Giorgio Iannetti

Craniomaxillofacial fibrous dysplasia: conservative treatment or radical surgery? A retrospective study on 68 patients.

Background: Fibrous dysplasia is a benign bone lesion characterized by replacement of normal bone with fibro-osseous connective tissue. The surgical treatment of fibrous dysplasia is based on one of two different approaches, conservative or radical. Methods: From January of 1980 to December of 2002, 95 patients with fibrous dysplasia located in the craniomaxillofacial area presented to the authors’ department. Twenty-one had the polyostotic type (22 percent), two had McCune-Albright syndrome (2 percent), and 72 had the monostotic type (76 percent). Of 95 patients, 68 underwent surgery; the remaining 27 refused. Among the 68 patients who underwent surgery, 61 had radical excision, six received conservative treatment, and a patient with mandibular involvement received radical excision and immediate reconstruction with a free fibula flap after a recurrence experienced 2 years after primary remodeling surgery Results: No disease recurrence was observed in cases treated with complete excision, whereas a case of mandibular involvement treated with remodeling required further surgery. Infection, resolved with antibiotics, was seen in one case, and palatal fistula was seen in two cases. In one case with cranial base involvement liquorrhea was observed. Conclusions: In most cases of monostotic or monofocal fibrous dysplasia of the craniofacial region, modern surgical techniques allow an aggressive but definitive treatment with good functional and aesthetic results. The authors perform radical treatment even in cases involving the maxilla and mandible, and prefer a conservative approach only in polyostotic cases and McCune-Albright syndrome.

Mandibular ameloblastoma: analysis of surgical treatment carried out in 60 patients between 1977 and 1998.

Ameloblastoma, a benign tumor of odontogenic type, represents 10% of all tumors of the jawbone. It is localized in the mandible in 80% of cases and in the upper jaw in the remaining 20%. In every case, the selection of the surgical treatment to be applied must consider some fundamental elements, including the age and general state of health of the patient, the clinicopathological variant, and the localization and extent of the tumor. In addition, it is necessary to evaluate whether the neoplasm to be treated is a primitive lesion or a recurrence. Although ameloblastoma has relative histological characteristics of benignity, this neoplasm has a high percentage of local recurrence and possible malignant development when treated inadequately. The aim of this study was to carry out a follow-up of 60 patients treated for ameloblastoma of the mandible between 1977 and 1998, analyzing the problems faced in removing this benign neoplasm and those concerning reconstruction of the surgical defect.

Surgical Treatment of TMJ Ankylosis : Our Experience (60 Cases)

Limitation of mouth opening can be caused by bony or fibrous ankylosis of the temporomandibular joint as sequela to trauma, infection, autoimmune disease, or failed surgery.Various procedures have been reported for treatment of temporomandibular joint (TMJ) ankylosis; this article aims to describe the diagnostic protocol and the surgical procedures adopted at the department of Maxillo-Facial Surgery of Rome University “La Sapienza”.Between 1980 and 2000, 123 patients affected by TMJ ankylosis came under our observation; 60 of them (25 females and 35 males of 30 years average age) underwent surgery; bilateral TMJ ankylosis was observed in 21 cases, right-sided in 20 cases, left-sided in 19 cases. In 12 cases coronoid processes were involved. Etiopathogenesis was traumatic in 48 cases, septic in 5 cases, auto-immune (RA and seronegative spondyloarthropathies) in 5 cases; after block removing, arthroplasty was performed with pedunculated flap of temporal muscle (10 cases), Silastic material (11 cases), or lyophilized dura mater (2 cases). Simple condylar shaving was used in the remaining 36 cases.All patients under treatment showed a distinctive improvement both in articular functionality and symptoms; secondary surgery was necessary in seven cases due to the onset of articular complications from previous surgery. Silastic removal was necessary in five cases due to its inducement of foreign body granuloma. Follow-up was performed at 12, 24, and 48 months and 5 years postoperatively.In our opinion the gold standard surgery of TMJ ankylosis today is represented by shaving of articular surfaces and subsequent arthroplasty with or without temporal muscle myofascial flap interposition, whereas the use of Silastic as alloplastic material could be associated to an increased persistence of the local symptoms and a higher risk of foreign body granuloma and it may favor ankylosis relapse and hinder rehabilitation.

Diabetes as main risk factor in head and neck reconstructive surgery with free flaps.

