Antonio Tullio

Subciliary versus swinging eyelid approach to the orbital floor

In this retrospective study, the authors compare the outcomes of two different approaches to the orbital floor: the classic subciliary versus the transconjunctival plus lateral canthotomy (swinging eyelid). Forty-five patients who underwent orbital surgery (47 approaches) for different indications (orbital fractures, correction of Graves exophthalmos, tumours of the internal orbit and correction of enophthalmos in secondary trauma) were placed in two groups, depending on the approach. The long-term effects of the incisions, the outcome of the approach and the complications were recorded and compared. The minimum follow-up for inclusion in the study was 1 year. Twenty-three orbits underwent subciliary incision, and 24 underwent swinging eyelid. No ectropion or entropion was seen in any patient. For the swinging eyelid approach, complications included three cases (12.5%) of canthal malposition; for the subciliary approach, five cases (21.14%) of lagophthalmos and 10 visible scars were observed. Our findings show the advantages of the swinging eyelid: better aesthetic results, the same or greater exposure of the orbital floor and the caudal part of the lateral and medial walls, shorter surgical time (sutureless) and a less extended scar. Although in our experience this approach is preferable in orbital surgery, some indications for the subciliary still remain.

Cheek mucosa: A versatile donor site of myomucosal flaps. Technical and functional considerations

Reconstruction of moderate‐sized mucosal defects of the oral cavity/oropharynx represents a surgical challenge. The most widely used reconstructive techniques are skin grafts, local or regional pedicled flaps, and free flaps, but they do not provide mucosal sensitivity, mobility, volume, or texture similar to that of native tissue. The cheek myomucosal flaps seem to provide “ideal reconstruction” because they carry a thin, mobile, well‐vascularized, and sensitive tissue, like those excised or lost. The purpose of this retrospective analysis was to evaluate the indications for the advantages and disadvantages of 6 types of buccinator myomucosal flaps which are possible to raise from the cheek mucosa.

Is neck dissection needed in squamous-cell carcinoma of the maxillary gingiva, alveolus, and hard palate? A multicentre Italian study of 65 cases and literature review

The occurrence of occult cervical metastases due to squamous-cell carcinoma of the hard palate and maxillary alveolar ridge has not been studied systematically. We have observed that many patients return with a delayed cervical metastasis following resection of a primary cancer at these sites. Some of these patients have died as a result of a regional or distant metastasis, despite control of the primary cancer. The literature contains few recommendations to guide the treatment of maxillary squamous-cell carcinoma; prospective studies are difficult due to the rarity of such tumours. The aim of this study is to define the incidence of cervical metastasis and to investigate whether elective neck dissection is justified. We present a retrospective multicentre study of 65 patients with squamous-cell carcinomas of the maxillary alveolar ridge and hard palate and review of the existing literature. The overall incidence of cervical metastases was 21%. We evaluated the significance of primary-site tumours as indicator of regional disease. The maxillary squamous-cell carcinoma cases in our multicentre study and in the literature review exhibited aggressive regional metastatic behaviour, comparable with that of carcinomas of the tongue, mouth floor, and mandibular gingiva. Based on our findings, we recommend selective neck dissection in clinically negative necks as a primary management strategy for patients with maxillary squamous-cell carcinomas involving the palate, maxillary gingiva, or maxillary alveolus.

Ameloblastic fibro-odontoma. Case report and review of the literature *

Ameloblastic fibro-odontoma (AFO) is defined by the World Health Organization (WHO) as a neoplasm composed of proliferating odontogenic epithelium. It is a benign, slow-growing, expansive tumour that clinically appears as a well-encapsulated, benign lesion. Histologically, AFO has been classified as an ameloblastic fibroma or odontoma. Despite numerous efforts, however, there is still considerable confusion concerning the nature, the histology and the therapy of these lesions. This paper reports an additional case of a large AFO and reviews the relevant literature regarding the clinical and pathologic features of this lesion.

