-up. The case presented shows that the final prosthesis on the residual teeth in patients affected by oligodontia may represent a possible alternative to implanto-prosthetic rehabilitation, presenting lower cost and requiring less time for definitive occlusal rehabilitation.

Clinical experience with spiramycin in bisphosphonate-associated osteonecrosis of the jaw.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) consists of an exposure of the jaw bone that persists for over 8 weeks in patients with positive history for bisphosphonates. Symptomatology is characterized by dull and ceaseless pain, and in advanced stages, the exposure of necrotic bone is evident, which is frequently associated with purulent secretions and faetor oris. Despite many different studies on BRONJ, there are no general guidelines to treat this disease. In this work, the authors present their experience in BRONJ conservative therapy with spiramycin by comparing the results achieved with amoxicillin and clavulanic acid. From January 1, 2008 to June 30, 2008, our department received 25 patients who were affected by osteonecrosis secondary to bisphosphonates. Thirteen had taken bisphosphonates for osteoporosis and 12 for malignancies. We divided the 25 patients into two groups: those who had not received any treatment and those who had received treatment. The first group of 13 patients had been treated only with spiramycin (S). The results from this group were only evaluated to test the efficacy of spiramycin and were not considered in the study. The second group of 12 patients had not undergone any previous treatment. This group was further divided in two groups of 6 patients each; one group was treated with spiramycin and the other with amoxicillin and clavulanic acid (ACA). The following criteria were used to evaluate the results of the study: pain, sensibility deficits, purulent secretion and bone exposure. All group results were evaluated according to the criteria chosen, and positive results were achieved in both groups S and ACA, such as reduction or disappearance of pain, sensibility deficits and purulent secretion and healing of bone exposition, although spiramycin showed itself to be more effective than the combination of amoxicillin and clavulanic acid. Spiramycin is a macrolide antibiotic with a wide spectrum of activity against Streptococci, Pneumococci, Diplococci, Gonococci and Staphylococci, which are typical in BRONJ. No resistance was indicated. Administration of the antibiotics can be intravenous, intramuscular, rectal or oral, which remains the most frequently used since spiramycin elimination also occurs with saliva and the antibiotic reaches high concentrations in the oral cavity where BRONJ is situated. Good compliance to the spiramycin regimen was observed in all three groups, with a general improvement in all of the parameters considered. In only two cases did patients have to undergo surgical curettage. The results showed that spiramycin can be a first choice drug in the treatment of BRONJ, and it should be strongly considered for patients where previous antibiotic therapy did not prove to be effective.

Skeletal stability in orthognathic surgery with the surgery first approach: a systematic review.

The surgery first approach (SFA) is a therapeutic strategy used in orthognathic surgery that is constantly evolving. With this approach, the pre-surgical orthodontic treatment can be eliminated, the maxilla and the mandible are surgically repositioned into the desired position, and the therapy is ended with a short orthodontic phase. Several studies have reported that the SFA is an acceptable approach, but postoperative stability is unclear. In this study, a systematic review on the SFA was performed. The PubMed, Google Scholar, Scopus, LexisNexis, Web of Science, and Cochrane Library databases were accessed. Studies from which data could be extracted on skeletal stability based on specific cephalometric points were included. The search yielded 2766 publications. Application of the selection criteria resulted in a final group of 14 articles. Five hundred and sixty patients with class III malocclusion underwent orthognathic surgery, 339 with the SFA. Study parameters such as evaluation time points and reference planes varied, making it impossible to perform a meta-analysis. The studies suggest that surgery with the SFA is as stable as surgery with the conventional approach. However, all articles described stability using a penultimate time point of 'after surgery' and not 'after debonding'; hence orthodontic movements and consequent mandibular movements could have influenced cephalometric measurements. Thus, to verify the real stability of the SFA, further research with longer follow-up periods is required, with evaluation at the same time points.

Trismus-pseudocamptodactyly syndrome: case report ten years after.

