Titanium Internal Fixator Removal in Maxillofacial Surgery: Is It Necessary? A Systematic Review and Meta-Analysis.

Titanium plates and screws are essential devices in maxillofacial surgery since late 1980s, but despite their wide use there is no consensus in titanium internal fixators removal after bone healing. A systematic literature review and meta-analysis were conducted on seventeen retrospective studies. Effect size and 95% confidence intervals were calculated for plate removal (per plate and per patient) and for removal causes (infection, pain, screws complications, exposition, palpability). Odds ratio, 95% confidence intervals, and χ 2 test were measured for sex, smoking, and implant site. Heterogeneity was evaluated with Cochran and Inconstancy test. Obtained data were used to design Forest and Funnel plots. The aim of the study is to identify and clarify reasons and risk factors for plates and screws removal. Infection is the most frequent reason; the habit of tobacco usage and implant site (mandibula) are the main risk factors. The administration of antibiotic prophylaxis is essential, and patients must quit smoking before and after surgery. In conclusion there is no scientific evidence supporting the removal of internal devices as mandatory step of the postoperative procedure.

The Role of a Deep Neuromuscular Block in the Treatment of Mandibular Subcondylar Fractures.

ABSTRACT: Mandibular fractures are the third most frequents maxillo-facial fractures. Most frequent site is the subcondylar region. Different approaches to reach subcondylar region, have been described. In the study was evaluated the advantages of neuromuscular block during endoscopic surgery for subcondylar fractures. Twenty-five patients affected by subcondylar fractures were enrolled in this study and divided in 2 groups; group A: patients who received an intraoperative booster of curare during surgical procedure and group B patients who underwent surgery treated without the intraoperative booster of curare. All patients were treated successfully by endoscope-assisted transoral approach. The analysis of time required for surgery showed a reduction in group A comparing to group B. The mean time for surgery for the patients in group B with displacement between 0° and 45° was 170 minutes, and for 45° to 90° was 230 minutes. In group A, the mean time was 117.5 minutes for patients with condylar displacement between 0° and 45°, and 147.5 minutes for the other group. In conclusion, deep neuromuscular block seems to improve the surgical conditions in patients undergoing subcondylar endoscopic assisted surgery, further study needs to assess this surgical technique in order to better define this surgical protocol.

Anthropometric Parameters for Nose Evaluation and Nasal Surgery Planning.

BACKGROUND: The esthetic characteristics of face and nose are commonly evaluated before rhinoplasty using a completely subjective method, due to the lack of validated and reliable methods for quantifying facial esthetics and for accurate nose treatment planning. The aim of the study was to review the literature to determine and evaluate the points, distances, and angles commonly used in the treatment planning for rhinoplasty. METHODS: Research based on anthropometric studies of the face and nose, published from 1987 to 2018 was included. Finally, 138 papers were selected after a statistical analysis through a simple random and non-random sample selection, and all papers were evaluated in their entirety. RESULTS: According to the frequency of citation, 198 points, 336 distances, and 199 angles were listed. The first quartile of each distribution was eliminated, and frequency of more than 25% was selected. A group of 49 points, 77 distances, and 11 angles, were classified according to their anatomical region, that is, bone and soft tissues, was obtained. CONCLUSIONS: An enormous inhomogeneity and lack of standardized anthropometric measurement system, specifically of the nose, was evident, as the studies were conducted by authors of different origins. According to universally accepted parameters, the importance of a reliable method for nose surgery planning is highlighted.

Guidelines and Recommendations for Patient Management, Surgical Activities, and Safety in the Maxillofacial Unit and Head and Neck Department During COVID-19 Pandemic.

The recent pandemic has led to an unprecedented overload of sanitary systems around the world. Despite that a maxillofacial department is not a frontline specialty in the treatment of coronavirus disease 2019 infections, our department has found itself faced with numerous problems in keeping the care system active and efficient while ensuring safety for patients and healthcare professionals. Massive redistribution of health personnel was needed to improve prevention and personal safety measures. The education and training system has been kept active, giving residents a decisive role in managing the state of emergency response. This article outlines new guidelines for infection prevention: from clinical control, treatment processes, clinical management, protection, and disinfection of healthcare professionals.

