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Study Design: Retrospective study. Objective: Following SARS-CoV-2 pandemic break-out a lockdown period for the population and a reorganization of the Health System were needed. Hub-function Centers for time-dependent diseases were identified and Niguarda Hospital (Milan) was selected as main Regional Trauma Center. The purpose of our study is to report the experience of Niguarda Maxillofacial Trauma Team during this period, pointing out epidemiological changes in the presentation of trauma in comparison to the previous 3 years. Methods: Two hundred and sixteen patients were admitted to the Emergency Department from 8th March 2020 to 8th May 2020. One hundred and eighty-one had a diagnosis of Major Trauma and 36 had also facial fractures; 35 patients had isolated facial fractures. Data were compared to the activity during the same period in 2017-2019 and statistical analysis was carried out concerning demographic and clinical characteristics, trauma dynamics and positivity to COVID-19. Results: Cumulative curves of patients admitted because of Major Trauma describe a superimposable linear trend in years 2017-2019, while 2020 shows an increase from April 16th. Average age and number of more severe patients were higher than previous years. Epidemiological changes concerned road accidents, accidents involving pedestrians and cyclists, interpersonal violence, suicide attempts and domestic accidents. The incidence of facial fractures was confirmed through years and, according to its measured severity, 75% of patients required management. COVID-19 positivity without systemic symptoms didn’t influence the type of treatment. Conclusion: The COVID-19 lockdown offers a unique opportunity to study the reversal epidemiological effects on trauma.

Objective: To evaluate patency of circummaxillary sutures in children with Apert, Crouzon, and Pfeiffer Syndromes and to compare it to a nonsyndromic matched control group. Design: Case–control study. Setting: Tertiary care public hospital. Materials and Methods: Thirty-eight computed tomography (CT) scans of patients affected by syndromic craniofacial synostosis (13 patients with Apert syndrome, 20 patients with Crouzon syndrome, and 5 patients with Pfeiffer syndrome), average age 5 ± 2.8 years, range 1.9 to 12 years, were compared to age- and sex-matched control CTs of 38 nonsyndromic children. Computed tomography scans of the study group had to be performed prior to any midfacial surgery. Main Outcome Measures: Midpalatal suture, zygomaticomaxillary sutures, and pterigomaxillary sutures were evaluated and scored. Results: The syndromic group showed a significant earlier ossification of all sutures compared to the nonsyndromic group. Significant differences were already present in early childhood and continued through adolescence. Conclusions: Based on the differences in terms of maxillary sutural ossification identified, midfacial hypoplasia does not seem to be only secondary to premature cranial base ossification, but also to primary synostosis of facial sutures, thus providing new insights into the pathogenesis of midface deficiency in children with craniofacial-synostosis. Care should be taken when planning any maxillary orthopedics, such as expansion or maxillary protraction, given the high frequency of early fusion of circummaxillary sutures.

BACKGROUND The avulsion of the impacted lower third molar is one of the most common procedures in oral surgery. Even though it is characterized by possible complications due to the lesion of lingual and inferior alveolar nerves, the intra-oral surgical approach represents the first choice strategy when planning surgery. However, in case of ectopic tooth in the mandibular basal bone, it is appropriate to consider an extra-oral transcutaneous surgical approach. The ectopia of the inferior wisdom tooth represents a very rare clinical condition and sometimes it is even unknown by patients and dentists: further evidence of this fact is represented by the paucity of paper related to the topic that can be found in the international scientific literature. METHODS The experience of the Department of Maxillofacial Surgery of San Gerardo Hospital in Monza (Italy) in management and treatment of ectopic impacted lower third molar is exposed through the presentation of three cases of ectopic third molar. RESULTS Two out of three patients, aware of the risks related to the surgical procedure, refused the treatment proposed. One patient underwent surgical avulsion of the wisdom tooth through extra-oral transcervical approach. No early or late complications have been observed. CONCLUSIONS Extra-oral surgical approach for ectopic lower third molar should be considered for selected cases. Given the rarity of the clinical condition and the procedure-related risks, accurate pre-operative information has to be provided to the patient by physician and the procedure should only be performed by expert and competent surgeons.

Study Design: Retrospective study. Objective: Resolution of clinical signs and symptoms following orbital fractures depends on the accurate restoration of the orbital volume. Computer-Assisted procedures and Patient Specific Implants represent modern solutions, but they require additional resources. A more reproducible option is the use of standard preformed titanium meshes, widely available and cheaper; with their use quality of results is proportional to the accuracy with which they are positioned. This work identifies 6 reproducible and constant anatomical landmarks, as an intraoperative guide for the precise positioning of titanium preformed meshes. Methods: 90 patients treated at the Maxillofacial Surgery Department, Niguarda Trauma Center, Milan, for unilateral orbital reconstruction (January 2012 to December 2018), were studied. In all cases reconstruction was performed respecting the 6 proposed anatomical landmarks. The outcomes analyzed are: post-operative CT adherence to the 6 anatomical markers and symmetry achieved respect to controlateral orbit; number/year of re-interventions and duration of surgery; resolution of clinical defects (at least 12-months follow-up); incidence of complications. Results: Satisfactory results were obtained in terms of restoration of orbital size, shape and volume. Clinical defects early recovered with a low incidence of complications and re-interventions. Operating times and radiological accuracy have shown a progressive improvement during years of application of this technique. Conclusions: The proposed “6 anatomical landmarks” is an easy free-hand technique that allows everyone to obtain high levels of reconstructive accuracy and it should be a skill of all surgeons who deal with orbital reconstruction in daily clinical activity.

