Valerio Ramieri

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.

Experience in the Management of Frontal Sinus Fractures

International guidelines for frontal sinus fractures, dealing with the indication of surgical treatment, obliteration of the frontal sinus, drainage, and cranialization, may differ. In this work, we describe our experience with frontal traumas, analyzing indications, type of treatment, and outcomes by reviewing all data of 112 patients treated for frontal fractures at the Department of Maxillo-Facial Surgery, Università degli studi di Roma Sapienza. We reviewed all clinical and surgical records of patients with traumatic frontal injury treated from 1997 to September 2008. Patients presenting displaced fractures of the anterior wall of the frontal sinus were treated through skin laceration, if existing, or through a coronal approach and fixed with rigid internal devices. Patients with fracture of the posterior wall of the frontal sinus underwent frontal sinus cranialization with galea pericranium pedicled flap to prevent eventful septic complications. Follow-up controls documented that 98 of 112 patients showed no neurologic impairment, no symptoms of cerebrospinal fluid leak, and no other complications after 6 months and 1 and 5 years when follow-up was possible. In the international literature, there is wide agreement about indications dealing with displaced fractures of the anterior wall, although there is a lively debate about posterior wall treatment. In our 10-year experience, the protocol we carried out showed satisfying outcomes, in particular, on the morphofunctional recovery and aesthetic results.

Mandibular distraction osteogenesis for neonates with Pierre Robin sequence and airway obstruction

Neonates with Pierre Robin Sequence (PRS) usually present with varying degrees of upper airway obstruction and difficulty feeding. Early treatment is important for such children in order to prevent impaired cognitive development resulting from hypoxemic episodes. Various procedures aimed at widening the pharyngeal space have been proposed, including prone position, tongue-lip adhesion, mandibular traction, non-invasive ventilation and palatal plates. Mandibular distraction osteogenesis (MDO) using external or internal devices has become increasingly popular as an alternative treatment option when other medical or surgical techniques do not prove to be satisfactory. This review summarizes current evidence on the effectiveness of MDO in infants with PRS. Because of a lack of studies comparing this treatment with other procedures, general recommendations cannot be drawn and treatment of infants with PRS still requires individualization.

A dental implant in the anterior cranial fossae

Foreign bodies in the anterior cranial fossa are unusual. This is a case of a 50-year-old man who presented with a dental implant displaced into the anterior cranial fossae, which was removed endoscopically with dural reconstruction.

Isolated sphenoid sinus mucocele: etiology and management.

Sphenoid isolated lesions are rare; they occur in 2% to 3% out of all paranasal sinus lesions. Diagnosis is based on the endoscopic examination and computed tomography scan or magnetic resonance imaging of the maxillofacial area. In this study, we present patients with sphenoid mucocele in the Maxillo-facial Surgery Department, University of Rome La Sapienza, treated with the endoscopic technique. Moreover, a literature review is performed, dealing with the evolution of approaches to the sphenoid sinus. From January 2001 to January 2007, we treated 75 patients affected by paranasal sinus mucocele. Out of this number, 8 patients (11%) presented an isolated localization in the sphenoid sinus. These patients were divided as follows: 5 involved the right sphenoid sinus and 3 involved the left sphenoid sinus. Isolated sphenoid sinus disease is a rare entity that can result in serious sequelae if diagnosis and treatment are inappropriately delayed. In our study, we highlighted how the endoscopic approach allows the removal of even large mucocele with the use of 45-degree angle optic and if it is possible to control and remove lateral walls of the sphenoid sinus. In our experience, we shifted from a traditional approach to the endoscopic approach. At the present time, the endoscopic approach represents the gold standard for sphenoid sinus mucocele treatment because it allows the best view of the sphenoid sinus and grants a better restoring of respiratory function and a higher compliance from the patient.

Myositis ossificans of the medial pterygoid muscle.

Myositis ossificans (MO) is a disease whose main feature is the formation of heterotopic bone involving muscle or any other soft tissue. Pathogenesis is not all clear, but trauma is universally recognized as a trigger event. Myositis ossificans can be divided into 2 classifications: MO progressiva and MO traumatica. The authors present a case of a 64-year-old man who was diagnosed with MOT of the left medial pterygoid muscle. The patient had a long clinical history of signs and symptoms of temporomandibular articulation related to previous conditions, and no major traumatic events were reported, apparently related to MOT.