Nasal mucosa healing after endoscopic sinus surgery in chronic rhinosinusitis of elderly patients: role of topic alpha-tocopherol acetate.

BACKGROUND: Chronic rhinosinusitis (CRS) in European country ranges in elderly patients from 4.5 to 12% of population and has a significant effect on quality of life. In these patients, rhinosinusitis is linked to immune functions changes with age and to mucosal paraphysiological alterations such as crusting formations with atrophic epithelium, variations of nasal airflow and modifications of the mucociliary clearance. Failure of medical treatments leads to surgery in patients with persistent symptoms and radiographic signs of CRS. The choice of appropriate post-surgical topic treatments is important for healing time and for preventing mucosal complications such as synechiae, crusting formation and atrophy with secondary bacterial and fungal infections. AIMS: Defining the effects of topic alpha-tocopherol acetate administration on nasal mucosa healing after endoscopic sinus surgery in CRS of elderly patients. METHODS: In this study were included 32 patients, mean age 68.6, who underwent FESS because affected by CRS not responsive to medical treatments. After surgical treatment, we distinguish two groups basing on local nasal therapy. RESULTS: We investigated, in the postoperative time, the role of alpha-tocopherol acetate compared to gomenol oil. Follow-up was performed at 7-15 days and 1-3 months after surgery. We evaluated mucosal restoration using Rhinoscopy Sum Score and quality of life using Nasal Six Items Symptom Questionnaire. We observed a faster healing time and less recurrence of complications in patients who underwent topic treatment with alpha-tocopherol acetate. DISCUSSION: In our research, we observed that alpha-tocopherol acetate has no contraindications and side effects. CONCLUSIONS: Our study showed the effectiveness of alpha-tocopherol acetate topic treatment in elderly patients affected by CRS after FESS, in improving and speeding up the process of restoring the sinonasal mucosa, compared to another topic medication.

Surgical evolution in the treatment of mandibular condyle fractures.

BACKGROUND: In Literature fractures of the mandible that involve the condyle ranges from 20% to 35% and various possible surgical options are described according to the varying pathological situations. Up to the present, numerous techniques have been used for the surgical treatment of condylar fractures. In this article we are proposing the combination of two surgical techniques as therapy for extra-capsular condylar fractures with dislocation. METHODS: From June 2003 to July 2007 30 patients were treated for condylar fractures with the application of a Rigid External Fixator under endoscopic assistance. This method includes a surgical reduction of the fracture with the aid of an endoscope, performing a transcutaneous insertion of a Rigid External Fixator to stabilize the fracture. RESULTS: Out of the total number of patients, 28 reached an optimal result without the need for temporary immobilization of the temporal mandibular joint and pre-auricular cutaneous access, thanks to the decisive aid of the video-endoscope. CONCLUSIONS: The endoscope allows perfect control over both the positioning of the external fixator and the surgical reduction, restoring the normal movement of the mandible with a return to full anatomical functioning of the temporo-mandibular joint. This approach avoids possible damages to the facial nerve branches. The rigid external fixation system is better than an internal one, because it is less restrictive in precise anatomical reduction, since with an REF the condylar fragment is kept in the correct anatomical position but is not obliged to maintain that exact position, and therefore it is possible to carry out all the repair mechanisms listed above. Endoscopic assistance allows a good positioning control of the REF although the endoscopy permits an optimal control of the condylemeniscal complex mobility after REF application.

Autologous fat grafting in facial volumetric restoration.

The authors reported their surgical experience about structural fat grafting in the management of facial volumetric deficit. The purpose of this study was to assess the real indications, cosmetic results, complications, and global patient satisfaction of the Coleman technique in redefining facial contours in congenital and postoperative deformities. A retrospective analysis of 32 patients grafted according to Coleman's technique was performed, and the long-term outcomes and patient satisfaction were evaluated. The mean postoperative clinical follow-up was 14 months. The morphological changes were analyzed by comparing the photographic presurgical facial contour and the postoperative correction of soft tissue defects. All consecutive cases reported showed a progressive fat resorption for 3 months after surgery and its stable integration only after this period. Best results were performed in the treatment of genetically determined syndromes, such as the Franceschetti and Romberg syndromes. The authors suggest this surgical technique also for the treatment of unaesthetic cutaneous abscess cavity after incision and drainage. Unsatisfactory outcomes were obtained in the treatment of the posttraumatic facial scar, which needed more surgical procedures.

