Gianmarco Saponaro

Clinical experience with spiramycin in bisphosphonate-associated osteonecrosis of the jaw

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) consists of an exposure of the jaw bone that persists for over 8 weeks in patients with positive history for bisphosphonates. Symptomatology is characterized by dull and ceaseless pain, and in advanced stages, the exposure of necrotic bone is evident, which is frequently associated with purulent secretions and faetor oris. Despite many different studies on BRONJ, there are no general guidelines to treat this disease. In this work, the authors present their experience in BRONJ conservative therapy with spiramycin by comparing the results achieved with amoxicillin and clavulanic acid. From January 1, 2008 to June 30, 2008, our department received 25 patients who were affected by osteonecrosis secondary to bisphosphonates. Thirteen had taken bisphosphonates for osteoporosis and 12 for malignancies. We divided the 25 patients into two groups: those who had not received any treatment and those who had received treatment. The first group of 13 patients had been treated only with spiramycin (S). The results from this group were only evaluated to test the efficacy of spiramycin and were not considered in the study. The second group of 12 patients had not undergone any previous treatment. This group was further divided in two groups of 6 patients each; one group was treated with spiramycin and the other with amoxicillin and clavulanic acid (ACA). The following criteria were used to evaluate the results of the study: pain, sensibility deficits, purulent secretion and bone exposure. All group results were evaluated according to the criteria chosen, and positive results were achieved in both groups S and ACA, such as reduction or disappearance of pain, sensibility deficits and purulent secretion and healing of bone exposition, although spiramycin showed itself to be more effective than the combination of amoxicillin and clavulanic acid. Spiramycin is a macrolide antibiotic with a wide spectrum of activity against Streptococci, Pneumococci, Diplococci, Gonococci and Staphylococci, which are typical in BRONJ. No resistance was indicated. Administration of the antibiotics can be intravenous, intramuscular, rectal or oral, which remains the most frequently used since spiramycin elimination also occurs with saliva and the antibiotic reaches high concentrations in the oral cavity where BRONJ is situated. Good compliance to the spiramycin regimen was observed in all three groups, with a general improvement in all of the parameters considered. In only two cases did patients have to undergo surgical curettage. The results showed that spiramycin can be a first choice drug in the treatment of BRONJ, and it should be strongly considered for patients where previous antibiotic therapy did not prove to be effective.

Clinical evaluation of obstructive sleep apnea in children

BackgroundObstructive sleep apnea syndrome (OSAS) is often found in children affected by congenital or acquired craniomaxillomandibular malformations. This disease carries different levels of risk, ranging from attention problems at school to growth problems and serious disorders, such as cor pulmonale or sudden infant death. The examination that is most commonly used to evaluate the severity of OSAS is polysomnography, and the therapeutic course is often determined by the disease state. Considering the discrepancy between clinical history and polysomnographic findings, we felt the need to identify an instrument for evaluating OSA to be used as a support for polysomnography. Materials and MethodsThis study was carried out on pediatric patients affected by congenital or acquired craniomaxillofacial malformations. We selected 34 pediatric patients, including 15 boys and 19 girls, aged between 1 and 16 years, with a mean age of 7.3 years. The study consisted of individuation of common clinical history data obtained from each patient and associating those data with the level of OSA severity identified by polysomnography. We were able to isolate certain symptoms and signs that can be predictive of OSA from research in the literature and our clinical experience with pediatric patients. In the clinic, we have found that the clinical history, given by the parents, often differs significantly from the instrumental findings obtained with polysomnography. From the previously expressed considerations and comparison of clinical history data and questionnaires, we have extracted the most significant questions for our questionnaire, which are present in the literature but formulated for adults. Results and ConclusionsThe obstructive airway child test was found to be a very efficient method to evaluate and diagnose OSA. In all patients, it consistently revealed the pathology and never underestimated OSA severity. The examination focuses on clinical signs and symptoms because, in our opinion, clinical history, reported by the parents, can be more accurate than any instrumental examination.