Security Hi-Tech Individual Extra-Light Device Mask: A New Protection for [Soccer] Players

Among professional [soccer] players, a relevant incidence of maxillofacial trauma has been reported. The main challenge in these particular patients is to give them the possibility of a very short convalescence period and to make possible their agonistic activity as soon as possible. The authors here present an innovative technique to realize this--the Security Hi-tech Individual Extra-Light Device Mask, a customizable protective shield based on the players face cast. A completely customized mask was forged over the players face cast to protect the injured area. This mask shortens convalescence period, and due to its realization, it is comfortable and easy fitting, thus allowing the player to perform at a professional level in his sport activity in the shortest time possible.

Le Fort III external midface distraction: surgical outcomes and skeletal stability.

Abstract A retrospective study on the stability of Le Fort III midface advancement with distraction in craniofacial dysostosis. Twenty-six surgical procedures for midface advancement were performed between 2000 and 2009. Subjects were 14 consecutive patients who underwent Le Fort III osteotomy with midface advancement using a rigid external distraction device (Synthes) in the Department of Maxillo-Facial Surgery of the University “Sapienza” of Rome. In this study, 8 patients (n = 3 females, n = 5 males) affected by craniofacial dysostosis (Crouzon, n = 5; Apert, n = 3; Pfeiffer syndrome, n = 1; and other, n = 1) were selected on the basis of age and radiologic documentation. The mean age at the time of the procedure was 8.6 years, and all the patients had at least 1 year of follow-up after distraction. The radiologic documentation of each case was composed of posteroanterior and lateral cephalograms preoperatively (T1), at the time of removal of the distractor device (T2), and at follow-up (T3). The average latency period before activation of the distractor was 5 days. The device was activated on an average of 15 mm (range, 7–22 mm) as recorded on the device at a rate of 1 mm/d. Activation period ranged from 7 to 15 days, and the consolidation period was 8 to 12 weeks. Seven anatomic landmarks and 5 cephalometric measurements were identified on the lateral cephalograms at each of the 3 time periods. The cephalograms underwent digital analysis via Dolphin imaging digitalization software by 2 operators independently. The displacement of each identified landmark was recorded and examined in relation to their position at each time point. Cephalometric analysis revealed stability of Le Fort III midface advancement during follow-up. However, bone growth after midface advancement is limited, and as reported in the literature, almost no spontaneous growth is present because of the intrinsic nature of malformations. Patients treated in the growing age benefit from midface advancement, with resolution of exophthalmos, ocular bulb exposure, airway impairment, and good aesthetic outcome.

Early Secondary Alveoloplasty in Cleft Lip and Palate

The aims of this study were to present a personal surgical technique throughout the review of international literature concerning surgical techniques, objectives, and outcomes in early secondary alveoloplasty and to describe our personal surgical techniques in alveolar bone defect repair in cleft lip and palate. Throughout a literature analysis, it is now settled that early secondary alveoloplasty could reestablish the continuity of alveolar bone and prevent upper dental arch collapse after presurgical orthopedic upper maxilla expansion; it also might give a good bone support for teeth facing the cleft and allow the eruption of permanent elements with the bone graft and rebalance the symmetry of dental arch, improve facial aesthetic, guarantee an adequate amount of bone tissue for a further prosthetic reconstruction with implant, and finally close the eventual oronasal fistula. The surgical technique we are presenting permitted a total number of 35 early secondary alveoloplasty on which a long-term follow-up is still taking place. We can assess that early secondary alveoloplasty must be performed before permanent canine eruption. Iliac crest is the suggested donor site for bone grafting; orthopedic and orthodontic treatments must be performed in association with surgery, and if there is the dental element agenesia, an implantation treatment must be considered.

TMJ replacement utilizing patient-fitted TMJ TJR devices in a re-ankylosis child

Temporomandibular joint (TMJ) ankylosis is a pathological condition characterized by articular bony or fibrous tissue fusion. TMJ ankylosis developing during childhood can lead to growth complications because of the loss of mandibular function. Hard and soft autogenous tissue grafting has been used for TMJ reconstruction in the growing patient. However, in cases where autogenous tissue grafts fail either due to unpredictable growth or ankylosis, total alloplastic temporomandibular joint replacement (TMJ TJR) can provide a viable option. The case of a 7-year old female suffering from recurrent bilateral TMJ ankylosis resulting from birth trauma, and with concomitant obstructive sleep apnea syndrome (OSAS) is presented. Due to prior surgical and autogenous graft failures, the decision was made to complete her joint reconstructions utilizing patient-fitted TMJ prostheses. Questions have been raised about the longevity of TMJ TJR devices as well as their lack of growth potential, but children with TMJ ankylosis do not have condyle-related growth potential and that replacing failed autogenous tissue graft material with more autogenous tissue will result in the same adverse outcomes. Therefore, in growing patients with recurrent TMJ ankylosis and/or failed autogenous tissue grafts, there may be a role for TMJ TJR.