Francesca Antonella Bianchi

Surgical Management of Orbital Trapdoor Fracture in a Pediatric Population

PURPOSE Orbital trapdoor fractures are pure orbital floor fractures with herniation and entrapment of the orbital contents, leading to restricted eye movement and diplopia. Trapdoor fractures in children have been discussed widely in published reports; however, the treatment policy and outcome remain controversial, although early treatment has been advocated. Our retrospective study analyzed the long-term results of pediatric patients undergoing surgery for trapdoor fractures to determine the outcome in relation to the type of fracture and the timing and technique of intervention. PATIENTS AND METHODS The present study included 24 patients (age range 6 to 16 years) who underwent surgery for trapdoor fractures from 1998 to 2007. The demographic, etiologic, radiologic, and surgical findings, interval between trauma and surgery, surgical techniques, and complications were recorded. Diplopia, ocular motility, dysesthesia, and scar quality were recorded at follow-up. RESULTS The follow-up duration averaged 36 months. At follow-up, 1 (8.3%) of 12 patients who underwent surgery within 24 hours (urgent treatment) had residual diplopia. In contrast, 3 (37.5%) of 8 patients who underwent surgery 24 to 96 hours (early treatment) and 4 (100%) of 4 who underwent surgery after 96 hours (late treatment) had diplopia. No sensory deficit of the skin or unesthetic eyelid scar was noted. CONCLUSIONS We found a correlation between the outcome and the timing of surgery for trapdoor fractures in the pediatric population. The success rate was significantly better when the fractures were treated within 24 hours of the injury. The results of the present study have strengthened the assertion that trapdoor orbital fractures pose a true surgical emergency.

Surgical treatment of odontogenic myxoma.

Background: There is no consensus about the surgical treatment of odontogenic myxoma. The aim of the current study was to present our experience and discuss the surgical management and outcome in 10 patients diagnosed with odontogenic myxoma. Methods: A retrospective review of charts of patients who were surgically treated for odontogenic myxoma was performed. Patients were recalled, and eventual recurrences were investigated. Results: Eight lesions were mandibular, whereas 2 were maxillary. In 3 patients, enucleation and curettage was performed. Instead, in the remaining 7 patients, segmental resection and immediate reconstruction were decided. At follow-up, no patient showed recurrence of the lesion. Conclusions: Our protocol is to perform conservative surgery by enucleation and curettage when lesions were smaller than 3 cm, whereas a segmental resection with immediate reconstruction is preferred in patients affected by bigger tumors. Long-term follow-up is required, in particular when conservative surgery is preferred.

Use of Patient and Observer Scar Assessment Scale for evaluation of facial scars treated with self-drying silicone gel.

In this prospective study, we used the Patient and Observer Scar Assessment Scale (POSAS) to evaluate the outcome of the healing process of posttraumatic and surgical facial scars that were treated with self-drying silicone gel, by both the patient and the observer. In our division, the application of base cream and massage represents the standard management of facial scars after suture removal. In the current study, 15 patients (7 men and 8 women) with facial scars were treated with self-drying silicone gel that was applied without massage, and 15 patients (8 men and 7 women) were treated with base cream and massage. Both groups underwent a clinical evaluation of facial scars by POSAS at the time of suture removal (T0) and after 2 months of treatment (T1). The patient rated scar pain, itch, color, stiffness, thickness, and surface (Patient Scale), and the observer rated scar vascularity, pigmentation, thickness, relief, pliability, and surface area (Observer Scale [OS]). The Patient Scale reported the greatest improvement in the items color, stiffness, and thickness. Itch was the only item that worsened in the group self-drying silicone gel. The OS primarily reported an improvement in the items vascularization, pigmentation, and pliability. The only item in the OS that underwent no change from T0 to T1 was surface area. The POSAS revealed satisfactory healing of posttraumatic and surgical facial scars that were treated with self-drying silicone gel.

