Rodolfo Benech

Analysis of complications following endoscopically assisted treatment of mandibular condylar fractures.

Background Within the field of facial reconstructive surgery, minimally invasive procedures are used for the treatment of temporomandibular joint disorders, traumas, and salivary glands and base of skull tumors. The recent report of endoscopic approach for treating subcondylar fractures of the mandible is designed to provide a new method for the treatment of subcondylar fractures using an endoscope through a limited transoral incision. To the best of our knowledge, the advantages and the disadvantages of an endoscopically assisted approach to mandibular condylar fracture have not been verified in studies with a high level of evidence. The objective of this article was to present our experience regarding the endoscopically assisted reduction of subcondylar mandibular fractures with a special focus on complications. Methods The records of 14 patients who underwent surgical repair of subcondylar fractures by transoral endoscopic-assisted technique from January 2005 to December 2008 at the Maxillofacial Surgery Unit of Novara Major Hospital were reviewed retrospectively. The measures for the surgical objectives included the following outcome variables: (1) operation time, (2) cosmetic outcome, (3) salivary fistulas, (4) infection, (5) delayed wound healing, (6) facial nerve damage, (7) hemorrhage, (8) repeat interventions, (9) bone consolidation, (10) occlusion changes, and (11) temporomandibular joint dysfunction. Results Our data show that we have had 4 complications (28%) experienced by 4 different patients: (1) arterial hemorrhage, (2) facial nerve injury, (3) nonunion, and (4) partial condylar reabsorption. Conclusions Although we cannot draw statistically significant conclusions, we think that further randomized clinical trials should be necessary to analyze this method; we believe that there is not an ideal approach for a fracture, but each patient needs to be fully evaluated carefully preoperatively, and the more convenient approach needs to be selected for each case.

Surgical management of posttraumatic intraorbital hematoma.

Retrobulbar hematoma is a rare condition but represents a diagnostic and therapeutic emergency. It occurs in between 0.3% and 3.5% of facial traumas and can be caused by direct or indirect injury of the orbit; they can be classified into intraorbital and subperiosteal hematoma. We describe 4 different cases of posttraumatic retrobulbar hematoma treated at the Unit of Maxillofacial Surgery of the Novara Major Hospital between January 2005 and December 2009, each different from the others for morphologic aspects, and we discuss its diagnosis and management. Surgery decompression of the orbit is recommended when visual deficit arises and when there is no response to pharmacologic therapy. Several techniques for orbital decompression have been proposed. The lateral canthotomy and/or the inferior cantholysis are the 2 techniques most practiced. Anterior-chamber paracentesis is effective, but it is rarely indicated for frequent complications such as cataract formation, herniation of the iris, infection, and trauma to the canal of Schlemm. Other procedures including transantral ethmoidectomy, transantral sphenoidectomy, and transfrontal craniotomy are described.

Maxillomandibular advancement in obstructive sleep apnea syndrome: a surgical model to investigate reverse face lift.

BackgroundThe aging process is characterized by multiple signs affecting the upper, the middle, and the lower third of the face; coventionally, face-lift procedures and structural fat grafting are performed to create a younger face. During the life, craniofacial skeleton atrophies, leading to a reduction of the facial height and depth, while increasing the facial width. Maxillomandibular advancement (MMA) by orthognathic surgery restores the lost space dimension, projecting the cheeks, the mouth, and the nose. The aim of this study was to analyze the morphologic change of the face after MMA in patients with obstructive sleep apnea syndrome, focusing on the previously mentioned stigmata of the middle and the lower third of the aging face. MethodsThe records of 16 patients who underwent MMA for obstructive sleep apnea syndrome between January 2005 and December 2008 in the Unit of Maxillofacial Surgery at the Novara Major Hospital were included in this study. We explained to the patients the stigmata of a standard aging face, and we asked them to evaluate each sign affecting the middle and the lower third of their preoperative condition. One positive point was given for the presence of each sign reported by the patients. At 2 years after surgery, we asked the patients to evaluate the previously mentioned aging signs of their postoperative face. Again, 1 positive point was given for the presence of each sign reported by the patients. ResultsAlthough we did not perform statistical evaluation, 13 patients showed a degree of rejuvenation after MMA (the score of the postoperative face is less than the score of the preoperative face). Three patients reported no postoperative change; none reported a more aging face, with a successful “reverse face-lift” occurred in 81% of our cases. ConclusionsSimultaneous maxillary and mandibular advancements change the skeletal framework of the face, improving soft-tissue support and resulting in rejuvenation of the middle and the lower third of the face. This condition is demonstrated by the results of our study in that all patients appeared postoperatively more youthful from a self-evaluation.

Orbital trapdoor fracture: can it occur also in adults?

We describe here a peculiar case of a 30-year-old woman presenting with an orbital trapdoor fracture. Preoperative and postoperative magnetic resonance images are provided to explain the mechanism of the injury.

