Microvascular reconstruction of the mandible with medial femoral condylar flap for treatment of mandibular non-union.

Mandibular non-union occurs in 2-9% after open reduction and internal fixation of a mandibular fracture (trauma surgery, orthognathic cases, access osteotomy for oncological purposes). The medial femoral condyle (MFC) has emerged more recently as one of the most versatile donor sites in the treatment of challenging bone reconstruction. This is the first description of MFC for treatment of mandibular non-union. A retrospective chart review was conducted for all patients who underwent reconstruction with a microvascular MFC flap for bone defects of the head and neck area between January 2015 and December 2018 at Careggi Hospital of Florence. Inclusion criteria were patients where the FMC was used for mandibular defects arising due to non-union. Seven patients presented mandibular defects reconstructed by MFC flap and were included in this investigation (two cases of segmental mandible defect due to post-traumatic non-union; two patients of pathological mandibular fracture after prolonged bisphosphonate therapy for osteoporosis; three patients with mandibular continuity loss after failed orthognathic surgeries). At one-year follow-up, all patients had satisfactory occlusion. One-year postoperative CTs revealed full osteointegration of the flaps. In conclusion, the MFC free flap is an attractive option for mandibular reconstruction. Small defects (3-5 cm) in poorly vascularized beds are the ideal target.

Orthognathic surgery for juvenile idiopathic arthritis of the temporomandibular joint: a critical reappraisal based on surgical experience.

Juvenile idiopathic arthritis (JIA) involving the temporomandibular joint (TMJ) can result in significant dentofacial deformities that may require orthognathic surgical correction. The aim of this study was to assess the functional and aesthetic results relative to stability after bimaxillary surgery with counterclockwise rotation of the occlusal plane in patients with JIA. A retrospective chart review was conducted of all patients affected by JIA who underwent orthognathic surgery between January 2000 and December 2019 at the Face Surgery Centre (Parma, Italy). Patient records were evaluated for surgical indications, complications, and outcomes. The final study sample included 13 patients (12 female, one male). The mean age of the patients was 18.6 years (range 17-26 years) at the time of surgery; 12 patients had bilateral TMJ disease. At the 1-year follow-up, all patients except one had a stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. The 1-year postoperative cone beam computed tomography (CBCT) scan revealed complete ossification at all osteotomy sites. Bilateral sagittal split osteotomy with mandibular advancement is an effective procedure with a low rate of complications for patients with JIA with stable disease confirmed by preoperative CBCT or magnetic resonance imaging.

Simultaneous Rhinoseptoplasty and Orthognathic Surgery: Outcome Analysis of 250 Consecutive Patients Using a Modified Le Fort I Osteotomy.

BACKGROUND: The purpose of the present study was to assess the safety and efficacy of both functional intranasal procedures and cosmetic rhinoplasty combined with bimaxillary surgery. METHODS: The author executed a retrospective cohort study derived from patients who underwent combined rhinoseptoplasty and bimaxillary surgery at a private practice setting (Face Surgery Center, Parma, Italy) between April 2006 and 2015 by a single surgeon. The minimum follow-up was 12 months. Patients underwent bimaxillary orthognathic surgery, functional nasal surgery and cosmetic rhinoplasty. RESULTS: Two-hundred and fifty (250) consecutive, non-randomized patients met the inclusion criteria to enter the study. The overall complication rate was 5%, whereas the revision rate was 9%, showing an overall low rate, comparable to that of primary rhinoplasty (control group). About 94% of the patients polled after this procedure asserted they definitely accepted to have rhinoplasty only because it was included in one single surgical act together with orthognathic surgery. CONCLUSION: Cosmetic rhinoplasty shows great potentials to change our patients' appearance, whereas orthognathic surgery corrects jaw skeletal deformities and builds the right foundation for facial harmony. The combination of both procedures magnifies the single results reciprocally and significantly enhances the final outcomes. The quality of the overall aesthetic results, the scarcity of complications and the low percentage of defects that require revisions lead to the conclusion that when alterations to both the jaws and the nose are detected, a single intervention can grant great benefit to the patients in terms of morbidity and costs. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orthognathic surgery with or without autologous fat micrograft injection: preliminary report on aesthetic outcomes and patient satisfaction.

