Preauricular versus intraoral condylectomy for the treatment of unilateral condylar hyperactivity.

In this study we retrospectively reviewed our clinic's treatment of unilateral condylar hyperactivity (UCH). We used computer-guided proportional condylectomy, which was conducted both through preauricular and intraoral approaches, then analysed the advantages and disadvantages of the two techniques. A computer-guided treatment algorithm is also presented. We enrolled 42 patients diagnosed with clinical asymmetry, with or without associated dentofacial deformities, which had been confirmed by single photon emission computed tomography (SPECT) to be UCH. These patients underwent proportional condylectomy: 26 of them had isolated proportional condylectomy, while 16 had proportional condylectomy with concomitant orthognathic surgery. The intraoral approach demonstrated a capacity and precision that was nearly equivalent to the extraoral approach. This mitigates the significant surgical risks associated with the extraoral approach, but it is important to acknowledge the learning curve associated with the intraoral approach. Utilising virtual surgical planning (VSP) and custom cutting guides is essential.

Validation of 'total face approach' (TFA) three-dimensional cephalometry for the diagnosis of dentofacial dysmorphisms and correlation with clinical diagnosis.

The last decades have witnessed significant improvements in orthognathic surgery, but a true standardization of cephalometric analysis to guide clinical assessment in three-dimensional (3D) virtual planning is still lacking. Therefore, the aim of this study was to validate the 'total face approach' (TFA) 3D cephalometric model for the diagnosis of dysmorphia and to analyse its correlation with the clinical diagnosis and virtual surgical planning performed in the Maxillofacial Surgery Clinic in Udine. This model was validated by studying different cephalometric points in three modules (vertical dimensions, sagittal dimensions, and symmetry) and their sections. Each section of the different modules evaluates the range of the studied patient according to the TFA analysis executed in Planmeca Romexis software and compares it with the ProPlan CMF data. The results of the statistical analysis defined the degree of concordance for each point studied. An overall high correlation was demonstrated for each of the cephalometric categories (weighted kappa between 0.442 and 0.642 in vertical dimension, between 0.587 and 1 in sagittal dimension, and between 0.773 and 1 in symmetry). The TFA model can be considered a valuable guide for the diagnosis of dysmorphia and 3D virtual planning of orthognathic maxillofacial surgery.

Systematic review of the software used for virtual surgical planning in craniomaxillofacial surgery over the last decade.

Craniomaxillofacial surgery has been experiencing a deep conceptual change in surgical planning over the last decade, with virtual reality technologies becoming widely adopted. The high demand has led to an exponential increase in available software. The aim of this review was to outline the current literature and provide evidence on the most used software for virtual surgical planning (VSP), and also to define contemporary knowledge on which procedures are more ready candidates for VSP. A search was performed in the major databases, and screening of the results according to the PRISMA statement identified 535 articles reporting the implementation of preoperative VSP during the years 2010-2020. A total of 77 different software programs were identified. The surgical procedures were assigned a standardized nomenclature and further simplified into 10 categories for analysis: temporomandibular joint (TMJ), implants (IMPL), malformations (MALF), reconstruction (REC), oncology (ONCO), oral surgery (ORAL), orthognathic surgery (ORTH), cranial surgery (CRANIO), trauma (TRAUMA), miscellaneous (OTHER). The journals they were reported in and the sample size of each study were also investigated. The results showed that the Materialise suite was the most widespread tool for VSP, with a prevalence of 36.3%, followed by the Geomagic family. Several packages were found to be associated with a specific type of surgical procedure. This review offers a synopsis of the array of VSP software reported in the literature and sets the basis for an informed, evidence-based use of this software in craniomaxillofacial surgery.

Virtual planning and navigation for targeted excision of intraorbital space-occupying lesions: proposal of a computer-guided protocol.

