Giancarlo Renzi

Posttraumatic obstruction of lacrimal pathways: a retrospective analysis of 58 consecutive naso-orbitoethmoid fractures.

Posttraumatic dacryostenosis represent a troublesome sequela for patients who have sustained centrofacial trauma and can determine complexity in diagnosis and treatment. This article, based on a retrospective analysis of 58 patients with naso-orbitoethmoidal (NOE) trauma, reports the incidence of posttraumatic dacryostenosis and the evolution of such impairments in consideration of fracture type. Experience in diagnosis and treatment is illustrated, and surgical outcomes 6 months after external dacryocystorhinostomy (DCR) are reported. Posttraumatic epiphora was observed in 27 patients with NOE fractures (46.5%). In 10 cases, temporary epiphora was encountered and spontaneous recovery of lacrimal drainage within 5 months was observed. In the remaining 17 cases, permanent epiphora was registered and a frequent association with delayed treatment of facial fracture repair or bone loss in the lacrimal district was found. Surgical reconstruction of lacrimal pathways was performed 6 months after primary surgery, with external DCRs in all 17 patients with epiphora and the presence of nasolacrimal duct obstruction observed with dacryocystorhinography. External DCR with a large rhinostomy achieved a success rate of 94% in the reconstruction of lacrimal drainage. Such a technique proved to be effective in the treatment of posttraumatic dacryostenosis, although patients considered the temporary presence of external scars and stenting material to be a major problem.

Inferior alveolar nerve impairment after mandibular sagittal split osteotomy: an analysis of spontaneous recovery patterns observed in 60 patients.

Sensory impairment after bilateral sagittal split osteotomy (BSSO) due to inferior alveolar nerve (IAN) lesions may be either temporary or permanent and either complete or partial. The aim of this prospective study is to evaluate, by means of objective sensory testing, IAN sensory disturbances development in patients who underwent BSSO.IAN sensory disturbances development at the first week, fourth week, sixth month, and twelfth month of follow-up review in a group of 60 patients who underwent BSSO from January 1, 1998, to July 31, 1999, at the Maxillofacial Surgery Department of the “La Sapienza” University of Rome. The 60 patients were examined in the presurgical period; the IAN functionality regarding thermal sensibility, nociception, and two-point discrimination, was assessed at follow-up in 120 sides. In our study the highest rate of spontaneous recovery of the entire IAN functionality was observed at the sixth month. This finding witnesses how neuropraxia and axonotmesis give a spontaneous recovery that most frequently occurs within 6 months from surgery, independently from age and sex of the patient. The persistence of anesthesia over 12 months could be a sign of neurotmesis.

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.

Craniofacial traumas: immediate and delayed treatment.

In 1998, 28 patients with craniofacial fractures have been under observation at the Emergency Room of the Policlinico Umberto I of Rome. Twenty-six patients have undergone reduction and contention surgery of the fractures. The diagnosis of the fractures has been achieved through CT axial scanning and coronal reconstruction as well as with three-dimensional CT. The CT spiral was used in those cases that required more rapid intervention, whereas the MRI was used to evaluate the condition of the eyeball. Twenty of such patients underwent surgical treatment a few hours after the trauma and, in such cases, excellent aesthetic and functional results were achieved. The general and neurological conditions of six patients did not permit prematurely proceeding with surgery. Two patients died a few hours after the trauma of the injuries sustained. Of the six patients who underwent delayed treatment, acceptable functional and aesthetic results were achieved in four, whereas the remaining two patients had inadequate results. The results we have obtained show that it is possible to achieve the best results, both aesthetic and functional, through immediate treatment. Delayed treatment is carried out at least 2 weeks after the trauma because of the patients condition and presents reconstruction difficulties that do not guarantee a satisfactory aesthetic reconstruction as well as, in some cases, an effective functional restoration.

Intraosseous hemangioma of the maxillofacial district: clinical analysis and surgical treatment in 10 consecutive patients.