BACKGROUND: In 1969, Hecht and Beals described for the first time a rare dominant autosomal syndrome characterised by reduced mouth opening, pseudocamptodactyly, short stature, and foot deformities. Recent studies have confirmed that TPS is caused by a mutation of MYH8 that is common to another disease called Carney syndrome. CASE REPORT: The authors describe the long term follow-up of a case presented in 2003, ten years after the first surgical procedure: a 14-year-old girl, affected by this rare syndrome, had underwent an early (at 4 years) surgical treatment of bilateral coronoidotomies to ensure safe airway management to allow subsequent surgical treatment to correct foot deformities. After six years, a complete relapse of the trismus occurred. Three years later, the patient underwent a second surgery of bilateral coronoidotomies to definitely solve trismus. At the 18 months follow-up, the mouth opening was stable.

Horizontal and vertical ridge augmentation for implant placement in the aesthetic zone.

Lack of sufficient bone to place an implant at the functionally and aesthetically most appropriate position is a common problem, especially in the upper anterior jaw. A surgical technique is proposed to augment the alveolar ridge for vertical and horizontal defects through a localized alveolar osteotomy and interpositional bone graft. Three bone cuts (two vertical and one horizontal) are made in the alveolar bone. This portion of bone is carefully down-fractured. The gap between this bone box and the alveolar bone is filled with an interpositional bone graft. An on-lay bone graft is placed in the buccal side of the defect and fixed with titanium osteosynthesis screws. The aim of this surgical technique is to achieve bone graft healing in a short period of time. The broad vascular pedicle on the palatal side is maintained to ensure a nutritional supply for the down-fractured bone and interposed bone graft. The on-lay bone graft augments the palatal-buccal dimension and the interposed graft guarantees vertical augmentation.

Trismus-pseudocamptodactyly syndrome: a case report.

BACKGROUND: Hecht and Beals in 1969 described an autosomal dominant syndrome characterised by severe restriction of mouth opening, camptodactyly, shortness of leg muscles and, as a direct consequence, foot deformities. CASE REPORT: A case of a 4-year-old girl affected by this unusual syndrome is described. The patient underwent bilateral resection of coronoid processes by intraoral approach. An intraoral device was used in the immediate postoperative period in order to maintain mouth opening. Once at home, the patient has had, for six months, phisiokinesic therapy by means of a modified Darcissac device.

[The use of Bichat's fat pad in temporomandibular joint surgery. First evaluation]. / L'utilizzo della bolla di Bichat nella terapia chirurgica dell'anchilosi dell'articolazione temporomandibolare. Prime valutazioni.

BACKGROUND: The study aimed to evaluate the possibility of using Bichat's fit pad as a free graft in the surgical treatment of ankylosis of the temporomandibular joint. METHODS: A retrospective study with a follow-up from 9 to 12 months was performed in six patients with ankylosis of the temporomandibular joint, for a total of nine joints treated at the Maxillofacial Surgical Unit of George Eastman Hospital in Rome. Five joints were treated using Bichat's fat pad and four with a myofacial flap of temporal muscle. Surgery was performed under general anesthesia. The ankylotic block was removed through a preauricular access and a graft was then inserted between the operated bone surfaces. All patients underwent a complete clinical examination to record maximum jaw aperture, lateral movements and protrusion. The following X-rays were also performed: tooth arches, bilateral temporomandibular stratigraphy in PA and LL projections,; with mouth open and closed, and CT using an axial and coronal projection. RESULTS: The tests showed good functional recovery of the joint after arthrotomy and free pad graft. No patient showed lateral deviation in maximum aperture or postoperative malocclusion. CONCLUSIONS: The technique used was simple and represents a valid alternative to other solutions. It is mainly indicated in the event of coronoidectomy concomitant to the removal of ankylosis or if the temporal muscle is not available.

[The use of osteodistraction in treatment of ankylosis of the temporomandibular joint. A case report]. / L'utilizzo dell'osteodistrazione nella terapia chirurgica della anchilosi dell'articolazione temoromandibolare. Presentazione di un caso clinico.