Open reduction and internal fixation of extracapsular mandibular condyle fractures: a long-term clinical and radiological follow-up of 25 patients.

BACKGROUND: During the last 2 decades, many studies on the treatment of mandibular condyle fracture have been published. The incidence of mandibular condyle fractures is variable, ranging from 17.5% to 52% of all mandibular fractures. This retrospective study evaluated the long-term clinical and radiological outcomes after surgical treatment of 25 patients with a total of 26 extracapsular condyle fractures. METHODS: We used 2 types of surgical approaches, the retromandibular retroparotid or preauricular approach. Three kinds of rigid internal fixation plates were used-single plate, double plate, and trapezoidal plate. The following post-operative clinical parameters were evaluated: dental occlusion, facial nerve functionality, skin scarring, and temporomandibular joint functionality. All patients underwent post-operative orthopanoramic radiography and computed tomography. The patients were also monitored for complications such as Frey's syndrome, infection, salivary fistula, plate fracture, and permanent paralysis of the facial nerve; the patient's satisfaction was also recorded. RESULTS: Of the 25 patients, 80% showed occlusion recovery, 88% had no facial nerve injury, and 88% presented good surgical skin scarring. The patients showed early complete recovery of temporomandibular joint functionality and 72% of them were found to be asymptomatic. The postoperative radiographs of all patients indicated good recovery of the anatomical condylar region, and 80% of them had no postoperative complications. The average degree of patient satisfaction was 8.32 out of 10. Our results confirm that the technique of open reduction and internal fixation in association with postoperative functional rehabilitation therapy should be considered for treating patients with extracapsular condylar fractures. CONCLUSION: The topic of condylar injury has generated more discussion and controversy than any other topic in the field of maxillofacial trauma. We confirm that open reduction and internal fixation is the treatment of choice for patients with neck and sub-condylar mandibular fractures.

Development and validation of the quality-of-life adolescent cleft questionnaire in patients with cleft lip and palate.

Only a few reports in the literature have described the use of specific instruments for assessing the quality of life in adolescents and young adults with cleft lip and palate (CLP). This condition markedly affects their lifestyle, even after surgical treatment. In the present study, we aimed to develop a quality-of-life assessment tool specifically designed for such patients with CLP. Our multidisciplinary team created a questionnaire focused on the physical, psychological, and social satisfaction of adolescents and young adults with CLP, which was adapted from 3 dimensions of the 36-item Short-Form Health Survey. The questionnaire was administered to a randomized sample of 40 adolescents and young adults (aged 16-24 years) with CLP who had completed treatment protocols and 40 (aged 16-24 years) who were not affected by CLP. The statistical results stated that the questionnaire had good reliability and validity; the Cronbach α coefficient was found to be 0.944. Moreover, factorial analysis confirmed the presence of 3 subscales that were the fundamental components of this questionnaire, which is consistent with the areas theoretically proposed and from which the items were designed and selected. Thus, we validated our novel questionnaire that was administered in the present study and proved its consistency. However, further investigations on a larger population would be useful to confirm these findings.

Piezoelectric bone surgery in the treatment of an osteoma associated with an impacted inferior third molar: a case report.

Operative removal of impacted mandibular third molars is a common and not riskless surgical procedure. We present an emblematic case of an osteoma closely associated with an impacted third left mandibular molar treated by Mectron Piezosurgery medical ultrasonic device.

Surgical management of Warthin tumor: long-term follow-up of 224 patients from 2002 to 2018.

