Minimally Invasive Approaches to the Lateral Cavernous Sinus and Meckel's Cave: Comparison of Transorbital and Subtemporal Endoscopic Techniques.

BACKGROUND: Transorbital and subtemporal keyhole approaches have recently been proposed to approach lesions in the lateral wall of the cavernous sinus (CS) and Meckel's cave (MC). Our goal was to compare these approaches and suggest indications for each of them. METHODS: Five cadaver heads (10 sides, 40 procedures) were used. The lateral transorbital approaches were carried out without and with the removal of the lateral orbital rim, herein referred to as the lateral transorbital approach (LTOA) and the lateral orbital wall approach (LOWA). The subtemporal approaches were performed without and with the removal of the zygomatic arch, referred to as the subtemporal approach (STA) and the subtemporozygomatic approach (STZA). Five targets were chosen and 2 triangles were created representing the lateral wall of the CS and MC. Stereotactic measurements were quantified to calculate angles of attack, surgical freedom, and temporal lobe retraction for each approach. RESULTS: LTOA presented the smaller horizontal angles of attack. LOWA increased the angles to the same level of STA and STZA. STA and STZA presented larger vertical angles of attack. The surgical freedom presented gradual increase from LTOA to LOWA, STA, and STZA. STA and STZA needed greater temporal lobe retraction for most targets. CONCLUSIONS: LTOA is a good option to biopsy a lesion in the lateral wall of the CS and LOWA increased the surgical corridor to work with microsurgical techniques. STA and STZA could be better options when wide exposure is necessary, but temporal lobe retraction should be taken into consideration.

Tratamento da bolsa malar e festoons / Treatment of malar mounds and festoons

Introdução: A alteração da região do malar, em muitos casos, é de difícil solução. O envelhecimento traz grande variação de deformidade na região. Neste sentido o objetivo do trabalho foi apresentar que procedimentos cirúrgicos com simplicidade e pouca agressividade têm demonstrado um bom resultado e rápida recuperação. Método: Desenha-se uma figura em forma de canoa ou elíptica margeando a bolsa malar ou da dobra de pele. Em seguida realiza-se a incisão até o plano do subcutâneo. Retira-se a pele e logo após realiza-se a sutura. Resultado: Os pacientes operados pelo método direto evoluíram de maneira convincente e com cicatrizes muito pouco visíveis. Conclusão: é uma maneira direta e que traz resultado bastante favorável e rápida recuperação. A indicação esta relacionada ao bom senso do cirurgião, a idade do paciente e a flacidez existente.

Introduction: Changes to the malar region are, in many cases, difficult to resolve. The ageing process causes great variation and deformity of this region. Therefore, the aim of this study was to describe a simple and less aggressive surgical procedure that has demonstrated good results and quick recovery. Method: A canoe-shaped or elliptical-shaped line is drawn bordering the malar mound or the skin fold. The skin is incised down to the subcutaneous plane. The excess skin is removed and a suture is then performed immediately. Result: The patients undergoing this direct surgical method showed a favorable postoperative course, and the scars were not very visible. Conclusion: This direct procedure provides a favorable result and quick recovery. Indications depend on surgical judgment, age of the patient, and degree of skin flaccidity.

Three-dimensional analysis of maxillary changes associated with facemask and rapid maxillary expansion compared with bone anchored maxillary protraction.

INTRODUCTION: Our objectives in this study were to evaluate in 3 dimensions the growth and treatment effects on the midface and the maxillary dentition produced by facemask therapy in association with rapid maxillary expansion (RME/FM) compared with bone-anchored maxillary protraction (BAMP). METHODS: Forty-six patients with Class III malocclusion were treated with either RME/FM (n = 21) or BAMP (n = 25). Three-dimensional models generated from cone-beam computed tomographic scans, taken before and after approximately 1 year of treatment, were registered on the anterior cranial base and measured using color-coded maps and semitransparent overlays. RESULTS: The skeletal changes in the maxilla and the right and left zygomas were on average 2.6 mm in the RME/FM group and 3.7 mm in the BAMP group; these were different statistically. Seven RME/FM patients and 4 BAMP patients had a predominantly vertical displacement of the maxilla. The dental changes at the maxillary incisors were on average 3.2 mm in the RME/FM group and 4.3 mm in the BAMP group. Ten RME/FM patients had greater dental compensations than skeletal changes. CONCLUSIONS: This 3-dimensional study shows that orthopedic changes can be obtained with both RME/FM and BAMP treatments, with protraction of the maxilla and the zygomas. Approximately half of the RME/FM patients had greater dental than skeletal changes, and a third of the RME/FM compared with 17% of the BAMP patients had a predominantly vertical maxillary displacement.