The aims of this study are to illustrate functional and esthetic results obtained with different surgical strategies and to report a review of the relevant literature. There were 6 female patients and 4 male patients included in this study, with an average age of 35.7 years. Zygomatic bone was affected in six cases, the mandible in two cases, the medial orbital wall in one case, and the upper jaw in one case. In all 10 patients, surgery consisted of a wide excision of the intraosseous hemangioma with margins of 3 mm at least to ensure complete removal. Immediate reconstruction was carried out in 5 of the 10 patients. An analysis indicates that intraosseous hemangiomas of the maxillofacial area are rare; diagnosis can be difficult and is mainly based on computed tomography scans. Surgical excision, with previous angiography and embolization in cases of intraosseous hemangioma with a larger dimension or abnormal blood supply, is the treatment of choice.

Complications of bicortical screw fixation observed in 482 mandibular sagittal osteotomies.

Bicortical screw fixation after bilateral sagittal split osteotomy (BSSO) of the mandible is commonly used in orthognathic surgery and allows many advantages compared with osteosynthesis wires and maxillomandibular fixation. Complications include early loosening, hardware exposition, skeletal instability or early relapses, persistent nerve impairments, infection, and scar formation. This article is based on a retrospective analysis of complications of bicortical screw fixation observed in 241 consecutive patients with dento-skeletal Class III, corresponding to 482 sides, during the immediate postoperative period and at 1, 3, 6, and 12 months’ follow-up. In the immediate postoperative period, poor stability of fixation caused by screw loosening was observed in 3 of 482 (0.62%) sides; at the 1-month follow-up, infections were encountered in 12 (2.48%) sides at mandibular angles. Additional complications were not seen in the series. Stability of fixation was found in the 482 sides at 12 months. However, complications directly related to bicortical screws were observed in 15 sides or 3.11%. Age and gender of patients were not correlated with the incidence of complications. Assiduous follow-up during the early postoperative period and 1 and 2 months after surgery is recommended in patients with bicortical screw fixation after BSSO to verify adequate oral hygiene and provide early observation of the onset of any infections, skeletal instabilities, or relapses.

Intracellular and extracellular tumor pH measurement in a series of patients with oral cancer.

Reversed pH gradient is an intrinsic feature of tumor phenotype resulting from an upregulation of glycolysis. This is crucial for tumor cell proliferation, invasion, metastasis, drug resistance, and apoptosis. Comprehension of mechanisms of pH regulation in tumors is of paramount importance for therapeutic implications. This is a preliminary report of a larger prospective study dedicated to the measurements of neutral or slightly alkaline pH/extracellular pH (pHi/pHe) in human patients affected by tumors of the head and neck. During surgery, four specimens were obtained from six patients with cancer: two from the tumor site and two from contralateral areas or sane areas near the tumor. pHe and pHi were measured and compared within normal and neoplastic tissues. Our data indicate that human spontaneous tumors show similar reversed gradients as observed in previous analysis on animal tumor models and cell lines.

Differential diagnosis between adenoid cystic carcinoma and pleomorphic adenoma of the minor salivary glands of palate.

Tumors arising from minor salivary glands of the palate may exhibit an overlap of clinical and biologic features that may produce diagnostic and therapeutic dilemmas. Surgical treatment can be very different, depending on the dimensions and malignant or benign nature of the tumors, and therefore should be planned on the basis of an accurate differential diagnosis.A retrospective analysis in 24 patients with pleomorphic adenoma and adenoid cystic carcinoma of minor salivary glands of the palate was performed to investigate the accuracy of fine needle aspiration cytology (FNAC) and biopsy with histology in the preoperative diagnosis. Preoperative diagnoses obtained with FNAC and biopsy were compared with findings of the definitive histopathologic examination performed on the resected mass.Correspondence between the preoperative diagnoses determined by FNACs and the definitive histopathologic results was observed in 22 of 24 cases, whereas a complete equivalence was found with regards to histology. In the analysis, FNAC was associated with 91.6% accuracy and an error rate of 8.4% in the diagnosis of pleomorphic adenoma and adenoid cystic carcinoma of the palate.From the results of the analysis, histologic examination is still the most accurate diagnostic tool in such tumors. FNAC can be considered in tumors of the head and neck regions that are difficult to reach by means of a common biopsy.

