Bone Regeneration and Polyetheretherketone Implants in Maxillo-Facial Surgery and Neurosurgery: A Multidisciplinary Study.

Polyetheretherketone (PEEK) in the last few years has emerged as an exceedingly promising material for craniofacial defects due to its biocompatibility and mechanical properties. However, its utilization remains controversial due to its inertness and low osteoinductivity. This study aimed to investigate the postoperative outcomes of patients undergoing maxillo-facial and neurosurgical procedures with PEEK implants. The focus is on evaluating bone regrowth on the surface and edges of the implant, periosteal reactions, and implant positioning. A retrospective analysis of 12 maxillo-facial surgery patients and 10 neurosurgery patients who received PEEK implants was conducted. CT scans performed at least one year post operation were examined for bone regrowth, periosteal reactions, and implant positioning. In maxillo-facial cases, the analysis included mandibular angle and fronto-orbital reconstruction, while neurosurgical cases involved cranioplasty. In maxillofacial surgery, 11 out of 12 patients showed radiological evidence of bone regrowth around PEEK implants, with favorable outcomes observed in craniofacial reconstruction. In neurosurgery, 9 out of 10 patients exhibited minimal or none bone regrowth, while one case demonstrated notable bone regeneration beneath the PEEK implant interface. The study highlights the importance of implant design and patient-specific factors in achieving successful outcomes, providing valuable insights for future implant-based procedures.

The Incidence of Obstructive Sleep Apnea in Patients with Dento-Skeletal Malformation.

Purpose: The aim of this article is to analyze the incidence of undiagnosed obstructive sleep apnea (OSA) in patients affected by dento-skeletal malformation. We also evaluated the patterns most affected by the condition and calculated the post surgical changes. Methods: We conducted a retrospective cohort study on 71 patients including 35 men and 36 women. The patients studied were affected by dento-skeletal class II and III malformations and underwent bimaxillary orthognathic surgery in all cases. Patients were evaluated with polysomnography before surgery and at least 6 months after surgery to assess any improvement or worsening of the apnea hypopnea index (AHI) index. Regarding AHI evaluation criteria, an AHI > 5 was considered indicative of OSA, 4 < AHI < 5 was considered borderline and AHI < 4 was considered indicative of non-OSA. We also considered demographic variables like age at the time of intervention and gender, and anatomical variables like the pattern of the dento-skeletal deformity and the presence or absence of maxillary hypoplasia. Qualitative variables were described as absolute and relative frequencies, while quantitative variables were summarized as mean and standard deviation. To quantitatively express the relationship between two variables, the correlation coefficient was calculated. The covariance array was used to evaluate multiple correlations. Results: Our study shows that there is a significant percentage (33%) of patients who undergo orthognathic surgery with an AHI > 5 and also a percentage of patients (11%) who can be considered to be "borderline." It emerges that the pattern most at risk is the one characterized by retruded maxilla and patients with dento-skeletal class II. Considering the post surgical period, the statistical analysis shows that after surgery, only 8% of malformed patients present an AHI > 5, compared to the 20.5% described in the Italian population. Conclusions: In patients who receive orthognathic surgery, the presence of obstructive sleep apnea is significantly higher than in the general population. When planning the surgical correction of a dento-skeletal malformation, the surgeon must aim not only for the esthetics results, but also for proper stomatognathic and respiratory function; this cannot be achieved without taking polysomnography information into account.

Arteriovenous fistula of the mandible: a case report.

Intraosseous arteriovenous malformations (AVM) are uncommon high-flow vascular malformation that can affect the maxilla or mandible. AVM may present with aspecific and misleading signs and symptoms. The diagnosis is often accidental and bleeding may represent the first symptom. Radiographically, there are few characteristic features and misdiagnosis is easy. Here we report the case of a young male affected by arteriovenous fistula on the right side of the mandible initially misdiagnosed as a cystic lesion. The patient underwent transarterial embolization of the vascular malformation and subsequently the lesion was surgically removed. 1-year follow-up showed complete healing of the mandibular bone and absence of recurrence. Intraosseous arteriovenous malformations are rare entities. However, due to their harmfulness, both clinicians and radiologists must be aware of this type of lesion and should always consider them in the differential diagnosis of osteolytic lesions.

The Resting Angle Suture.

