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Aim: The aim of this study was to analyze the physiopathology of the acute cervical injure in the event of mandibular condylar fractures., Methods: As in the Part 1, 25 non-consecutive cases of condylar mandibular fractures (16 males and 9 females, mean age: 22.96/range 14-36 years) observed and treated in the Maxillofacial Surgery Department of the University of L'Aquila, have been studied. Types of fractures examined included: unilateral: 19 cases (solitary: 12; associated with other mandibular fractures: 7, homolateral: 2); bilateral: 6 cases (equivalent: 2, not equivalent: 4). A control group was constituted of 10 patients, 5 males and 5 females, aged from 19 to 24 years (mean range: 21.6) suffering from acute isolated cervical distorsion (whiplash). The study has been performed by means of the analysis of X-ray and computed tomography (CT)-CT/3D of the mandibular condylar regions, the occipital-atlanto-axial structures and the cervical region., Results: In all the patients the following constant alterations that link up with these fractures have been observed: the rotation of atlas, the atlanto-axial subluxation and the derangement of the occipital-atlanto-epistropheal joint, homolateral to the side of the mandibular condylar fracture. The cervical spine shows the constant loss of physiological lordosis with hinge between C3 and C4. In the whiplash, as the authors have been able to assess in the control group, there are no alterations of occipital-atlanto-axial joint and the kinetic vector is placed on the longitudinal plane. In the mandibular condylar fractures the kinetic mechanism is completely different regarding the whiplash. The point of entry is the chin and the kinetic vector is oriented down-up, sometimes oblique in the opposite side. Subsequently the kinetic force is transmitted throughout the mandibular structure and causes the condylar or bicondylar fracture. The kinetic vector is placed before on the vertical plane, then on the horizontal plane and later on the vertical plane. Therefore the dynamics of the crash cannot cause the swaying of the head as in the whiplash. Indeed in the mandibular condylar fractures the authors have observed the cervical distortion with the loss of lordosis on the sagittal plane without whiplash and also a constant derangement of the cranio-cervical joint and the atlanto-axial subluxation., Conclusions: These results allow to delineate a different physiopathological mechanism: in the event of mandibular condylar fractures, the sprain of the cervical spine seems to be caused by the acute atlanto-axial subluxation.

Aim: The aim of this study was to analyze the acute repercussions of condylar mandibular fractures on occipital-atlanto-axial joint., Methods: Twenty-five non-consecutive cases (16 males and 9 females, mean age: 22.96/range 14-36 years), observed and treated in the Maxillofacial Surgery Department of the University of L'Aquila have been considered. Types of fractures examined included: unilateral: 19 cases (solitary: 12; associated with other mandibular fractures: 7; homolateral: 2); bilateral: 6 cases (equivalent: 2; not equivalent: 4). A control group was constituted of 10 patients, 5 males and 5 females, aged from 19 to 24 years (mean-range: 21.6) suffering from acute isolated cervical distorsion (whiplash). The study has been performed by means of the analysis of X-ray and computed tomography (CT)-CT/3D of the mandibular condylar regions, the occipital-atlanto-axial structures and the cervical region., Results: In all the cases of fractures of the mandibular condyle an acute alteration of the junctional atlanto-axial structures was present. In case of unilateral solitary condylar fractures the authors have observed an atlas rotation, homolateral to the side of the condylar fracture, independent from the level of the fracture (intra- or extracapsular). The rotation seems to be proportional to the entity of the condylar fragments dislocation on the horizontal plane and it causes a modification of the articular relations between atlas and axis (atlanto-axial subluxation) and between the atlas and the occipital bone. The authors have observed a constant derangement of the cranio-axial joint on the three planes of the space. In particular, on the vertical plane the CT reconstructions show on the right and left side a different height between the atlanto-axial articular spaces. The largest one is homolateral to the side of the condylar fracture. In case of unilateral condylar fractures associated with other mandibular fracture (homolateral or not) the authors have observed the same alterations of the occipital-atlo-epistropheal joint, but while on the horizontal plane the rotation of the atlas is always homolateral to the condylar fracture, on the vertical plane the largest atlanto-axial articular space is homolateral to the mandibular fracture with more dislocation of the fragments of fracture (usually the associated not homolateral mandibular fracture). In case of bilateral condylar fractures the authors have observed no alteration of the cranio-cervical joint. In the non-equivalent fractures, they have observed the atlas rotation on the horizontal plane and the junctional derangement on the vertical plane, homolateral to the condylar fracture with greatest dislocation. In the control group the loss of the physiological cervical lordosis has been observed. Alterations on the horizontal and vertical planes, as the rotation of the atlas, atlanto-axial subluxation or the joint derangement, instead, has never revealed., Conclusions: The authors state that these results represent a new nosographic entity associated with the condylar mandibular fractures with important clinical, insurance and legal repercussions.

