Cleft lip and palate outcomes: Multidisciplinary approach for comprehensive management

In patients with cleft lip and palate the most common associated dental problem is lateral incisor agenesis, often associated with lack of support and definition of the nasal tip. In many cases, adhesions deriving from surgical procedures and skeletal discrepancy make orthognathic surgery and rhinoseptoplasty unavoidable. In the present case report a dental rehabilitation with canine substitution and prosthetic-implant treatment in a posterior area is described. The use, during rhinoseptoplasty, of a customized titanium prosthesis, which provides projection for the tip of the nose, is also introduced. The patient was administered two questionnaires in order to assess the psychological aspects related to the cleft outcomes and the influence that the treatment conveyed.

Impact of the SARS-CoV-2 pandemic on the diagnostic delay of oral carcinoma: a retrospective analysis

BACKGROUND

The aim of the present study was to investigate how the organisation of healthcare activity during the first wave of the SARS-CoV-2 pandemic affected the timing of diagnosis of oral carcinoma in the Functional Head and Neck Department of Padua (Italy). This study gives an effective temporal dimension of the diagnostic delay that occurred during the pandemic, compared with data from the literature.

METHODS

A retrospective analysis of the diagnostic path of a patient affected by oral cancer during COVID-19 pandemic was performed. The time elapsed from the patient's awareness of the problem to the first curative surgical intervention was considered both during the blockage of elective care activities and in the period immediately following. The results were compared to a group of patients treated in the same period of the year 2019.

RESULTS

The territorial time was 53.9% longer in the post-lockdown period than in the lockdown period (39.6 days) while the hospital time was 56.6% shorter than in the post-lockdown period (56 days).

CONCLUSIONS

The response time of territorial medicine has been longer during the pandemic peak. The unintentional creation of exclusive pathways for oncological patients speeded up the diagnostic process. The organization and accessibility of operating theatres can become particularly problematic during the acute phases of a pandemic.

The Global Impact of COVID-19 on Craniomaxillofacial Surgeons: A Follow-Up Survey After One Year

Study Design

Comparative cross-sectional.

Objective

To measure the impact that COrona VIrus Disease-19 (COVID-19) has had on craniomaxillofacial (CMF) surgeons after 1 year and compare it with 2020 data by (1) measuring access to adequate personal protective equipment (PPE), (2) performance of elective surgery, and (3) the vaccination status. This should be investigated because most CMF surgeons felt that hospitals did not provide them with adequate PPE.

Methods

The investigators surveyed the international AO CMF membership using a 30-item online questionnaire and compared it to a previous study. The primary predictor variable was year of survey administration. Primary outcome variables were availability of adequate personal protective equipment (adequate/inadequate), performance of elective surgery (yes/no), and vaccination status (fully vaccinated/partly vaccinated/not vaccinated). Descriptive and analytic statistics were computed. Binary logistic regression models were created to measure the association between year and PPE availability. Statistical significance level was set at P < .05.

Results

The sample was composed of 523 surgeons (2% response rate). Most surgeons reported access to adequate PPE (74.6%). The most adequate PPE was offered in Europe (87.8%) with the least offered in Africa (45.5%). Surgeons in 2021 were more likely to report adequate PPE compared to 2020 (OR 3.74, 95% CI [2.59-4.39]). Most of the respondents resumed elective surgery (79.5% vs 13.3% in 2020) and were fully vaccinated (59.1%).

Conclusions

Most CMF surgeons now have access to adequate PPE, resumed elective surgery, and are either fully or partly vaccinated. Future studies should investigate the long-term impact of the fast-evolving COVID-19 pandemic on CMF surgeons.

