Treatment of extreme maxillary atrophy with Zygoma implants.

The implant-prosthetic rehabilitation of severe maxillary atrophy often requires difficult bone grafting techniques or microvascularized flaps with long healing time and severe discomfort for the patients. An alternative is represented by the use of particular thick bone areas like "zygomatic buttresses" that are away from the alveolar ridge but they are good for anchoring implants. From 2008, 31 patients, aged between 52 and 82 years, with severe maxillary atrophy, have been rehabilitated using zygomatic implant (Zygoma Brånemark System®) and conventional implants (4 mm of diameter and a length of 13 to 15 mm); a total of 152 implants were inserted, 78 Zygoma implants and 74 conventional implants in the premaxilla. As dictated by our protocol, all of them were followed by immediate prosthetic loading. Follow-up ranges from 20 months to 5 years. Two Zygoma implants failed out of 78 fixtures inserted with a success rate of around 98%. No failure of conventional implants. Two patients developed a postoperative sinusitis; one case healed only after endoscopically guided medium meatal antrostomy. In one case the removal and reinsertion of one Zygoma implant was necessary. We observed two cases of temporary zygomatic hypoesthesia, two cases of persistent oedema for three weeks and one case of facial postoperative haematoma; all of them spontaneously solved after a few weeks. Our results are in agreement with the Literature and lead to the conclusion that the use of Zygoma implants is a reproducible and predictable alternative to bone grafts, with the advantage of a considerable saving of time.

Assessment of difficulty in third impacted mandibular molar surgery: the Conti Scale.

AIM: We suggest a numerical method for the preoperative assessment of difficulty in mandibular third molar surgeries. METHODS: This study enrolled 1000 subjects ranging in, age from 17 to 91 years, who presented to the Clinic of Maxillary Facial Surgery at the, University of Florence in Italy, for impacted mandibular third molars removal in 2013. The difficulty of extraction was analyzed for each patient. RESULTS: Comparison of preoperative difficulty assessment scores with the actual difficulty encountered by an operator, confirming the reliability of our protocol. CONCLUSION: Careful preoperative analysis of the extraction difficulties and correct surgical planning can reduce intra and postoperative complications, in the third impacted mandibular molar surgeries. The use of an easy and rapid method for the assessment of difficulty in third molar surgeries, is an efficient clinical methodology for preoperative analysis.

Dissection with harmonic scalpel versus cold instruments in parotid surgery.

BACKGROUND: The harmonic scalpel (HS) has been used successfully in several head and neck surgical procedures. Some authors highlighted its advantages in reducing operative time, blood loss, and damages to surrounding tissue. In our study, we compared the results obtained during parotidectomy using the HS with the traditional approach to determine the benefits of the HS. METHODS: 130 patients with benign parotid tumors were enrolled and randomized into two groups for this prospective study. 63 patients underwent HS parotidectomy, and 67 patients received a parotidectomy using cold instruments and bipolar electrocautery hemostatic control (CI). 20 HS and 2 CI patients did not meet the inclusion criteria requirements, and were excluded. RESULTS: The admission time was significantly shorter in the HS group than the CI group (3.9 ± 1.2 days and 4.7 ± 1.4 days, respectively, p < 0.01). In the early post-operative period, 84% of HS patients and 60% of CI cases showed no facial nerve impairment (p = 0.01). Significantly more CI patients than HS patients showed the onset of Frey's syndrome (29% and 9%, respectively, p = 0.01). Multivariate stepwise regression analysis confirmed the reduction in admission length (Odds Ratio (OR): 0.62; p = 0.02) and the lower risk of Frey's syndrome (OR: 0.29; p = 0.04) in HS compared to CI parotidectomies. CONCLUSIONS: In parotid surgery, the HS is useful in preventing Frey's syndrome and reducing early transitory facial nerve dysfunction and admission times, and results in decreased medical costs and increased quality of life.

Broken anesthetic needle in the pterygomandibular space. Four case reports.

Needle breakage in the oral cavity during local anesthesia is a rare but possible complication. In the majority of cases this happens in the pterygomandibular space during an inferior alveolar nerve block and the causes are multifactorial. The treatment recommended is localization and removal of the extraneous body, as soon as possible, in a surgical setting so as to prevent possible migration of the metal fragment with consequent possible lesions to the surrounding anatomical structures. We present four case studies that have occurred since 2011.

Expression and localization of VEGF receptors in human fetal skeletal tissues.