The purpose of this study was to present an innovative approach for the preoperative assessment and intraoperative targeted excision of masses occupying the intraorbital space based on multimodal image fusion, segmentation, virtual models, digital planning, and navigation. Nineteen patients were studied and underwent surgery using the presented workflow, in both open and endoscopic procedures. Three main scenarios were standardized for the application of computer-guided surgery: single masses of the superior-lateral compartment, single masses of the inferior-medial compartment, and multifocal masses. An operative protocol was devised, and the accuracy of the osteotomies was analysed. All patients were managed successfully by applying the same protocol. No intraoperative complications were reported. The accuracy of the osteotomies was evaluated as a surrogate endpoint for the overall precision of surgery, showing average discrepancies of <1 mm for lateral marginotomies and <0.5 mm for endoscopic osteotomies. This study outlines an operative workflow for the implementation of virtual models to excise orbital masses, enhancing in-depth preoperative understanding of the anatomical relationships within the orbital space and increasing precision in both open and endoscopic approaches.

The use of cutting/positioning devices for custom-fitted temporomandibular joint alloplastic reconstruction: current knowledge and development of a new system.

Alloplastic replacement of the temporomandibular joint (TMJ) is the treatment of choice in cases of TMJ end-stage disease. Improvements in computer-aided design/computer-aided manufacturing (CAD/CAM) translated into the possibility ongf designi very precise TMJ prostheses based on the anatomy of each single patient. Custom-made TMJ prostheses are described in the most recent literature and provide facilitations in terms of ease of placement and accuracy. Although before the era of custom-made surgical guides, they did not play a prominent role in the field of TMJ surgery, their use has become mandatory when custom-made prostheses are used. Surgical guides, generally known also as cutting guides, allow the subcondylar bone cut to be performed according to the exact shape and size of the planned prostheses. Additionally, they allow the predrilling of fixation holes in the mandible to minimize errors in prostheses positioning. However, the design of surgical guides did not evolve over time as much as prostheses did. In this paper the authors critically analysed literature on this topic and described the improvements of surgical guides over time. Moreover, based on the findings of literature research, a new cutting guide system was developed and is proposed in this article.

Protocol for fully digital and customized management of concomitant temporomandibular joint replacement and orthognathic surgery.

End-stage temporomandibular joint (TMJ) disease is caused by a multitude of pathological processes that impair TMJ anatomy and function. In many cases, end-stage TMJ disease and dentofacial skeletal deformities coexist. The optimal treatment for such conditions is total alloplastic joint replacement and orthognathic surgery. Such procedures have historically been conducted in two separate stages. Furthermore, while technological improvements resulting from the widespread adoption of virtual reality initially led to significant improvements in the field of orthognathic planning, the adoption of virtual design techniques to optimize TMJ reconstruction was a later achievement. Therefore, planning for TMJ replacement and orthognathic surgery did not develop in parallel, leading to various combinations of planning for orthognathic surgery and TMJ replacement with the aim of performing both procedures simultaneously in one stage. Nowadays, improvements in virtual planning and three-dimensional printing have allowed these procedures to be conducted in the same surgical step based on fully digital planning and entirely customized surgery. This paper introduces a fully digital protocol for the treatment of end-stage TMJ disease and associated acquired dentofacial deformities, in which all surgical steps are customized and the whole surgery is performed in succession using automated procedures, thanks to the combined use of virtual surgical planning, surgical guides, custom-designed TMJ prostheses, and patient-fitted osteosynthesis devices.

Cubik system: maximizing possibilities of in-house computer-guided surgery for complex craniofacial reconstruction.

Craniofacial reconstruction represents a major challenge due to the complex anatomical morphology. Although implant production has often been outsourced to external companies, in-house planning and manufacturing has developed in many centres. This note introduces a conceptualized modular mould system to perform any desired craniofacial reconstruction, named 'Cubik', inspired by the famous Rubik's cube. A sophisticated virtual process is described that simulates realistic cranio-orbital resections, and the workflow to create multi-component moulds in order to achieve intraoperatively moulded implants is presented. The description focuses on the appropriate definition of interfaces between the subdivision surfaces of the planned implant, which is the key element to successful design and function of the moulds during surgery and is the peculiarity of the Cubik system. The use of Cubik does not prolong the overall duration of surgery, and it appears to be a very versatile tool, allowing personalized implants with different morphology to be created, which are suitable to cover every potential defect of the skull and the orbital region. This study extends the potential of in-house production, allowing highly accurate implantable craniofacial implants to be fabricated, and in the future this might represent a solution to achieve in-house replacement of other segments of the facial skeleton.

