Mario Mantovani

Prevention and treatment of postoperative infections after sinus elevation surgery: clinical consensus and recommendations.

Introduction. Maxillary sinus surgery is a reliable and predictable treatment option for the prosthetic rehabilitation of the atrophic maxilla. Nevertheless, these interventions are not riskless of postoperative complications with respect to implant positioning in pristine bone. Aim. The aim of this paper is to report the results of a clinical consensus of experts (periodontists, implantologists, maxillofacial surgeons, ENT, and microbiology specialists) on several clinical questions and to give clinical recommendations on how to prevent, diagnose, and treat postoperative infections. Materials and Methods. A panel of experts in different fields of dentistry and medicine, after having reviewed the available literature on the topic and taking into account their long-standing clinical experience, gave their response to a series of clinical questions and reached a consensus. Results and Conclusion. The incidence of postop infections is relatively low (2%–5.6%). A multidisciplinary approach is advisable. A list of clinical recommendation are given.

Importance of ENT assessment in stratifying candidates for sinus floor elevation: a prospective clinical study

OBJECTIVES The aim of this article was to describe our experience in the field of preoperative ear, nose and throat (ENT) assessment in each candidate for (maxillary) sinus floor elevation (SFE) after the introduction of a systematic protocol. The protocol evaluates the sinus compliance by means of ENT preliminary examination with nasal fiberoptic endoscopy to identify all of the situations that may predispose to post-lifting complications, i.e. potentially irreversible (PIECs) and presumably reversible (PRECs) ENT contraindications to SFE, and to evaluate its impact on SFE success. MATERIAL AND METHODS Patient candidates for SFE were carefully assessed by means of case-history collection, complete ENT evaluation with nasal fiberoptic endoscopy and imaging to detect PIECs, PRECs, or no ENT contraindications for SFE. In case of PRECs, SFE was postponed until complete clinical recovery. Impact of preoperative ENT assessment on SFE outcome was assessed by means of post-lifting telephonic interview and ENT evaluation. RESULTS PRECs were detected and resolved before SFE was performed in 38.2% of our 34 patients; no intra- or post-lifting complications occurred in the patients with no ENT contraindications or PRECs. CONCLUSIONS The results of the study suggest that a careful multi-tasking preoperative management, including an ENT assessment with fiberoptic endoscopy and a radiological evaluation extended to the ostio-meatal complex, is very useful in candidates for SFE.

Treatment of Velopharyngeal Insufficiency by Pharyngeal and Velar Fat Injections

The aim of this prospective study was to evaluate the effectiveness of fat injections in the treatment of velopharyngeal insufficiency (VPI). The study involved 10 patients (6 adults aged 19-48 years and 4 children aged 5-13 years) with mild/moderate VPI who were injected with 3.5 to 8 mL of fat in the posterior, lateral pharyngeal walls and soft palate under general anaesthesia. A second fat-grafting procedure was performed in 2 patients to achieve further improvement. Nasoendoscopy revealed a reduction in the closure gap in all patients, and the perceptual evaluation demonstrated improved speech intelligibility and resonance and reduced nasal air leakage in all cases (P < .005). The aerodynamic assessment showed a significant reduction in nasal airflow during phonation (P < .05). Follow-up was 6 to 23 months. In conclusion, fat injections improved voice resonance and reduced nasal air escape in all treated cases and can be a promising alternative to major procedures, such as velopharyngoplasties, for the treatment of mild/moderate VPI.

Fat injections for the treatment of velopharyngeal insufficiency.

