Roberto Becelli

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.

Abrikossoff's Tumor

Abrikossoffs tumor is a disease that more commonly affects the oral cavity but can also occur at other sites. It develops between the second and sixth decades of life, more frequently among women and blacks. The neoplasm can affect all parts of the body. The head and neck areas are affected in 45% to 65% of cases and of these, 70% are located interorally (tongue, oral mucosa, hard palate). The benign form shows polygonal cells with granular, eosinophilic cytoplasm and small nuclei. The malignant form, however, is associated with a high mitotic index and pleomorphic cellular tissue. The clinical aspect of the neoformation is a swelling covered by mucus of normal appearance. Studies of the neoformation show that in addition to the objective examination, further instrumental research is necessary, i.e., with nuclear magnetic resonance or computed tomography with contrast CT scan. However, the only examination that can confirm the clinical diagnosis is the histological examination. The only treatment for Abrikossoff tumor is surgery. The surgical treatment provides for an extirpation of the neoformation with the overhanging mucus and the underlying periosteum. In this work, the authors discuss a case of Abrikossoff tumor affecting the mucus of the right side of the hemipalate in a 53-year-old patient and present a review of the literature.

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.

Soccer-related craniomaxillofacial injuries

The authors assessed the rate of craniomaxillofacial fractures in soccer and the areas where they occur, describing above all the injury pattern of this sport. Over a 5-year period (1995–2000) 46 cases of 329 with fractures associated with different sports activities have been surgically operated at the maxillofacial surgery department of the Policlinico “Umberto I” Hospital, University “La Sapienza” of Rome.All data collected have been selected on the basis of sex, age, anatomic site of the fracture, and the practiced sport. Information on injury patterns, severity, and play circumstances have been documented.The department examined 7 sports disciplines, but soccer was responsible for sports-related maxillofacial fractures in 34 of 46 cases (73.9%). All 34 fractures occurred to men.In soccer, the zygomatic and nasal regions are mainly involved. In fact the authors examined zygomatic fractures in 15 cases and nasal fractures in 10 cases. Direct contact between players generally causes soccer-related maxillofacial fractures: head–elbow impacts (21 cases) or head–head impacts (14 cases).The male:female ratio is 6.6:1, while the average age is 25 years for males and 23 years for females.In comparison with other sports (rugby, football, etc...) where physical contact occurs more frequently and the higher incidence of traumatic events justifies the use of protective measures, soccer is not a particularly violent sport. In soccer, maxillofacial traumas are caused by violent impacts between players that take place mainly when the ball is played with the forehead. In this moment there can be an elbow–head impact or a head–head impact.The authors believe that the low incidence of fractures, severity of the lesions, and discomfort caused by possible protective masks make their use unjustified. The data collected during this study witness that in soccer 21 of 34 cases of maxillofacial fractures are caused by elbow–head impacts. This fact suggests a preventive strategy against violent behavior in soccer play. Because the use of any sort of helmet proved impossible, the introduction of more severe penalties and a greater respect for the rules of the game by the players could reduce the percentage of impacts during matches. Impacts cause the most serious and frequent lesions in the maxillofacial region.

Schwannoma of the mandible.

&NA; Schwannoma is a benign neoplasm originating from Schwanns cell. It involves neurons and axons of peripheral nerves. This tumor has a predilection for the head and neck region, and often occurs as soft tissue lesion. Intraosseous sheath tumors are rare, comprising less than 1% of all bone tumors; the mandible is the most common site. The literature reports only 30 acceptable cases of schwannoma of the mandible. We report a new case of schwannoma that is unusual in its intraosseous localization and the patients comparatively young age.

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.