Our experience in complications of orthognathic surgery: a retrospective study on 3236 patients.

BACKGROUND AND OBJECTIVES: From 1989 to 2009, at the Department of Cranio-Maxillo-Facial Surgery, Umberto I Polyclinic, "Sapienza" University of Rome, 3236 patients affected by maxillo-mandibular malformations were submitted to orthognathic surgery, by means of rigid internal fixation. Follow-up highlighted the surgical complications and the possible functional and/or esthetical disorders in the treatment of those pathologies. The data collected have been compared with the ones reported in the literature. MATERIALS AND METHODS: 3236 patients were evaluated clinically and radiographically. The X-rays have been performed before the study, after 24-48 hours, at 6 months and year after surgery. RESULTS: The most frequent surgical complication was the mandibular nerve sensitivity deficit (19%), irreversible only in 2% of the cases. Temporomandibular joint disorders (TMD), which are widely reported in the international literature, have been relevant in our study too. In particular, TMD occurred in those patients who were already affected by the disorder (from 28.3% to 18.1%); besides, in 11% of cases the symptom appeared after surgery and was treated by means of splint or physiotherapy. Infectious complications occurred in 2% of cases and fractures of the bone elements in 1.5% of cases. The other complications quoted internationally occurred in an irrelevant percentage in our study. CONCLUSIONS: We believe that orthognathic surgery complications are quite rare and the percentages reported both in our study and in the literature have to be considered as surgical mistakes related to the surgeon experience or as real complications of the orthognathic surgery. Furthermore, as the success of this kind of surgery depends upon many factors, surgical complications represent only one of the causes of the failure. Other causes could be mistakes in planning, unsuitable orthodontic treatment and, finally, an unsuitable assessment of the patients' esthetical and functional problems.

Use of irradiate animal pericardium membrane for prevention of Frey's syndrome after parotidectomy.

BACKGROUND: Frey syndrome is a common complication that appears few months after parotid surgery with flushing and sweating of the parotid-temporal area during mastication. It presumably originates from an aberrant nervous regeneration in which the parasympathetic fibers of the parotid gland would combine themselves with the sympathetic fibers of the sweat glands and with the cutaneous vessels. AIM: In the present study we analyze the effectiveness of a collagenous membrane derived from animal pericardium (APM) to prevent Frey's syndrome after parotidectomy. MATERIALS AND METHODS: We studied a total of 40 patients with benign tumors of the parotid gland, including 30 patients with pleomorphic adenoma, 7 patients with Warthin tumor and 3 with basal cells adenoma. The patients were divided into 2 groups: group 1 (experimental n=20) executed superficial parotidectomy with replacement of bovine pericardial matrix (BPM); group 2 (control n=20) underwent superficial parotidectomy followed by reposition of superficial musculoaponeurotic system (SMAS) flap. All patients were questioned over their subjective symptom and tested with Minor's test after 12 months from the intervention and introduced in a follow-up of 3 years. RESULTS: Subjectively Frey syndrome was referred in 5% of patients in group 1 and in 10% in group 2, while 0 cases were observed in group 1 after the starch-iodine test, 2 cases in group 2 (10%). CONCLUSIONS: Considering the present results, although this study needs further implementation, we can affirm that BPM is a valid option in preventing Frey's syndrome whereas SMAS flap is not available.

An orbital roof and anterior skull base fracture: case report.

Blow-out fractures usually involve the orbit in the floor or in the medial wall. Anyway, if the roof of the orbit is thin and direct compressive or buckling forces impact the orbit the fracture can involve the upper roof. We describe the case of a blow-out fracture of the orbital roof with enophtalmus and cerebrospinal fluid leak from lacero-contusive subciliar wound

A retrospective analysis of the headache associated with temporomandibular joint disorder.

BACKGROUND: Headache is a common symptom, that can be extremely disabling, affecting 26 million of patients only in Italy. ICHD-II has reported two categories: "primary headaches" and "secondary headaches". Temporomandibular joint disorders can lead to a secondary headaches. AIM: We want to evaluate the prevalence and clinical features of headache among a series of patients having temporomandibular joint disorders and we illustrate the evolution of headache following medical treatament of temporomandibular joint (TMJ) disorders. MATERIALS AND METHODS: This is a retrospective study carried out on chart review of 426 consecutive patients with various degrees of temporomandibular disorders and treated with medical devices from 2007 to 2011. RESULTS: Headache was reported by 73 patients (17.14%). Headache was observed in 36 of 51 patients with lock and in 32 out of 130 patients with mandibular deflections (Table I). The remaining 5 patients with headache had articular noise. CONCLUSIONS: Headache is not a rare finding in a population with temporomandibular dysfunctions and is more often a tension-type rather than trigeminal headache.

Le Fort III osteotomic variants.