Three-dimensional primary reconstruction of anterior mouth floor and ventral tongue using the ‘trilobed’ buccinator myomucosal island flap

Three-dimensional reconstruction of the anterior mouth floor and ventral tongue after ablative surgery can be achieved using several techniques. The ideal reconstruction should be accomplished with the same or similar type of tissue, and cheek axial myomucosal flaps based on the branches of facial or internal maxillary arteries seem ideal for this purpose. From March 2005 to May 2007, 23 patients underwent cheek axial myomucosal flap reconstruction after oral cancer surgical ablation. Thanks to their thinness and pliability, these flaps were frequently shaped to obtain an accurate reconstruction. According to Whetzels hypothesis, an intraoral flap designed to include the axial vessel of one area can safely carry the mucosa of a neighbouring vascular area. The authors describe a large buccinator myomucosal island flap based on the branches of the facial artery and formed in a trilobed shape in order to capture the adjacent buccal mucosal angiosome from the internal maxillary artery. The flap provided the correct anatomical oral reconstruction for the anterior mouth floor and ventral tongue. The function of the tongue, oral intake and mastication were not impaired. The trilobed buccinator myomucosal island flap is a suitable option for the three-dimensional reconstruction of the anterior mouth floor and ventral tongue.

Computed tomography-guided implant surgery for dental rehabilitation in mandible reconstructed with a fibular free flap: description of the technique

The fibular free flap, with or without a cutaneous component, is the gold standard for reconstructing mandibular defects. Dental prosthetic rehabilitation is possible this way, even if the prosthesis-based implant is still a challenge because of the many anatomical and prosthetic problems. We think that complications can be overcome or reduced by adopting the new methods of computed tomography (CT)-assisted implant surgery (NobelGuide, Nobel Biocare AB, Goteborg, Sweden). Here we describe the possibility of using CT-guided implant surgery with a flapless approach and immediate loading in mandibles reconstructed with fibular free flaps.

Delayed Iliac Abscess as An Unusual Complication of an Iliac Bone Graft in an Orthognathic Case

The reconstruction of large maxillofacial defects generally requires harvesting bone from extra-oral sites. The main source of autogenous bone is the iliac crest. This donor site is used to obtain bone for augmentation in orthopaedic surgery, neurosurgery, and oral and maxillofacial surgery, where the main indications are secondary and tertiary osteoplasty in patients with cleft-lip and palate, reconstruction of bony defects after operations for tumours, and augmentation of severe atrophy of the alveolar crest in preprosthetic surgery. A review of the literature on complications following bone harvesting from the anterior iliac crest reveals persistent pain, nerve injury, haemorrhage, limping, persistent gait abnormalities, conspicuous scarring, bone contour alteration, infection, fracture, meralgia paraesthetica, peritonitis, and herniation. The authors report an unusual complication: a huge iliac abscess that appeared 4 years after bimaxillary surgery involving iliac bone grafts.

Computer-assisted orthognathic surgery for correction of facial asymmetry: results of a randomised controlled clinical trial.

In this randomised controlled clinical trial, 2 homogeneous groups of patients with facial asymmetry (n=10 in each) were treated by either classic or computer-assisted orthognathic corrective surgery. Differences between the 2 groups in the alignment of the lower interincisal point (p=0.03), mandibular sagittal plane (p=0.01), and centering of the dental midlines (p=0.03) were significant, with the digital planning group being more accurate.

Computer assisted dental rehabilitation in free flaps reconstructed jaws: one year follow-up of a prospective clinical study

Continuity defects in bone after resection of the jaw may cause problems, and osseo-myocutaneous free flaps are the gold standard for their reconstruction. Implant-supported prosthetic rehabilitation is reliable with these microvascular options, although it is still a serious challenge. The aim of this prospective clinical study was to describe the advantages of implants restored according to a computer-assisted surgical protocol. A group of 10 consecutive patients (both sexes) had already been treated and followed up for at least 1 year after prosthetic loading. The NobelGuide protocol had to be modified to adapt the technique for these patients who had had reconstructions. A total of 56 fixtures were installed and, when possible, immediately loaded (overall survival of implants 95%). Every patient was given correct provisional prosthetic rehabilitation, which was most satisfactory as far as chewing, social functioning, and overall quality of life were concerned. Three-dimensional computed tomographic (CT) examination showed a mean (SD) marginal bone loss of 1.06 (0.5)mm. We used a modified technique of computer-assisted implant surgery in jaws that had been reconstructed with free flaps; from these preliminary findings this approach seems valid when it comes to function, improving prosthetic restoration, and aesthetics.

Management of midcheek masses and tumors of the accessory parotid gland

Tumors of the lateral wall of the mouth have different origins and behaviors. These lesions often arise from salivary tissues, such as the accessory parotid gland, but tumors can also originate from the muscles, buccal fat pad, or other structures. Surgical approaches are limited in this region by the presence of the facial nerve and the Stensens duct. In this article, we present 9 cases of midcheek masses that were operated on via extra- or intraoral approaches. We discuss the problems related to the diagnosis of such tumors, as well as the indications and rationales for different treatment approaches.