Roberto Boniello

Fanconi anemia manifesting as a squamous cell carcinoma of the hard palate: a case report

Fanconi Anemia is a rare autosomal recessive disorder characterized by various congenital malformations, progressive bone marrow failure at a very young age and of solid tumors development. The authors present a rare case of a squamous cell carcinoma of the hard palate in a Fanconi Anaemia patient. The atypical clinical manifestation rendered the diagnosis more difficult. This case, for age of appearance, sex and localization, is unique in international literature. We recommend a quarterly follow up of the oral-rhino-pharynx complex in FA patients and to consider as carcinomas, all oral lesions that last more than two weeks.

Techniques on modeling the vascularized free fibula flap in mandibular reconstruction

In mandibular reconstruction with bone grafts, the functional and aesthetic outcomes are clearly influenced by reconstructive techniques. Vascularized free fibular flaps are considered the most suitable choice for mandible reconstruction because of their good aesthetic and functional outcomes. Several techniques have been described in literature. According to various authors, shaping of the fibular graft can be performed by means of computer-aided design/computer-aided modeling procedures for the evaluation of the presurgery anatomy and three-dimensional models of fibula graft. However, these models are expensive, require a strict realization of the programmed intervention, and are not easily adaptable to a surgical treatment different from the planned one. We report our experience on a technique for mandibular reconstruction using a free fibular flap, obtained by modeling a template on the resected mandible. Our operative technique consists of 5 steps: preplating, resection, template modeling, contouring of the fibula, and fixing the flap on the mandible.Template modeling is performed to record the length of the resected bone, the mandibular curvature on the 3 space planes, and the width of the basal bone. On the basis of the template, the fibula flap was modeled while still attached to the pedicle. The plates, positioned at the level of the fibular osteotomies, were preformed to make the fibula precisely fit in the template. Once the fibula was shaped, mandibular reconstruction was completed by positioning the fibula graft on the mandibular stumps. Bone graft modeling by means of template is a rapid, safe, and flexible method to reconstruct the mandible.

Three-dimensional analysis in facial asymmetry: comparison with model analysis and conventional two-dimensional analysis

The purpose of this study was to compare a computed tomographic (CT) three-dimensional analysis with a model analysis to use it as diagnostic aid for the evaluation of occlusal plane tilting in facial asymmetry. Ten patients with facial asymmetry underwent CT three-dimensional examination, plaster cast analysis, and two-dimensional cephalometric analysis. The distance between a reference plane to the upper first molar and upper canine was measured on three-dimensional CT, on models, and on cephalograms to assess occlusal plane tilting. Measurements taken on three-dimensional CT were compared with those taken on articulator and cephalograms, and the level of discordance between the different analyses was evaluated. Quantitative data on the occlusal tilting are similar, but three-dimensional CT gives a better representation of anatomy, thus reducing interpretative problems about altered individual anatomy. Three-dimensional CT seems to be so helpful in detecting individual anatomical variations that it can be adopted in the diagnosis for severe craniofacial asymmetry.

Aneurysmal Bone Cyst located in the Mandibular Condyle

A rare case of aneurysmal bone cyst (ABC) located in the mandibular condyle in a 10-year-old boy is presented. The patient came to our attention for a sudden swelling in the right temporomandibular region, the mouth opening was not reduced.A rapid growing mass, depicting soft tissue invasion, in the right condyle of the mandible was found. Clinically and radiographically it resembled to a malignant lesion. The surgical excision of the mandibular condyle allowed a complete removal of the lesion. The histological examination revealed a pseudocystic expanding osteolytic lesion containing blood-filled space separated by connective tissue and many osteoclastic giant cells, which was a conventional vascular ABC.The ABC is an infrequent bone lesion which can only be found very rarely at the craniofacial skeleton. There have been described about 160 cases of ABC originated in the molar region or in upper maxilla and even more rare is the location of this cyst in the mandibular condyle. Only 6 cases were reported in the literature to date.A complete surgical resection of this osteolytic lesion is the treatment of choice considering its high recurrence rate. The condyle was not replaced with any graft. Therefore a functional device was used after surgery to overcome the lack of the condyle and to stimulate the growth of the ramus.

Surgical Therapy for Osteonecotic Lesions of the Jaws in Patients in Therapy With Bisphosphonates

Objective: Surgical therapy to improve the symptoms and the lesions in osteonecrosis (ON) of the jaws in patients in therapy with bisphosphonates. Design: to evaluate the patients therapeutic protocols, performance status, and factors promoting ON to prevent surgical failure. Materials and Methods: 18 patients affected by osteonecrotic lesions of the jaws associated to BF, were treated by surgery. Results: The results were recorded after 6 months. All the patients showed improvement of symptoms, in particular the pain. In addition, all the patients referred to a sensation of fresh and clean mouth, the disappearance of fetor ex ore, and a healthy mouth. Conclusions: The management and the resolution of BF osteonecrotic lesions is arguable and complex because in most cases, the patients are affected by oncologic disease when the better approach is prevention, but when the ON lesion is clear, surgery can improve the symptoms and in some cases, it can be resolute. To prevent surgical failure, it can be useful to evaluate the patients therapeutic protocols, performance status, and factors promoting ON.