PURPOSE: Warthin tumors (WT) are the second most common benign parotid gland neoplasms. They can occur as synchronous or metachronous lesions in 6-10% of cases. This study aims to compare the complication rate in 224 patients who underwent extracapsular dissection (ECD) or superficial parotidectomy (SP) for the treatment of a WT. METHODS: This retrospective study was conducted at the Department of Maxillo-Facial Surgery at the University of Naples "Federico II" from February 2002 to December 2018 on a group of patients who underwent surgical treatment for WT. The type of surgical technique was chosen based on Quer's classification. The complications evaluated were facial nerve palsy, hematoma, Frey's syndrome, and bleeding. RESULTS: A total of 224 patients treated from 2002 to 2018 for Warthin tumor were included in the study. Two hundred elven had solitary tumors (94.1%) and 13 had multicentric lesions (5.8%), of which 9 cases presented synchronous lesions and 4 cases presented metachronous lesions. Extracapsular dissection (ECD) was performed in 130 patients (58.3% of cases) and superficial parotidectomy (SP) in the other 94 (41.7% of cases). CONCLUSIONS: We consider both surgical techniques as valid. In our opinion, it is essential to study each case based on Quer's Classification to obtain the best surgical outcome. Based on a lower observed rate of complications such as facial nerve palsy, Frey's syndrome, and bleeding, ECD seems to be the best option for the surgical treatment of Quer Class I lesions.

Efficacy of auriculotherapy in the control of pain, edema, and trismus following surgical extraction of the lower third molars: a split-mouth, randomized, placebo-controlled, and triple-blind study.

BACKGROUND: The aim of this split-mouth, randomized, placebo-controlled, and triple-blind study was to evaluate whether auriculotherapy had any effect on the post-operative course after the extraction of third molars in terms of the control of pain, edema, and trismus. MATERIALS AND METHODS: The study included 42 patients (84 teeth) who had undergone a surgical extraction of the lower third molars. In each patient, the two extractions were randomly assigned to two study groups. In the therapy group, the patients underwent auriculotherapy with vaccaria seeds applied with patches in 6 ear points. In the control group, the patches were applied, without seeds, to the same ear points. After the extraction, the patients were asked to stimulate the ear points three times a day and whenever they felt pain. The patients were asked to keep a diary in which they assessed their pain by means of the Visual Analog Scale (VAS) for 8 days. Edema and trismus were assessed 1, 2, 3, and 8 days after surgery. RESULTS: The differences between the two groups were statistically significant at the 12-h control (auriculotherapy group (AG) VAS 5.5 [IQR 4.25-6.75], placebo group (PG) VAS 6 [IQR 5-8], p = 0.040), after 24 h (AG VAS 5 [IQR 4-6], PG VAS 6 [IQR 4.25-7], p = 0.024), after 2 days (AG VAS 4 [IQR 3-5], PG VAS 4.5 [IQR 4-6], p = 0.044), and after 3 days (AG VAS 3 [IQR 0-5], PG VAS 4 [IQR 3-5], p = 0.024). Throughout the observation period, the AG took a significantly lower number of painkillers than the PG (AG 6 [IQR 4.25-7]; PG 8 [IQR 8-9], p < 0.001). There were no significant differences in the levels of edema and trismus between the two groups throughout the observation period. CONCLUSIONS: On the basis of the results of the present study, auriculotherapy can be considered as a cost-effective adjuvant pain reliever treatment in patients undergoing an extraction of the lower third molars.

Effects of serial swabs on the nasopharyngeal mucosa: our experience in SARS-CoV2 screening.

INTRODUCTION: The purpose of the study was to analyze the effect of swabs on nasal mucosa. METHODOLOGY: Since May 2020, our department was responsible for screening coronavirus disease 2019 (COVID-19) among the employees of a company that continued its activity during the pandemic. The screening protocol consisted of two swabs per week. The samples were analyzed through objective endoscopic and subjective clinical evaluations with sino-nasal outcome test (SNOT Test) at three time points (T0, T1 - three months, T2 - six months). RESULTS: 23.76% of patients showed an increase in the SNOT score at T1, and the score decreased at T2. This could be due to the phenomenon of "adaptation" of the nasal mucosa. Endoscopic control showed that at T1, secretion, hyperemia, and edema are the most common signs. At T2, however, the crusts accounted for 52.94% of all damage. It is evident that at T1 the endoscopically detected signs of "acute" damage were more represented than at T2, while the signs of "chronic" damage increased as the number of swabs increased. CONCLUSIONS: We demonstrated that mucosal damage and perceived symptoms were absolutely acceptable compared to the diagnostic advantage obtained with serial screening.

