Dario Bertossi

Contemporary Management of Vascular Malformations

PURPOSE To review the literature on vascular malformations and to clarify their diagnosis, clinical presentation, and treatment options. MATERIAL AND METHODS The authors reviewed the current literature on vascular malformations looking for more innovative and credited diagnostic criteria and treatment protocols. RESULTS The review is divided in 4 sections (capillary, venous, arteriovenous, and lymphatic malformations). In each section, the clinical presentation, radiologic features, and treatment options for each kind of vascular malformation are described. The experience and results of the authors also are presented. CONCLUSIONS Vascular malformations are a heterogeneous group of diseases. Each type of malformation has unique features that make it largely different from the others. Only a clear and correct diagnosis can lead to optimal results.

Orthodontic Microsurgery for Rapid Dental Repositioning in Dental Malpositions

PURPOSE Malposition of dental elements can be easily corrected when the patient is young; however, the opposite is true for adults. Middle-age patients normally request a rapid solution, but they usually also have associated pathologic features, such as advanced periodontal disease, dental migration, and ankylosis. Shortening the orthodontic treatment time is possible but not easy to achieve. We applied piezosurgical bone cuts to 10 patients affected by different dental malformations to determine the effects of a shorter treatment time. MATERIALS AND METHODS A total of 10 patients (8 women and 2 men) were treated using the monocortical tooth dislocation and ligament distraction technique. We included 5 patients with dental ankylosis (group A, with a range of 4 to 5 mm of dental intrusion into the bone), who presented with at least 4 elements included in the mandible, and 5 preoperative patients affected by maxillary hypoplasia and transverse maxillary diameter reduction (group B, with a range of 6 to 8 mm measured at the first molar palatal cusp). RESULTS Dental repositioning was achieved within 18 to 25 days for the dental intrusion group (group A) and within 68 to 150 days for the preoperative group (group B). The average period was 20 days for group A and 100 days for both dental arches in group B. The decrease in orthodontic treatment time was 70% for the ankylotic teeth and 65% for the preoperative group. We observed no periodontal or gingival damage, although all 10 patients experienced moderate edema and pain. CONCLUSIONS This method of shortening the orthodontic treatment time is simple, and performing osteotomic lines laterally and apically to the tooth radix on the bone has proved useful in reducing the treatment time. In addition, the technique is very easy to use and has a low incidence of side effects.

TOOTH ORTHODONTIC MOVEMENT AFTER MAXILLOFACIAL SURGERY

The purpose of this study is to compare the rate of orthodontic tooth movement in regenerated bone, created after mandibular Distraction Osteogenesis (DO), with the rate of orthodontic tooth movement in patients who had extractions. The sample group (treated subjects) was composed of 14 Class II patients (5 males and 9 females, mean age 25.0±1.1years) treated with a Distraction Osteogenesis appliance; the control group (extraction cases) was composed of 14 subjects (mean age 21.9±3.1 years). Both groups were followed by conventional orthodontic treatment for space closure. Teeth movements (amount and fate) were evaluated by measuring the distance between the distal wing of the canine bracket and the mesial wing of the first or the second premolar bracket, depending on the group, using Vernier callipers (Dentaurum). Readings were noted every 2 weeks until space closure was completed. In this study the mean duration of the post-distraction orthodontic treatment was 12±0.3 months. Our study showed that the space created by distraction was closed in 10±1 months; while with conventional orthodontic treatment the average time to complete space closure was 5.90±0.9 months. The average space closure was 6.50±0.10 mm with conventional orthodontic treatment and 7.90±0.38 mm in the patients treated with DO. The mean rate of tooth movement was 1.27±0.23 mm/month in the group with conventional orthodontic treatment and 0.68±0.20 mm/month in the group treated with DO. Unpaired t test showed a significant difference between tooth movement in the study sample and in the control group (p<.05). As suggested by most scientific literature, in our sample dental movement was started at the end of the consolidation phase. However, the rate of space closure in the distraction area was higher than with conventional orthodontic treatment. Undoubtedly, this approach can be used for the treatment of very severe skeletal malocclusions and maxillofacial deformities, but it cannot be considered an alternative to conventional orthodontic surgery to accelerate treatment because tooth movement in edentulous spaces created by osteodistraction requires more time.