SUMMARY: The goal of every rhinoplasty surgeon is to create a functional and aesthetically pleasing nose. The lateral crura resting angle, a recently described key concept, should be taken into consideration to achieve a satisfactory result. In this article, the authors describe the resting-angle suture, a novel technique derived from the inversion suture used to correct ectropion deformity in lower eyelid surgery.

Orbital Exenteration in Recurrence Cancer: 5 Years Experience.

INTRODUCTION: The purpose of this study was to assess the overall survival (OS) and disease-free survival (DFS) of patients who underwent orbital exenteration for periorbital, conjunctival, and primary intraorbital carcinomas. Additionally, we assessed the outcomes of anterior retrograde temporalis muscle flap restoration. METHODS: For all patients who had orbital exenteration in the previous five years, a non-comparative retrospective assessment of their medical records, histology, and radiographic imaging was carried out. We investigated the relationships between the various qualitative factors using Cramer's V Kaplan-Meier (KM) analysis. For each of the patient's categorical factors that were of relevance, estimates of the survival distribution were displayed, and log-rank tests were used to determine whether the survival distributions were equal. RESULTS: This study looks at 19 participants. The sample is made up of 13 men (68%) and 6 women (32%). The degree of relationship (Cramer's V index) between lymph node metastases (N) and the existence of distant metastases (M) is high, at 64%, and is statistically significant because the p-value is 0.0034 < 0.005. Lymph node metastases had a statistically significant impact on overall survival (p = 0.04 < 0.05). Thirteen of the nineteen patients tested had no palsy (68%). There was no one presenting a CSF leak. CONCLUSION: Our findings show how crucial it is to identify any lymph node involvement that orbital neoplasms may have. In patients who have received many treatments, sentinel lymph node biopsy (SLNB) may be used to determine the stage and spread of the cancer. To determine whether additional tumor characteristics may be explored, more expertise in the SLNB field for patients with orbital cancer who have received many treatments may be helpful. To prevent additional scarring and to be comparable to previous techniques for facial nerve lesions, the anterior retrograde approach and the transorbital procedure for temporal muscle flap in-setting are both effective methods.

The Use of a CAD/CAM Thermoformed Splints System in Closed Reduction of Condylar Fractures.

(1) Background: Mandibular fractures are very common. Common indications of closed treatment for mandibular fractures are non-displaced or minimally displaced simple fractures in adult compliant patients with good dentition, the absence of occlusal disruption, and fractures in growing children. In closed treatment, the mandible is maintained in centric occlusion with a maxillomandibular fixation (MMF) with orthodontic elastics. Many methods of MMF have been described, often using orthodontic appliances. In recent years, CAD-CAM technology has improved many procedures used in maxillofacial surgery and orthodontics. The device we present is manufactured following a digital workflow, and was designed specifically for MMF. (2) Materials: Two patients with mandibular fractures were treated with an MMF method whose procedure comprised scanning of the dental arches, followed by construction of thermoformed splints on which buttons for the elastics and retention holes are made. The splints were fixed on the dental arches with composite resin at the level of the holes, and were kept in place for the period of healing of the fracture, with the intermaxillary elastics hooked to the buttons. (3) Results: The application time of the splints was very quick. The splints remained stable for the necessary time, without causing particular discomfort to the patients. (4) Conclusions: From our experience, this technique has proved to be reliable and reproducible and could represent a valid tool in the closed treatment of mandibular fractures.

Patient-Specific Facial Implants in Polyetheretherketone and Their Stability: A Preliminary Study.