Full-arch rehabilitation of severely atrophic maxilla with additively manufactured custom-made subperiosteal implants: A multicenter retrospective study.

The aim of this retrospective study was to analyze a series of patients who underwent full-arch rehabilitation of the atrophic maxilla using additively manufactured subperiosteal implants, between August 2018 and January 2023, at the Universities of Sassari and Poznan. In total, 36 patients and 72 implants were included, with no implants lost during follow-up, and a success rate of 90.3%. Seven (9.7%) of the implants showed class 1 exposure. Bleeding on probing was detected in 10.4% of the abutments at 6 months, 7.9% at 1 year, 10% at 2 years, 7% at 3 years, and 11.4% at 4 years. No significant bone resorption under the abutments was detected during the whole observation period. Based on the findings from this study, additively manufactured subperiosteal implants could represent a safe and reliable technique for full-arch rehabilitation in patients with severe maxillary atrophy.

In house 3-D printed surgical guide for frontal sinus osteotomy in traumatology: A technical note.

Frontal sinus surgery and particularly frontal sinus osteotomy represent historically a procedure demanding precision and careful planning. Achieving optimal results while minimizing complications requires meticulous preoperative planning and execution. Cutting guides are crucial tools in surgical procedures, particularly in complex osteotomies like could be those involving the frontal sinus. The aim of the study is to show the worflow for the in-house custom made cutting guide for secure and accurated frontal sinus approach. Given the simplicity, efficacy, rapidity, and safety of the procedure, the workflow for programming the cutting guide can be considered valid for all surgical procedures that contemplate performing an osteotomy on the anterior wall of the frontal sinus, such as trauma pathology, inflammatory naso-sinus pathology, benign or malignant neoplastic pathology, and craniofacial malformation pathology.

Epidemiological analysis of the facial fractures pattern in relation to motorcycle helmet type: A retrospective study on 282 patients.

Most maxillofacial traumas are caused by road traffic collisions and, in particular, by motorcycle accidents. Helmets represent an efficient protective tool in these traumas but they do not provide complete protection. The aim of this study was to perform an epidemiological analysis of facial fractures pattern in relation to the helmet type worn during the accident. The study was a retrospective analysis of 282 patients with a diagnosis of maxillofacial fracture caused by a motorcycle accident. The patients were divided in three groups based on helmet type (Group A: full-face helmet; Group B: modular [half-face] helmet; Group C: open-face helmet). For each group, fractures type and trauma severity, using the Comprehensive Facial Injury (CFI) scale, were recorded. Results showed that isolated midface fractures were strongly related to full-face helmet wearing (p < 0.001), while mandibular fractures and panfacial trauma/combined fractures were negatively correlated (p < 0.001). Mandibular fractures (p < 0.001) and panfacial trauma/combined fractures (p < 0.001) were strongly related to open helmet. Moreover, severe trauma (CFI 8.16) was recorded for open-face helmet wearing. In conclusion, full-face helmet wearing reduced the risk of facial fracture, in particular panfacial trauma/combined fractures, while open-face helmet wearing increased the risk of these fractures.

The "canine first technique" in maxillary impacted canines: analysis of the treatment duration and success of therapy.

Objectives: The goal of the study was to analyze the eruption time of the maxillary impacted canines treated with the "canine first technique" and evaluate the success rate. Materials and methods: A total of 103 patients with 131 impacted canines were treated. Alpha angle, Erickson-Kurol sectors, and age were studied to assess the difficulty of canine eruption. All the canines were treated with the "canine first" approach. The median follow-up time was evaluated using the Kaplan-Meier inverse procedure. The primary outcome (canine eruption time) was analyzed using Kaplan-Meier curves. The curve comparison between the different known risk factors was made using the log-rank test. The median eruption time (95% confidence interval) was calculated for each result. Results: The majority of the canines (66.4%) were placed palatally and positioned in sector 3 (30.16%). The median alpha angle was 38.7°. In 88.9% of cases, canines erupted and the median time of eruption was 4.2 months. A statistically significant difference in alpha angle >/<22° able to influence the eruption time was assessed. The variation of the alpha angle (>/<22°) has found to be statistically significative when compared to the eruption time variation. Conclusion: The canine first technique is effective for the eruption of impacted canines, and an alpha angle <22° can be considered a favorable prognostic factor.

