Evaristo Belli

Surgical timing in orbital fracture treatment: experience with 108 consecutive cases.

Orbital fractures can lead to esthetic deformities and functional impairments, and adequate surgical timing is considered important in obtaining good results from surgery. By means of chart review, a retrospective analysis was carried out in 108 consecutive cases of pure orbital fractures to investigate the differences in surgical timing and the correlations with patient age and clinical and radiographic findings. In this analysis, surgical timing of pure orbital fractures was strongly related to the combination of parameters such as anatomical location of the fracture, eventual exposure of the fracture, cerebrospinal fluid (CSF) leakage or penetrating wounds, age of patients, eventual functional impairments or muscle entrapment, and serious conditions of compression or ischemia. As the data confirmed, an urgent approach was considered indispensable in severe orbital apex fractures and in orbital fractures with CSF leakage, penetrating objects, or exposure. Early surgery was necessary within 3 days in children with diplopia (type IIIb) and mainly within 7 days in adults with double vision (type IIIa). Delayed surgery, within 12 days in all cases, was performed orbital wall fractures with no impairments (type II) or in orbital rim fractures (type I). Data from this retrospective analysis confirm the need for an aggressive approach to all orbital fractures. In our experience, surgery was performed within 12 days and most orbital fractures were treated during the first week after trauma, which is earlier than previously reported.

Schwannoma of the mandible.

&NA; Schwannoma is a benign neoplasm originating from Schwanns cell. It involves neurons and axons of peripheral nerves. This tumor has a predilection for the head and neck region, and often occurs as soft tissue lesion. Intraosseous sheath tumors are rare, comprising less than 1% of all bone tumors; the mandible is the most common site. The literature reports only 30 acceptable cases of schwannoma of the mandible. We report a new case of schwannoma that is unusual in its intraosseous localization and the patients comparatively young age.

Sclerosing Osteomyelitis of Garre Periostitis Ossificans

Sclerosing osteomyelitis of Garré is a rare syndrome; the mandible is the most commonly affected bone segment in the cervicofacial region. This chronic disease is characterized by a nonsuppurative ossifying periostitis with subperiosteal bone formation, commonly reactive to a mild infection or irritation. The differential diagnosis must be made with similar clinical conditions with hard mandibular swelling associated with bony sclerosis. Presumptive diagnosis can be achieved by radiology, but such diagnosis must be confirmed by histology. The aim of therapy is to remove the cause when recognized, aided by an adequate antibiotic therapy. Clinical, radiographic, and histologic features are presented in this case report.

Autogenous platelet-rich plasma in combination with bovine-derived hydroxyapatite xenograft for treatment of a cystic lesion of the jaw.

In the last 5 years, many studies about autogenous platelet-rich plasma have been undertaken pointing out its regenerative and reparative properties on tissues. The features of this product are an attribute of platelet cells, which, after cellular interactions, release growth factors. These molecules promote tissue healing and also induce cellular regeneration. Bone is a dynamic tissue subject to balanced processes of bony formation and reabsorption; autologous platelet gel or concentrate (PRP) can be used alone or in association with bony graft for the treatment of bony defect, cystic lesions, alveolar bone defects, and periodontal pockets. Its application fields are oral and maxillofacial surgery, plastic surgery, and general surgery, and it can be applied particularly in patients with coagulation diseases. In our experience, a giant cystic lesion of the jaw was treated with PRP and granules of bovine-derived hydroxyapatite xenograft to enhance bony regeneration and promote tissue healing.

Cold therapy in maxillofacial surgery.

Background: Cryotherapy (the application of ice for therapeutic purposes) is one of the most common treatment modalities used inthe immediate management of acute soft tissue injury. Despite itswidespread clinical use, the precise physiological responses totherapeutic cooling have not been fully elucidated, and effective evidence-based treatment protocols are yet to be established (BMC Musculoskelet Disord 2007;8:125). Patients and Methods: From January 2008 to July 2008, 10 patients (4 men and 6 women) affected by dental-skeletal classes II and III were treated. Considering the biologic effects and the low temperature achieved, in this study, a cooling and compression system, at fixed temperature and adjustable for maxillofacial cutaneous tissues, called Hilotherapy system (Hilotherm GmbH, Ludwigsburg, Germany) was used. Results: With the use of Hilotherapy system, the swelling and pain decrease in intensity and time, allowing a quicker path to recovery of mandibular dynamics, a better comfort for patients, and an easy management of patients by medical attendants. Conclusions: The Hilotherapy system has been proven to have a safe and effective use as a cold therapy to control postsurgery course.

Evolution in diagnosis and repairing of orbital medial wall fractures.