Characteristics of maxillofacial trauma in females: A retrospective analysis of 367 patients

INTRODUCTION Epidemiological characteristics of maxillofacial injuries are typically reported for male patients, as males represent 70% of the studied population. This retrospective study analysed the aetiology and patterns of maxillofacial fractures in female patients only. MATERIAL AND METHODS A total of 367 female patients, examined between 2001 and 2008, were divided into three age groups (<16, 17-60, and >60 years). Data were collected on aetiology, fracture site, associated lesions, type of treatment, and length of hospital stay. RESULTS The typical female patient presented a mean age of 43 and 25% were over 60 years of age. Falls were the most frequent cause of maxillofacial trauma (43%), followed by motor vehicle accidents (MVAs) (38.7%), assaults (9.3%), sports accidents (6.3%), and other causes (2.7%). The middle third of the face was most frequently affected (53.9%). Associated fractures, mostly orthopaedic and secondary to MVAs, occurred in 23.2% of cases. The over-60 age group had the greatest number of non-operated fractures (27.9%) and the longest mean hospital stay (5.7 days). CONCLUSIONS This study considered only the female population, thereby highlighting epidemiological characteristics of maxillofacial trauma not apparent in the existing literature. Clear distinctions between genders are important for better comparison of data in the future.

Single-Step Resection and Reconstruction Using Patient-Specific Implants in the Treatment of Benign Cranio-Orbital Tumors

PURPOSE The aim of this study was to evaluate surgical outcomes using patient-specific prostheses produced by computer-aided design and manufacturing for primary reconstruction in patients with benign cranio-orbital tumors. Polyetheretherketone was used to manufacture the implants. MATERIALS AND METHODS The present study included 3 patients who underwent fronto-orbito-pterional craniotomy using individual custom-made surgical guides. Patient-specific polyetheretherketone prostheses were used for reconstruction during the same surgery. All patients underwent esthetic examination (facial and orbital symmetry, globe projection and position), ophthalmologic examination (diplopia with the Hess-Lancaster test, visual field and acuity), and radiologic evaluations (computed tomography and magnetic resonance imaging) during the preoperative and follow-up periods. Operating time and short- and long-term complications were recorded. RESULTS The immediate and long-term morphologic results were satisfactory; in particular, ocular globe position and projection were correct. After 25 to 31 months, none of the patients developed implant-related complications, such as infection, extrusion, or malposition. Two-year postoperative computed tomograms and magnetic resonance images showed no recurrences. CONCLUSION Single-step resection and reconstruction with computer-aided designed and manufactured implants is a challenging new technique that decreases operative time and morbidity. The implants adequately restore an anatomically complex area with satisfactory cosmetic results.

Primary and secondary reconstruction of complex craniofacial defects using polyetheretherketone custom-made implants

PURPOSE The aim of this study was to evaluate the surgical outcomes using polyetheretherketone (PEEK) patient-specific prostheses produced by computer-aided design and manufacturing for primary and secondary reconstruction in patients with craniofacial defects. MATERIAL AND METHODS The study included 13 patients who underwent reconstruction for craniofacial defects using PEEK patient-specific implants (PSI). Eight patients underwent single-step primary reconstruction using individual custom-made surgical guides and custom-made prostheses during the same surgery; five patients underwent delayed reconstruction. The material used to manufacture the implants was PEEK in 13 cases. All patients underwent esthetic examination, ophthalmological examination, and radiological evaluation during the preoperative and follow-up periods. The operation duration and short- and long-term complications were recorded. RESULTS The shape and global position of the implants were satisfactory in each case. Fitting of the implant during surgery required extensive adaptation in 1 case and minor in 11 cases. Of 13 implants, 11 adequately restored a morphological complex area with satisfactory cosmetic results. No complications related to the implants were reported. CONCLUSION Reconstruction for cranio-facial defects using PEEK computer-aided designed and manufactured implants is a promising new technique that allows for accurate restoration of the complex 3D anatomy of the craniofacial region.

Soft tissue changes after orthodontic surgical correction of jaws asymmetry evaluated by three-dimensional surface laser scanner.