The buccal fat pad flap: an option to prevent and treat complications regarding complex zygomatic implant surgery. Preliminary report.

PURPOSE: To evaluate the use of the buccal fat pad flap (BFPF) technique as an option to prevent complications in the treatment of patients with atrophic maxillae rehabilitated after complex zygomatic implant surgery. MATERIALS AND METHODS: A retrospective study was made of completely edentulous patients submitted to zygomatic implant surgery between May 2005 and November 2007. Patients with severely atrophic maxillae received conventional and zygomatic implants and were followed after the implants were loaded. Preoperative evaluation included panoramic radiography and computed tomographic scans of the maxilla to identify the anatomic conditions and presence of pathology. RESULTS: Eight male patients with a mean age of 57 years and atrophic maxillae were rehabilitated with zygomatic implants placed using the BFPF technique. The BFPF technique was used in complex situations, including oroantral communication-associated sites, areas that had lost the sinus wall, and extrasinus implant placement. A total of 16 conventional implants, 4 long (21-mm) tilted implants, and 22 zygomatic implants was placed. The patients were rehabilitated with fixed prostheses and were followed for a minimum of 15 months. None of the conventional implants failed and none of the zygomatic implants failed or presented with soft tissue complications. CONCLUSION: The BFPF presented a high success rate, demonstrating that it is a viable and predictable treatment option to prevent and treat soft tissue complications in complex zygomatic implant surgery.

Evaluation of fixation techniques with titanium plates and Kirschner wires for zygoma fractures: preliminary study.

OBJECTIVE: The aim of the present study was to assess the quality of treatment using two reduction and fixation techniques for zygoma fractures. PATIENTS AND METHODS: A randomized clinical trial was carried out involving a sample of 10 patients with Knight and North type III, IV and V zygoma fractures divided into two groups. One group underwent the closed reduction technique and fixation with Kirschner wire and the other group underwent the open reduction technique and fixation with titanium plates. The groups were submitted to subjective evaluation based on the patient's perception of areas of deformity and paresthesia as well as the measurement of range of mouth opening and pain upon mouth opening in the preoperative (T0) and postoperative (T1) periods. The assessment of bone reduction quality was performed using quantifiable points (lateral wall of the orbit, anteroposterior projection of the zygoma and ocular globe projection), measured based on tomographic images. RESULTS: Seventy percent of the patients remained with paresthesia and 20% remained with the complaint of deformity at T1. Mouth opening range increased in both groups at T1. In the overall sample, mean total disjunction of the lateral wall of the orbit and the difference in the anteroposterior projection of the zygoma were reduced between T0 and T1 (4.36 mm to 1.25 mm and 6.94 mm to 2.86 mm, respectively). There was also a reduction in ocular globe projection in both groups between T0 and T1. CONCLUSIONS: Both techniques achieved adequate reduction of zygoma fractures in the postoperative period.

Treatment of zygomatic arch fracture with lag screws.

Zygomatic arch fractures often occur as part of a zygoma fracture or Le Fort type III fractures of the maxillary. Isolated fractures of the zygomatic arch comprise around 10% of all zygoma fractures. The main etiologic factors are traffic accidents, falls, assaults, and sport accidents. Treatment may involve minimally invasive surgical procedures for slightly dislocated fractures or surgery with more extensive access for large dislocations of bone segments. This article reports the case of a 41-year-old male victim of physical aggression to the face with a steel sickle with an exposed, unstable fracture of the zygomatic arch. The patient underwent general anesthesia, and after the reduction of the fractures, the bone segments were fixed with 2.0-mm screws.

Relationship between the angle of the coronoid process of the mandible and the electromyographic activity of the temporal muscle in skeletal Class I and III individuals.