Accuracy of custom-fitted temporomandibular joint alloplastic reconstruction and virtual surgical planning.

The purpose of this study was to evaluate the accuracy of temporomandibular joint (TMJ) custom-made replacements by means of virtual surgical planning. The authors review 11 TMJ custom-made prostheses made of both mandibular and fossa components. Surgeries were virtually planned and patient-specific devices were designed together with surgical cutting and positional guides. Three-dimensional models for both preoperative planning and postoperative computed tomography scans were generated and overlapped in order to evaluate differences in measurements. Correlation between virtual preoperative and real postoperative prosthesis positioning was described by Lin's coefficient. Results of statistical analysis showed an almost perfect concordance. Wilcoxon's matched-pairs test showed no statistically significant deviation between preoperative virtual surgical planning and postoperative results. Colour map analysis confirmed the correspondence between virtually planned positioning of the devices and postoperative results. All the prostheses were placed with great accuracy. In conclusion, virtual surgical planning, surgical guides and patient-specific devices provide accuracy and precision in surgery for custom-made TMJ replacement.

Osteogenesis distraction and platelet-rich plasma: combined use in restoration of severe atrophic mandible. Long-term results.

OBJECTIVES: The purpose of this paper is to report long-term results on the use of autologous bone graft and platelet-rich plasma in alveolar distraction osteogenesis (DO) for restoration of severe atrophic mandible. We tested the efficacy as to reabsorption of bone volume, peri-implant reabsorption, implant survival and success rate. MATERIALS AND METHODS: Twelve patients were treated. The surgical procedure consisted in mixing autologous bone, harvested from the iliac crest, with autologous platelet concentrate (APC) and in filling the distraction gap with this graft. After a latency of 15 days, a distraction rate of 0.5 mm/day was followed. After a 60-day period of consolidation, the distraction device was removed and implants were placed simultaneously. The abutment connection was accomplished after 6 months. In addition, every patient was evaluated clinically and radiographically annually for 5 years. RESULTS: Planned alveolar height was reached in 11 out of 12 patients. The total number of implants positioned was 47. At the time of implant positioning, the mean decrease of total bone volume was 2.3%. The mean peri-implant resorption was 0.40 mm at the time of abutment connection, 0.61 mm 1 year after implant loading and 1.51 mm after 5 years. After 5 years of follow-up, the mean rate of vertical bone loss was 18.7%. Instead, the implant survival and success rates were 97.9% and 91.5%, respectively. CONCLUSIONS: Long-term results allow us to confirm the combination of autologous bone-platelet gel with alveolar DO as an effective and predictable procedure in restoration of severe atrophic mandible.

Functional endoscopic sinus surgery for the treatment of Aspergillus mycetomas of the maxillary sinus.

AIM: The proper treatment for Aspergillus mycetoma (AM) of the maxillary sinus is a complete removal of the sinus fungal masses and improvement of aeration for the involved sinuses. We report our experience in the treatment of AM of the maxillary sinus by functional endoscopic sinus surgery (FESS). METHODS: Thirteen immunocompetent patients with AM underwent FESS under general anesthesia. Mycotic concretions were endonasally removed through the enlarged maxillary natural ostium. Care was taken to avoid any removal of the maxillary sinus mucosa. Only in one case complete removal could not be achieved and therefore we opened the maxillary sinus via the canine fossa and cleared it of fungal masses. Follow-up has ranged from 6 months to 4 years after surgery. Patients were all closely followed postoperatively with serial endoscopic examinations in order to verify the maintenance of opening of the maxillary natural ostium. RESULTS: Histological examination was positive for Aspergillus in all the patients. Postoperative radiographs and endoscopic examinations revealed maintenance of the antrostomy performed during FESS without mucosal degeneration and no evidence of recurrence. All patients were free of symptoms after a mean follow-up of 31 months. None of the patients required a second procedure. CONCLUSION: Surgical treatment of AM with FESS appears a reliable and safe surgical treatment. Sinus physiology is preserved in the event of a future bone reconstruction for prosthetic purposes.