STUDY DESIGN: Retrospective study. OBJECTIVE: Following SARS-CoV-2 pandemic break-out a lockdown period for the population and a reorganization of the Health System were needed. Hub-function Centers for time-dependent diseases were identified and Niguarda Hospital (Milan) was selected as main Regional Trauma Center. The purpose of our study is to report the experience of Niguarda Maxillofacial Trauma Team during this period, pointing out epidemiological changes in the presentation of trauma in comparison to the previous 3 years. METHODS: Two hundred and sixteen patients were admitted to the Emergency Department from 8th March 2020 to 8th May 2020. One hundred and eighty-one had a diagnosis of Major Trauma and 36 had also facial fractures; 35 patients had isolated facial fractures. Data were compared to the activity during the same period in 2017-2019 and statistical analysis was carried out concerning demographic and clinical characteristics, trauma dynamics and positivity to COVID-19. RESULTS: Cumulative curves of patients admitted because of Major Trauma describe a superimposable linear trend in years 2017-2019, while 2020 shows an increase from April 16th. Average age and number of more severe patients were higher than previous years. Epidemiological changes concerned road accidents, accidents involving pedestrians and cyclists, interpersonal violence, suicide attempts and domestic accidents. The incidence of facial fractures was confirmed through years and, according to its measured severity, 75% of patients required management. COVID-19 positivity without systemic symptoms didn’t influence the type of treatment. CONCLUSION: The COVID-19 lockdown offers a unique opportunity to study the reversal epidemiological effects on trauma.

Introduction: Motorcycle accidents are one of the most frequent causes of trauma. Safety devices and helmets can influence the severity of injuries. Our retrospective study wants to evaluate the different effectiveness of Open-face and Full-face helmets in the prevention of craniofacial trauma. Materials and Methods: The sample consists of 440 patients admitted to two Level I Trauma Centres in Northern Italy, between January 2002 and February 2019, because of motorcycle-related craniofacial trauma. For each patient personal data were collected, as well as type and site of fractures, type of helmet, if worn, Comprehensive Facial Injury (CFI) score and Abbreviated Injury Score (AIS-Head) for head injuries. Inferential statistical analysis was then conducted. Results: Two hundred and eighty-eight patients wore Open-face helmets (69.7%) and 125 patients wore Full-face ones (30.3%). Mean CFI score (Standard deviation-SD) observed in patients with Open-face helmets was 7.0 (SD: 6.8) and surgery was required in 149 cases (51.7%); while it was 4.9 (SD: 6.0) in patients with Full-face helmets for whom surgery was required in 43 cases (34.4%) (P < 0.0001 and P = 0.002, respectively). Multivariate analysis shows that severity of facial trauma is a significant risk factor for head injury severity with OR 1.90 (95% confidence interval: 1.43-2.51) and P < 0.0001. Discussion: Full-face helmets are definitely considered to be more protective for facial trauma, which is also a significant risk factor for the severity of head injuries. The type of helmet chosen influences the need of surgical treatment in case of craniofacial trauma.

The study aims to assess the influence on mortality of motorcycle road accidents, caused by injuries to the head, chest, abdomen, face, skin, pelvis and extremities. Road motorcycle accidents consecutively admitted to Level I Trauma Center were retrospectively analyzed. Each body site involvement was classified through Abbreviated Injury Score (AIS-98), and Comprehensive Facial Injury (CFI) score; Injury Severity Score (ISS) was also calculated. The data collected were subjected to a descriptive analysis and inferential statistic, with uni- and multivariate analysis; mortality was the main outcome examined. 1862 patients were studied. Limbs (53.9%) and Head (53.8%) are the most involved body site, facial trauma regards 19.4% of the sample. Only 4.4% of Facial injuries occurred as isolated, 71.6% were associated to Head involvement. The overall mortality was 4.6% and 80.0% of dead patients were affected by Head injury. Multivariate analysis shows that head (OR=3.06, p

Aim: the purpose of this work is to present an innovative protocol for virtual planning and surgical navigation in post-oncological mandibular reconstruction through fibula free flap. In order to analyze its applicability, an evaluation of accuracy for the surgical protocol has been performed. Methods: 21 patients surgically treated for mandibular neoplasm have been included in the analysis. The Brainlab Vector Vision 3.0® software for surgical navigation has been used for preoperative surgical planning and intra-operative navigation. A post-operative accuracy evaluation has been performed matching the position of mandibular landmarks between pre-operative and post-operative CT scans. Results: the maximal discrepancy observed was included between −3.4 mm and +3.2 mm, assuming negative values for under correction and positive values for overcorrection. An average grade of accuracy included between 0.06 ± 0.58 mm and 0.43 ± 0.68 mm has been observed for every mandibular landmark examined, except for mandibular angles that showed a mean discrepancy value included between 1.36 ± 1.73 mm and 1.46 ± 1.02 mm when compared to preoperative measurements. Conclusion: a satisfying level of accuracy has been observed in the protocol presented, which appears to be more versatile if compared to closed custom-made systems. The technique described may represent a valid option for selected patients, but it cannot be considered for routine activity because of the complexity of the method, the mobility of the jaw, the necessity of surgical navigator and the long surgical learning curve that is required.