Abstract Aesthetic improvement is an essential goal of treatment of facial asymmetry, and it is often difficult to achieve. Reliable three-dimensional measurements are required to support outcome studies. In this study, 15 white adult subjects, 9 females and 6 males, with maxillomandibular asymmetry and malocclusion were studied. The patients were treated with orthodontics and different surgical procedures in single or multiple steps. All patients received double-jaw surgery, except 1 patient who underwent only maxillary osteotomy. Nine of the 15 patients received additional procedures (genioplasty and rhinoplasty) to achieve better symmetry. Posterior-anterior and lateral cephalometry and three-dimensional facial surface data were obtained before (T0) and 1 year (T1) after surgery. Scan data at T0 and T1 were pooled by electronic surface averaging to obtain the mean pretreatment and posttreatment facial model. A symmetric model was constructed by averaging the actual T0 scans and their mirrored models to obtain the virtual optimal symmetric face. Different linear and angular measurements were then calculated for comparison of the mean T0 and T1 models. The normalization of facial proportion and a high increase in symmetry were evident. Residual defects were documented in the postoperative symmetry of the chin. Treatment of facial asymmetry, combined with dental occlusion problems, is still a challenge for maxillofacial surgeons. Orthognathic surgery provides an important improvement of symmetry, but further refinements of technique are still required. Three-dimensional evaluation results in an effective method to support outcome studies on the surgical correction of complex facial deformities.

Three-dimensional laser scanner evaluation of facial soft tissue changes after LeFort I advancement and rhinoplasty surgery: patients with cleft lip and palate vs patients with nonclefted maxillary retrognathic dysplasia (control group).

OBJECTIVE The aim of this study was to analyze the differences in facial soft tissue changes, despite the same extent of upper jaw forward movement, between patients with unilateral cleft lip and palate (uCLP) and those without, after LeFort I osteotomy and secondary rhinoplasty. STUDY DESIGN Twelve patients with maxillary retrognathic dysplasia and nose deformity were divided in 2 groups, A (uCLP) and B (control), and compared on the basis of the same maxillary advancement. Cephalometry and 3D mean facial model of groups A and B were obtained before and after surgery. Linear and angular measurements were calculated. RESULTS Upper vermilion and alar base remained unchanged in group A but increased in group B. In both groups, symmetry of the nasal base was improved, and an increase of the sagittal projection of the lips was observed. CONCLUSIONS 3D analysis showed that surgical procedures for uCLP can provide a satisfactory aesthetic outcome, but some differences are evident in comparison with the control group.

Facial mobility after bimaxillary surgery in class III patients: a three-dimensional study.

AbstractQuantifying soft tissue changes after orthognathic surgery is increasingly important in surgical planning, but little is actually known about the changes in facial mobility after surgery. In the current study, we investigated facial mimics in patients before and after orthognathic surgery.Eleven patients with jaw discrepancy requiring maxillary and/or mandibular surgery were considered. Facial landmarks were applied, and facial surface data were acquired using a three-dimensional laser scanner before surgery and after 3, 6, and 12 months.The facial movements were frowning, eye closure, grimace, smiling, and lip purse. They were described in terms of surface and landmark displacements. Mean and SD were calculated for the right and left sides of the face and compared with normal values previously obtained in control subjects.We compared the results in 4 groups of patients: all the patients together (group A), bimaxillary surgery (group B), basal surgery without ancillary procedures (group C), and basal surgery plus rhinoplasty and/or genioplasty (group D).After surgery, modifications of symmetry were evident in many subjects, but after 1 year, facial movements were statistically similar to presurgical registrations. In smiling, the single case observations revealed a postsurgical improvement of amplitude in 8 subjects.In conclusion, orthognathic surgery did not significantly modify facial mobility in the long term. On the contrary, the amplitude of movement during smiling seems to increase in the majority of subjects. Our evaluation of three-dimensional laser scanning of facial movement showed that it can detect small posttreatment changes on soft tissues.

Surgical extraction of deeply horizontally impacted mandibular second and third molars.

The presence of deeply horizontally impacted lower second and third molars is unusual. The arrested eruption of the lower second and third molars can determine disturbances of mastication and aesthetics. Moreover, an increased risk of caries in the distal side of the first lower molar is possible. Different therapeutic approaches could be proposed for second and third molar impaction and malposition. In this article, we report the management and the outcome of the surgical treatment of a patient with impacted mandibular second and third molars.