Tito Matteo Marianetti

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.

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.

Anterolateral thigh flap for the reconstruction of head and neck defects: alternative or replacement of the radial forearm flap?

This paper presents our clinical experience with head and neck reconstruction using radial forearm flap and our preliminary experience with anterolateral thigh (ALT) flap. We analyze the advantages and disadvantages of these 2 flaps from the complications we have encountered. From 1993 to 2006, the radial forearm flap has been used in 75 patients, whereas we began using the ALT flap in 2006. Since this time, we have used the ALT flap in 10 patients. One flap partial loss was observed in a patient who underwent reconstruction of the ethmoid region and nasal bones with an osteofasciocutaneous radial flap. In one patient who underwent reconstruction with ALT flap, inadequate venous outflow was discovered, and the flap was salvaged with reexploration, removing of the cutaneous component of the flap and using antithrombotic agents. Donor-site complications were experienced in 8 of 75 patients who underwent reconstruction with radial forearm flap, whereas all donor thighs healed uneventfully. Anterolateral thigh flap gives optimal results either at the donor site or at the accepting site, being easy to harvest and providing an ideal reconstructive option. Nevertheless, radial forearm flap remains a valuable alternative in case of a thin soft tissue reconstruction because of its thinness and versatility; furthermore, it can provide a long and constant pedicle of large caliber. However, since we began using the ALT flap, we had only performed this flap with respect to radial forearm flap because of its lower donor-site morbidity.

A new surgical approach for the treatment of chronic recurrent temporomandibular joint dislocation.

Chronic recurrent temporomandibular joint (TMJ) dislocation is defined as the complete loss of articular relationships, during mouth-wide opening, between the articular fossa of the temporal bone and the condyle-disk complex. The most frequent pathogenetic factors involved in chronic recurrent dislocation of the TMJ are supposed to be trauma, abnormal chewing movements, TMJ ligaments, capsule laxity, and masticatory muscles disorders. In fact, TMJ dislocation occurs more frequently in people with general joint laxity and in patients with internal derangement of the TMJ or with occlusal disturbance. Management of TMJ dislocation remains a challenge. Eminectomy, whose validity has been demonstrated by several authors, acts on the bony obstacle, preventing condylar locking, but does not have a therapeutic effect on TMJ ligament and capsular laxity or masticatory muscle incoordination, which seem to be the real cause of TMJ dislocation in most cases. The authors present a mini-invasive modified technique of eminectomy, which aims to act on both the obstacle and the cause with respect and restoration of TMJ biomechanical constraints.

Pleomorphic adenoma and benign parotid tumors: extracapsular dissection vs superficial parotidectomy—review of literature and meta-analysis

OBJECTIVE This study compared extracapsular dissection (ED) vs superficial parotidectomy (SP) in the treatment of pleomorphic adenoma and benign parotid tumors. STUDY DESIGN The research covered the years 1950-2011 in PubMed, Ovid MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus. Of 1152 articles screened, 123 studies met the inclusion criteria. A review of the nomenclature of the different parotid surgery techniques was done. Recurrence rate, permanent facial nerve paralysis, and Frey syndrome of patients who underwent ED vs those who underwent SP were compared by meta-analysis. RESULTS Our meta-analysis data comparing ED and SP found that: (1) the recurrence rate is higher in patients treated with SP; (2) SP has a higher incidence of cranial nerve VII paralysis; and (3) Frey syndrome is more common after SP. CONCLUSIONS ED may be a viable option in the treatment of unilateral benign parotid tumors of the superficial lobe, sized less than 4 cm, without involvement of the facial nerve.

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).

Hilotherm efficacy in controlling postoperative facial edema in patients treated for maxillomandibular malformations.

BackgroundA cooling system based on polyurethane preshaped masks for postoperative cryotherapy, named Hilotherm, has been recently introduced. The purpose of this study was to evaluate the effectiveness of this equipment in controlling postoperative edema and compare the results with those obtained with a group treated with conventional cryotherapy and a group not treated with cryotherapy. MethodsNinety patients were included in this randomized controlled trial. The 90 patients were divided into 3 groups. Group A was treated with Hilotherm. Group B was treated with conventional cryotherapy. Group C was not treated with cryotherapy. Using a tape measure, we measured for both sides of the face the distances in centimeters between point 0 and external canthus (&agr;), most lateral point on the ala of the nose (&bgr;), commissura labialis (&ggr;), and Pos (&dgr;). We performed a Kruskal-Wallis test comparing the average variation of edema on the right and left sides of the face for each facial segment of patients of the 3 groups from time 0 to time 24 hours. ResultsNo cryotherapy is the worst treatment for every segment studied. In anatomic regions defined &bgr;, &ggr;, and &dgr;, Hilotherm was more effective in containing edema than the ice pack 24 hours after the first measurement. Opposite results were seen on district &agr;, the site not completely enclosed in the mask. ConclusionsThe substantial difference between different treatments probably consisted in the greater reliability of the Hilotherm system, which is characterized by easy handling, constant temperature control, comfort, and practicality of the masks.