Odontogenic Chronic Rhinosinusitis: Structured Histopathology Evidence in Different Patho-Physiological Mechanisms

An increased odontogenic chronic rhinosinusitis (oCRS) occurrence rate has quite recently been reported, likely due to an intensification of conservative dental surgery and implantology. The main aim of the study was to report for the first time the structured histopathological characteristics of the surgical specimens of oCRS. Possible associations between histopathological features and oCRS patho-physiological mechanisms were also evaluated. Structured histopathology features were investigated in the sinonasal mucosa tissue of 42 consecutive oCRS patients.Mean tissue eosinophil counts were significantly different between oCRS with radicular cysts, dental implants, or other dental diseases (p =0.0118): mean tissue eosinophil count was higher in oCRS with dental implants. Sub-epithelial edema score and squamous metaplasia presence were significantly different when comparing the above-mentioned sub-cohorts of oCRS (p =0.0099 and p =0.0258). In particular, squamous metaplasia was more present in oCRS cases with radicular cysts than in those with a dental implant (p =0.0423). Fibrosis presence was significantly different comparing the three sub-cohorts of oCRS (p =0.0408), too. This preliminary evidence supports the hypothesis that: (i) structural histopathology can become a useful tool for clinic-pathological practice in diagnostic, therapeutic, and prognostic terms in CRS; (ii) that oCRS, as CRS in general, is a histo-pathologically heterogeneous disease; (iii) oCRS resulting from dental implants disorders can frequently be characterized as a CRS with a rich tissue eosinophilic component.

Bezold's abscess secondary to os tympanicum cholesteatoma in Goldenhar syndrome

OBJECTIVES

The diagnosis of Bezold's abscess can be challenging especially when craniofacial malformations imply facial and cervical morphological asymmetries. In addition, craniofacial malformations might predispose to the occurrence and atypical diffusion pathways of suppurative processes originating from abnormally developed temporal bone structures.

METHODS

A 30-year-old female presented with a left laterocervical swelling, worsening over time. The female was affected by Goldenhar syndrome. CT and MRI were performed.

RESULTS

CT revealed a dysmorphic os tympanicum and a deep cervical abscess in continuity with its cavity. Drainage of the cervical abscess was performed but a subsequent brain MRI detected a large cholesteatoma that was removed with left lateral petrosectomy.

CONCLUSIONS

Radiology has a crucial role in the diagnosis and planning of the treatment of Bezold's abscesses, particularly in syndromic patients. MRI, in this case, helped in diagnosing the presence of the cholesteatoma and consequently appropriately approach the surgical removal.

Human amniotic membrane: an improvement in the treatment of Medication-related osteonecrosis of the jaw (MRONJ)? A case-control study

The aim of this article is to report the results obtained by the use of HAM in surgical wound healing and the reduction of relapse in patients affected by Medication-related osteonecrosis of the jaw (MRONJ).The study involved patients with the diagnosis of MRONJ, surgically treated between October 2016 and April 2019, in a case-control setting. Enrolled patients were randomly divided into 2 groups. One group will be treated with resective surgery and with the insertion of HAM patch (Group A), while the second group had been treated exclusively with resective surgery (Group B).The patients underwent MRONJ surgical treatment with the placement of amniotic membrane patches at the wound site. Data regarding the long-term complications/functions were evaluated at 3, 6, 12, and 24 months after surgery. Pain measurements were performed before the intervention (T0), 7(T1) and 30(T2) days after surgery. 49 patients were included in the study. 2 patients of GROUP A after 30 days since they were surgically treated showed persistent bone exposure. 5 patients of group B demonstrated a lack of healing of the surgical wound with the persistence of bone exposed to 30 days after surgery. Statistical analysis ruled out any difference in OUTCOME (relapse) between GROUP A and B (p = 0.23). However, the Fisher test highlighted a significant difference between the use of HAM and only surgical treatment in pain at rest (p = 0.032). The use of amniotic membrane implement the patient's quality of life and reduce pain perception. has a learning curve that is fast enough to justify its routine use.

Does overweight affect the sagittal dimension of the posterior airway space in a non-OSAS population? A case control study

OBJECTIVE

The null hypothesis was that, in a non-obstructive sleep apnea syndrome population, overweight do not reduce the antero-posterior dimension of the posterior airway space.

MATERIALS AND METHODS

The author retrospectively reviewed the records of subjects evaluated at the Maxillofacial Surgery Unit, Department of Neurosciences, University of Padova Medical School, Padova, Italy, from 2016 to 2018. Only patients with complete demographic, anthropological and CBCT dataset were enrolled. OSAS patient were also ruled-out. Enrolled patients were divided into overweight (28 cases) and non-overweight (32 controls) groups according to the patient's Body Mass Index. Each two-dimensional cephalometric radiography obtained from the cone-beam computer tomography dataset was evaluated in order to measure linear and angular distances between standardized cephalometric landmarks. The two-sample t-test was the statistical test applied to compare the case and control data.