Abstract The aim of this article was to describe the technical details of a fat injection procedure for the treatment of mild to moderate velopharyngeal insufficiency (VPI). Before surgery, the velopharyngeal gap is assessed by means of flexible nasoendoscopy, and speech intelligibility, hypernasality, and nasal air escape are perceptually evaluated and scored by independent raters; nasal airflow during speech is objectively measured. The lipoaspirate is centrifuged at 1200g for 3 minutes to separate and remove blood, cell debris, and the oily layer. Patients are injected with 3.5 to 8 mL of fat in the posterior and lateral pharyngeal walls and soft palate under general anesthesia. The fat is placed within the superior constrictor muscle on the posterior pharyngeal wall to avoid injection behind the prevertebral fascia and possible intraoperative or postoperative fat displacement in a caudal direction. A 19-gauge malleable, blunt, single-hole cannula is used for fat grafting, and the operative field is exposed by means of a Digman mouth gag. Two Nelaton probes are inserted through the nostrils and retracted from the mouth under moderate tension to favor visualization of the nasopharynx. No donor-site or injection-site morbidity has been observed so far, and the 12 patients (aged 5–48 y) treated so far have not manifested snoring or nasal obstruction at any time after surgery. Improved voice resonance is audible soon after the operation, and no hyponasality can be detected. The patients are discharged the day after surgery. Subsequent fat grafting procedures can be performed to achieve further improvement. Correctly performed fat injections improve voice resonance and reduce nasal air escape in VPI, as demonstrated by nasoendoscopy, speech perceptual evaluation, and the objective measurement of nasal airflow and represent an alternative to velopharyngoplasty for mild to moderate VPI.

Antral retriever and displaced dental implants in the maxillary sinus

PurposeRemoval of antral foreign bodies after implantation is mandatory to avoid infectious processes and may be a troublesome question. Different surgical approaches could be considered, with several limitations and morbidities. MethodsWe present a new tool (Antral Retriever) conceived to remove antral dental implants or any other migrated material through a minimally invasive canine fossa approach, under continuous endoscopic view and local anesthesia. Results and ConclusionsAntral Retriever enables the surgeon to successfully remove antral foreign bodies through a canine fossa approach under continuous endoscopic visualization and local anesthesia, with minimal discomfort for the patient.

The back-and-forth septoplasty

&NA; This paper describes a new technique of septoplasty especially devised to minimize and simplify surgery and to preserve at the same time the integrity of mucosa at the critical area of articulation between the caudal quadrangular cartilage and the vomeropremaxillary crest. Two special instruments specifically designed for this type of operation are illustrated. The technique finds a specific clinical application to cosmetic surgery of the nose when a functional problem exists. (Plast. Reconstr. Surg. 97: 40, 1996.)

Cell kinetics of human nasal septal chondrocytes in vitro: importance for cartilage grafting in otolaryngology.

In the field of reconstructive plastic surgery, grafts of autologous cartilage are sometimes used to replace damaged or pathologic tissues, particularly in the nose, ear, and trachea. However, this procedure is difficult to apply, especially because of the scarcity of donor sites. In this study, we have cultured and characterized human chondrocytes from human nasal septal cartilage biopsies. The proliferative activity was evaluated by incorporation of 3H-thymidine into deoxyribonucleic acid (DNA) both under normal culture conditions and with different growth factors and serum concentrations. Identification of chondrocytes in culture was performed with immunohistochemistry and production of matrix with specific histochemical indicators. We observed a significant increase of cell kinetics of differentiated chondrocytes, embedded with intense metachromatic matrix, in the presence of transforming growth factor beta, and low concentrations of fetal calf serum. Therefore, in suitable conditions, human chondrocytes obtained even from small specimens can produce in vitro considerable quantities of pure autologous cartilaginous tissue within a few days. This newly formed cartilage can be used as a grafting material in reconstructive surgery, particularly in otolaryngology.

Tilted Trans-Sinus Implants for the Treatment of Maxillary Atrophy: Case Series of 35 Consecutive Patients