Necrotizing fasciitis (NF) is a destructive and potentially fatal soft tissue infection characterized by extensive necrosis and gas formation in subcutaneous tissues and fascia, with serious involvement of muscles, vessels, nerves, and fat. In the maxillofacial region, NF is less common. The process can represent the evolution of a dental infection supported by aerobic and anaerobic bacteria that are resistant to antibiotic therapy (multidrug resistance) in immunocompromised patients or the natural evolution of untreated infection. Because of the rarity of the disease, diagnosis and treatment are often delayed, which may result in a fatal outcome due to respiratory problems or systemic complications. The success of the treatment is surgical debridement and high doses of antibiotic therapy. The AA described a case of NF in a female, 59 years old, who developed NF in the maxillofacial and neck region following dental infection and after consulting our Institute for remarkable swelling of the right cheek, palpebral and parotid regions, submaxillary region, and neck; this swelling is associated with hyperpyrexia, trismus, poor systemic conditions, and serious respiratory difficulty. Through prompt clinical diagnosis, early surgical treatment, appropriate antibiotic therapy (culture analysis revealed sensitivity to Imipenem and Levofloxacina), and local control of the lesion through surgical medications twice daily, we were able to not only avoid serious and fatal evolution of the process, but also to limit tissue involvement, preventing further extension of the necrosis to other anatomical structures of the region. A satisfactory clinical result was thus obtained.

Aim: Facial asymmetries are often associated with cervicobrachial pain and headache. The aim of the study was to evaluate the influence of surgical orthognathic correction of facial asymmetries on the intensity of cervicobrachial pain and headache in the short and long term., Methods: Thirty-two patients affected by maxillomandibular asymmetries associated with pain referred to occipital, cervical, dorsal and scapulohumeral areas who were undergoing orthodontic surgical correction were enrolled in the study. The pain intensity at rest and on fibromyalgia trigger points was assessed using a 0-10 Visual Analogue Scale (VAS) preoperatively (T(0)) and 5 days (T(1)), 6 months (T(2)) and 12 months (T(3)) after surgery. Functional limitation was evaluated by the same method at T(0),T(2) and T(3)., Results: VAS scores at rest were significantly lower at T(1), T(2) and T(3) compared to T0 in every area to which pain was referred. After 12 months (T(3)), pain at rest was completely absent in 23 patients (71.8%) in the occipital region, in 23 patients (71.8%) in the cervical area, in 22 patients (68.7%) in the dorsal area, and in 28 patients (87.5%) in the scapulohumeral area. In the other patients, the pain scores in all areas were < 1 (0.77, 0.83, 0.95, 0.5 in the occipital, cervical, dorsal, and scapulohumeral areas respectively). The VAS at neck fibromyalgia points were significantly reduced at T(1), T(2), T(3) and functional limitation was improved at T(3) and T(4) (P=0.00)., Conclusion: This study appears to demonstrate the utility of orthognathic surgery when facial asymmetry is associated with cranial-cervicobrachial pain syndrome, presumably through a new musculoskeletal rearrangement of stomatognathic apparatus. Indeed, the surgical correction has resulted in morphological, functional and symptomatic effects.

The chemical burns in the oral mucosa as consequence of accident of suicide attempt are relatively frequent. The evolution of the repairing process is conditioned by the quality and concentration of the caustic as by the location and time exposure of the affected region. At this report, we document a form of conservative treatment for the limitation of mouth opening, which the patient presented after swallowing a detergent acid. In order to obtain a minimal oral opening, a screwed cone, whose action mechanism was acting as a cradle between both jaws, was used. Once achieved a 10 mm opening, it was possible to use an external distractor to accomplish a continuous traction.