Penetrating injury of the facial skeleton through the orbit, by a massive metallic shotgun block: A case report.

We present a case of invasion of the orbit and the infra-temporal fossa by a massive breechblock from a shotgun. The block was removed and two months later the orbit was reconstructed with iliac crest. Six months after that the patient had plastic surgery and insertion of ocular prosthesis.

Disc-repositioning surgery of the temporomandibular joint using bioresorbable screws.

For successful disc-repositioning surgery, following arthrotomy and disc recovery by the release of attachments, the disc must be fixed and stabilized in the correct relationship with the condyle and fossa. This report describes a new surgical technique for fixing the disc to the condyle using two resorbable screws.

Arthroscopic laser surgery in temporomandibular functional joint disorders.

AIM: The authors present the 1-year results of combined use of arthroscopic lysis and lavage procedure, capsular stretch and holmium:yttrium-aluminium-garnet (Ho:YAG) laser techniques for the treatment of chronic closed lock of the temporomandibular joint. METHODS: Twelve joints were treated in 10 patients (9 females and 1 male) affected by anterior disk displacement without reduction not responsive to conservative treatment. All the patients were studied with preoperative magnetic resonance immaging (MRI). Surgical procedures included lysis and lavage, capsular stretch and Ho:YAG laser techniques with anterior release, posterior scarification and debridment of cartilage surface. The individual outcome was evaluated with the clinical examination, a visual analogue scale (VAS) for pain and a questionnaire concerning mandibular functional impairment. Patients were followed-up for 1 year. RESULTS: One-year results show that 9 patients (success rate 90%) achieved improvement of mandibular function and reduction of pain. The clinical recordings at the 1-year follow-up indicated good outcomes. Nine patients could masticate a regular diet at 1-year follow-up. CONCLUSIONS: These findings seem to justify the use of Ho:YAG laser techniques together with the lysis and lavage procedure and capsular stretch for the treatment of chronic closed lock of the temporomandibular joint. These arthroscopic procedures represent the first choice and an effective approach in the surgical treatment of this condition.

Stability of skeletal Class III malocclusion after combined maxillary and mandibular procedures.

The aim of this study was to evaluate the skeletal stability and time course of postoperative changes after surgical correction of skeletal Class III malocclusion. Combined maxillary and mandibular procedures were performed in 40 consecutive patients. Bilateral sagittal split osteotomy stabilized with wire osteosynthesis for mandibular setback and low-level Le Fort I osteotomy stabilized with plates and screws for maxillary advancement were performed. Maxillomandibular fixation (MMF) was in place for 6 weeks. Lateral cephalograms were taken before surgery, immediately postoperatively, 8 weeks after surgery, and 1 year postoperatively. Patients were divided into 2 groups according to vertical maxillary movement at surgery: a maxilla-up group with upward movement of the posterior nasal spine of 2 mm or more (group 1, n = 22), and a minimal vertical change group with less than 2 mm of vertical repositioning (group 2, n = 18). The results indicate that surgical correction of Class III malocclusion with combined maxillary and mandibular osteotomies appears to be fairly stable. One year postsurgery, maxillary stability was excellent, with a mean horizontal relapse at point A that represented 10.7% of maxillary advancement in group 1 and 13.4% in group 2. In the vertical plane, maxillary stability was also excellent, with a mean of 0.18 mm of superior repositioning at point A for group 1 and 1.19 mm for group 2. The mandible relapsed a mean of 2.97 mm horizontally at pogonion in group 1 (62% of mandibular setback) and 3.41 mm (49.7% of setback) in group 2. Bilateral sagittal split osteotomy with wire osteosynthesis and MMF was not as stable as maxillary advancement and accounted for most of the total horizontal relapse (almost 85%) observed. A trend to relapse was observed for maxillary advancement greater than 6 mm, while the single variable accounting for mandibular relapse in group 1 was the amount of surgical setback. Clockwise rotation of the ascending ramus at surgery was not correlated with mandibular relapse in relation to the type of fixation performed and therefore does not seem to be responsible for relapse.