Current opinions on surgical treatment of fractures of the condylar head.

Treatment of mandibular condyle fractures is still controversial, with surgical treatment slowly becoming the preferred option. However, fractures of the condylar head (diacapitular fractures) are still treated conservatively at many institutions. Recently, more and more surgeons have begun to perform open treatment for diacapitular fractures because it allows to restore the anatomical position of the fragments and disc, it allows an immediate functional movement of the jaw, and avoid the ankylosis of the temporomandibular joint induced by the trauma. Several techniques have been proposed to reduce and fix fractures of the condylar head, such as standard bone screws, resorbable screws, resorbable pins, and cannulated lag screws. Therefore, the aim of this article is to review the literature about the surgical treatment of fractures of the condylar head to resume the current knowledge about open treatment of such fractures.

Review of peripheral giant cell granulomas.

To the Editor: Historically, localized gingival enlargements have been named epulides that described pedunculated or sessile swellings of the gingiva. Anyway, the term ‘‘epulis’’ is a topographic term that does not indicate a specific histopathological lesion.1Y40 Among such localized reactive gingival enlargements, a commonly observed lesion is the peripheral giant cell granuloma (PGCG) that originates from the connective tissue of the periosteum or the periodontal membrane. Etiopathogenesis of this lesion is still unclear, but it is associated with local irritating factors such as tooth extraction, impacted food, poor dental restorations, ill-fitting dentures, calculus, plaque, and chronic trauma. Therefore, in this letter we investigate the etiology as well as the epidemiology of 874 cases of PGCGs that were treated between January 1, 1995 and December 31, 2009 in 2 centers in the North West of Italy. A retrospective chart review was performed of all cases of PGCG treated and histologically examined at the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, University of Turin, Turin, Italy, and at the Otorhinolaryngology Institute, University of Turin, Turin, Italy between January 1, 1995 and December 31, 2009. Cases of brown tumor (in relation to hyperparathyroidism) and pyogenic granuloma (so called pregnancy tumor) were excluded from the study sample. This retrospective study was exempted from review as a retrospective series by our institutional review board human studies committee. We followed Helsinki Declaration guidelines. A total of 874 cases were included. The data collected included age at diagnosis, gender, comorbidity or pregnancy, lesion location, clinical manifestations, radiographic features, treatment modality, and recurrence. The microscopic slides were reviewed to confirm the histological diagnosis of PGCG, to exclude diagnosis of pyogenic granuloma or peripheral ossifying fibroma, and to search for the presence of osseous metaplasia. The clinical manifestations at diagnosis included the dimensions of the lesions, the characteristics of lesion base (pedunculated or sessile), and the presence of ulceration. The treatment provided was also determined from a review of the operative report and recorded. Recurrences in the first 3 years after surgery were recorded after review of the follow-up hospital records. Statistical analysis was used to search for associations among multiple variables and recurrences. A total of 874 patients with 874 PGCGs underwent surgical treatment during the study period. The age range was 8 to 89 years (mean, 48.8; median, 47; standard deviation, 19.5). PGCGs most commonly occurred in patients in the fourth decade of life (166 patients, 19%), followed by those in the third (160 patients, 18.3%; Fig. 1). Of the 874 patients, 545 (62.3%) were female and 330 (37.7%) were male. Therefore, the ratio of males to females was 1:0.6, with a female predilection. Forty-four patients were pregnant when the lesion was diagnosed, whereas comorbidities were observed in 45 patients. In particular, 28 patients suffered from hyperparathyroidism, 10 patients had hepatitis C infection, 5 patients had cardiovascular diseases, and the remaining 3 patients had HIV infection. The maxilla was involved in 442 lesions (50.6%), and 432 PGCGs (49.4%) were located in the mandible (ratio, 1.02:1) (Fig. 2). Of the 874 lesions, 169 (19.4%) were located in the molar region, 212 (24.2%) in the premolar region, 218 (24.9%) in the canine region, and 275 (31.5%) in the incisor region (Fig. 3). The incisor region was the most frequently involved area, though the most commonly involved tooth was the canine. In 81.6% of cases, an etiologic factor was found. Most frequently observed associated factors were impacted food (314 cases), inappropriate fillings (207 cases), fixed partial dentures (124 cases), and dental implants (6 patients). Nineteen PGCGs were found in edentulous patients (12 lesions in the maxilla and 7 lesions in the mandible), whereas 6 PGCGs were observed in correspondence of dental implants. As for clinical manifestations, 356 lesions out of 874 presented ulceration. The mean lesion size was 12 mm (range, 2 to 35; median, 1; standard deviation, 0.6). The mean size of the