The aim of the present study was to verify the relationship between the angle of the coronoid process of the mandible in the latero-lateral direction and electromyographic activity of the anterior part of the temporal muscle in skeletal Class I and III individuals. Forty-five volunteers were assessed subdivided into two groups, according to angle ANB, in Class I and III. Two radiographic examinations were performed, one lateral cephalogram to measure angle ANB and one frontal cephalogram to measure the angle of the coronoid process. The electromyographic examination of the volunteers' temporal muscles was performed. Statistical analysis of the data showed that the relationship between the angle of the coronoid process and the skeletal class was negative for both classes analysed. The relationship between electromyographic activity of the temporal muscle and angle of the coronoid process was negative for Class I individuals. In the Class III group, smaller angles of the coronoid process were related to higher values of electromyographic activity of the temporal muscle. There was no statistically significant difference between the electromyographic activity of the temporal muscle in skeletal Class I and III individuals. Based on the results obtained, it was concluded that there was no influence of the skeletal classes analysed on the angle of the coronoid; the angle of the coronoid process may be influenced by the electromyographic activity of the temporal muscle in the Class III group; the electromyographic activity of the temporal muscle is not influenced by the skeletal class in Class III individuals.

Implante duplo zigomático com carga imediata / Four zigoma fixtures in immediate loading

Edêntulos com quantidade e qualidade insuficiente de osso, determinando perda de retenção e instabilidade protética geralmente tem de submeter-se às cirurgias de enxertos autógenos que demandam maior tempo de tratamento. As fixações zigomáticas surgiram como alternativa cirúrgica para esses pacientes e têm sido utilizadas com uma margem de sucesso similar aos implantes convencionais. Após a comprovação da existência de uma atrofia severa da maxila criouse um Protocolo para Fixações Zigomáticas em sistema de Carga Imediata. A cirurgia foi efetuada sob anestesia geral com intubação. Foi eleito o acesso intraoral com incisão supracrestal. A profundidade foi conferida e um implante de fixação zigomática de 42.5mm e 45mm foi implantado dois de cada lado foram utilizados implantes zigomáticos do Sistema de Implantes Nacional (SIN).A ótima qualidade óssea do zigoma provou ser uma região de estabilização rígida assegurando a otimização do tratamento e o benefício ao paciente, que submetido a um custo menor e tempo menor, apresentou estética facial harmônica, melhoria na mastigação e principalmente restabeleceu o individuo para a vida social, devolvendo-lhe sua autoestima.

Edentulous patients with insufficient bone quantity and quality, resulting in loss of retention and prosthetic instability often have to undergo multiple autogenous bone graft surgeries, which demand more treatment time. Zygoma fixations were introduced as a surgical alternative for these patients and have been used with a success rate similar to standard fixtures. Once identified severe maxillary atrophy, a protocol for zygoma fixation was created for immediate loading. Surgery was conducted under general anesthesia with intubation. The intra-oral access along with a supracrestal incision was elected. Depth of penetration was confirmed and a 42.5 and 45mm two zygoma fixture was installed bilaterally implants (SIN). Provisional complete dentures were processed and worn for 48 h until definitive prosthesis is inserted. Good zygomatic bone quality served as a rigid stabilization area, providing not only treatment optimization and patient comfort, but also less cost and chair time, as well as harmony in facial esthetics and masticatoryimprovement. Finally, patients regained self-steem and social capabilities.

Quiste aneurismático del maxilar superior. Reporte de un caso / Aneurysmal bone cyst of the maxilla. Report of one case

Aneurysmal bone cysts are benign fibro osseous lesions, rarely present in maxillary region. We report the CT and morphological findings of aneurysmal bone cyst of the maxilla in a 15 years old female. The patient was subjected to a maxillectomy, preserving the orbit floor. The postoperative evolution has been uneventful. The tumor mainly involved the maxillary sinus with extension to the orbit wall and osseous palate. Very few cases of aneurysmal bone cysts of the maxilla have been reported in the literature.

[Aneurysmal bone cyst of the maxilla. Report of one case]. / Quiste aneurismático del maxilar superior. Reporte de un caso.

Aneurysmal bone cysts are benign fibro osseous lesions, rarely present in maxillary region. We report the CT and morphological findings of aneurysmal bone cyst of the maxilla in a 15 years old female. The patient was subjected to a maxillectomy, preserving the orbit floor. The postoperative evolution has been uneventful. The tumor mainly involved the maxillary sinus with extension to the orbit wall and osseous palate. Very few cases of aneurysmal bone cysts of the maxilla have been reported in the literature.