Orbital reconstruction in cases of trauma is usually performed using the unaffected side orbital volume as a reference, but this measurement does not fully consider the anatomical characteristics of orbital surfaces. We propose a novel procedure based on the registration of 3D orbital segmented surfaces. Reconstructed orbits from 20 patients and healthy orbits from 13 control subjects were segmented from the post-operative CT-scans. The 3D orbital model from the unaffected orbit was “mirrored” according to the sagittal plane and superimposed onto the reconstructed one, with calculation of volumes, asymmetry index and point-to-point RMS (root mean square) distances. Inter- and intra-observer errors were tested through Bland–Altman plot. Differences in volume, asymmetry index and RMS value between the control group and the treated patients were assessed through two-way ANOVA and Student's t-test (p < 0.05). According to Bland–Altman test, intra- and inter-operator repeatability was respectively 87% and 89%. No significant differences in volume or asymmetry index between the control group and the treated patients were observed (p > 0.05), but the RMS value was significantly larger in the latter ones (on average, 0.90 ± 0.26 mm vs. 0.67 ± 0.17 mm, p < 0.05). Results show that the reconstructed orbits present a morphologically different surface from the unaffected ones.

The care and the management of the healing of difficult wounds at the level of the skull-facial face many problems related to patient compliance and the need to perform multiple dressings, with long periods of healing and, occasionally, a very long hospitalisation period. The introduction and evolution of negative pressure wound therapy (NPWT) in the treatment of difficult wounds has resulted in better healing, with a drastic reduction in terms of time and biological costs to the patient and cost to the health care system. The main aim of this study is to describe and discuss, using out our experience, the usefulness of NPWT in the cranial-facial-cervical region. We studied 16 patients with complex wounds of the cranial-facial-cervical region treated with NPWT. We divided clinical cases in four groups: cervicofacial infectious disease, healing complications in oncological-reconstructive surgery, healing complications of injury with exposure of bone and/or internal fixations and healing complications in traumatic injury with loss of substance. We evaluated complete or incomplete wound healing; application time, related also to hospitalisation time; days of intensive care unit (ICU) stay; management of the upper airways; timing of medication renewal; and patient comfort and compliance (on a scale of 1-5). Depression values were always between -75 and -125 mmHg in a continuous aspiration pattern. For every patient, we used the ActiVAC Therapy Unit, derived from the vacuum-assisted closure system (Kinetic Concepts Inc., San Antonio, TX). Medication renewals were performed every 48-72 hours. The NPWT application time ranged from 4 to 22 days (mean of 11·57 day). Therapy was effective to gain a complete restitutio ad integrum in every patient included in the group of cervicofacial infectious disease. Therapy has, however, been well tolerated in our series; this is probably due to the decreased number of applications, the ease of use and the comfort of the system relative to traditional dressing. Results were satisfactory for most of cases treated; faster and more effective wound healing was achieved. The lower number of NPWT applications, relating to standard dressings, led to an increase in patient comfort and compliance and a decrease in the use of medical, and in some cases economic, resources according to international literature.

Comprehensive facial injury (CFI) score is a powerful and extremely simple scale used to grade the clinical severity of all facial injuries, and is expressed in terms of the overall surgical time needed for definitive treatment. Its statistical validation was previously reported in 2019. The aim of this study was to investigate further the link with duration of surgery, applying the score to a larger sample of patients, and to evaluate the relationship between CFI score and other extremely relevant dependent variables: length of stay (LOS) in high care units (HCU) and in intensive care units (ICU). 1406 patients with diagnosis of at least one facial bone fracture, and treated by the same team in two highly specialized trauma centers, were studied. For each patient a specific CFI score is assigned and overall surgical time, length of stay, and presence of associated injuries were recorded. Data were divided into six clusters according to CFI score: (1) 0–5, (2) 6–10, (3) 11–15, (4) 16–20, (5) 21–25, and (6) >25. Regressions between CFI clusters and duration of surgery (minutes), LOS in ICU (days), and in HCU (days) were established. In addition, the presence of associated head and/or somatovisceral injuries was analyzed and related to CFI score. Statistical analysis confirmed linear regression existing between each CFI cluster and overall surgical time (p < 0.00001), with improved significance of the results using median values of surgical duration for each cluster (p = 0.0001). It also demonstrated the existence of linear regression between all CFI clusters and LOS in HCU (p = 0.0001) and between CFI clusters 3–6 and median values of LOS in ICU (p = 0.0001). Finally, associated injuries were observed to be more frequent in high CFI score clusters, occurring in around 90% of patients with a CFI score >25 (p < 0.00001). Association of head and facial injuries play a major role in high LOS in ICU values, whereas coexistence of facial, head and somatovisceral involvement increases LOS in ICU to over twice that for single association. Surgical time and length of stay are outcomes traditionally used to assess the statistical significance of many new proposed trauma score. The strong correlation demonstrated between CFI score and each of these variables confirms its value and reliability. CFI score is proven to be an ideal, simple, informative, and reproducible tool for measuring severity of facial injuries and their clinical impact. It allows correlation with associated head and somatovisceral injuries, focusing attention on the interesting field of reciprocal influences in simultaneous, multidistrectual involvement. None of the previously proposed facial injury severity scales have offered such informative and statistically significant features.