BACKGROUND: Polyetheretherketone (PEEK) is a synthetic material with many favorable characteristics; PEEK implants are increasingly used for a variety of applications ranging from cranioplasty to orthopedic surgery and facial implants. METHODS: This study is a retrospective review of patients who underwent PEEK implant placement in our department over the last 5 years. Polyetheretherketone computer-aided design and manufacture facial implants were designed from high-resolution computed tomography (CT) scans of each patient. The implants placed were onlay implants used for facial rehabilitation purposes to correct malformative and posttraumatic malformations. RESULTS: Twenty-eight consecutive patients (11 males and 17 females) underwent PEEK implant positioning between January 2015 and December 2020. Common indications were anterior plagiocephaly, hemifacial microsomia, and residual facial imbalance after orthognathic surgery. No complications of implant breakdown, exposure, infection, or displacement were noticed during the follow-up period. During routine controls on 3 patients, we requested a craniomaxillofacial CT scan for reasons unrelated to the implanted prostheses. The CT scans were all high resolution (<1-mm slices). The CT images indicated that bone was starting to form around the implant in all 3 patients as well as in the penetrating holes that were planned in the implants. CONCLUSIONS: In our experience, computer-designed, patient-specific PEEK onlay implants are a valid option for the treatment of malformative and posttraumatic malformations. This is, to the best of our knowledge, the first clinical report on bone reaction to PEEK implantation in the maxillofacial field. Moreover, based on the signs of bone regrowth that we observed in CT controls we can presume that the design of this type of prosthesis can probably take advantage of some technical stratagems not yet codified and fully exploited. Despite our preliminary favorable results, further multicentric and comparative studies are necessary to evaluate outcomes and better understand the behavior of this promising material and thus optimize its use in craniomaxillofacial surgery.

Influence of SARS-CoV-2 lockdown on the incidence of facial trauma in a tertiary care hospital in Rome, Italy.

BACKGROUND: Italy has been the first affected country in the western hemisphere by SARS-CoV-2 with over 200,000 cases during the first months of the pandemics. To control the spread of the virus, the whole country was placed under lockdown with limitations in the circulation of people and vehicles from March 2020 to the first half of the month of May. METHODS: We aimed to analyze the incidence and type of facial traumas referred to our tertiary care hospital during the months of Italy lockdown due to SARS-CoV-2 spread compared with those during the same months of 2019 to determine eventual variations in the incidence, type and causes of trauma. RESULTS: During the 2 months of COVID-19-related lockdown, a dramatic decrease in facial trauma patients was observed at our tertiary care hospital with a shift toward older age ranges. Regarding the causes of trauma, the largest percentage reduction was found in road, sports and work accidents; this percentage reduction was not found in aggressions. CONCLUSIONS: A small increase in the percentage was also found regarding surgical indications, likely because more severe cases were more prone to be referred to the hospital despite the fear of being infected.

An Orthodontic Index assessment and its relationship with total treatment time in surgery first orthognathic approach: an observational study.

BACKGROUND: The aim of this study was to highlight the connection between orthodontic difficulty before surgical treatment and in the transient malocclusion as evaluated by the mean of the of Complexity, Outcome, and Need (ICON) Score and total treatment time in surgery-first approach (SFA). METHODS: For each patient, the ICON Score was evaluated preoperatively and on the 3rd postoperative day in order to assess the orthodontic difficulty of presurgical occlusion and the transient malocclusion. RESULTS: Our group of patients at the preoperative stage showed score values between hard and very hard with only one patient scored as "easy" and nine "medium" patients. All scores lowered after surgical treatment. This confirms that the surgery first approach can change a malocclusion from not orthodontically treatable to an orthodontically treatable one. In our study, this was objectified by improvements in the ICON Score. CONCLUSIONS: In the conventional three-phase approach of orthognathic surgery the total treatment time found in literature is around 18-36 months. In our study, even the most difficult cases do not have a duration of more than 15 months This demonstrates that the surgery-first approach can reduce the total treatment time even in more severe cases.

Approach to Fronto-Orbital Sequelae in Anterior Synostotic Plagiocephaly: Our Flow Chart Based on Di Rocco Classification.

INTRODUCTION: Anterior synostotic plagiocephaly recognizes the synostosis of one of the hemicoronal sutures as a cause and can manifest itself with varying degrees of severity. Clinically it presents a reduction of the sagittal growth of the affected side and flattening of the frontoparietal complex. MATERIALS AND METHODS: The authors retrospectively examined our case sample dividing it into 3 groups based on the Di Rocco classification. For each category, we assessed the extent of facial alterations at the end of skeletal growth and retrospectively analyzed the surgical options aimed at correcting aesthetic and skeletal deficits. RESULTS: The authors found that predictable results could be obtained by standardizing the surgical procedure based on Di Rocco's classification groups; in particular, the authors achieved satisfactory results by assigning a specific surgical procedure to each class.

Functional Upper Airway Space Endoscopy: A Prognostic Indicator in Obstructive Sleep Apnea Treatment with Mandibular Advancement Devices.