Osteoma of the zygomatic arch--report of a case.

An osteoma of the zygomatic arch in a 55-year-old woman is reported. Surgical resection through a preauricular incision was easily performed. The lesion was very large, but pedicled.

Angioma de región malar / Angioma of zygomatic region

Los angiomas son tumores que afectan al endotelio de los vasos sanguíneos y linfáticos, conformando de este modo canales vasculares que no siguen un patrón normal. Histológicamente se pueden observar características similares al tejido normal y de acuerdo al diámetro de estos canalículos se desprende la clasificación en capilares, cavernosos y mixtos. Afectan a tejidos blandos y duros, dando diferentes características clínicas según su ubicación y la alteración que sufra el endotelio vascular. Se enumeran los estudios complementarios y los posibles tratamientos. Se describe el síndrome de Sturge-Weber-Dimitri. Por último se comenta un caso clínico. (AU)

Craniofacial asymmetry in development: an anatomical study.

The purpose of this study was to evaluate the occurrence of craniofacial asymmetries in four areas of human skulls of various age groups to test the hypothesis that there is craniofacial symmetry before the chewing habit is established. The data were obtained from 95 skulls of fetuses, infants, children, and adults, from the collection of Federal University of São Paulo. The following measurements were taken on each skull with a digital caliper: from the infraorbital foramen to the anterior nasal spine (IOF); from the greater palatine foramen to the posterior nasal spine (GPF); from the spinous foramen to the basion (SF); and from the spinous foramen to the zygomatic arch (ZA). On different occasions, each measurement was taken three times on both sides of the skull in random order. The mean of the right-side measurements were subtracted from the mean of the left-side measurements, and the differences were transformed into percentages. Comparisons were made by analysis of variance. The presence of cranial asymmetry was statistically significant throughout the whole sample. The minimum value found was 2.8% and the maximum 6.5%. All age groups presented the same degree of asymmetry of distances IOF, GPF, and SF. The group of infants presented a higher degree of asymmetry on distance ZA, followed by the groups of fetuses, children, and adults. This study confirmed statistically significant craniofacial asymmetry in fetuses and infants (before dentition). Therefore, the hypothesis that craniofacial asymmetry only appears after establishment of the chewing habit was not supported.

Three-dimensional evaluation of skeletal and dental asymmetries in Class II subdivision malocclusions.

The objective of this study was to determine if any significant differences existed with regard to dental and skeletal asymmetries between subjects with Angle Class II subdivision malocclusions and subjects with normal occlusions. The sample consisted of 30 subjects in each of the 2 groups. Each possessed a full complement of permanent teeth, including first molars. The average age of subjects was 15.76 years in the Class II subdivision group and 22.42 years in the normal occlusion group. Measurements were obtained with the use of submentovertex, posteroanterior, and corrected oblique cephalometric radiographs. In the submentovertex radiographs, symmetry was assessed by measuring the relative differences in the spatial positions of dental and skeletal landmarks between the right and the left sides in both anteroposterior and transverse dimensions. Coordinate systems were used to represent the mandible, cranial floor, and the maxilla. In the posteroanterior radiographs, symmetry was assessed similarly by measuring the relative differences in the spatial positions of dental and skeletal landmarks between the right and the left sides. In the corrected oblique radiographs, symmetry was assessed by measuring the differences in size of dental and skeletal structures between the right and the left sides. Variables were analyzed with multivariate logistic regression analysis. The results demonstrated that the primary contributor to the differences between the 2 groups was the distal positioning of the mandibular first molars on the Class II side in patients whose mandibles showed no unusual skeletal or positional asymmetries. A secondary contributor was the mesial positioning of the maxillary first molars on the Class II side. Furthermore, the posteroanterior radiographic analysis showed that the more frequent distal positioning of the mandibular molars on the Class II side, compared with the mesial positioning of the maxillary molars on that side resulted in mandibular dental midline deviation to the Class II side more frequently than the maxillary dental midline to the opposite side.

Hydroxylapatite implants with or without collagen in the zygomatic arch of rats. Histological study.