At the time of writing there is no measuring scale for the severity of facial trauma that can effectively summarize its clinical relevance, and can therefore be proposed as a definitive tool in trauma center decision making. This paper introduces a new, simple, comprehensive, and reproducible score for facial trauma, in which its severity is expressed in relation to the surgical duration necessary for definitive treatment. This parameter is identified as the most significant in expressing the commitment of care required. Statistical validation of this comprehensive facial injury (CFI) score involved a sample of 1050 patients, treated by the same team in two highly specialized trauma centers. It demonstrated a linear regression between CFI score and surgical duration, and a high degree of accuracy in forecasting overall surgical time for each type of facial injury. The descriptive capacity of CFI score, and its extremely simple use, make it a perfect tool for widespread application and for facilitating communication inside trauma centers. It also allows the classification of homogeneous groups of patients - a prerequisite for benchmarking and effective analysis of results. The CFI model is definitively proposed for the classification of facial injuries, and therefore for the integration of maxillofacial skills, within the trauma team.

Maxillofacial involvement in patients with multiple trauma injuries is usually frequent and noticeable, but it is mainly dangerous for ATLS priorities, meaning that it can compromise airway protection (A) and circulation (C) and it can often be associated with brain and cervical spine injuries. Facial hemorrhages are rarely one of the main causes of hemodynamic instability, but their early detection and prompt local control must be supported by each emergency surgeon. In very few, selected and complex cases, when local measures fail, endovascular treatment is today the best option available to achieve definitive control of refractory bleeding. Once the lifesaving priorities are successfully managed, clinicians have to preserve patients’ eyesight as well as limbs; timely clinical diagnosis and appropriate treatment work-up are essential to preserve visual function. On the other hand, we have a few, easy, damage control surgical procedures to save time, thus managing visual-threatening injuries, for instance, anterior orbitotomy is more effective, having a better aesthetic outcome. Being more confident with facial trauma emergency issues allows clinicians to be better able to deal with the comprehensive care of acutely injured patients.

Purpose: Autogenous bone represents the best material in pediatric reconstructive cranioplasty because of its compatibility with growth; however, its availability is limited. Alternative use of alloplastic materials would have the advantage of unlimited amount, but shows an increased risk of complications and incompatibility with growth. Fresh frozen banked cadaveric bones could be ideal for the reconstruction of large cranial defects in growing patients, because it offers unlimited amount of structural grafts with biomechanics properties quite similar to the autologous bones. Results: The authors report 2 cases of growing patients (13 months female and 9 years old male) undergoing the reconstruction of large (about 70 cm2 and 50 cm2 respectively) cranial vault defects, by using structural homologous banked bone grafts. Analytic main reconstruction materials risks/benefits evaluation, literature review of few previously reported pediatric cranioplasty with homologous bone, and both clinical cases satisfactory radiologic long-term results (beyond 4 years of F.U.) are reported. Conclusion: Structural homologous banked bone grafts appear as a valid solution for pediatric canioplasty reconstruction of wide defects, entailing the advantages of available without limitations and compatibility with future growth. The risk of transmissible infections seems minimal and is totally counterbalanced by the stability of long-term results.

The Carey-Finema-Ziter syndrome (CFZS, MIM 254940) is an apparently autosomal recessively inherited disorder consisting of the combination of non-progressive congenital myopathy with Moebius and Pierre Robin sequence, facial anomalies and growth delay. Mental development has been described as normal or delayed. Temporomandibular joint (TMJ) ankylosis is the immobility of the joint caused by ankylotic fusion of the mandible to the cranial base or zygoma. It is a serious and disabling condition that may cause problems in mastication, digestion, speech, appearance, and oral hygiene. Most often is a true ankylosis of the TMJ but other pathological mechanisms are described (i.e., the fusion of the coronoid process to temporal bone or with the zygoma, or a variety of soft tissues disorders like Fibrodysplasia Ossificans Progressiva). Here we report a 2-year-old girl fitting with a clinical diagnosis of CFZS associated with a limited mouth opening in which temporomandibular joint ankylosis was suspected. Because it has been postulated that many clinical features in CFZS may only be secondary effects of brainstem anomalies and muscle weakness during development, the limited opening of the mouth observed in our patient could represent a rare clinical feature of CFZS itself. © 2016 Wiley Periodicals, Inc.