Among oral and maxillofacial diseases, the maxillary osteolytic lesions constitute a rich and investigated field to define the more appropriate diagnosis and treatment. In the maxillary region, the same tumors of the other bones (osteogenic sarcoma, chondroma, etc.) cause found together with tumors and dysembryoplasias connected with the teeth development (ameloblastoma, odontoma, odontogenic myxoma, etc.). Moreover in the medullary spaces of the bones, there are reticular and hematopoietic cells that are connected with different diseases (leucemia, myeloma, lymphoma, etc.). What's more, due to the possible presence of pseudotumors (fibrous dysplasia, giant cell tumor, etc.) and metastases of tumors of other regions (breast, lung, prostate gland, etc.), the diagnosis of this disease could be difficult. In this paper the more important pictures of this disease, that due to its recurrence or malignity needs an accurate diagnosis by imaging like CT, CT-3D, MR, etc, are analyzed. The more suitable surgical approach is presented, according to the forms of the disease.

The lipoma is a circumscribed mesenchymal tumour originating from adipose tissue. The lesion is usually small and asymptomatic, and is most frequently located in the neck region. The case of a 77-year-old woman with chronic extrasystolic arrhythmia caused by a non-specified ischemic cardiopathy is reported. The woman presented a swelling at the front of her neck, observed for the first time about 6 months previously. This swelling progressively increased in size, provoking dysphagia, dysphonia, persistent cough, dyspnea, light jugular turgor and palpitations. Chest X-rays showed and opaque area at the front of the neck, which extended beyond the jugular incisure by about 2 cm. NMR of the neck showed a gross lipomatous formation at the front, mainly of the left, continuing in the front mediastinal region; the trachea was dislocated to the right and compressed at the back; the vasculo-nervous fasciculus, especially on the left, was compressed and enveloped by the adipose formation. The Holter test confirmed the presence of ventricular and supra-ventricular extrasystoles. Surgery was carried out under local anaesthesia because the displacement of the laryngo-tracheal axes precluded intubation. Histological analysis of the 9 x 4 x 2.2 cm mass confirmed the diagnosis of lipoma. After removal of the mass all the symptoms, which had been provoked by compression, as well as the cardiac arrhythmias disappeared. The prompt disappearance of the latter was particularly surprising. The possibility of the external compression of the nervous structures of the neck should be taken into consideration in cases of ventricular arrhythmia of unknown origin, and systematic study of the region carried out.

The authors carried out immunohistochemical and genetic research on the tumor suppressor protein p53 and H-RAS oncogene in oromaxillofacial neoplasms. The purpose was to verify, genetically, the presence of correlations between the degree of histopathological overexpression (per cent) of oncogenes and chemoresistance. The study was carried out on 15 patients with squamous cell carcinoma of the oromaxillofacial region, of equal histopathological grade (G2), who underwent neoadjuvant chemotherapy: cis-diaminodichloroplatinum (CDDP, 20 mg/m2 i.v. days 1-5) and 5-fluorouracil (5-FU 1000 mg/m2 continuous infusion, volumetric pump 2 ml/h, for 5 days). Restaging was carried out after three cycles of chemotherapy to evaluate clinical response. The p53 immunohistochemical study (clone DO-7) showed a pathological overexpression in 9/15 cases; whereas the genetic exam (PCR method, wild DNA) showed mutations in 5/15 cases, with individual corresponding percentages of 95%, 80%, 70%, 45% and 95%. The H-RAS immunohistochemical study (AB-1) (clone 235-1.7.1) showed a pathological overexpression in 12/15 cases; the genetic exam showed mutations in 9/15 cases, corresponding to, respectively, 90%, 35%, 10%, 20%, 77%, 90%, 85%, 25%, 75%. The response to the neoadjuvant chemotherapy was as follows: 2 partial responses (PR) (90%) in 1 tumor of the cheek and in 1 tumor of the soft palate, with global survival (GS) of, respectively, 18 and 15 months. 1 PR (75%) and 4 PR (55%) in 5 tumors of the gum, with GS of, respectively, 10, 6, 8 , 9 and 8 months. Two objective improvements (OI) in, respectively, 1 tumor of the floor of the mouth and 1 tumor of the gum, with GS of, respectively, 5 and 6 months. Three patients had stable disease (S) in 2 tumors of the tongue and 1 tumor of the gum, with GS of, respectively, 10, 7 and 7 months. Three patients had progression (P) in 2 tumors of the floor of the mouth and in 1 tumor of the cheek, with GS of, respectively, 8, 8 and 6 months. This study showed some correlation between genetic analysis and immunohistochemical investigation of 73.3% of cases for p53 and of 80% of cases for H-RAS (Chi-Square Test: p=0.3089). These data do not permit definition of the range of oncogene overexpression which corresponds to mutation, thus serving as a marker of chemoresistance. However, the cases studied confirm that, in regard to p53, there is a certain degree of correlation between absence of mutations and sensitivity to neoadjuvant chemotherapy.