PURPOSE To evaluate tilted trans-sinus implants for rehabilitation of the atrophic maxilla. MATERIALS AND METHODS A case series of 35 patients (32 consecutive edentulous and 3 partially edentulous patients) treated with trans-sinus dental implants is presented. Edentulous patients received 4 or 6 implants depending on anatomic conditions and a 12-unit final restoration; partially edentulous patients received 2 implants supporting a 3-unit partial fixed bridge. RESULTS Thirty-five patients (14 men, 21 women) underwent rehabilitation. Thirty-two patients with 190 implants placed received a full-arch fixed prosthesis supported by axial and trans-sinus tilted implants. Three patients each received 2 implants with a 3-unit fixed restoration. The mean age at surgery was 59.2 ± 9.5 years. The cumulative survival rate was calculated only for the full-arch fixed prosthesis group and was 98.42%. Crestal bone loss averaged 0.9 ± 0.4 and 0.8 ± 0.5 mm for the axial and tilted implants, respectively, at the 12-month evaluation. Biological complications at the implant level were 1 case of peri-implantitis and 3 cases of mucositis; no patient developed sinus infections. The prosthetic complications encountered were screw loosening in 17.5% of cases and chipping of the esthetic part in 30% of cases. These complications were easily resolved chairside and did not lead to prosthetic failure. CONCLUSIONS Trans-sinus tilted implants and sinus membrane distal displacement appear to be a viable minimally invasive alternative for the treatment of maxillary atrophy.

The dragonfly splint: a new disposable device designed to prevent both medial and lateral turbinate synechiae after sinonasal surgery.

AbstractPeriturbinal adhesions are among the most frequent and challenging complications of sinonasal surgery. Endonasal paraseptal splints have proved to be very efficient in preventing “medial synechiae,” that is, adhesions located between the medial faces of the middle/inferior turbinates and the septum. However, none of these devices for guiding mucosal healing can prevent “lateral synechiae” (adhesions between the lateral face of the middle turbinate and the lateral nasal wall) inside the middle meatal cleft, which is a very critical area for the physiology of the anterior sinus system. For this reason, if followed by the formation of lateral synechiae, the surgical maneuvers used to treat sinus diseases could paradoxically become a cause of persistent functional impairment and lead to iatrogenic sinusitis or mucocele.We describe our preliminary experience with a new endonasal splint called “Dragonfly” (because of its shape), which has been designed to prevent both medial and lateral postsurgical synechiae. This device has a long lateral wing designed to separate the mucosal surfaces of the middle meatal/ethmoid cavities and prevent adhesions during the postoperative process of healing. The device must be kept in situ for 3 to 4 weeks to permit the re-epithelialization of the internal nasal surfaces. Our experience shows that the splints are well tolerated and highly efficient, preventing both medial and lateral synechiae in 100% of cases. A randomized controlled study has now been started to confirm these positive preliminary findings in a larger patient population.

In reply to "mucociliary function during maxillary sinus floor elevation".

To the Editor: A s described in ‘‘Mucociliary function during maxillary sinus floor elevation,’’ Griffa et al have recently tested mucociliary function during sinus lift by evaluating methylene blue diffusion from the antral floor to the ostium region endoscopically via the canine fossa at the time of lifting and found the substantial preservation of mucociliary function throughout the antrum except for the detached area of the Schneider membrane. On the basis of the anatomophysiology regulating maxillary homeostasis, sinus drainage and ventilation are significantly altered not only under pathological conditions considerably affecting ciliar activity but also in the case of impaired ostiomeatal patency in the middle meatal region. The authors do not seem to have made a transnasal endoscopic evaluation either preoperatively (to assess the patency of the ostiomeatal complex) or perioperatively to assess tracer diffusion inside the nose. As we have previously suggested, in candidates for sinus lifting, preoperative endoscopy of the middle meatal region and the ostiomeatal complex can exclude the presence of a pathological condition impairing maxillary drainage and ventilation, which may predispose to postlifting maxillary sinusitis and lead to a negative surgical outcome. Moreover, perioperative transnasal endoscopy is a useful means of investigating whether the apparently preserved mucociliary function is really enough to achieve good nasosinusal drainage because every surgical approach to the maxillary sinus (including sinus lifting) transiently impairs antral homeostasis as a result of temporary inflammation. Finally, we would also like to point out that, although endoscopic evaluation via the canine fossa is a minimally invasive procedure, it may give rise to unpleasant complications such as numbness of the upper lip because of alveolar nerve injury, and this should be clearly stated in the informed consent document given to patients.