In the last decades, diagnostical imaging, surgical techniques, alloplastic materials, and surgical instruments development allowed a great progress in management of orbital fractures; the aim of the present study was to focus on the progress and changes in the management of orbital medial wall fractures. Isolated medial wall fractures are not a common clinical evidence, and those necessitating surgery is relatively rare. Diagnostical refinements allowed to detect such fractures more commonly than suspected, and the indications to surgical treatment had been increased by the progresses that minimized morbidity of patients and allowed better restoration of the functional anatomy. Mainly, the endoscopic surgery as an alternative to open reduction allowed to manage such fractures with less unwanted sequelae; endoscopy decreases morbidity and improves the results with respect to open reductions. In literature, currently, it can be noticed that there is an increased trend in surgical treatment of the patients with orbital medial wall fracture because endoscopy decreased perisurgical morbidity and improved long-term results. Endoscopic repair of orbital blowout fractures represents an innovative and highly successful and safe alternative to external repairs owing to its introduction in orbital trauma management; actually, indications for surgical intervention are in the course of revision. New deal is important for the future treatment of patients sustaining orbital trauma. The authors present their experience.

The surgical approaches to nasopharyngeal angiofibroma.

After a short summary of the aetiopathogenesis, the routes of extension and the diagnostic features of nasopharyngeal angiofibroma, the importance of early diagnosis and careful surgical planning is underlined. In particular the extension and topographic localization allows the choice of the best approach to optimize surgical radicality--the prime concern in the treatment of nasopharyngeal angiofibroma. Different surgical approaches are proposed for the tumour removal according to our experience in 17 patients.

Open reduction and internal fixation of extracapsular mandibular condyle fractures: a long-term clinical and radiological follow-up of 25 patients

BackgroundDuring the last 2 decades, many studies on the treatment of mandibular condyle fracture have been published. The incidence of mandibular condyle fractures is variable, ranging from 17.5% to 52% of all mandibular fractures. This retrospective study evaluated the long-term clinical and radiological outcomes after surgical treatment of 25 patients with a total of 26 extracapsular condyle fractures.MethodsWe used 2 types of surgical approaches, the retromandibular retroparotid or preauricular approach. Three kinds of rigid internal fixation plates were used—single plate, double plate, and trapezoidal plate. The following post-operative clinical parameters were evaluated: dental occlusion, facial nerve functionality, skin scarring, and temporomandibular joint functionality. All patients underwent post-operative orthopanoramic radiography and computed tomography. The patients were also monitored for complications such as Frey’s syndrome, infection, salivary fistula, plate fracture, and permanent paralysis of the facial nerve; the patient’s satisfaction was also recorded.ResultsOf the 25 patients, 80% showed occlusion recovery, 88% had no facial nerve injury, and 88% presented good surgical skin scarring. The patients showed early complete recovery of temporomandibular joint functionality and 72% of them were found to be asymptomatic. The postoperative radiographs of all patients indicated good recovery of the anatomical condylar region, and 80% of them had no postoperative complications. The average degree of patient satisfaction was 8.32 out of 10. Our results confirm that the technique of open reduction and internal fixation in association with postoperative functional rehabilitation therapy should be considered for treating patients with extracapsular condylar fractures.ConclusionThe topic of condylar injury has generated more discussion and controversy than any other topic in the field of maxillofacial trauma. We confirm that open reduction and internal fixation is the treatment of choice for patients with neck and sub-condylar mandibular fractures.

Sagittal split osteotomy of the fibula for modeling the new mandibular angle.

Abstract Fibula modeling techniques for mandible reconstruction carry a high risk of bone perfusion impairment and low predictability of osteotomy angles. To restore the parabolic shape of the mandible, the number of osteotomies should be as small as possible to preserve both periosteal and endosteal perfusion. We report our approach with sagittal split osteotomy (SSO) technique for mandibular angle reconstruction. Obwegeser-Dal Pont SSO of fibula flaps was performed on 10 patients who underwent mandibular angle reconstruction. Bone segments were tilted according to stereolithographic template and fixed with 3 bicortical screws in triangular fashion. Fibula-gonial angle at 15 days and 6 months from surgery was compared with the contralateral-mandibular-gonial angle using Kruskal-Wallis test with a P < 0.05 considered significant. Mean bone length and skin paddle size were 15.6 cm (range, 13–18 cm) and 22.5 cm2 (range, 3 × 4 cm to 11 × 5 cm). Bone unions occurred at 12 months (mean follow-up, 39 months). No differences (P > 0.05) between fibula-gonial angle at 15 days (mean, 122.88 ± 0.55 degrees; range, 122.49–123.27 degrees) and 6 months (mean, 123.36 ± 0.88 degrees; range, 122.73–123.99 degrees) and contralateral-mandibular-gonial angle (mean, 123.20 ± 0.80 degrees; range, 122.62–123.77 degrees) were observed. Fibula SSO allows for new-mandible angle shaping, reducing risk of pedicle and endosteal vascular impairment. Triangular bone fixation thereby emerges as a reliable technique, enhancing functional and aesthetic long-term outcomes.

Ameloblastoma relapse after 50 years from resection treatment.

Ameloblastoma is a slow-growing, locally invasive, epithelial odontogenic tumor of the jaws with a high rate of recurrence if not removed adequately but with virtually no tendency to metastasize (World Health Organization Classification of Tumors: Pathology and Genetics of Head and Neck Tumours, 2005). This paper presents a case of a woman who was treated in 1961, when she was 25 years old, for an ameloblastoma in the right posterior region of the mandible. After 50 years, the ameloblastoma relapsed, and another surgical treatment was necessary.