RESULTS

There were no statistical differences between the two study groups for any of the evaluated variables: the null hypothesis was accepted.

CONCLUSION

This study showed that in a non-obstructive sleep-apnea population, overweight and class I obesity does not influence the airway space in the antero-posterior dimension. Further investigation should focus on categorized overweight-obese population. Accurate and reliable protocol for tridimensional airways assessment should be implemented.

A systematic review of the literature on the role of tracheostomy in COVID-19 patients

The Coronavirus Disease 2019 (COVID-19) is a viral infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which emerged in East Asia and spread around the world from December 2019. The most severe stage of COVID-19 pathology is characterized by respiratory distress requiring intubation. In specific cases, tracheostomy is indicated to ensure the safety of the procedure. The aim of our study was to analyze the scientific literature identifying the indications for tracheostomy and safety precautions to reduce contamination. We analyzed the literature from February 2003 to April 2020, including papers on pandemics of other coronaviruses, such As Severe Acute Respiratory Syndrome Coronavirus 1 and Middle East Respiratory Syndrome Coronavirus, to obtain a variety of relevant information. We focused on indications for tracheostomy in patients affected by COVID-19 or related viruses and the measures adopted to perform a safe procedure. We included 35 papers, of which 24 (68.57%) discussed guidelines for tracheostomy indications. All 35 studies discussed the procedures for performing tracheostomy safely. Data obtained indicated that the authors generally agreed on safety measures but expressed different opinions about indications. Therefore, we provided guidelines addressing safety recommendations. After the pandemic has been resolved, we plan to conduct an international retrospective study to identify the criteria for tracheostomy indications.

AO CMF International Task Force Recommendations on Best Practices for Maxillofacial Procedures During COVID-19 Pandemic

The COVID-19 pandemic is a global problem that has adversely and significantly impacted the safe practice of maxillofacial surgery. The risk lies in the heavy viral load in the oral/nasal/upper respiratory mucosal surfaces. Surgical procedures performed in this anatomic regional produce aerosalized viral particles which are highly infectious. Best practices and recommendations are outlined to mitigate the risk to the provider.

The Global Impact of COVID-19 on Craniomaxillofacial Surgeons

STUDY DESIGN

The COrona VIrus Disease-19 (COVID-19) pandemic has disrupted craniomaxillofacial (CMF) surgeons practice worldwide. We implemented a cross-sectional study and enrolled a sample of CMF surgeons who completed a survey.

OBJECTIVE

To measure the impact that COVID-19 has had on CMF surgeons by (1) identifying variations that may exist by geographic region and specialty and (2) measuring access to adequate personal protective equipment (PPE) and identify factors associated with limited access to adequate PPE.

METHODS

Primary outcome variable was availability of adequate PPE for health-care workers (HCWs) in the front line and surgeons. Descriptive and analytic statistics were computed. Level of statistical significance was set at P < .05. Binary logistic regression models were created to identify variables associated with PPE status (adequate or inadequate).

RESULTS

Most of the respondents felt that hospitals did not provide adequate PPE to the HCWs (57.3%) with significant regional differences (P = .04). Most adequate PPE was available to surgeons in North America with the least offered in Africa. Differences in PPE adequacy per region (P < .001) and per country (P < .001) were significant. In Africa and South America, regions reporting previous virus outbreaks, the differences in access to adequate PPE evaporated compared to Europe (P = .18 and P = .15, respectively).

CONCLUSION

The impact of COVID-19 among CMF surgeons is global and adversely affects both clinical practice and personal lives of CMF surgeons. Future surveys should capture what the mid- and long-term impact of the COVID-19 crisis will look like.