The aim of our study was to demonstrate the role of certain risk factors in reconstructive head and neck surgery with free flaps. The data taken from the charts of all patients who received free flap for head and neck reconstruction in our department between January 2001 and December 2004 were analyzed. We evaluated the association of preexisting risk factors with the onset of surgical complications such as orocutaneous fistulae, flap infections, hematomas, thrombosis, and necrosis. One hundred and twenty-two free flaps have been used for the reconstruction of head and neck area in 118 patients. Preoperative risk factors included smoking habit (77 patients), alcohol use (6 patients), hypertension (9 patients), diabetes mellitus (8 patients), family history positive for vascular disorders (27 patients), and hypercholesterolemia/hypertriglyceridemia (5 patients). The percentage of full flap survival was 95.08%. Statistical analysis showed that diabetes mellitus (P < 0.01) is significantly associated with a negative prognosis for free flap reconstructive operation, whereas a smoking habit seemed to be at the verge of statistical significance. Therefore, our current practice is to prefer as much as possible the use of local flaps as opposed to free flaps in the reconstruction of head and neck defects in diabetic patients.

Ozone therapy in the treatment of avascular bisphosphonate-related jaw osteonecrosis.

Avascular osteonecrosis of the jaw (ONJ) may occur as a consequence of several conditions, even including chemotherapy treatment in patients affected by tumors or osteoporosis. We report our clinical experience in treating bisphosphonate-induced ONJ with a therapeutic methodology that includes ozone therapy as a new and original approach for the clinical management of maxillary necrotic lesions. Of 58 patients with ONJ observed at our department, 33 gave their informed consent to be part of the research and were treated according to a therapeutic approach, which included noninvasive surgery associated with pre- and postsurgical cycles of ozone therapy consisting of eight sessions lasting 3 minutes each besides antibiotic and antifungal therapies. Outcomes showed how ozone therapy increases the benefits of surgical and pharmacologic treatments, increasing the complete healing of the lesions with the disappearance of symptoms and brings cases of lesion progression down to zero. In conclusion, ozone therapy is a reliable presidium in treatment of ONJ; its benefits are remarkable and improve significantly the outcomes of the surgical approach.

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.

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.

Long-term skeletal stability after surgical correction in class III open-bite patients: A retrospective study on 40 patients treated with mono- or bimaxillary surgery

Many reports have paid attention to skeletal stability after orthognathic surgery, but only few focalize attention on patients with III class III malocclusion and open bite. In this article, long-term stability (2 yr) of the maxilla and the mandible after orthognathic surgery in 40 patients with class III malocclusion and anterior open bite is evaluated. The sample has been obtained from those 420 patients with class III malocclusion treated with Le Fort I osteotomy isolated (group A, 20 patients) or in association with bilateral sagittal split osteotomy (group B, 20 patients) from 1985 to 2003. On the basis of cephalometric analysis obtained in the immediate postoperative period and 2 years after surgery, in class III patients with anterior open bite treated with mono- or bimaxillary surgery and stabilization with rigid internal fixation, the maxilla was demonstrated to remain in the postsurgical position, whereas a moderate rate of mandibular relapse dependent on the amount of surgical alteration of the mandibular position was present.

Total Spontaneous Regression of Advanced Merkel Cell Carcinoma after Biopsy: Review and a New Case

The clinical behavior is characterized by high incidence of local recurrence (27%–60%), of lymph node metastases (45%–91%), and of distant metastases in the liver, bone, brain, lung, or skin (18%–52%). The incidence of disease-related death is as high as 35% to almost 50%. Despite its highly malignant nature, spontaneous regression has occasionally been reported. The first recorded case of spontaneous regression (CSR) of MCC was described in 1986; since then, other such cases have been reported, bringing the total to 14. Of the total number of 14 cases, 12 cases can be classified as complete spontaneous regression after only the performance of a biopsy.

Evaluation and management of nonsyndromic craniosynostosis

Craniosynostosis (craniostenosis) is premature fusion of the sutures of the cranial vault. Several factors can affect the growth of the cranial vault during embryonic life and after birth, leading to different types of craniosynostosis; these can be classified on the basis of the specific sutures that are fused. Prognosis is improved by early diagnosis, and it is important to establish the correct approach to these patients on the basis of clinical and neuroradiological investigation. The first priority is to identify the type of craniosynostosis and to distinguish between the types that require surgical intervention and those that do not. We report on the different forms of nonsyndromic craniosynostosis, their clinical and neuroradiological diagnoses, and surgical strategies.