A short-term in vitro experimental study was performed to analyze the effects of metallic miniplates used in maxillo-facial rigid internal fixation on some functional features of human erythrocytes that represent a pivotal rheological component for correct blood flow in the tissular area surrounding metallic implants. In our working conditions, no interference on osmotic fragility, intracellular ATP content and spontaneous hemolysis was observed. Conversely, a statistically significant increase of rigidity in the deeper lipid region of erythrocyte membrane was verified. On the basis of our results, the in vitro erythrocyte modifications after 18 h of whole blood/metallic device contact are relatively small and negligible.

Material and Methods: The authors carried out a p53 genetic research on native DNA in 15 oral-maxillofacial squamous cell carcinomas, lymph nodes metastasis, treated with neoadjuvant chemotherapy, checking the p53 "status" and the clinical response to the chemotherapeutic treatment (three 5-FU/CDDP cycles)., Results: The authors found p53 mutations in 3/15 cases. In these cases, at post-chemo restaging, it resulted 2 progressions and 1 stability of disease. In the 12 cases with wildtype p53: 4 objective improvements and partial responses (PR), respectively, of 55% (1), 60% (1), 65% (1), 70% (1), 75% (2) and 90% (2). The 15 patients were treated then by surgery and adjuvant chemotherapy (three C-F cycles). These results seem to confirm the outcome of the researches "in vitro" and they provide first correlations between p53 mutations and chemoresistance in oral squamous cell carcinomas. The survival evaluation also, in the examined cases, shows, but with medium-term follow-up, the tendency to a poor prognosis when p53 is altered., Conclusions: This research outlines the possibility, also for oral and maxillofacial tumors, to utilize, p53 as a prognostic and chemoresponse marker, useful, with the otherwise well-known prognostic factors, for the evaluation of advanced cancers, in the interests of a more suitable therapeutic protocol.

p53 is a "tumor suppressor gene" with a basic function in the cellular cycle control and subsequently in the induction of the neoplastic process. p53 found changed in the majority of malignant human tumors. In the oral and maxillofacial cancers p53 mutations varies from 4% to 60% of the cases. Researches in vitro in tumors of the colon-rectum, breast, lung, ovary, testicle, bladder and in leukaemia, show a correlation between p53 overexpression (mutation) and resistance to the anti-tumor agents. The functional connection between the p53 and the chemotherapic drugs action which cause a direct DNA damage, is the apoptosis, a physiologic mechanism activated by p53 for regulating cell growth but also indispensable for the cytotoxic effects (apoptosis is an irreversible process culminating in cell death). Loss of the p53 activity (mutation) in the tumoral cells determines non-activation of the apoptosis and the drug resistance. These results have led to early clinical applications. In the breast cancers the p53 is already utilized as chemoresistance marker, directing the therapy, if changed to alternative drugs (Taxolo) which have a p53-independent action. Even into cell lung cancers a retroviral vector containing the wild-type p53 gene was produced to mediate transfer of wild-type p53, noting tumor regression. In oral and maxillofacial tumors surgery is elective. It is emphasized that, in advanced cancers, it is included in multimode protocols where the neoadjuvant chemotherapy has an important clinical function, with precise indications. The possibility to determine previously the p53 "status" in the cancer cells by genetic study, may give a specific factor of screening, indicative of the tumor chemoresponse, together with other well-known prognostic factors, with advantage for the therapeutic programming and especially for the known surgical treatment.

Angiofollicular lymph node hyperplasia, or Castleman's disease, is a condition of uncertain cause usually presenting with mediastinal lymphadenopathy. Occasionally other lymph node groups may be involved with or without associated systemic manifestations. A case of Castleman's disease involving parotid lymph nodes is reported in a 16-year-old female patient who presented with a painless swelling that initially was noticed at the age of 3 years. Diagnosis was established by histopathologic examination of the respected specimen. Histologic and clinical features of Castleman's disease are also discussed.