Orthognathic surgery leaves the intrinsic volume of the facial soft tissues untouched, sometimes resulting in unsatisfactory improvements in aesthetics. The aim of this study was to evaluate the aesthetic outcomes and patient satisfaction following bimaxillary orthognathic surgery with or without simultaneous facial lipofilling procedures. The preoperative and postoperative facial appearances of 210 patients were compared through analysis of photographs and postoperative clinical evaluation. A patient questionnaire was used to assess the perceived improvement in aesthetics. One hundred and twenty patients (mean age 20.3 years) underwent bimaxillary orthognathic surgery and simultaneous facial lipofilling procedures (group I). The remaining 90 patients (mean age 19.8 years) underwent skeletal procedures only (group II). The overall aesthetic improvement was similar in the two groups (group I 92.5%, group II 91.1%). Greater higher-level aesthetic improvement scores were recorded for group I (group I 80%, group II 55.6%). The overall patient satisfaction was 98.3% for group I and 97.8% for group II. Greater higher-level satisfaction scores were recorded for group I (group I 14.2%, group II 6.7%). The simultaneous use of the autologous fat micrograft is a promising technique that may improve the aesthetic outcomes of orthognathic surgery, leading to greater patient satisfaction.

Bilateral posterior maxillary segmental osteotomy to rehabilitate edentulous mandibular area: case report.

The purpose of this work was to describe a clinical case with reduced vertical height in both the posterior sectors, due to maxillary dento-alveolar extrusion in mandibular edentulous space, as a result of some extractions which have not been promptly replaced by a prosthetic rehabilitation, eventually resolved with a bilateral posterior segmental maxillary osteotomy (PMSO). Our surgical technique was practised under general anesthesia according to Kufner's version of Schuchardt's original description. In the light of the present outcomes, in severe clinical cases of dento-alveolar extrusion, the PMSO can be considered the optimal solution, because of the quality and the stability of the final result, the short therapeutic times, the limited morbidity and the modest compliance asked to the patient.

Ex vivo evaluation of the accuracy of two electronic apex locators during root canal length determination in primary teeth.

AIM: To evaluate ex vivo the accuracy of two electronic apex locators during root canal length determination in primary incisor and molar teeth with different stages of physiological root resorption. METHODOLOGY: One calibrated examiner determined the root canal length in 17 primary incisors and 16 primary molars (total of 57 root canals) with different stages of root resorption based on the actual canal length and using two electronic apex locators. Root canal length was measured both visually, with the placement of a K-file 1 mm short of the apical foramen or the apical resorption bevel, and electronically using two electronic apex locators (Root ZX II--J. Morita Corp. and Mini Apex Locator--SybronEndo) according to the manufacturers' instructions. Data were analysed statistically using the intraclass correlation (ICC) test. RESULTS: Comparison of the actual root canal length and the electronic root canal length measurements revealed high correlation (ICC = 0.99), regardless of the tooth type (single-rooted and multi-rooted teeth) or the presence/absence of physiological root resorption. CONCLUSIONS: Root ZX II and Mini Apex Locator proved useful and accurate for apex foramen location during root canal length measurement in primary incisors and molars.

Temporal galeal fascia cover of custom-made gold lid weights for correction of paralytic lagophthalmos: long-term evaluation of an improved technique.