The authors evaluate the possible use of osteodistraction techniques to restore the vertical dimension of the mandibular ramus after reduction during surgical treatment of TMJ ankylosis. They report the case of a fully grown female patient with monolateral right TMJ ankylosis following previous fracture injury who was treated at the Maxillofacial Surgery Unit of George Eastman Hospital in Rome. The patient underwent removal of the ankylotic block and the concomitant restoration of the vertical dimension of the mandibular ramus achieved using subperiosteal osteodistraction. Bichat's bubble flap was used as the interarticular interposition material. The distractor was activated one week after surgery with daily increments of 1 mm for a total of 7 days. Clinical and instrumental tests performed after the removal of the distractor and after a cycle of physiotherapy confirmed the good functional recovery of the joint and the restored vertical dimension of the mandibular ramus. The authors affirm that the method used represents a valid alternative for correcting loss of height after extensive resection of ankylotic joint processes in fully-grown patients.

Augmentation of the atrophic edentulous mandible by a bilateral two-step osteotomy with autogenous bone graft to place osseointegrated dental implants.

Extensive resorption of the mandible increases the interarch space and rehabilitation with traditional dentures is often unsatisfactory due to the superficialization of intraoral muscles. A study of 19 patients who underwent augmentation of an atrophic mandible using a bilateral two-step osteotomy and interpositional bone graft technique is presented. Three horizontal bone cuts (one in the intraforamina and two in the molar region) were made and jointed together by two short vertical bone cuts mesialy to the mental nerve. The cranial fragment was lifted and the iliac bone graft was interposed recreating the correct intermaxillary relationship. A broad vascular pedicle was maintained during surgery, ensuring nutrition from the lingual side, essential to reduce resorption of the bone graft and cranial fragment. 141 Biomet 3i Osseotite((R)) implants were placed. Patients were rehabilitated with a full-arch implant-supported fixed prosthesis or an implant-supported overdenture. This clinical study describes the resorption process over a 4 year follow-up. 3 of 19 suffered from persistent neurosensitive disturbances. In conclusion, bilateral two-step osteotomy in association with interpositional bone graft is a reliable surgical means to recreate the anatomical morphology of the mandible.

Surgical treatment of severe athropic maxilla by means of multiple extraoral harvesting.

AIM.: The aim of the present clinical study is to evaluate the efficacy of autologous bone multiple harvesting in the surgery of the severe atrophic maxilla, in term of quantity and quality of the grafts for the following implant-supported prosthesis treatment. MATHERIAL AND METHOD.: For 5 patients a combined on-lay bone grafting and bilateral sinus lift elevation procedure was performed under general anesthesia. Harvesting site was anterior iliac crest and calvaria. Clinical and radiographic (Rx-OPT and CT Dentascan) examinations were performed to evaluate the bone defects and to programme surgical treatment and during the follow up. RESULTS.: Postoperative complications' evaluation showed no significative problems. Radiographic controls at 4 months showed a minimum or no resorption of calvaria harvesting. CONCLUSION.: In the reconstruction of the severe atrophies of the alveolar edentoulus crests, a multiple extra-oral harvesting seems to improve quality and quantity of bone graft, so that the following implant-supported prosthesis treatment is facilitated.

Segmental Le Fort I osteotomy with bone grafting in unilateral severely atrophied maxilla.

This study describes the use of a segmental Le Fort I osteotomy for interpositional autogenous iliac bone grafts in 5 patients with severe unilateral atrophy of the maxilla. Unilateral pterygomaxillary disjunction and osteotomy of the lateral and medial walls of the maxillary sinus were performed. The mucosa of the maxillary sinus was preserved and lifted cranially. It was stabilized with autogenous cancellous bone grafts. One side of the maxilla was gently downfractured until it replaced the original morphology of the alveolar crest. The inter-arch space was therefore reduced to the ideal level for placing implants. Lateral widening of the alveolar crest was obtained with on-lay bone grafts. Segmental osteotomy with bone grafting is a modification of Le Fort I swing osteotomy that has several advantages. The in-lay graft was not resorbed because it was rapidly revascularized and implant placement was delayed. This article presents a surgical technique for the reduction of vertical inter-arch space for the correct positioning of osseointegrated implants.