Nasal and ethmoidal alterations in anterior synostotic plagiocephaly

Background: Nasal deviation plays an important role in plagiocephaly nosography, and it is frequent in plagiocephaly and objectivable both in early treated patients and in those patients who did not undergo any surgical correction. Patients and Methods: The group analyzed consisted of 12 patients affected by anterior synostotic plagiocephaly. All of them had reached the end of growth. A morphological analysis was made by using anthropometry. All patients were asked to undergo computed tomography, and all the scans were then reconstructed into three-dimensional models using a dedicated software. We made two-dimensional assessments on coronal and axial slices, and three-dimensional reconstruction was used to evaluate the volumetry of ethmoidal cells. Results and Discussion: From anthropometry, we realized that, in all patients, not only that the tip of the nose is deviated to the not affected side but also that the root itself does not lie on the midline and it is tilted to the synostotic side. Analysis of the computed tomographic scan results shows that the ethmoid bone, as much as the vomer and the upper maxilla, is deeply involved in these nasal abnormalities, presenting a deviated position and an altered development. Conclusions: We concluded that nasal morphology in plagiocephaly is strictly related to basicranium dysmorphism.

Long Term Follow-Up in Inferior Alveolar Nerve Transposition: Our Experience

Introduction. Inferior alveolar nerve transposition (IANT) is a surgical technique used in implantoprosthetic rehabilitation of the atrophic lower jaw which has not been well embraced because of the high risk of damage to the inferior alveolar nerve (IAN). There are cases in which this method is essential to obtain good morphologic and functional rebalancing of the jaw. In this paper, the authors present their experience with IANT, analyzing the various situations in which IANT is the only surgical preprosthetic option. Methods. Between 2003 and 2011, 35 patients underwent surgical IANT at our center. Thermal and physical sensitivity were evaluated in each patient during follow-up. The follow-up ranged from 14 to 101 months. Results and Conclusion. Based on our experience, absolute indications of IANT are as follows: (1) class IV, V, or VI of Cawood and Howell with extrusion of the antagonist tooth and reduced prosthetic free space; (2) class V or VI of Cawood and Howell with presence of interforaminal teeth; (3) class V or VI of Cawood and Howell if patient desires fast implantoprosthetic rehabilitation with predictable outcomes; (4) class VI of Cawood and Howell when mandibular height increase with inlay grafts is advisable.

Surgery-first orthognathic approach vs traditional orthognathic approach: Oral health-related quality of life assessed with 2 questionnaires

Introduction The purposes of the study were to investigate and evaluate the differences detected by the patients between the traditional orthognathic approach and the surgery‐first one in terms of level of satisfaction and quality of life. Methods A total of 30 patients who underwent orthognathic surgery for correction of malocclusions were selected and included in this study. Fifteen patients were treated with the conventional orthognathic surgery approach, and 15 patients with the surgery‐first approach. Variables were assessed through the Orthognathic Quality of Life Questionnaire and the Oral Health Impact Profile questionnaire and analyzed with 2‐way repeated‐measures analysis of variance. Results The results showed significant differences in terms of the Orthognathic Quality of Life Questionnaire (P <0.001) and the Oral Health Impact Profile (P <0.001) scores within groups between the first and last administrations of both questionnaires. Differences in the control group between first and second administrations were also significant. Questionnaire scores showed an immediate increase of quality of life after surgery in the surgery‐first group and an initial worsening during orthodontic treatment in the traditional approach group followed by postoperative improvement. Conclusions This study showed that the worsening of the facial profile during the traditional orthognathic surgery approach decompensation phase has a negative impact on the perception of patients’ quality of life. Surgeons should consider the possibility of a surgery‐first approach to prevent this occurrence. HighlightsBenefits of traditional orthognathic surgery and surgery‐first approach were studied.Self‐esteem, body image, level of satisfaction, and quality of life were compared.The results showed significant benefits with the surgery‐first approach.

The use of piezosurgery in cranial surgery in children

AbstractPiezosurgery is an alternative surgical technique, now widely tested, that uses ultrasounds for bone cutting. This device uses ultrasounds to section hard tissues without harming surrounding soft tissues. The authors analyzed their experience in craniomaxillofacial procedures with piezosurgery. A comparison between operation timing and complication rates between piezosurgery and traditional cutting instruments has been performed. A total of 27 patients were examined (15 females and 12 males; average age, of 5.5 months) affected by craniosynostosis. The aim of this study was to analyze the advantages and disadvantages of piezosurgery in pediatric craniofacial procedures. Piezoelectric device in this study has shown being a valid instrument for bone cutting in accurate procedures, because it allows performing a more precise and safer cutting, without the risk of harming surrounding tissues.

Diagnostic Accuracy of Obstructive Airway Adult Test for Diagnosis of Obstructive Sleep Apnea.