BACKGROUND: Chronic paralytic lagophthalmos is a condition that is often conservatively treated with ophthalmic ointments and eye drops, but usually requires definitive surgical correction. PURPOSE: An effective modification of the gold lid loading technique is described, which we have found to be the simplest and most reliable method for lid reanimation. MATERIAL: After empiric evaluations with lead fisherman's weights 'glued' to the eyelid, a custom-made gold lid weight is made by a jeweller on the basis of the tarsal dimensions of the individual patient, and then sutured to the tarsus under local anaesthesia and covered with a fine sheet of temporal galea. Other ancillary procedures (lower lid suspension, lateral tarsal strip, lateral tarsoplasty) are added as required. METHODS: Between 1990 and 1996, 27 patients underwent this type of surgery, of whom 24 were re-evaluated after a mean follow-up period of 73.2 months (range 36-96 months), 14 of these for a minimum of 5 years. RESULTS: None of the gold weights was extruded, all 24 patients experienced marked improvement of their dry-eye symptoms and expressed a high degree of satisfaction. Six patients underwent further minor surgery (lateral McLaughlin tarsorrhaphy) in order to improve relative underaction. Two patients had ptosis (less than 2 mm of asymmetry) of the affected side but refused further correction. CONCLUSION: The use of custom-made gold lid weights and a protective galeal layer is a simple, reliable and successful means for permanently rehabilitating paralysed eyelids.

Reconstruction of the orbital walls in surgery of the skull base for benign neoplasms.

Surgery for benign neoplasm extending into the orbital roof requires immediate reconstruction to avoid complications, which include transmission of the cerebral pulse to the globe, bulbar dystopia, diplopia, and fibrosis of the oculomotor muscles. Many alloplastic materials have been employed for such reconstruction, but currently most authors agree that autologous bone graft is the best option. Using calvarial bone in adults and split ribs in children, we have operated on eight patients for fibrous dysplasia (five cases), neurofibroma (two cases), or meningioma (one case). After a median follow-up period of two years and six months, good morphology of the orbit was maintained with no ocular symptoms.

[Secondary oro-mandibular reconstruction using revascularized bone flaps]. / Ricostruzione oro-mandibolare secondaria con i lembi ossei rivascolarizzati.

BACKGROUND: Oro-mandibular reconstruction using vascularized bone-containing free-flaps can be accomplished with flap survival rates in the range of 95%. Primary reconstruction offers the best opportunity to achieve the optimal aesthetic and functional results. Patients presenting for secondary oro-mandibular reconstruction have a unique set of problems; these include the presence of soft tissue contracture displacing the mandibular segments in malposition and soft tissue deficiencies, that makes surgical correction more difficult and potentially more hazardous. Vascularized bone-containing free-flaps are indicated in secondary oro-mandibular reconstruction where both hard and soft tissues replacement is needed or when the recipient bed is unfavourable due to previous surgery and/or radiation. METHODS: Authors presents personal experience in ten cases of secondary oro-mandibular reconstruction treated at Maxillofacial Department of Parma from September 1995 to September 1996 with secondary oro-mandibular reconstruction using bone containing free flaps. Two different donor sites were used to harvest bone-containing free flaps: iliac crest in 2 cases and fibula in the others. In 4 cases the flap was only osseous while in the other 6 cases it was osteocutaneous. RESULTS: All flaps were transplanted successfully; in 1 case necrosis of the skin component of the flap was observed. CONCLUSIONS: The introduction of vascularized bone containing free flaps transferred from distant sites by microvascular techniques has changed mandibular reconstruction. Vascularized bone transferred into tissue beds compromised by salivary contamination and previous irradiation and the rational use of the soft tissutal components of the flap permit also the restoration of articulation, deglutition and mastication with quality of life better than non-vascularized alternatives.

[Secondary reconstruction, after maxillectomy, using an osteocutaneous flap from the fibula. Report of a case]. / Il lembo rivascolarizzato osteocutaneo di fibula nella ricostruzione secondaria dopo maxillectomia. Caso clinico.

Surgical functional reconstruction after partial maxillectomy with fibula free flap. A bilateral upper alveolar bone, gingival and palatal defect after tumor resection, has various problems originating from reconstruction with prosthesis or temporalis muscle flap. We report a secondary reconstructive procedure using the fibula osteocutaneous free flap. The combined bone segments created the upper alveolar arch, and the skin paddle closed the palatal defect. This procedure restored the patient to masticatory function of the upper jaw, intelligible speech and natural facial appearance. As a result quality of life of patient was extremely improved.