Osteoblastoma is a benign tumor of bone, representing less than 1% of bone tumors. Craniomaxillofacial localizations account for up to 15% of the total and frequently involve the posterior mandible. Endo-orbital localization is very rare, with most occurring in young patients. Very few of these tumors become malignant. Orbital localization requires radical removal of the tumor followed by careful surgical reconstruction of the orbit to avoid subsequent aesthetic or functional problems. Here, we present a clinical case of this condition and describe a surgical protocol that uses and integrates state-of-the art technologies to achieve orbital reconstruction.

Aim: Comparison of the long-term follow-up until the completion of growth of two homogeneous samples of children affected by hemifacial microsomia (HFM), one treated by mandibular distraction osteogenesis (DO) in the deciduous or early mixed dentition, the other not subjected to any treatment until adulthood. Material: Fourteen patients affected by vertically severe type I or II HFM were operated at an average age of 5.9 years with an average follow-up of 11.2 years. They were compared to a sample of eight patients who were never treated until the completion of growth. Methods: Mandibular vertical changes were measured on panoramic radiographs taken at different time points. Ratios between affected and non affected ramal heights were calculated and compared. Results: In the DO sample, after correction, mandibular vertical changes showed a gradual return of the asymmetry with growth in all patients. The ratio in the non treated sample was unchanged between the initial and the long term panoramic x-rays. Conclusion: The facial proportions of HFM patients are maintained, when not treated, throughout growth. The same proportions return to their original asymmetry after DO. Even though short term aesthetic and psychological advantages of distraction osteogenesis are well accepted, early surgery should only be applied after careful patient selection and honest clarification of the long term recurrence by genetically guided craniofacial growth pattern. © 2011 European Association for Cranio-Maxillo-Facial Surgery.

Acute posttraumatic enophthalmos is a well-known symptom occurring in orbital blowout fractures. Its late onset in the absence of radiologic evidence of displaced fractures is rare and traditionally attributed to ischemic liponecrosis or fibrotic scarring of endo-orbital soft tissues. In this article, we describe a case of facial trauma, diagnosed and treated at the Maxillo-Facial Surgical Department of Hospital Ca’ Granda Niguarda of Milan, in which delayed monolateral enophthalmos is associated with CT evidence of remodeling of orbital walls attributed to atelectasis of the maxillary sinus, as occurs spontaneously in patients suffering from silent sinus syndrome (SSS). Despite that classic criteria exclude traumatic etiology of SSS, recent literature suggests the possibility to include it. Our case is the first reported in literature supported by complete clinical and radiological documentation obtained before and after the condition established itself. The analogy with cases of spontaneous obstacle of aeration allows us to choose “two-step” surgical treatment with endoscopic uncinectomy and antrostomy and a delayed surgical correction of orbital volume to improve aesthetic results. The case described in this article and the review of the literature may focus physicians’ attention on evaluating the possible traumatic changes in the physiologic sinus drainage system.

Aim Synovial Chondromatosis (SC) is a rare, benign non neoplastic arthopathy characterized by the metaplastic development of cartilaginous nodules within the synovial membrane. In only 3% of all cases does it affect the temporomandibular joint (TMJ) and cases that arise from the lower compartment are rarely found in literature. The aim of this paper is to report a new case of SC of the inferior TMJ compartment with the description of the clinical, therapeutic and histopathological findings. Case report This article presents a 68-year-old woman with preauricular swelling on the right side, pain, crepitus and limited joint motion. This patient was evaluated by preoperative clinical manifestation, CT scan and MR images. Both showed multiple, calcified loose bodies in the inferior compartment. Based on these images as well as the patient's signs and symptoms, a surgical intervention was performed. A good functional recovery with no signs of recurrence at 36 months of follow up was obtained. Conclusion Among cases of synovial chondromatosis in literature, only twelve originating in the lower compartment have been reported, this one included. In all the cases treated for SC in the lower compartment, both in literature and in our case report, surgical treatment led to healing.

Summary Background Maxillary distraction osteogenesis (DO) in cleft lip and palate patients has been described by several authors, but most studies have a relatively short follow-up and do not clearly separate growing patients from non-growing patients. Method The records of 22 consecutive patients affected by cleft lip and palate, who underwent Le Fort I osteotomy and maxillary distraction with a rigid external distractor (RED), were reviewed. The sample was subdivided into a growing and a non-growing group. All patients had pre-DO cephalometric records, immediately post DO, 12 months post DO and long-term records with a long-term follow-up of >5 years (range 5–13 years). As a control sample for the growing group, cleft children with a negative overjet not subjected to distraction or any protraction treatment during growth were followed up until the completion of growth. Results The average maxillary advancement in the growing group was 22.2 ± 5.5 mm (range: 15–32 mm); in the non-growing group, it was 17.7 ± 6.6 mm (range: 6–25 mm). Excellent post-surgical stability was recorded in the adult sample. On the other hand, growing children had an average 16% relapse in the first year post DO and an additional 26% relapse in the long-term follow-up. Conclusions This study seems to point out that early Le Fort I DO allows for the correction of very severe deformities. It is followed by a relatively high amount of true skeletal relapse in children with cleft lip and palate. Prognosis should be discussed in depth with the family and true aesthetic and psychological needs assessed.

