Davide Sozzi

A Quantitative Three-Dimensional Assessment of Abnormal Variations in Facial Soft Tissues of Adult Patients With Cleft Lip and Palate

OBJECTIVE To supply quantitative information about the facial soft tissues of adult operated patients with cleft lip and palate (CLP). DESIGN, SETTING, AND PATIENTS The three-dimensional coordinates of soft tissue facial landmarks were obtained using an electromagnetic digitizer in 18 Caucasian patients with CLP (11 males and 7 females aged 19 to 27 years) and 162 healthy controls (73 females and 89 males aged 18 to 30 years). From the landmarks, 15 facial dimensions and two angles were calculated. Data were compared with those collected in healthy individuals by computing z-scores. Two summary anthropometric measurements for quantifying craniofacial variations were assessed in both the patients and reference subjects: the mean z-score (an index of overall facial size), and its SD, called the craniofacial variability index (an index of facial harmony). RESULTS In treated patients with CLP, facial size was somewhat smaller than in normal individuals, but in all occasions the mean z-score fell inside the normal interval (mean +/- 2 SD). Almost all patients had a craniofacial variability index larger than the normal interval, indicating a global disharmonious appearance. Overall, in patients pronasale, subnasale, and pogonion were more posterior, the nose was shorter and larger, the face was narrower, and the soft tissue profile and upper lip were flatter than in the reference population. CONCLUSIONS The facial soft tissue structures of adult operated patients with CLP differed from those of normal controls of the same age, sex, and ethnic group. In this patient group, surgical corrections of CLP failed to provide a completely harmonious appearance, even if the deviations from the reference were limited. Further analyses of larger groups of patients are needed.

Three-dimensional lip morphometry in adults operated on for cleft lip and palate

Measurements were taken from 18 patients operated on for cleft lip and palate, aged 19 to 27 years, and 162 control subjects matched for sex, age, and ethnic group. Nine soft-tissue landmarks on the lips were digitized by a three-dimensional electromagnetic instrument. From the landmarks, several linear distances (mouth width, philtrum width, vermilion height of upper and lower lip, total vermilion height, total lip height), the interlabial angle, and some areas (vermilion of upper lip, vermilion of lower lip, total vermilion) and volumes (upper lip volume, lower lip volume, total lip volume) were calculated. Patient and reference data were compared by t tests and Watson-Williams tests. In the men, significant differences (p < 0.05) were found in width of the philtrum, height and area of the vermilion part of the upper lip, and total vermilion height and area (all larger in male patients than in controls). In the women, significant differences were found in the height and area of the vermilion part of the upper lip (larger in female patients than in controls), and in the height and area of the vermilion part of the lower lip (smaller in patients than in controls). In both sexes, the interlabial angle was smaller than in the reference population. In conclusion, the upper lip of adult patients operated on for cleft lip and palate differed from that of healthy controls of the same age, sex, and ethnic group. Surgical correction of cleft lip and palate failed to provide a completely normal appearance. The analysis pointed out those parts of the lips and mouth (in particular, the vermilion part of the upper lip) that differed the most from the norm. The method may be used to indicate to the surgeon and patient where additional procedures might be performed to approximate the morphologic characteristics of a reference population.

Three-dimensional mandibular motion after closed and open reduction of unilateral mandibular condylar process fractures.

OBJECTIVE To detect the changes in 3D mandibular motion after two types of condylar fracture therapies. MATERIALS AND METHODS Using a 3D motion analyzer, free mandibular border movements were recorded in 21 patients successfully treated for unilateral fractures of the mandibular condylar process (nine patients: open reduction, rigid internal fixation, and functional treatment; 12 patients: closed reduction and functional treatment; follow-up: 6-66 months), and in 25 control subjects. RESULTS No differences were found among the groups at maximum mouth opening (MO), protrusion and in lateral excursions. During opening, the patients had a larger maximal deviation to the fractured side than the controls (controls 2.3 mm, open treatment 3.9 mm, closed treatment 4.2 mm; Kruskal-Wallis test, p=0.014; closed treatment vs. controls, p=0.004), with a larger coronal plane angle (controls 2.4°, open treatment 3.6°, closed treatment 4.4°; p=0.016; closed treatment vs. controls, p=0.013). In the closed treatment patients, a longer follow-up was related to increased maximum MO (p=0.04), sagittal plane angle (p=0.03), and reduced lateral mandibular deviation during MO (p=0.03). CONCLUSION Mandibular condylar fractures can recover good function; some kinematic variables of mandibular motion were more similar to the norm in the open treatment patients than in closed treatment patients.

Ameloblastic carcinoma in a young patient

Owing to the rarity of publications describing ameloblastic carcinoma, little is known about this entity in pediatric patients. To our knowledge, malignant transformation from an odontogenic cyst into an ameloblastic carcinoma in a pediatric patient has not been documented to date. We present the case of a 14-year-old boy in whom a large osteolytic lesion associated with an impacted right maxillary third molar germ was fortuitously detected by orthopanoramic radiography. With a preoperative clinical-radiographic diagnosis of odontogenic cyst, the patient underwent surgical enucleation of the lesion. Histologic evaluation rendered a diagnosis of follicular cyst with a focal area of ameloblastic carcinoma. The literature addressing ameloblastic carcinoma is reviewed.