In vitro experiments were performed to evaluate the biocompatibility of metallic plates used in reconstructive maxillofacial surgery, analyzing the effect of titanium, nickel-chromium-molybdenum and stainless steel plates on some functional features of human erythrocytes and platelets, being rheological properties and platelet responsiveness pivotal for the perfusion of the tissues surroding the metallic implants. Our data underline that the tested plates are not responsible for significant alterations of the erythrocyte rheological features and of platelet reactivity.

The AA. examine the possibilities of the present imaging to the diagnostic definition of the extensive and destructive forms of the Central Giant cells Tumor of the maxilla. The CT and MR studies are compared with conventional x-Ray. The analysis performed evinces, besides the well-known semeiological CT superiority for the evidence of the osseous erosions, the ability to follow by MR imaging the evolution of the tumor, in the its relationships with the fascial, muscular, adipose and fibromucous soft tissues, when it exceeds the osseous barrier of the maxillofacial skeleton, enclosed therein the palatal plane.

The diagnostical possibilities of the RM in the study of the odontogenic myxoma at extensive diffusion in the upper maxilla are examined. Owing to its complexity and to close connections with the surrounding soft tissues, the midfacial region makes the conventional means of imaging difficult and inadequate. Really the tumor have very high local aggressivity. Where it is much bulky, invades diffusely the cavitary components, damages their walls with laminar structure, insinuates itself among the soft tissues of the jugal, pterygo-maxillary and infraorbital regions, taking up gorges where it slips the classical clinical an also the conventional instrumental diagnostics. The AA. have verified the utility of the MR imaging to the definition of the limits of the tumor, which makes the surgery more adequate to the necessities of an oncological treatment tending both to the radicality and to conservation of structures with high morphological and functional complexity.

The Authors consider the main clinical aspects that characterize the Long Face Syndrome. In the more serious cases, where it is the global presence of the several elements which concur to the increase of the vertical facial dimension, it is suitable a precise diagnostic checking to the three-dimensional surgical correction to realize in one time. The Authors, in the treated cases, emphasize, on the one hand, besides the traditional cephalometry, the importance of the counter-party analysis of Enlow and, on the other, they emphasize the use of the present imaging means like CT and MR to the structural evaluation of the dysmorphism in the muscular and skeletal components. From the surgical aspect the Authors emphasize the favourable results obtained associating the surgical expansion of the upper maxilla with autogenous osseous graft to the traditional maxillary osteotomies, that favours: 1) the increase of the transverse diameter, to the orthognatodontic correction of the crossbite; 2) the correction of the nasal respiratory insufficiency; 3) the precise definition and the correction of the vertical dimension of the upper maxilla.

MRI findings in 13 patients with monolateral parotid tumor were compared with US, sialographic and CT findings. MRI did not allow an accurate diagnosis in 2 patients with diffuse chronic parotitis. MRI was superior to CT in 1 case in defining the intraglandular site of the lesion, and in 2 patients in showing the extraglandular involvement. MRI proved to be superior to CT thanks to its contrast resolution and to multiplanar imaging. MRI high contrast resolution made it possible to demonstrate neoplastic lesions of 4 mm in diameter. The lesion has low signal intensity on T1-weighted images and high signal intensity on T2-weighted. Parotid tumors cannot be characterized by signal intensity alone: only morphology allows to discriminate between benign and malignant lesions. To conclude, US is a screening method, while MRI is helpful in detecting multifocal lesions and in evaluating the tumor extent.

Ten patients with squamous cell carcinomas located in the maxillo-facial region were studied. In all cases the staging by Computed Tomography (CT) and Magnetic Resonance (MRI) revealed metastatic lesions in stage T3-T4. All patients underwent polichemotherapy before surgery. MRI proved to be more accurate in the staging of tumors in 3 cases only, while in 7 cases both techniques showed the same diagnostic accuracy. In the follow-up, MRI allowed the evaluation of the effect of chemotherapy on the carcinomas: it demonstrated the regression and necrosis of 9 tumors out of 10 (the patients could undergo surgery), and the progression of the tumor in 1 case. The study of bioptic specimens demonstrated the lack of correlation between histological grading of the tumors with MRI signal intensity and T1, T2 relaxation time, as measured by spectroscopy.