Impact of COVID-19 epidemic on maxillofacial surgery in Italy

Maxillofacial departments in 23 surgical units in Italy have been increasingly involved in facing the COVID-19 emergency. Elective surgeries have been progressively postponed to free up beds and offer human and material resources to those infected. We compiled an inventory of 32 questions to evaluate the impact of the SARS-COV2 epidemic on maxillofacial surgery in 23 selected Italian maxillofacial departments. The questionnaire focused on three different aspects: the variation of the workload, showing both a reduction of the number of team members (-16% among specialists, -11% among residents) due to reallocation or contamination and a consistent reduction of elective activities (the number of outpatient visits cancelled during the first month of the COVID-19 epidemic was about 10 000 all over Italy), while only tumour surgery and trauma surgery has been widely guaranteed; the screening procedures on patients and physicians (22% of maxillofacial units found infected surgeons, which is 4% of all maxillofacial surgeons); and the availability of Personal Protective Equipment, is only considered to be partial in 48% of Maxillofacial departments.

This emergency has forced those of us in the Italian health system to change the way we work, but only time will prove if these changes have been effective.

Trans-nasal endoscopic and intra-oral combined approach for odontogenic cysts

Maxillary cysts are a common finding in maxillofacial surgery, dentistry and otolaryngology. Treatment is surgical; a traditional approach includes Caldwell-Luc and other intra-oral approaches. In this article, we analyse the outcomes of 9 patients operated on using a combined intra-oral and trans-nasal approach to the aforementioned disease. Although the number of patients is small, the good results of this study suggest that the combined approach might be a reliable treatment option.

Displaced Dental Materials in the Maxillary Sinus: An Original Series. Analysis and Definition of a Surgical Decision-Making Process

OBJECTIVES

Displacement of dental materials into the maxillary sinus occurs in daily dental practice; dental implants have become a new common foreign body (FB), as implantation has become routine. The main goal of the present study was to analyze an original series of patients consecutively treated for maxillary sinus FBs. A secondary goal was to propose a decision-making flowchart on the basis of the authors' experience and a critical analysis of literature to select the most appropriate surgical approach.

METHODS

Eleven consecutive patients evaluated for maxillary sinus FBs consisting of dental material were considered.

RESULTS

For removal of the FBs, a nasal endoscopic approach was preferred in 5 cases, a nasal combined approach in 2 cases, an oronasal combined approach in 2 cases, and a lateral window approach in 2 cases. In 2 of 11 cases, complications were reported. A decision-making flowchart to select the best surgical approach is reported.

CONCLUSIONS

The correct choice and application of FB removal techniques allow minimization of unfavorable outcomes and creation of an appropriate environment for new dental treatment. Prospective, large series-based studies will be necessary to confirm the safety and clinical efficacy of the proposed decision-making flowchart.

Metastasis to parotid gland from non Head and Neck tumors

PURPOSE

Most primary tumors spreading metastasis to the parotid gland are usually located in the head and neck region, nonetheless, rarely, parotid gland can also be the target of metastatic localization site of distant primary tumors. The purpose of this study was to describe a clinical series of metastasis to the parotid gland from distant primary tumors (non Head & Neck).

METHODS

The clinical databases of parotid tumors in two academic centers have been analyzed and 11 cases of parotid metastatic cancers from distant primary tumors were found.

RESULTS

Primary tumor was lung cancer in 8 cases, and breast cancer, gastric carcinoma and pancreatic carcinoma in one case each.

CONCLUSIONS

Parotid metastases can be the first clinical manifestation of a malignant tumor from a distant site and can manifest years after curative-intent treatment of the distant primary. Histopathology and immunohistochemistry can help in the identification of the primary site. Parotidectomy with complete excision of the parotid lesion may have diagnostic and/or loco-regional control and/or curative intent, however there is still no international consensus about the therapy of parotid malignant metastasis.

Incidental finding of upper lip Warthin tumor

AIM

This report shows an incidental finding of Warthin tumor in upper lip mucosa during hospitalization for a biting lesion of cheek mucosa MATERIALS AND METHODS: A 32-year-old male affected by a biting lesion of cheek mucosa was presented at Maxillo- Facial Unit of Federico II University. Clinical examination showed as an incidental finding a solid mass in the superficial layer of upper lip mucosa. We performed mini-invasive surgical treatment to obtain a radical excision of the cheek lesion at the same time as excision of Warthin tumor.

RESULTS

a follow up of 12 months was performed. The complete healing of the two wounds was achieved, with no recurrence of any of the pathologies.