Augmentation of the atrophic edentulous mandible by a bilateral two-step osteotomy with autogenous bone graft to place osseointegrated dental implants

Extensive resorption of the mandible increases the interarch space and rehabilitation with traditional dentures is often unsatisfactory due to the superficialization of intraoral muscles. A study of 19 patients who underwent augmentation of an atrophic mandible using a bilateral two-step osteotomy and interpositional bone graft technique is presented. Three horizontal bone cuts (one in the intraforamina and two in the molar region) were made and jointed together by two short vertical bone cuts mesialy to the mental nerve. The cranial fragment was lifted and the iliac bone graft was interposed recreating the correct intermaxillary relationship. A broad vascular pedicle was maintained during surgery, ensuring nutrition from the lingual side, essential to reduce resorption of the bone graft and cranial fragment. 141 Biomet 3i Osseotite((R)) implants were placed. Patients were rehabilitated with a full-arch implant-supported fixed prosthesis or an implant-supported overdenture. This clinical study describes the resorption process over a 4 year follow-up. 3 of 19 suffered from persistent neurosensitive disturbances. In conclusion, bilateral two-step osteotomy in association with interpositional bone graft is a reliable surgical means to recreate the anatomical morphology of the mandible.

Cranial reshaping using methyl methacrylate: technical note

Reconstruction of the facial skeleton and cranial vault has always posed difficult problems. To obtain a good result, various autologous, homologous, and heterologous grafts and biomaterials can be used. In this work, the authors present their experience in the use of methyl methacrylate (MMA) presenting a simple technique for application of the material that reduces the risk of complications. The authors also performed a review of the international bibliography relative to the use of MMA as an autologous bone substitute, analyzing the risks, complications, and results obtained. Between October 2003 and September 2007, the authors used MMA in procedures of cranial reshaping on 9 patients who underwent surgery to repair the damage caused by cranial-facial traumas and malformations. The technique of layered application of MMA made it possible to obtain excellent aesthetic and functional results in 8 patients, whereas in 1 case, the material had to be removed when the patient developed complications due to infection. Methyl methacrylate still remains the material of choice for cranioplasty on adult patients. The application of the material and sequenced layers makes it possible to reduce perioperative complications to the utmost, providing an excellent aesthetic and functional result.

Evaluation of 2 different reference planes used for the study of asymmetric facial malformations

The purpose of this study was to evaluate if Frankfort plane (FH) and plane passing through the lateral semicircular canals (LS) can be used as reference planes in three-dimensional analysis. Ten patients with facial asymmetry underwent a three-dimensional computed tomography. Computed tomographic images were processed by means of a commercial software and a personal computer to obtain a three-dimensional virtual craniofacial model. The average Frankfort plane and the plane passing through the LS were identified. The distance from the above-mentioned planes to the first upper molar and upper canine cusp was measured. It was not possible to detect an FH plane in any of the patients. Right FH, left FH, average FH, and LS plane were traced. The discrepancies among reference planes were significant in cases with severe asymmetry. A minimal discrepancy was noticed in patients with light asymmetry. In patients with severe asymmetry, the LS plane results in steady, reproducible, detectable, and closer to the patients anatomy, representing a valid reference plane for three-dimensional computed tomography analysis.

TMJ metastasis: A unusual case report

The metastases to the TMJ from a primary lung tumour is a very rare occurrence.This case is unusual in several aspects, as the non-reducible dislocation of the TMJ was the first clinical manifestation of the tumour. CT staging showed that this secondary tumour in the condyle was the only bone metastasis.

Autofluorescence and Early Detection of Mucosal Lesions in Patients at Risk for Oral Cancer

Loss of autofluorescence as an early phenomenon associated with tissue degeneration seems to be promising for the diagnosis of oral cancer. The method seems to make visible early structural and biochemical alterations of the oral mucosa not always evident under direct inspection of the oral cavity. For this reason, the margins of the mucosal lesions usually appear wider compared with direct visualization. Actual extension of the potentially malignant lesions must be precisely perceived to avoid any underestimation of the tumor. In this study, 32 patients at risk for oral cancer underwent autofluorescence test. Of these patients, 12 (group A) experienced potentially malignant diseases. The other 20 patients (group B) were previously operated on for oral cancer. In addition, 13 patients showed loss of autofluorescence (8 patients from group A and 5 patients from group B). Among these 13 patients, 12 were affected with lesions of relevance (in group A, 6 had squamocellular carcinoma and 2 had low-grade dysplasia; in group B, 2 patients had high-grade dysplasia, 2 had low-grade dysplasia, and 1 had an epithelial hypertrophy with inflammatory cells). Preliminary results seem to indicate that autofluorescence is a high-performing test for the individuation of oral cancer in populations at risk (sensibility up to 100% and specificity up to 93% in this study).