INTRODUCTION: Midface hypoplasia is a skeletal defect involving all three space planes, hence needing a three-dimensional repositioning. This research study shows two cases of cranio-facial dysostosis, on which two Le Fort III variants were performed. CASE REPORT: In the first case we report the performing the two types of osteotomy simultaneously. Le Fort I, however, has been performed without any pterygomaxillary disjunctions, thus accomplishing a complete midface mobilization without any variation of the occlusal ratios. In the second case a modified Le Fort III osteotomy has been performed with median disjunction; reduction of the transverse interdacryal diameters and of the pyriform opening. DISCUSSION: Among all osteotomic variants we would like to mention the one introduced by Obwegeser in 1969 where, in patients with acceptable dental occlusal ratios, Le Fort III and Le Fort I have been performed in conjunction. This technique allows a different midface and dental occlusion repositioning. CONCLUSIONS: In adult patients with permanent dentition and normal occlusal ratios this technique may be chosen for a midface advancement without compromising the dento-skeletal relations, in order to achieve the best functional and aesthetical results.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ): 5 year experience in the treatment of 131 cases with ozone therapy.

BACKGROUND: Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) are the result of the assumption of such drugs. The most widely used molecules are pamidronate and zoledronic acid, which are pyrophosphate analogues and are usually given to patient with bone remodelling diseases. International literature reports showed an association between this therapy and avascular necrosis, thus leading to review the guidelines for their administer. AIM: The authors present their protocol based upon medical treatment, antibiotic and antimycotic, together with minimally invasive surgery and ozone therapy developed after a 5 year experience to assess the viability of this treatment. MATERIALS AND METHODS: In the last years researchers studied treatment protocols, both medical and surgical, for the management of BRONJ. Among these Ozone therapy is being adopted by several centers. From February 2004 and December 2010 a total number of 131 patients affected by BRONJ have been observed. Collected data include patients' age at the time of disorders, gender, presenting signs and symptoms, primary diagnosis, type and characteristics of the treatment performed, radiological findings and post-treatment results. CONCLUSIONS: At the present time there are no major guidelines in international literature for the treatment of BRONJ, the Authors then propose a therapeutic protocol based upon minimally invasive surgery, antibiotic and anti mycotic therapy with the adoption of ozone as regenerating factor for tissues. In 90% of the cases the results confirmed the procedure with successful outcomes.

The development of CD4+ T effector cells during the type 2 immune response.

Multiple pathways may be involved in the development of interleukin 4 (IL-4) producing T helper (Th) cells and the associated type 2 immune response. Increasing evidence suggests that the strength of signals delivered to the T cell may favor the development of the type 2 response. In contrast, antigen-presenting cell- (APC) derived stimuli produced following pattern recognition receptor binding during the innate response promotes the development of interferon-gamma (IFN-gamma) producing cells and the associated type 1 immune response. In many cases, the balance between increased signaling strength and the innate response may determine whether the type 2 response develops. T cell receptor (TCR), CD4, and costimulatory molecule interactions may all contribute to signal strength, but the type 2 immune response may be particularly dependent on the availability of coreceptor and costimulatory molecule interactions. B7 ligand interactions are required for the development of the type 2 immune response and interaction of CD28 with either B7-1 or B7-2 can provide sufficient signals for its initiation. In B7-2-deficient mice, the initial type 2 immune response is intact, but the response is not sustained, suggesting that B7-2 is important at later stages of the type 2 immune response. The roles of CD28 and CTLA-4 during the type 2 response remain unclear. The type 2 response to infectious pathogens is pronounced in CD28-/- mice, suggesting that other costimulatory molecule interactions can substitute for CD28 for the development of IL-4 producing T cells and the associated type 2 immune response.

Do effector and memory T helper cells also need B7 ligand costimulatory signals?

Blocking B7 ligand-costimulatory molecules can inhibit a primary T-dependent immune response, but whether these interactions also mediate ongoing or memory immune responses is less clear. Development of immunotherapies based on blocking B7 ligand interactions would be limited if they were effective only at the initiation of an immune response. We discuss the conditions under which T helper effector and memory cells may or may not require B7 ligand interactions for their function.

IL-13-mediated worm expulsion is B7 independent and IFN-gamma sensitive.

B7 costimulation is a required component of many type 2 immune responses, including allergy and protective immunity to many nematode parasites. This response includes elevations in Th2 cytokines and associated effector functions including elevations in serum IgG1 and IgE and parasite expulsion. In studies of mice infected with Trichuris muris, blocking B7 ligand interactions inhibited protective immunity, suppressed IL-4 production, and enhanced IFN-gamma production, but unexpectedly did not inhibit production of the Th2 cytokine, IL-13. Blocking both IFN-gamma and B7 restored protective immunity, which was IL-13 dependent, but did not restore IL-4 or associated IgE responses. Although IL-13 was required for worm expulsion in mice in which both IFN-gamma and B7 were blocked, IL-4 could mediate expulsion in the absence of both IL-13 and IFN-gamma. These studies demonstrate that 1) B7 costimulation is required to induce IL-4, but not IL-13 responses; 2) IL-13 is elevated in association with the IFN-gamma response that occurs following inhibition of B7 interactions, but can only mediate IL-4-independent protection when IFN-gamma is also inhibited; and 3) increased IL-13 production, in the absence of increased IL-4 production, is not associated with an IgE response, even in the absence of IFN-gamma.