During development the vertebrate skeleton is the product of deriving cells from distinct embryonic lineages. The craniofacial skeleton is formed by migrating cranial neural crest cells, whereas the axial and limb skeletons are derived from mesodermal cells. The Vascular Endothelial Growth Factors (VEGFs) / receptors (VEGFRs) system plays an important role in angiogenesis, as well as osteogenesis, during bone development, growth, and remodeling, attracting endothelial cells and osteoclasts and stimulating osteoblast differentiation. Recent evidence has shown that during development VEGFR-3 is also expressed in neural and glial precursors of forebrain and cerebellum, as well as in the eye. In this study, we found that VEGFR-1, VEGFR-2 and VEGFR-3 are expressed in human bone both in fetal and adult life. The gene expression levels were significantly higher in fetal samples especially in mandibles. In addition, higher levels of VEGFR-3 in orofacial district were confirmed by western blotting analysis. We also observed that in fetal mandibular samples VEGFRs colocalized in several osteoblasts, osteoclasts and osteoprogenitor cells. Furthermore, some cells coexpressed VEGFR-3 and ET-1, a marker of neural crest cells. The results demonstrated different expression of VEGFRs in human mandibular and femoral bones which could be correlated to their different structure, function and development during organogenesis. VEGFR-3 might represent a specific signal for ectomesenchymal lineage differentiation during early human development.

Spindle cell liposarcoma of the face: case report and literature review.

Liposarcoma is a common soft tissue sarcoma accounting for approximately 20% of all mesenchymal tumours across all ages. Recently, collaborative research in the specialties of pathology and genetics has led to the delineation of several tumour variants with different behaviours and prognoses, one of which includes the very rare spindle cell liposarcoma (SCL) subtype. We present the first case of an SCL arising in the subcutaneous tissue of the forehead of a 78-year-old man. In light of the rarity of this tumour, we describe the tumour and its clinical and pathological characteristics and undertake a literature review to clarify the surgical management and prognosis of SCL, and increase awareness to avoid misdiagnosis of a benign soft tissue neoplasm.

Genetic and clinicopathologic aspects of Gorlin-Goltz syndrome (NBCCS): presentation of two case reports and literature review.

Gorlin-Goltz Syndrome (Nevoid Basal Cell Carcinoma Syndrome) is a well-known disorder with distinctive symptoms, which are studied since the 1960s. This is an hereditary disease, with autosomal dominant trait, characterised by high penetration and variable expressivity. Only recently it has been ascertained that it is caused by the aberration of the long arm of the chromosome 9q22.3, mapped specifically in the area of Patched gene (PTCH). In particular, the PTCH gene is important both for embryonic structuring and cellular cycle, therefore, its mutation represents a key event for the development of the disease. From a clinical point of view, the syndrome requires a multidisciplinary approach meaning that a successful treatment needs the simultaneous co-operation of different specialists. Thus, a correct treatment entails the following steps: an early detection of the disease, an extended family history and a careful evaluation of symptoms. The aim of this article was to highlight the main pathologic and genetic features of Gorlin-Goltz Syndrome, its outbreak frequency and the main characteristics of the population clusters it is more likely to hit. Furthermore, due to the predisposition of the disease to relapse, a constant clinical follow-up combined with a correct treatment are important.

Submandibular cellulitis (Ludwig's angina) associated to a complex odontoma erupted into the oral cavity. Case report and literature review.

The clinical presentation of Ludwig's angina consists in a severe expanding cellulitis causing swelling of the floor of the mouth, tongue and submandibular region, thus resulting in a possible obstruction of the airway and in a rapid progress in deep neck soft tissue infection and mediastinitis with potentially fatal consequences. Frequently, submandibular cellulitis develops from an acute infection spreading from the lower molar teeth. Mandibular fractures, traumatic laceration of the floor of the mouth, and peritonsillar abscesses are other concomitant clinical features. A case of Ludwig's angina associated with a large erupted odontoma and with a deeply impacted third molar displaced to the border of the mandible is described. The patient was affected by enlargement of submandibular space, marked face swelling causing an evident face deformity, tenderness and redness of the neck and limited movement of the neck and mouth. In the past, Ludwig's angina was frequently fatal, however aggressive surgical and medical therapy have significantly reduced the mortality rate. The reported case can be considered as important, not only because of the rarity of the odontoma eruption in the oral cavity, but mainly for the extent of the clinical manifestation of a lesion usually described in literature as asymptomatic.

Histologic aspects of the bone and soft tissues surrounding three titanium non-submerged plasma-sprayed implants retrieved at autopsy: a case report.

The authors report the histological features found around three non-submerged titanium plasma-sprayed implants retrieved, after a 10-month loading period, from an autopsy case. At the time of implant insertion, the clinician had noted a wide vestibular dehiscence of the central implant, and it was decided to use a bioabsorbable membrane for guided bone regeneration in this area. After specimen processing, it was possible at low magnification to observe that in the most vestibular slides, the central implant was almost completely surrounded by connective tissue, while in the most lingual slides, the quantity of bone around the implant tended to increase. The other two implants had a bone-implant contact percentage of about 60%. Only in a few areas was mineralized bone in direct contact with the metal surface, while around the major portion of the implant perimeter a layer of unmineralized, red-stained, osteoid material was present. No inflammatory infiltrate was present in the epithelium and in the supracrestal connective tissues. The fibers of this tissue had a different orientation: in the most coronal portion of the implants (smooth surface), they tended to run parallel implant's surface, while in the most apical region (plasma-sprayed surface), they tended to be arranged in a perpendicular fashion. These results, in man, were strikingly similar to those previously reported in dogs and monkeys.