Cosmetic Procedures in Orthognathic Surgery

PURPOSE Orthognathic surgery produces cosmetic and functional effects, and patients should be evaluated for additional cosmetic improvements beyond those possible with orthognathic surgery. Soft tissue procedures can be performed on an outpatient basis in an office environment and can be combined with orthognathics and delayed in a second stage. METHODS Systematic accurate facial evaluation is necessary to focus on cosmetic soft tissue problems. Features that make the patient look unattractive, old, tired, out of shape, weak, or sad must be identified by accurate clinical analysis and 3-dimensional planning. Then it will be possible to select the treatment plan according to the patients input, prioritizing the additional cosmetic improvements that can be added to primary surgery. RESULTS It is particularly important to review the results and the patients satisfaction by clinical examination, a questionnaire, and with 3-dimensional pictures, and to understand if the treatment options have been accurately chosen and their lasting effect on follow-up. The treatment sequence is analyzed, and if there are residual defects, a secondary cosmetic procedure can be planned to complete the result. CONCLUSIONS The surgeons goal must be the simultaneous treatment of malocclusions and facial esthetic disharmonies, and orthognathic surgical procedures and facial cosmetics must be performed simultaneously, if possible. Residual defects must be treated after at least 6 to 12 months.

Piezosurgery Versus Conventional Osteotomy in Orthognathic Surgery: A Paradigm Shift in Treatment

Abstract The aim of the study was to compare in a randomized controlled clinical trial the use of the piezoelectric osteotomy as an alternative to the conventional approach in terms of surgery time, intraoperative blood loss, cut quality, nerve injury, and costs. One hundred ten patients who had orthognathic surgery procedures with bimaxillary osteotomy were divided into 2 groups: group A was treated with a piezosurgery device, and group B, with a reciprocating saw and bur. The piezosurgical bone osteotomy permitted individualized cut designs. The surgical time in group A was reduced, with a mean for the mandibular osteotomy (1 side) between 3 minutes 31 seconds and 5 minutes 2 seconds, whereas in group B, the surgical time was between 7 minutes 23 seconds and 10 minutes 22 seconds. The surgical time in group A for the Le Fort I osteotomy was between 5 minutes 17 seconds and 7 minutes 55 seconds in group A and between 8 minutes 38 seconds and 15 minutes 11 seconds in group B. All patients in group A had a low blood loss (<300 mL) versus patients of group B who had a medium to high blood loss (medium loss: 400 mL, high loss: >500 mL). Inferior alveolar nerve sensation was retained in 98.2% of group A versus 92.7% in group B at 6 months postoperative testing. Piezoelectric osteotomy reduced surgical time, blood loss, and inferior alveolar nerve injury in bimaxillary osteotomy. Absence of macrovibrations makes the instrument more manageable and easy to use and allows greater intraoperative control with higher safety in cutting in difficult anatomical regions.

Gridplan midfacial analysis for alloplastic implants at the time of jaw surgery.

Background: Middle-third facial implants are primarily indicated for facial plastic surgery and orthognathic surgery as well as the secondary treatment of facial trauma and congenital malformations. Several methods of clinical analysis have been described both for defect classification and for surgical technique and implant materials. These prove very difficult to apply so as to establish a precise standard. Methods: A new frontal-view facial analysis was developed on the basis of a grid of three vertical and five horizontal lines, divided in turn into six high and four lower middle-third areas with three vertical lines on side view. These vertical lines (LC and P) prove useful for the purposes of quantifying degree of defect. The lines can be marked on the patient’s face during the intraoperative phase so as to ensure correct implant placement. Medpor implants were applied and secured by means of circumvestibular incision during Le Fort I osteotomy with titanium miniscrews. Results: One hundred fifty-one patients with zygomatic defects were treated by means of this method during the correction of facial malocclusion. The results were achieved as planned during the preoperative phase in all cases. Postoperative complications were of minor severity, and only one implant was removed. Conclusions: This method of facial analysis is simple, and the drawing of lines proves useful to ensure correct implant positioning and symmetry during the surgical phase. In addition to being very easy to apply, position, and shape, Medpor implants also offer long-term stability and involve no any major complications.

The use of computer-guided flapless dental implant surgery (NobelGuide) and immediate function to support a fixed full-arch prosthesis in fresh-frozen homologous patients with bone grafts.