Purpose Correction of post traumatic orbital and zygomatic deformity is a challenge for maxillofacial surgeons. Integration of different technologies, such as software planning, surgical navigation and stereolithographic models, opens new horizons in terms of the surgeons' ability to tailor reconstruction to individual patients. The purpose of this study was to analyze surgical results, in order to verify the suitability, effectiveness and reproducibility of this new protocol. Methods Eleven patients were included in the study. Inclusion criteria were: unilateral orbital pathology; associated diplopia and enophthalmos or exophthalmos, and zygomatic deformities. Syndromic patients were excluded. Pre-surgical planning was performed with iPlan 3.0 CMF software and we used Vector Vision II (BrainLab, Feldkirchen, Germany) for surgical navigation. We used 1:1 skull stereolithographic models for all the patients. Orbital reconstructions were performed with a titanium orbital mesh. The results refer to: correction of the deformities, exophthalmos, enophthalmos and diplopia; correspondence between reconstruction mesh positioning and preoperative planning mirroring; and the difference between the reconstructed orbital volume and the healthy orbital volume. Results Correspondence between the post-operative reconstruction mesh position and the presurgical virtual planning has an average margin of error of less than 1.3 mm. In terms of en- and exophthalmos corrections, we have always had an adequate clinical outcome with a significant change in the projection of the eyeball. In all cases treated, there was a complete resolution of diplopia. The calculation of orbital volume highlighted that the volume of the reconstructed orbit, in most cases, was equal to the healthy orbital volume, with a positive or negative variation of less than 1 cm3. Conclusion The proposed protocol incorporates all the latest technologies to plan the virtual reconstruction surgery in detail. The results obtained from our experience are very encouraging and lead us to pursue this path.

BACKGROUND: People with severe mental illness (SMI) generally have high rates of metabolic syndrome (MetS). Proposed explanations remain conjectural. Relatively little is known about Mets in SMI in Southern Europe, an area with generally healthy dietary traditions. PURPOSE: To establish prevalence rates of MetS in an Italian sample, and testing hypotheses about putative reasons for the excess in the SMI group. METHODS: We compared the prevalence and correlates of MetS in inpatients with SMI and controls randomly chosen from patients undergoing routine maxillofacial surgery. We employed formal tests of mediation. RESULTS: The MetS prevalence rate was 26.1 % in the SMI group and 15.9 % in the comparison group. After controlling for age, people with SMI were three times more likely to have MetS than their non-SMI counterparts. Smoking and a family history of cardiovascular disease were strongly related to MetS in both groups. However, these factors could not explain the excess of MetS in the SMI group, and we found no effect of antipsychotic dose. CONCLUSIONS: SMI remained prominent in increasing the likelihood of MetS in this low prevalence population, and putative determinants of MetS were common to people with SMI and to controls. Explanations for high MetS rates in SMI may lie in health behaviours other than smoking.

Background: Midface distraction osteogenesis (DO) in craniofacial synostosis (CFS) patients has been described by several authors. However, very few cephalometric and computed tomography (CT) long-term follow-up studies are available. Method: A total of 40 consecutive patients affected by CFS subjected to Le Fort III and rigid external distraction (RED) were examined. All patients had pre-DO cephalometric records, immediately post-DO and 6-12 months post-DO. Twenty-seven patients had mid-term records (3 years post-DO) and 20 patients had long-term records (5-10 years post-DO). Fourteen patients had CT data within 1-year of DO, while 10 patients had long-term CT data (range 5-9 years). Results: Excellent post-surgical stability was recorded. Short- and long-term CT data demonstrated excellent ossification at the osteotomy sites post-DO. In the growing patients, surface resorption in the zygomatic-temporal and in the subspinal area (p < 0.05) was observed in the long-term follow-up, as well as a mild increment of the corrected exorbitism (p < 0.05), as only appositional and no sutural growth occurs post Le Fort III, whereby orbital volume does not increase after surgery. Conclusion: Significant advancement of the midface can be achieved and maintained through Le Fort III and RED. In the long term, in growing patients, in general a class III malocclusion does not re-occur, but physiological remodelling processes at the maxillary-zygomatic level, not coupled with sutural growth, tend to mildly re-express the original midfacial phenotype and the exorbitism. © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

An essential step in the navigation procedure is the recording of markers required for the triangulation of the intraoperative navigation system. The aim of this study was to describe the procedure and preliminary results of a simple methodology for the application of dental markers to achieve good triangulation of the navigation system in maxillofacial surgery, highlighting the indications, contraindications, and possible limitations. We analyzed results from a sample of 7 patients with orbital or orbitozygomatic fractures, who were subjected to surgical intervention for the reduction and synthesis of the zygomatic fracture and from 1 case of untreated orbital fracture with enophthalmos and diplopia. We used 2 different types of dental markers: in 3 patients, we used 4 or 5 ordinary orthodontic brackets, which we placed on their upper maxillary teeth, and in 1 patient, the hexagonal-headed screws used in osteosynthesis. The accuracy of the recording was assessed during surgery by checking healthy anatomic structures against computed tomographic images. By analyzing our clinical results in light of the most recent literature, we highlighted that the application of dental markers is comparable with the best recording systems requiring a discrepancy of less than 1 mm. From the preliminary clinical analysis of the results, we confirm that the introduction of this new and simple procedure enables the successful triangulation of the navigation system, which can be used whenever the use of a navigator is required.