PURPOSE: The use of a mandibular advancement device (MAD) in the treatment of obstructive sleep apnea (OSA) is a consolidated therapy. This study aimed to evaluate the predictive value of awake upper airways (UA) functional endoscopy in identifying the outcome of MAD therapy. METHODS: This observational prospective study included 30 adult OSA patients, all patients underwent pre-treatment awake UA functional endoscopy, during the exam subjects were instructed to advance their mandible maximally, and they were divided into three different groups according to the response of the soft tissue, group A (expansion), group B (stretch), group C (unchanged). The results of this test were used in combination with other noninvasive indexes to predict the treatment outcome in terms of apnea-hypopnea index (AHI) reduction. RESULTS: We found that a substantial AHI reduction occurred in group A and group B while e slight AHI reduction was measured in group C. CONCLUSION: Based on our experience the awake UA endoscopy is a valid prognostic exam for discriminating responder and non-responder patients; in addition our results indicate the possibility of predicting a range of post-treatment AHI index values.

Virtual Surgical Planning for Reconstruction of Giant Ameloblastoma of the Mandible.

Ameloblastoma is a histologically benign tumor that behaves aggressively because of its tendency to invade local structures, and it has a high probability of local recurrence. If neglected, ameloblastomas can grow substantially over the course of years, reaching the size of giant ameloblastomas. This large size can lead to deformities in facial appearance and impairments in speaking, swallowing, eating, and breathing.Surgical planning can be challenging because of the extension of the tumor and the consequent reconstructive issues.In this article, we present our experience with the reconstruction of 2 cases of giant ameloblastomas planned on the basis of occlusal casts and acrylic splints. In these patients, computerized planning was rendered complex and potentially inaccurate because of the dimensions of the tumor, the loss of anatomical landmarks, and the loss of occlusal landmarks. The cases were successfully reconstructed, but the technique can be flawed. A 3-dimensional virtual model of the mandible can be used as a template to develop cutting guides for reconstruction with free fibular flaps. This will allow us to overcome limitations, standardize the procedure, and achieve optimal functional and aesthetic results.

Use of an Oral Device in the Stabilization of Facial Advancement after Early Removal of the Osteodistraction Device for Postoperative Sequelae.

The aim of this study is to present an oral device that improves splanchnocranium stability after osteodistraction in children treated for correction of craniofacial malformations. When removal of the distraction device before the end of the treatment is necessary, the reposition of a new fixation system might not be possible. In these cases, regrown bone is immature, and relapse of malformation occurs frequently. We have been treating these cases by the application of an oral device named Maxillary Advancement Contention (MAC). MAC is used in every patient when any complication interrupts the protocol of osteodistraction before the end of the stabilization time. The device is placed immediately after the removal of the distraction device and left in place for at least three months. We used MAC in six children surgically treated for correction of craniosynostosis with facial or craniofacial advancement. To establish the relapse of malformation we analyzed relations Sella-Nasion-Orbitale (SNOr) and Sella-Nasion-A point (SNA) angles before application of the MAC and after one year. The analysis of stability was excellent in every patient. This device might help, with a minimally invasive procedure, to maintain the obtained advancement allowing stabilization of the regrown bone.

Use of Navigation System in Craniofacial Surgery.

The use of navigated surgery in the treatment of craniofacial malformations can help obtain optimal results. In this article, the authors will discuss a case of anterior plagiocephaly, corrected with frontorbital bandeau remodeling. Navigation was used during the osteotomy and the reposition phase to ensure the correct positioning of the osteotomy instruments. It was also used to ensure that the bandeau was correctly repositioned in accordance with the surgical plan determined during the virtual simulation phase of the surgery.

The Rules of Attractiveness: A Study on the Lower Facial Third.