Bilateral Oral Non-endemic Burkitt Lymphoma

To the Editor: Burkitt lymphoma (BL) is a high-grade, aggressive B-cell lymphoma that is characterized by a high cell proliferation rate and a C-MYC gene overexpression because of reciprocal chromosomal translocations of the C-MYC proto-oncogene with different immunoglobulin heavy-chain genes. It is classified into 3 clinical variants or subtypes: endemic, sporadic or non-endemic, and immunodeficiency associated. Typically, the endemic subtype involves the jaws and abdomen, whereas the non-endemic variant usually presents as an abdominal mass involving the mesenteric lymph nodes or ileocecal region, with an extremely rare involvement of the jaws. BL is usually diagnosed in children and young adults, and its primary involvement of the oral soft tissue in adults is extremely rare.1,2,4 We report a case of non-endemic bilateral oral BL of the maxillary tuber arising in a 35-year-old man. A 35-year-old man presented with a painless mucosal swelling in correspondence of the maxillary tuber bilaterally. His recent medical history included an unknown fever and progressive weakness for the last 4 weeks. He referred the lesion had progressively developed for the previous 3 months. Intraoral examination of the lesions revealed ulcerative, nontender, soft swelling in correspondence of the maxillary tuber bilaterally, measuring about 1.5 cm inmaximum diameter, suggestive of tumor masses (Figs. 1, 2). The HIV enzyme-linked immunosorbent assay test was negative. The EBV test results were also negative. An incisional biopsy was performed of the tuber swelling bilaterally. Histological examination showed a typical ‘‘starry sky’’ appearance with an infiltrate of neoplastic lymphoid cells. Immunohistochemical staining showed that these neoplastic lymphoid cells were negative for bcl-2, but positive for CD20, CD10, and BCL6. The Ki-67 proliferation index was 98%. Immunological examination was negative for antiYEpstein-Barr virus immunoglobulins. IGH/MYC translocation was detected by fluorescence in situ hybridization. These histological and immunohistochemical findings were suggestive of a BL. Bone marrow biopsy indicated no bone marrow involvement. CT scan also revealed the presence of an abdominal mass, in correspondence of the stomach. Multiple biopsies confirmed the suspect of localizations of BL. Therefore, a final diagnosis of BL was confirmed. The patient was referred to the hematologic center, and chemotherapy was promptly instituted. BL is a mature, aggressive B-cell lymphoma that presents a high degree of C-MYC gene expression. The male/female ratio in nonendemic BL ranges from 2:1 to 6.5:1. Approximately one quarter of non-endemic BL cases involve the head and neck, most commonly in the form of cervical lymphadenopathy, whereas jaws involvement has been rarely reported. Differential diagnosis of BL includes dentoalveolar infection, other lymphomas, squamous cell carcinoma, ossifying fibroma, osteosarcoma, Langerhans cell disease, salivary gland tumors, Ewing sarcoma, chondrosarcoma, and fibrosarcoma. However, the World Health Organization criteria for BL had to be considered in our case. They include classic/atypical histology, positivity for CD20, bcl-6, and CD10, and negativity for bcl-2 and CD5, in addition to a Ki-67 score higher than 95%, and IG/MYC +. Our patient fulfilled these criteria, thus supporting a diagnosis of BL. The importance of an early diagnosis of BL should not be overlooked, and the jaws should be recognized as potential site for this tumor. In fact, delays in treating BL may increase the risk of cancer spreading to other parts of the body. Open biopsy is necessary to obtain adequate information about the tissue architecture and sufficient tissue for appropriate immunohistochemical studies. The primary therapeutic modality for BL is chemotherapy because of its fast growth and high mitotic index. Monoclonal antibodies, such as rituximab, have recently been added to the regimen. In conclusion, an early diagnosis and prompt chemotherapy are crucial to try to prevent the dissemination of the disease and to improve the prognosis of patients with BL.

Superior Orbital Fissure Syndrome in Lateral Orbital Wall Fracture: Management and Classification Update.

The superior orbital fissure syndrome (SOFS) is an uncommon complication rarely occurring in association with craniofacial trauma. Work-up of a patient injured by a traumatic right orbitozygomatic complex fracture and SOFS is presented. Accurate computed tomography scan and three-dimensional reconstruction showed a medial displacement of the lateral orbital wall, compressing the right superior orbital fissure (SOF), without intraorbital bone fragment displacement or hemorrhage. Imaging also revealed a frontosphenotemporal fracture, according to Pellerin et al, that is, frequently associated with visual impairment. Our primary choice of therapy was a corticosteroid treatment in association with an early surgical approach. It consisted in en bloc reduction and osteosynthesis of the fracture through a bicoronal approach, recovering SOF size. A prompt and almost complete recovery of the abducens movement, without diplopia, was achieved in 1 week. The authors discuss indications and management of SOFS. The presence of fractures should urgently lead to surgery. We deny waiting for a medical treatment result, while preferring the prompt reduction of the fractures and extrication of the soft tissues. The main focus of this study is on patients anatomical feature and fracture patterns.