The management of atrophic mandibular fractures in edentulous patients represents an insidious issue for the maxillofacial surgeon due to the biological and biomechanical conditions that are unfavorable for fracture fixation and bone healing. The purpose of this study was to evaluate the results of the treatment of atrophic mandibular fractures and to compare the outcomes of different plating systems used for stabilization. We selected a study group of 16 patients with fractures of completely edentulous atrophic mandibles who were treated in our department between 2004 and 2010. All patients were surgically treated by open reduction and internal rigid fixation using 2.0-mm large-profile locking and 2.4-mm locking bone plates. All patients achieved a complete fracture healing and fast functional recovery of mandibular movements without intraoperative or postoperative surgical complications. The results of our study demonstrated the efficacy of this type of treatment in association with a low postoperative complication rate, a reduction in the recovery time, and the possibility to have an immediately functional rehabilitation. There were very similar results using each of the two bone plating methods considered: no case had hardware failure or nonunion of the fracture. The 2.0-mm large locking plate is thinner, exposes through the soft tissues less frequently, and is much easier to shape and adapt to the mandibular anatomy. However, the 2.4-mm locking plate system still represents the reference hardware in the condition of severe bone atrophy.

Bilateral cleft lip and palate patients may present a vertical excess of the premaxilla, which is a severe aesthetic and functional problem. Early surgical correction may lead to secondary growth impairment. We present a suggested protocol based on the severity of the vertical excess and on the age of the patient, which includes orthopedic, orthodontic, and surgical corrections. Patients are presented to elucidate each different approach.

Aim The aim of this study is to analyze the transconjunctival approach in the treatment of orbital fractures and to evaluate the indications, the advantages of the surgical approach, and the occurrence of possible complications. Materials and methods From 2005 to September 2009 we used a transconjunctival approach on 53 patients for a total of 56 cases of orbital fractures (three cases with bilateral floor fractures), 54 cases of acute trauma, and two outcomes of previous fractures. We evaluated the incidence of intra or postoperative complications and in the postoperative follow-up we investigated the presence of: entropion, ectropion, scleral show, trichiasis, conjunctival granuloma, mobilization or exposure of orbital reconstruction material. Results In 56 cases we had four temporary postoperative complications and no long-term complications; two cases of trichiasis and two cases of partial entropion were treated only with medical therapy. All complications, as described in the literature, were transitory and did not require corrective surgery. Conclusion The transconjunctival approach is the most effective surgical access, not only to the medial orbital wall, but also to the orbital floor, as it does not interfere with the lachrymal drainage system and gives as wide a visualization of the orbital floor as does the palpebral approach. This surgical approach is simple to perform and gives good functional and aesthetic results.

Summary Aim After mandibular unilateral distraction osteogenesis (DO) a gradual reappearance of the vertical asymmetry during growth is observed. A pre- and post-surgical functional-orthodontic treatment was added to our distraction protocol in the attempt to increase long-term stability. In order to evaluate the actual efficacy of such a combined treatment, two samples of children affected by hemifacial microsomia were compared long-term. Material Ten children were treated by a combined orthodontic–distraction treatment, seven by distraction only. Method Only the vertical changes in the mandible and maxilla in the panoramic and postero-anterior cephalometric X-rays were measured. Results All of the patients showed a gradual return of the asymmetry with growth. Occlusal plane correction and, to a much lesser extent, mandibular vertical ramus height correction were better maintained over 5 years post-DO in the orthopaedic group. Conclusion Although orthopaedic treatment allows for a more stable occlusal plane and for a slower return of the mandibular vertical asymmetry, it has mainly a dento-alveolar effect. Therefore, the decision of applying an orthopaedic treatment associated with distraction, should be taken by surgeon and orthodontist together, considering both the advantages and the disadvantages of this treatment.

This is a longitudinal cephalometric study of patients with craniofacial synostosis (Crouzon's and Apert's) syndromes who underwent Le Fort III advancement during early childhood. The objectives of the study were to quantify presurgical growth, surgical results, and surgical stability as well as long-term postsurgical growth. Of the 31 patients operated on during their growth period (less than 10 years of age), 17 had sufficient records to be included in the study: at infancy, before the Le Fort III osteotomy (average age=7.3 years, range: 4.8-10 years), and immediately after surgery. Ten of the patients were followed radiographically long term for an average of 6.1+/-2.7 years (range: 4.5-10.8 years). The presurgical abnormal midfacial vertical growth pattern was accurately described with a progressive class III discrepancy and an increasing exophthalmos. Remarkable postoperative stability of the maxillary segment was observed. After surgery, growth of the midface was measured, together with minimal, if any, anterior growth, similar to the presurgical growth pattern and rate. No actual detrimental or beneficial effect of surgery on subsequent growth was seen. This study quantitatively confirms that the standard Le Fort III osteotomy is a stable and effective but generally not definitive procedure in childhood. This study might also serve as a control sample to compare with groups of patients undergoing distraction osteogenesis to verify the actual advantages and shortcomings of this alternative technique.