What is considered attractive may not fall into the "norm," and it can vary from culture to culture and depending on the historical time, for this reason the standard cephalometric and antropometric references may not be sufficient in these cases.Lately some techniques have arose to popularity that are aimed to changing the frontal and lateral aspect of the facial lower third, such as V-line or the Chin-Wing Osteotomy technique, but no reference system exists at the moment to define to which extent a modification of the lower third falls within what is considered beautiful, and everything is left to the patient's will or to the surgeon's sensitivity.The aim of this article is to study which antropometric value is considered attractive by the most for what concerns the frontal shape of the lower third of the face.Twenty-four female models were enrolled in this study and the angle taken into consideration was the one at the intersection between the 2 lines connecting the cutaneous gonial angle of each side of the face and the most external part of the chin on the same side. Measures were made on pictures in frontal view.Two hundred two random examiners were asked to see the pictures and rate them as attractive or nonattractive.Results were then paired with the angles values.Among the models the higher angle measured was 107.5° (found in 1 individual) while the lower angle was 76° (found in 1 individual), the average measure calculated was 88.3° while the median angle was 89.5°.According to the result the subjects considered more attractive were those with an angle between 84.5 and 91.5 (92 for male examiners).This could be an important starting point for studies who can evaluate attractiveness from a numerical point of view.

Phosphaturic mesenchymal tumor, an unusual localization in head and neck.

Phosphaturic mesenchymal tumor (PMT) is a rare mesenchymal neoplasm associated with tumor-induced osteomalacia involving bone and soft tissue that produces paraneoplastic hypophosphatemic osteomalacia. The common physiologic defect in this conditions involves an impairment in renal tubular phosphate reabsorption with a downregulation of renal 1α-hydroxylase activity, while calcium metabolism remains essentially unaffected. Microscopic features consist of spindle cells, multinucleated giant cells and calcifications embedded in a chondromyxoid matrix with variable cellularity and prominent vascularity. Approximately 95% of PMTs involve the extremities and appendicular skeleton, with only 5% occurring in the head and neck region. Localization in the head and neck is pretty uncommon, nose and paranasal sinuses are preferentially affected. Due to its rarity, the purpose of the study was to report a new case of PMT whose locations in temporomandibular joint was never reported in literature.

The Arterialized Facial Artery Musculo-Mucosal Island Flap for Post-Oncological Tongue Reconstruction.

BACKGROUND: In 1992, Pribaz described the facial artery musculomucosal flap (FAMM), an axial musculomucosal flap based on the facial artery. The FAMM flap, a modification of the nasolabial and buccal mucosal flaps, is widely used in the reconstruction of defects in the oral cavity. Many modifications of this flap have been described in the literature. Here we aimed to explore the use of an arterialized tunnelized FAMM island flap (a-FAMMIF) for the reconstruction tongue defects after tumor resection. METHOD: From January 2015 to December 2016, five cases of tongue cancer were selected for the use of arterialized FAMMIF flap to reconstruct defects after tumor resection. RESULTS: Reconstruction was successful in all cases, except one case of total flap necrosis; partial necrosis of the flap occurred in two patients, which were solved with medications. CONCLUSION: The authors consider the a-FAMMIF an unreliable flap in the reconstruction of tongue defects.The authors recommend avoiding tunneling and island modification when the vein is not included in the pedicle.

Pseudoaneurysm of the internal maxillary artery secondary to subcondylar fracture: case report and literature review.

Pseudoaneurysms are an uncommon complication of mandibular condylar-subcondylar fractures; however, if present, their recognition and management is mandatory to avoid life-threatening situations. The authors report a case of internal maxillary artery pseudoaneurysm rupture that occurred after an open reduction and internal fixation of a mandibular subcondylar fracture, along with a review of the literature.

The Use of Ropivacaine in Therapeutic Treatment of Oral Aphthosis.

The use of anaesthetic drugs in the treatment of oral aphthosis is one of the pharmaceutical possibilities that a doctor can use for the most painful forms. Normally, Lidocaine or Diclofenac is used to treat this disease, but they can be used for a very limited time and so they are of little practical use. In this study, the authors have used Ropivacaine whose pharmaceutical kinetics allows the analgesic effect to be active for 60 to 90 minutes. In our research, we compared 8 groups of patients who have been given 3 principal pharmaceutical products: one group was given an anaesthetic drug, one had a topical medication administered which is often used for the treatment of aphthous lesions, and the last group was given a multivitamin. These pharmaceutical products were used alone and in various possible combinations in the 8 groups. The results of this study are very interesting and show that in all the groups that used anaesthetics there was more satisfaction on the patients' part because their pain level became more manageable right after the first application of the drug and the patients could carry on with their normal lives.