Taste and olfactory disturbances after upper and middle third facial fractures: A preliminary study

To estimate smell and taste after traumatic disturbances, the authors questioned a sample of 92 patients who underwent surgical treatment for upper third and/or middle third facial fractures between January 1, 1988, and May 31, 1996, at the Department of Maxillofacial Surgery, University of Rome “La Sapienza,” Italy. A total of 86 patients included in the study had a facial fracture sustained during a motor vehicle accident. Twenty-nine patients reported smell and/or taste after the traumatic disturbance. Of these 29 patients, 8 patients had hyposmia and/or anosmia without taste deficit, 10 patients had taste disturbances without smell loss, and 11 patients noted disturbance in both smell and taste. The authors encountered posttraumatic smell disturbances in 19 patients in their sample. Nasozygomatic–Le Fort fractures, fronto-orbital fractures, and pure Le Fort fractures were found to determine posttraumatic smell disturbances in these 19 patients. Nasal fractures, naso-orbital–ethmoidal fractures, ethmoidal fractures, frontal–Le Fort fractures, and nasal–Le Fort fractures did not determine any olfactory dysfunction. Posttraumatic hypogeusia and ageusia were found in 21 patients and was caused by nasozygomatic–Le Fort fractures, fronto-orbital fractures, and pure Le Fort fractures. The authors did not find any taste deficits after patients sustained other kinds of facial fractures. In the 11 patients observed, disturbances in both smell and taste were noted. Nasozygomatic–Le Fort fracture was the most common in these 11 patients. At 5 years’ of follow-up, the results indicate that hypogeusia and hyposmia are connected with the etiology of fracture, the violence of the trauma, and the involvement of specific facial bone regions.

Treatment of oligodontia with endo-osseous fixtures: experience in eight consecutive patients at the end of dental growth.

Clinical manifestations of oligodontia consist in agenesia of multiple teeth eventually with deciduous retained teeth, atrophy of alveolar ridge, aberrations of teeth dimension, and shape, with consequent aesthetic and functional defects. The first choice treatment is based on a team collaboration of maxillo-facial surgeon, orthodontist, and prosthodontist, and is conditioned by various clinical parameters as number and site of lacking teeth, age and dental development of patients, eventual alveolar ridge atrophy. Treatment planning should be individualized for each patient. In our experience, based on 8 consecutive patients at the end of dental growth affected by oligodontia, endo-osseous fixtures positioning was carried out in consideration of long-lasting stability and optimal aesthetical characteristics. In 5 patients rehabilitative preprosthetic surgical procedures were performed, consisting in 2 sinus lift with immediate positioning of 3 fixtures in both cases, 4 heterologous bone graft in postextractive sites with retained ankylotic deciduous teeth and 1 positioning of reabsorbable biomembrane. A temporary removable denture was positioned immediately after surgery in order to obtain a prompt aesthetical and psychosocial restore. Osseointegration ratio as observed at 8.5 years follow-up was analyzed according to surgical variables and differences in prosthetic rehabilitation (fixtures supporting single crown versus multiple crowns). Successful osteointegration was observed at 8.5 years mean follow-up in 58 fixtures, corresponding to a 96.6% ratio. Failure of integration was encountered in fixtures immediately positioned in postextractive sites having a mild grade of bone atrophy, supporting single crown. A rate of success of 100% was observed in cases of immediate or delayed positioning in postextractive or traditional sites. Fixtures positioning in patients affected by isolated oligodontia, without malformative syndromes, and at the end of dental development, is subject to the same recommendations for patients with lacking permanent teeth not caused by agenesia.