Summary Aim Prospective, longitudinal, clinical long-term follow-up study of a homogeneous sample of children affected by hemifacial microsomia and treated by mandibular distraction osteogenesis. Material Eight patients affected by types I and II hemifacial microsomia were operated on at an average age of 5.6 years with an average follow-up of 5.8 years. Methods Vertical changes were measured on postero-anterior cephalometric and panoramic radiographs taken sequentially. Results Angular changes of the infraorbital and nasal floor planes were not significant, showing that distraction osteogenesis starting after 5 years of age did not influence the maxillary skeletal base. Occlusal (plane) cant was reduced by 7° on average following distraction osteogenesis, showing good dentoalveolar plasticity. Mandibular vertical changes showed a gradual return of the asymmetry, with growth in all patients (the ratio between affected and non-affected rami returned by 77% of the correction obtained by means of distraction 5 years postoperatively). Conclusion Although aesthetic and psychological advantages of distraction osteogenesis are well accepted it should only be applied after careful patient selection and honest explanation of the long-term recurrence by genetically determined craniofacial growth patterns.

A case of mandibular leiomyoma in a 8-month-old baby is reported. This is the 5th case of intrabony leiomyoma of the jaws reported so far. The tumor presented as a symptomless swelling of the mandibular ramus and required a limited resection. The pertinent literature is reviewed and the histological features discussed.

In the treatment of the severely damaged TMJ structural components (ankylosis, arthrosis, tumour, perforation or degeneration of the disc), it is advisable to insert a biological interposition between bony articular surfaces. The temporal muscle, due to its anatomical, topographical, and functional properties, can be successfully employed for this purpose. Based on the experience of Tessier, Delaire and Rowe, a temporalis muscle flap, inferiorly based, is rotated downwards and medially to the zygomatic arch, interposed and then fixed to condyle and capsule. Using this surgical technique, 12 patients and 13 temporo-mandibular joints were treated with good functional results and without any complication.

A case of melanotic neuroectodermal tumour of infancy (MNTI) which occurred in the left lower jaw of a 15-months old child was studied by electron microscopy and immunohistochemical methods to verify the neural crest origin of this tumour. Two cell population were observed: pigment melanocyte-like cells and non-pigmented nerve-like cells. Immunohistochemical analysis with neuron-specific enolase (NSE) and S-100 protein visualized two cell subtypes in the non-pigmented cell population. The combined ultrastructural findings and immunohistochemical data confirm the neural crest origin of MNTI.

The authors have made a study of 100 consecutive cases in whom a pectoralis major myocutaneous flap was employed for reconstruction after surgical ablation of advanced malignant tumours in the head and neck. The results obtained show that primary healing took place in 74% of cases with a relatively low incidence of complications. The authors therefore confirm the reliability of the pectoralis major myocutaneous flap, which, owing to its rich blood supply, offers the possibility of providing large cutaneous islands, and its proximity to the site of ablation provides a simple and reliable method which may be used in the majority of cases of immediate or delayed reconstruction of the cervico-maxillo-facial area.

Summary A series of 100 surgical procedures on the parotid gland affected by tumours is reported, with a detailed analysis of facial nerve function after parotid surgery. A low percentage of temporary lesions (28 %) affecting only one branch of the facial nerve, all of which regressed in a short time, and only one case of a permanent lesion affecting the whole nerve, anatomically intact, however, was observed. The authors confirm the safety of parotidectomy, if correctly performed.

Summary When cancer of the tongue reaches a large size (T 3 , T 4 ) it is almost impossible to treat it successfully with radiotherapy. The only therapeutic possibility in such cases is, therefore, total glossectomy. This may be effected without laryngectomy and with immediate reconstruction using musculo-cutaneous flaps. Such an operation allows total removal of the tumour and is followed by an acceptable though impaired functional result. Eight cases subjected to total glossectomy without laryngectomy are presented and aspects of ablative and reconstructive surgery are discussed. A report is made of postoperative complications and of functional rehabilitation: mastication is certainly impaired. However, swallowing is regained rapidly and phonation, although altered, is still comprehensible. An acceptable quality of life and good possibilities for a return to a working life result.

In oncological surgery of the pterygomaxillary fossa it is essential to achieve a wide access. For this purpose we have employed the old Jaeger's incision extended posteriorly in association with access osteotomies (zygoma and coronoid). In our experience (9 cases) the jugal access has provided good results without noticeable cutaneous scars. The technique is described with the presentation of 2 cases.