DISCUSSION

The location of this Warthin tumor of minor salivary glands is very unusual. The role of imaging in diagnosis of Warthin tumor of minor salivary glands is to define localization, shape and dimension, contour, malignant features, nodal involvement. The role of fine needle aspiration cytology (FNAC) is critical in the diagnosis and therapy of minor salivary gland tumors. The surgical treatment in patients affected by Warthin tumour of minor salivary glands is local excision with a wide tumor free margin to prevent potential recurrence.

CONCLUSIONS

Warthin tumor of minor salivary glands is a rare disease. We report a singular case of Warthin tumor localized in the upper lip mucosa, found as an incidental finding during a recovery for a biting lesion of cheek mucosa.

KEY WORDS

Incidental finding, Minor salivary glands, Warthin tumor.

Surgical treatment of class II dento-facial deformity during adolescence: Long-term follow-up

PURPOSE

The purpose of this study is to evaluate the long-term stability of patients operated during adolescence on the base of clinical measurements and cephalometric analysis. Although, the potential benefits of early orthognathic surgery are known to be a reduction in treatment times and a greater healing potential leading to a better adaptation and stability of the occlusion, muscles, bones and joints, no consensus can be found in literature on the minimum age for surgical correction.

MATERIALS AND METHODS

In this study, thirty patients (age ≤ 15) with a class II dento-skeletal malocclusion were selected, of which 11 having a hyperdivergent (II,1) and 19 a hypodivergent (II,2) growth pattern, representing 2 distinct groups with a different treatment plan and long-term behavior.

RESULTS AND CONCLUSION

Observing the performance of all parameters over-time, it is seen that subjects belonging to division II,2 have a modification of the growth vectors maintaining the harmonious development between the jaws and the facial aesthetics. Less predictable is the trend in hyperdivergent patients, which are more prone to relapse in the long-term. Early surgery in these patients should be considered in the light of the degree of deformity and its influence felt by the patient on his development of self-image and interpersonal relationship.

Facial asymmetry quantitative evaluation in oculoauriculovertebral spectrum

OBJECTIVES

Facial asymmetries in oculoauriculovertebral spectrum (OAVS) patients might require surgical corrections that are mostly based on qualitative approach and surgeon's experience. The present study aimed to develop a quantitative 3D CT imaging-based procedure suitable for maxillo-facial surgery planning in OAVS patients.

MATERIALS AND METHODS

Thirteen OAVS patients (mean age 3.5 ± 4.0 years; range 0.2-14.2, 6 females) and 13 controls (mean age 7.1 ± 5.3 years; range 0.6-15.7, 5 females) who underwent head CT examination were retrospectively enrolled. Eight bilateral anatomical facial landmarks were defined on 3D CT images (porion, orbitale, most anterior point of frontozygomatic suture, most superior point of temporozygomatic suture, most posterior-lateral point of the maxilla, gonion, condylion, mental foramen) and distance from orthogonal planes (in millimeters) was used to evaluate the asymmetry on each axis and to calculate a global asymmetry index of each anatomical landmark. Mean asymmetry values and relative confidence intervals were obtained from the control group.

RESULTS

OAVS patients showed 2.5 ± 1.8 landmarks above the confidence interval while considering the global asymmetry values; 12 patients (92%) showed at least one pathologically asymmetric landmark. Considering each axis, the mean number of pathologically asymmetric landmarks increased to 5.5 ± 2.6 (p = 0.002) and all patients presented at least one significant landmark asymmetry.

CONCLUSIONS

Modern CT-based 3D reconstructions allow accurate assessment of facial bone asymmetries in patients affected by OAVS. The evaluation as a global score and in different orthogonal axes provides precise quantitative data suitable for maxillo-facial surgical planning.

CLINICAL RELEVANCE

CT-based 3D reconstruction might allow a quantitative approach for planning and following-up maxillo-facial surgery in OAVS patients.