Histological findings on jaw osteonecrosis associated with bisphosphonates (BONJ) or with radiotherapy (ORN) in humans.

Abstract Objective. To describe the histological features of bone tissue harvested from patients affected by jaw osteonecrosis associated with bisphoshponates (BONJ) or with radiotherapy (ORN), in undecalcified ground sections. Materials and methods. Sixteen bone tissue samples from 14 patients with BONJ and two patients with ORN were processed in order to obtain both ground, undecalcified sections and decalcified sections. The sections underwent histometric and morphometric analysis. Results. Bone tissue samples obtained from patients with BONJ or ORN of the jaws shared some histological characteristics. Common histological features included the loss of bone architecture, the absence of a proper Haversian system and proper marrow spaces, the presence of necrotic spots of non-mineralized tissue, areas of empty osteocytic lacunae next to areas of hypercellularity, the presence of resorption pits with rare osteoclast-like cells and the presence of bacteria and of an inflammatory infiltrate. A violet rib of tissue characterized by large resorption pits facing was frequently observed between the mineralized bone and the inflammatory infiltrate. Conclusions. The histological features of BONJ and ORN are similar and resemble those of osteomyelitis. Even though it is not clear whether infection is the cause or consequence of bone exposure, inflammatory cells, bacteria or their products may have a massive, direct lytic effect on bone tissue challenged by bisphosphonates.

Primary Intraosseous Squamous Cell Carcinoma of the Jaws: 6 New Cases, Experience, and Literature Comparison.

PURPOSE To analyze the clinical, histologic, radiologic, therapeutic, and prognostic aspects of 6 cases of an uncommon head and neck malignancy and compare these results with data in the literature. MATERIALS AND METHODS The medical histories of all patients treated in the Maxillofacial Surgery Unit in San Gerardo Hospital (Monza, Italy) for primitive intraosseous squamous cell carcinoma (PIOSCC) of the jaw were reviewed. All patients were considered suitable for inclusion in the study, specifically those whose oral mucosa had not been compromised and who did not have distant metastases. RESULTS Six patients were included (4 male, 2 female). The odontogenic origin was histologically shown in only 2 patients. The male-to-female ratio was 2:1, and the malignancy occurred in the posterior mandible in 50% of cases. The most common symptoms were swelling and pain, but no sensory disturbances were observed. Radiologic findings indicated considerable variation in presentation, including small cystic lesions, which might complicate a pathologic diagnosis. All patients in the study were treated with surgery, and 2 patients received adjuvant radiotherapy. Cervical node metastases were present in 33% of patients. All patients are currently alive and free of disease. CONCLUSION PIOSCC is a rare malignancy of the head and neck. Diagnosis can be difficult during the early stages of disease owing to a lack of clinical symptoms or radiologic presentation. Treatment is surgical and, like every other cancer, must be adequate to cure the cancer.

Assessing the precision of posttraumatic orbital reconstruction through 3D-3D “mirror” orbital superimposition: 3D surface point-to-point distance versus volume

Posttraumatic orbital fractures are mainly reconstructed through orbital meshes. The most frequently used method to assess the success of orbital reconstruction is based on the comparison of orbital volumes [1]. However, the modern techniques of 3D elaboration enable to perform innovative procedures of comparison, such as the 3D-3D registration and quantification of point-to-point distances. Ten patients who underwent to orbital reconstruction through titanium meshes in the Department of Maxillofacial Surgery, University of Milano-Bicocca, were recruited (patients group), together with a ten patient control group. Volumes of orbits were segmented on CT scans and automatically calculated. The 3D model from the unaffected orbit was then flipped according to the sagittal plane in order to obtain a “mirror” image of the contralateral orbit, and automatically registered on the reconstructed one. Point-to-point RMS (Root Mean Square) distance between the 3D models was then calculated. The same procedure was applied also to the CT-scans from unaffected patients. Possible statistically significant differences in volume and surface RMS distance were assessed through Student’s t-test (p 0.05); on the other side, mean RMS value was significantly higher in the former group than in the latter one (0.78 mm versus 0.59 mm, p<0.05). Discordant areas are more frequently observed on the floor of the orbital cavity where the titanium mesh is applied. The present study highlights the use of 3D surfaces point-to-point distance as a parameter for assessing anatomical success of orbital reconstruction: the next studies will verify the relation of this parameter with clinical signs reported by patients.

Orbital Osteoblastoma: Technical Innovations in Resection and Reconstruction Using Virtual Surgery Simulation

Osteoblastoma is a benign tumor of bone, representing less than 1% of bone tumors. Craniomaxillofacial localizations account for up to 15% of the total and frequently involve the posterior mandible. Endo-orbital localization is very rare, with most occurring in young patients. Very few of these tumors become malignant. Orbital localization requires radical removal of the tumor followed by careful surgical reconstruction of the orbit to avoid subsequent aesthetic or functional problems. Here, we present a clinical case of this condition and describe a surgical protocol that uses and integrates state-of-the art technologies to achieve orbital reconstruction.