Rationale. The gold standard for the diagnosis of Obstructive Sleep Apnea (OSA) is polysomnography, whose access is however reduced by costs and limited availability, so that additional diagnostic tests are needed. Objectives. To analyze the diagnostic accuracy of the Obstructive Airway Adult Test (OAAT) compared to polysomnography for the diagnosis of OSA in adult patients. Methods. Ninety patients affected by OSA verified with polysomnography (AHI ≥ 5) and ten healthy patients, randomly selected, were included and all were interviewed by one blind examiner with OAAT questions. Measurements and Main Results. The Spearman rho, evaluated to measure the correlation between OAAT and polysomnography, was 0.72 (p < 0.01). The area under the ROC curve (95% CI) was the parameter to evaluate the accuracy of the OAAT: it was 0.91 (0.81–1.00) for the diagnosis of OSA (AHI ≥ 5), 0.90 (0.82–0.98) for moderate OSA (AHI ≥ 15), and 0.84 (0.76–0.92) for severe OSA (AHI ≥ 30). Conclusions. The OAAT has shown a high correlation with polysomnography and also a high diagnostic accuracy for the diagnosis of OSA. It has also been shown to be able to discriminate among the different degrees of severity of OSA. Additional large studies aiming to validate this questionnaire as a screening or diagnostic test are needed.

Mandibular alterations and facial lower third asymmetries in unicoronal synostosis

PurposeMaxillary and mandibular alterations in children affected by anterior synostotic plagiocephaly have, until today, received only scarce attention. The goal of this paper is to focus on the mandibular alterations, persisting after the early correction of anterior plagiocephaly during the first year of life.MethodsMaxillary and mandibular metric measurements were performed on high resolution, thin slices CT scans; all images were reconstructed into 3D models which were used to perform the metrical assessments.ResultsTwelve patients were selected; all of them had been treated in early age with a neurosurgical intervention and had reached the end of maxillo-mandibular growth at the time of the evaluation. Significant discrepancies were documented between the two affected sides, with all measured distances being shorter on the synostotic side than the nonsynostotic one, the only exception being the vertical dimension of the mandibular ramus.DiscussionMandibular alterations resulted to be characterized by lower jaw hypoplasia on the side of the affected suture and anterior displacement of the glenoid fossa; these two entities compensated each other uncompletely, ending in a rotation of the mandibula towards the synostotic side.

Evaluation of obstructive sleep apnea in pediatric patients with facio-craniostenosis: a brief communication

PurposeThis study aimed to evaluate our experience in treating cranio-maxillo-mandibular malformations with hypoplasia of the upper and middle third of the face. We wished to determine a new diagnostic path involving a new clinical questionnaire for obstructive sleep apnea (OSA) evaluation, which we have developed by merging existing tests, literature findings, and our clinical experience to obtain a high level of information with minimal cost. This questionnaire is an improvement of the other anamnestic tests in the literature.MethodsThe study was carried out on 17 pediatric patients affected by syndromic craniofacial malformations and treated with surgical advancement of the middle third of the face, associated with or without upper third advancement, through osteodistraction. We used the obstructive airway child test (OACT) for clinical evaluation. The OACT is an OSA assessment test based on questions proposed to the patient’s relatives. All patients underwent polysomnography for instrumental assessment of OSA. These patients were also required to have a computed tomography scan for surgical planning. At the start of the treatment, 11 patients had severe OSA, 4 patients had moderate OSA, and 2 patients had slight OSA.ResultsAt the end of the treatment, 6 patients had slight OSA and 11 patients had no OSA; these data were confirmed with OACT and polysomnography.ConclusionsBased on our results, we suggest the following flowchart: OACT for OSA clinical evaluation; CT scan for evaluation of the volume of the rhinoropharyngeal air column, anatomical obstruction detection, and surgical planning; and polysomnography for diagnostic confirmation.

Zygomatic sagittal split osteotomy: a novel and simple surgical technique for use in midface corrections

Background: The correction of many craniofacial malformations requires the improvement and stabilization of the midface area. In this article, we present a simple surgical technique for improving and correcting the orbitozygomatic area. This technique is called zygomatic sagittal split osteotomy (ZSSO). Methods: Between September 2003 and June 2008, we performed ZSSO on 12 patients. The technique is described in the article. We performed a clinical evaluation of the technique using the following criteria: postsurgical complications, loss of stability, and sagittal prominence. In addition, a radiologic evaluation was performed on axial computed tomographic images. We considered a 1-year follow-up. Results: We performed 15 ZSSO procedures. No evidence of postsurgical complications, loss of stability, or sagittal prominence was reported during the 1-year follow-up. Conclusions: Zygomatic sagittal split osteotomy is a simple surgical technique to be used in the correction and stabilization of the midface area. It can be performed without using graft or osteodistraction device.