Fresh Frozen Homologous Rib Cartilage: A Narrative Review of a New Trend in Rhinoplasty.

Background: Revision rhinoplasty is a technically demanding surgical procedure that can put every surgeon in trouble. The main issue of these cases is often an altered osteocartilaginous framework following over-resection during the first intervention. Moreover, the available septal or auricular cartilage for grafting is usually not enough. This review aims to examine contemporary advances in applications of fresh frozen cartilage in rhinoplasty. Methods: A structured review of the current literature (up to December 2023) was performed on four bibliographic databases: PubMed, EMBASE, Cochrane and Medline. The search terms were combinations of "Rhinoplasty" and "Cartilage Graft", "Allograft" or "Fresh Frozen Cartilage". The citations of selected studies and review articles were also evaluated if present. Results: The research resulted in 152 articles, and only ten met the inclusion criteria: nine clinical articles and one in vitro study. One of the ten eligible articles was excluded. Conclusions: Fresh frozen rib cartilage proved to be a viable alternative to autologous rib grafts and irradiated homologous rib graft. Despite the higher costs, FFRG can provide a sufficient amount of tissue for grafting avoiding donor site complications and reducing the operative time and proved to have more chondrocytes and to be less prone to resorption compared to irradiated rib.

Submental intubation in complex maxillofacial trauma: Pilot balloon protection.

AIMS: This study aims to describe our refined technique of submental intubation to avoid the recorded intraoperative complications related to tube passage and pilot balloon rupture. CASE SERIES: This is a retrospective case series of 21 patients with complex maxillofacial trauma who underwent submental intubation from January 2019 to January 2023. All the patients underwent to the same procedure with a new technique of pilot balloon protection: the pilot balloon was not deflated because, once the connector was removed, only the tube was curved and passed through the incision extraorally while the cuff remained inflated. The wire of the pilot balloon was passed behind the last tooth so as not to interfere with the maxillary-mandibular fixation, remaining extraorally under the anesthetist's view. DISCUSSION: Only 2 patients (9.5%) reported complications related to submental intubation: in particular a patient (4.8%) reported oral floor infection, and in another patient (4.8%) an unesthetic skin scar was observed. No patients reported intraoperative complications related to the procedure. CONCLUSION: The technique of pilot balloon protection that we have proposed seems to be effective in reducing the intraoperative complications related to the passage of the pilot balloon, such as rupture, damage or early extubation.

Epidemiological analysis of patients with isolated blowout fractures of orbital floor: Correlation between demographic characteristics and fracture area.

Isolated orbital floor fractures are more frequent due to low bone thickness (2 mm). The aim of this study was to conduct a retrospective epidemiological analysis on these fractures, investigating demographic variables and fractures' features and their statistical correlation. A total of 120 patients with isolated orbital floor fracture, admitted at the Maxillofacial Surgery Unit of University of Naples Federico II, from 2010 to 2022 were enrolled in the study. Patients were evaluated for age, sex, smoke, comorbidities, post-traumatic clinical manifestation,s and defect side and size. Statistical analysis was conducted using the Pearson regression coefficient (r). The fractures were more frequent in men (male:female 2.2:1) because of road accidents (30% of cases). The average age was 48 years. Enophthalmos, diplopia and ocular motility anomalies were observed in 31%, 23% and 21% of cases, respectively. Statistical analysis revealed that age was related to fracture area; in particular, older patients showed larger fractures (p < 0.001). Interpersonal violence and traffic accidents were related to younger age (p < 0.001). Data analysis revealed that isolated orbital floor fractures are more frequent in young men (<40 years) because of road accidents or interpersonal violence. There is a statistical correlation between fracture area and patient age; in particular, older age corresponds to larger defects.