Clinical experience with spiramycin in bisphosphonate-associated osteonecrosis of the jaw

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) consists of an exposure of the jaw bone that persists for over 8 weeks in patients with positive history for bisphosphonates. Symptomatology is characterized by dull and ceaseless pain, and in advanced stages, the exposure of necrotic bone is evident, which is frequently associated with purulent secretions and faetor oris. Despite many different studies on BRONJ, there are no general guidelines to treat this disease. In this work, the authors present their experience in BRONJ conservative therapy with spiramycin by comparing the results achieved with amoxicillin and clavulanic acid. From January 1, 2008 to June 30, 2008, our department received 25 patients who were affected by osteonecrosis secondary to bisphosphonates. Thirteen had taken bisphosphonates for osteoporosis and 12 for malignancies. We divided the 25 patients into two groups: those who had not received any treatment and those who had received treatment. The first group of 13 patients had been treated only with spiramycin (S). The results from this group were only evaluated to test the efficacy of spiramycin and were not considered in the study. The second group of 12 patients had not undergone any previous treatment. This group was further divided in two groups of 6 patients each; one group was treated with spiramycin and the other with amoxicillin and clavulanic acid (ACA). The following criteria were used to evaluate the results of the study: pain, sensibility deficits, purulent secretion and bone exposure. All group results were evaluated according to the criteria chosen, and positive results were achieved in both groups S and ACA, such as reduction or disappearance of pain, sensibility deficits and purulent secretion and healing of bone exposition, although spiramycin showed itself to be more effective than the combination of amoxicillin and clavulanic acid. Spiramycin is a macrolide antibiotic with a wide spectrum of activity against Streptococci, Pneumococci, Diplococci, Gonococci and Staphylococci, which are typical in BRONJ. No resistance was indicated. Administration of the antibiotics can be intravenous, intramuscular, rectal or oral, which remains the most frequently used since spiramycin elimination also occurs with saliva and the antibiotic reaches high concentrations in the oral cavity where BRONJ is situated. Good compliance to the spiramycin regimen was observed in all three groups, with a general improvement in all of the parameters considered. In only two cases did patients have to undergo surgical curettage. The results showed that spiramycin can be a first choice drug in the treatment of BRONJ, and it should be strongly considered for patients where previous antibiotic therapy did not prove to be effective.

Mandibular reconstruction with different techniques

AbstractTraumas, malformative or dysplastic pathologies, atrophy, osteoradionecrosis, and benign or malignant neoplasm can cause bone deficits in the mandible. Consequent mandibular defects can determine aesthetic and functional problems; therefore, being able to perform a good reconstruction is of critical importance.Several techniques have been proposed for mandibular reconstruction over the years. In this article, we present and discuss the evolution during the time of the methods of mandible reconstruction as well as pros and cons of each procedure on the basis of experience of 10 years in the maxillofacial department of the Catholic University of Sacred Heart of Rome.Free flaps represent the gold standard method of reconstruction of large mandibular defects: the fibula bone flap represents the best choice for large defects involving the arch and the mandibular ramus, whereas the deep circumflex iliac artery represents a valid alternative for mandibular defects involving the posterior region.In cases where free flap reconstructions are contraindicated, the use of regional pedicle flap combined with autologous bone grafts still represents a valid choice. Patients who are not deemed suitable for long and demanding surgery can still be treated using alloplastic materials in association with regional pedicle flap or, when adjuvant radiation therapy is needed, by simple locoregional pedicle flap. Finally, in selected cases, the bone transporting technique should be considered as a valid alternative to the more “traditional” reconstructive methods because of the extraordinary potential and its favorable cost-benefit ratio.

Clinical evaluation of obstructive sleep apnea in children

BackgroundObstructive sleep apnea syndrome (OSAS) is often found in children affected by congenital or acquired craniomaxillomandibular malformations. This disease carries different levels of risk, ranging from attention problems at school to growth problems and serious disorders, such as cor pulmonale or sudden infant death. The examination that is most commonly used to evaluate the severity of OSAS is polysomnography, and the therapeutic course is often determined by the disease state. Considering the discrepancy between clinical history and polysomnographic findings, we felt the need to identify an instrument for evaluating OSA to be used as a support for polysomnography. Materials and MethodsThis study was carried out on pediatric patients affected by congenital or acquired craniomaxillofacial malformations. We selected 34 pediatric patients, including 15 boys and 19 girls, aged between 1 and 16 years, with a mean age of 7.3 years. The study consisted of individuation of common clinical history data obtained from each patient and associating those data with the level of OSA severity identified by polysomnography. We were able to isolate certain symptoms and signs that can be predictive of OSA from research in the literature and our clinical experience with pediatric patients. In the clinic, we have found that the clinical history, given by the parents, often differs significantly from the instrumental findings obtained with polysomnography. From the previously expressed considerations and comparison of clinical history data and questionnaires, we have extracted the most significant questions for our questionnaire, which are present in the literature but formulated for adults. Results and ConclusionsThe obstructive airway child test was found to be a very efficient method to evaluate and diagnose OSA. In all patients, it consistently revealed the pathology and never underestimated OSA severity. The examination focuses on clinical signs and symptoms because, in our opinion, clinical history, reported by the parents, can be more accurate than any instrumental examination.