Abstract The behavior of fresh-frozen homologous bone (FFB) when used in combination with computer-guided implant surgery has not been investigated yet, and there is a lack of clinical evidence in the literature. The purpose of this retrospective study is to evaluate the implant survival and related fixed full-arch prostheses at the 1- to 5-year follow-up when performed with immediate function using a flapless surgical procedure and computer-aided technology (NobelGuide; Nobel Biocare AB, Goteborg, Sweden) in patients previously treated with FFB grafts. Furthermore, the related values of torque and complications observed were analyzed and discussed. Clinical charts of patients with edentulous arches treated with FFB grafts and NobelGuide system with at least 1 year follow-up were reviewed retrospectively. A total of 65 patients met the criteria of inclusion, receiving a total of 342 implants and 77 full-arch prostheses, with a mean follow-up of 32.87 months (range, 1–5 years). Survival of implants and prostheses was high, reaching 96.5% and 95%, respectively. Factors significantly related to failure of the implants were smoking, position of the implant as last distal abutment, and fracture of basal maxillary bone. Prostheses survival was influenced by bruxism, failure of multiple implants, and torque level of implant equal to 0 at implant insertion. All implants and prostheses failures occurred in the first year. A higher torque level at implant insertion did not correspond to a lower risk of implant failure. Within the limitations of our retrospective study, this treatment modality was predictable with high survival rates and high insertion torque. However, a few implant and prosthetic failures were found, together with several complications.

Surgical treatment of unilateral condylar hyperplasia with piezosurgery.

IntroductionUnilateral condylar hyperplasia (UCH) is a disorder of unknown etiology mainly seen in growing patients, which results in facial asymmetry. High condylectomy alone or in association with orthognathic surgery can improve the occlusion and the facial aesthetics. Materials and MethodsBetween 2005 and 2012, a total of 5 patients underwent high condylectomy for UCH using a piezoelectric cutting device. All patients were treated postoperatively with functional rehabilitation. ResultsThe long-term follow-up showed that all patients had a satisfactory temporomandibular joint articular function associated with stable occlusion without any recurrence of further condylar growth. ConclusionsHigh condylectomy in the surgical treatment of unilateral UCH seems to be the procedure of choice in growing patients. The use of a piezoelectric cutting device allows a safe and less invasive high condylectomy.

Hyaluronic acid: in vitro and in vivo analysis, biochemical properties and histological and morphological evaluation of injected filler

BACKGROUND No human model has emerged as an accepted standard to evaluate tissue filler longevity. OBJECTIVES To validate a human model adequate to compare soft tissue filler degradation and tissue reaction. MATERIALS AND METHODS We evaluated in 18 patients the persistence of hyaluronic acid (HA) filler injected into labial tissue analyzing hyaluronidase (HYAL) activity by means of in vitro and in vivo tests, MRI and histological and ultra-structural examination at 3 and 6 months postop. RESULTS MRI examination revealed the presence of HA filler in a clear hyperintense area. Histology demonstrated fibroblast activation. The amount and the degradation rate of HYAL and HA did not show a linear correlation. CONCLUSION MRI demonstrated the presence of HA in lip tissue even after 6 months. Biopsies at 3 months revealed tissue maturation and at 6 months confirmed the ability of HA to reorganize and integrate the extracellular matrix. The absence of linear correlation between HYAL and HA revealed that the result clinically is probably dependent on systemic factors which can determine HYAL activity and therefore HA longevity.

Eagle syndrome surgical treatment with piezosurgery.

IntroductionEagle syndrome (ES) is an uncommon complication of styloid process elongation with stylohyoideal complex symptomatic calcification. It is an uncommon condition (4% of the population) that is symptomatic in only 4% of the cases. Eagle syndrome is usually an acquired condition that can be related to tonsillectomy or to a neck trauma. A type of ES is the styloid-carotid syndrome, a consequence of the irritation of pericarotid sympathetic fibers and compression on the carotid artery. Clinical manifestations are found most frequently after head turning and neck compression. Although conservative treatment (analgesics, anticonvulsants, antidepressants, local infiltration with steroids, or anesthetic agents) have been used, surgical treatment is often the only effective treatment in symptomatic cases. Materials and MethodsWe present the case of a 55-year-old patient, successfully treated under endotracheal anesthesia. The cranial portion of the calcified styloid process was shortened through an external approach, using a piezoelectric cutting device (Piezosurgery Medical II; Mectron Medical Technology, Carasco, Italy) with MT1-10 insert, pump level 4, vibration level 7. ResultsNo major postoperative complications such as nerve damage, hematoma, or wound dehiscence occurred. After 6 months, the patient was completely recovered. Two years after the surgery, the patient did not refer any symptoms related to ES. ConclusionsThe transcervical surgical approach in patients with ES seems to be safe and effective, despite the remarkable risk for transient marginal mandibular nerve palsy. This risk can be decreased by the use of the piezoelectric device for its distinctive characteristics—such as precision, selective cut action, and bloodless cut.