The temporoparietal fascial flap in reconstruction of the cranio-maxillofacial area.

An improved understanding of the vascular supply of the layers of the temporal fossa has increased the potentiality of reconstructive techniques involving this area. Each separate vascularized layer of this region can be used, yet the temporoparietal fascial flap is the more useful for treating a wide range of composite defects. It represents an ultra thin coverage which is useful in resurfacing exposed bone, tendons and vital structures such as nerves and vessels, in providing neovascularity as a recipient graft bed and in providing coverage or lining in major facial reconstructions. We describe our experience with the temporoparietal fascial flap which represents our choice for reconstructing composite defects in orbital, malar, auricular and cheek areas when what is required is a thin, pliable, well vascularized flap to carry a scalp or skin graft, to resurface exposed cartilage, bone and nerve, and to fill soft tissue contour defects. Illustrative cases from the authors' clinical experience are presented, to demonstrate various combinations of the temporoparietal fascial pedicle with other tissues in the reconstruction of the ear, eyebrows, eyelids, malar, cheek and parotid areas.

Orbital marginotomies for treatment of orbital and periorbital lesions.

Access osteotomies allowing temporary displacement of various segments of the orbital rim provide direct visualization of deep orbital and paraorbital regions. These marginotomies are classified, according to the orbital region involved, as lateral, medial, superior, or inferior, and they provide adequate exposure of the corresponding orbital wall and its surrounding structures. Since these procedures are without complications and cause no unpleasant cosmetic effects, they are highly recommended for the treatment of various lesions in this area as well as for correction of malformations.

[The oral manifestations during Kaposi's disease]. / Manifestazioni orali in corso di malattia di Kaposi.

Kaposi's sarcoma is a rare neoplastic disease of the vascular system with multiple foci. Oral manifestations are uncommon. The authors report an oral localization of a Kaposi's disease; the etiopathogenesis, the clinical features and the treatment of such lesions are discussed.

[Orthopedic surgery for edentulous malocclusion]. / Chirurgia ortopedica nell'edentulo disgnatico.

The treatment of maxillary deformities in edentulous patients, with reference to tooth-bearing ones shows some differences concerning both the treatment planning and the surgical procedures. The Authors present in detail their way of planning the treatment and some expedients and modifications they apply to the usual surgical procedure in this special kind of maxillary deformities.

Mandibular leiomyoma in an infant. Report of a case.

A case of mandibular leiomyoma in a 8-month-old baby is reported. This is the 5th case of intrabony leiomyoma of the jaws reported so far. The tumor presented as a symptomless swelling of the mandibular ramus and required a limited resection. The pertinent literature is reviewed and the histological features discussed.

The temporalis muscle flap in temporo-mandibular joint surgery.

In the treatment of the severely damaged TMJ structural components (ankylosis, arthrosis, tumour, perforation or degeneration of the disc), it is advisable to insert a biological interposition between bony articular surfaces. The temporal muscle, due to its anatomical, topographical, and functional properties, can be successfully employed for this purpose. Based on the experience of Tessier, Delaire and Rowe, a temporalis muscle flap, inferiorly based, is rotated downwards and medially to the zygomatic arch, interposed and then fixed to condyle and capsule. Using this surgical technique, 12 patients and 13 temporo-mandibular joints were treated with good functional results and without any complication.

[Aggressive juvenile fibromatosis]. / La fibromatosi aggressiva giovanile.

Aggressive juvenile fibromatosis is not metastasizing disease characterized by a neoplastic proliferation of fibroblasts that rarely involves surrounding bone. The Authors describe one case observed by them and suggest the surgical procedure as elective treatment of the disease. In cases where a mandibular resection is performed, a simultaneous bone reconstruction, when feasible, is indicated.