A case of cephalic tetanus in a developed country

Tetanus is a potentially life-threatening infection that results from contamination of skin wound by Clostridium Tetani spores. Although, it remains an important health problem in developing countries without strict national immunization programs, this condition is rare in the developed world. The most frequent presenting symptoms are trismus and dysphagia, due to the spasmodic contraction of the masticatory muscles. Then the disease usually diffuses with a descending pattern inducing a generalized contraction of the agonist and antagonistic muscles, which characterize a tetanic spasm. Mortality usually results from respiratory failure, cardiovascular collapse, or autonomic dysfunctions. Treatment usually requires the prompt admission to the intensive care unit to avoid the development of potential life-threatening complications. We report the case of a 78-year-old farmer, who was referred to us with progressive onset of lock-jaw and muscular stiffness of the facial region, that had occurred after he had scratched himself with a rose. The recognition of the presenting signs of cephalic tetanus allowed the prompt management of the infection. However, because of the rarity of this condition, the clinicians may be unfamiliar with the clinical presentation, and be unsuspecting of the diagnosis.

Local anesthesia needle breakage in a 5-year-old child during inferior alveolar nerve block with the Vazirani-Akinosi technique

Breakage of a local anesthetic needle in dentistry is a rare but potentially serious event. Here we describe a case of breakage of a hypodermic needle during administration of local anesthesia with a Vazirani-Akinosi mandibular nerve block in a 5-year-old uncooperative patient under moderate sedation with midazolam. The needle was localized using a fluoroscopy device and then removed under general anaesthesia. The postoperative course was unremarkable, without any neurological or vascular deficits.

Modified enucleation for choroidal melanoma with large extrascleral extension

PURPOSE

To report the technique and the outcome of modified (enlarged) enucleation via lateral orbitotomy for choroidal melanomas with massive extrascleral extension.

METHODS

5 patients with choroidal malanoma with massive, circumscribed perioptic/posterior extrascleral extension underwent modified enucleation via lateral orbitotomy. After lateral orbitotomy and orbital mass exposure with direct tumor visualization, a long optic nerve stump was cut and the orbital component of the tumor was completely (macroscopically) removed along with the globe in all cases. After haemostasis and orbital reconstruction an orbital implant was then placed. Follow-up was longer than 12 months.

RESULTS

Excellent cosmetic outcome was acheived in all patients (100%) without operative or postoperative complications. At pathologic examination, tumors were completely removed in all cases (100%).

CONCLUSIONS

Modified (enlarged) enucleation via lateral orbitotomy for selectd choroidal melanomas with massive, circumscribed perioptic/posterior extrascleral extension allows complete tumor removal and placement of an orbital implant, avoiding the long healing process of orbital exenteration with excellent clinical and cosmetic outcome.

Psychological aspects of orthognathic treatment

AIM

The aim of this study was to examine the psychological state of 30 patients subjected to corrective orthognathic surgery and their expectations, as well as the influence of an in-depth psychological evaluation on the success of the operation.

METHODS

The study was performed by giving 30 patients (12 men, 18 women), affected by dental-skeletal facial abnormalities and treated with orthognathic surgery, a questionnaire with 19 questions aimed at examining their preoperative emotional state (desired esthetic and functional improvements) and postoperative emotional state (expectations after surgery and associated psychological state of anxiety and depression).

RESULTS

All patients (100%) expressed a clearly positive reaction to their experience. Approximately 70% of the patients observed an improvement in their masticatory function following surgery and 96.6% an improvement in esthetic appearance. Almost none of the patients (96.6%) experienced difficulty in adapting to a change in appearance, while as a result of the surgery 66.6% experienced an increase in self-esteem and confidence. In addition, the opinion of relatives and friends of the patients was favorable in most cases (76.6%).

CONCLUSIONS

In order to enable the patients to face their therapeutic program with greater confidence, a team of orthodontists, surgeons and psychologist observe the patients from the beginning of treatment, having them interact with other patients who have already experienced the same situation and by showing them pre- and postoperative pictures of other patients subjected to orthognathic surgery.

Reconstruction of a large post-traumatic cranial defect with a customized titanium plaque

The treatment of serious cranial defects has always been a fascinating and controversial issue for craniofacial surgeons and in the last years many solutions have been proposed. One of the most effective method is a personalized titanium plaque prepared by processing anatomical data obtained with a CAT of the patient. A case of wide cranial defect on the left fronto-parietal region in a 56-year-old man treated with a personalized titanium plaque obtained by processing the data of a spiral CAT of the skull is described. No complications were observed in the postoperative course and follow-up after 6 moths showed that the patient was in good general condition.