The authors studied the behavior of calcium phosphate materials used as inlay implants into bone cavities prepared in the zygomatic arch of rats. Fifty male albino rats were divided into four groups as follows: group I-preparation of bone cavities which did not receive any implant material as controls; group II-implants of Interpore 200; group III-implants of experimental hydroxylapatite; group IV-implants of experimental hydroxylapatite combined with collagen. The animals were sacrificed after 5, 15, 30, 60 and 120 days and the specimens were submitted to histological analysis. Results showed that the experimental hydroxylapatite used in group III presented better osteogenic properties compared to the other materials. All tested materials were biocompatible, although group IV presented a more intense inflammatory response.

Cambios histológicos en el epitelio de la mucosa del carrillo en sujetos masticadores de hojas de coca / Histologic changes in the cheek mucosal epithelium of coca leaves chewing subjects

El propósito del presente trabajo de investigación es describir las características histológias del epitelio de la mucosa del carrillo relacionadas con el hábito de masticación de hojas de coca, determinado según edad y tiempo total de exposición de la mucosa al bolo de coca. Los criterios de evaluación para describir las características del epitelio fueron observados a nivel de las cuatro capas (basal, espinosa, intermedia y superficial). La muestra estuvo constituida por 43 biopsias (30 pertenecientes a masticadores de hojas de coca y 13 sujetos que no presentaban el hábito) entre 40 y 70 años ed edad, de una comunidad andina de Huánuco, Perú. Se encontró acantosis en el 100 por ciento de los sujetos con el hábito, así como células eosinófilas en las capas espinosa e intermedia enel 76,6 por ciento y el 53,3 por ciento respectivamente, e hiperqueratosis en el 96,6 por ciento. No se encontraron cambios correspondientes a displasia epitelial y en todas las capas del epitelio se halló inflamación crónica de grado leve a moderado, observándose que el epitelio de la mucosa del carrillo de los masticadores de coca sufre un proceso de adaptación que corresponde al cambio de un epitelio no queratinizado a paraqueratinizado, el cual se mantiene sin progresar a cambios histológicos mayores. No se encontró diferencia estadísticamente significativa (>0,05) entre los hallazgos histológicos y la edad ni con el tiempo total de exposición de la mucosa al bolo de coca

Zygomatic-transmandibular approach for giant tumors of the infratemporal fossa and parapharyngeal space.

OBJECTIVE: The surgical anatomy of the infratemporal fossa and parapharyngeal space is often not properly understood by neurosurgeons, because these areas are more related to other medical disciplines. This article provides a detailed description of the infratemporal fossa and parapharyngeal space anatomy in cadaveric specimens and offers a neurosurgical perspective on a surgical approach that allows wide exposure and complete resection of giant tumors in this location. METHODS: Ten cadaveric specimens were prepared for anatomic study. Dissections were performed to emphasize the relationship between bone, muscles, and neurovascular structures and to simultaneously expose the middle cranial fossa, the infratemporal fossa, and the parapharyngeal space. Ten patients with giant lesions in these areas (with maximum tumor diameter >8 cm) were treated via this approach. RESULTS: The main obstacles to approaching the infratemporal fossa and the parapharyngeal space are the zygomatic arch, the parotid gland, the facial nerve, and the ascending ramus of the mandible. Thus, by combining a pterional-zygomatic craniotomy with transmandibular access, working up and down the parotid gland, the exposure is wider and safer. Among the 10 patients treated, tumors were totally resected in 7, subtotally resected in 2, and partially resected in 1. Morbidity was unremarkable, and, in 8 patients, clinical status improved dramatically. CONCLUSION: The zygomatic-transmandibular approach allows resection of giant lesions in the middle cranial base, when they are invading the infratemporal fossa and parapharyngeal space, with a low morbidity rate.

Fibroma desmoplásico nos ossos maxilar e zigoma esquerdos (revisão da literatura e relato de um caso) / Desmoplastic fibroma of the maxillary bone and left zygoma: (literature review and case report)

Com a apresentação de um caso de fibroma desmoplásico do maxilar e zigoma esquerdos em uma menina de um ano e meio de idade, foi feita uma revisão dos casos publicados na literatura, bem como uma discussão de seus aspectos clínicos e radiográficos, histopatológicos, tratamento e prognóstico