Clinical outcomes and periodontal conditions of dental implants placed in free fibula flaps (FFF): a retrospective study with a mean follow-up of 6 years

OBJECTIVES

Up-to-date literature regarding long-term success of implant rehabilitations after microvascular reconstructions with free fibula flap (FFF) is still very scarce. This study aimed to evaluate clinical outcomes, especially related to oral hygiene conditions, of patients rehabilitated with this technique.

MATERIALS AND METHODS

A total of 25 patients who underwent maxillofacial reconstructive surgery with FFF were retrospectively evaluated for soft tissues conditions, oral hygiene habits, and implant survival and success, assessed with a mean follow-up of 6 (range 2-15) years after loading.

RESULTS

Fourteen patients received full-arch fixed prostheses and 11 removable bar-supported overdentures. At the follow-up evaluation, 52% of prostheses did not allow proper accessibility for oral hygiene. Overall prosthetic survival was 100%, and implant survival and success were respectively 93.6% and 72%. Prevalence of peri-implantitis was 29% at implant level and that at patient level 96%.

CONCLUSIONS

Six-year clinical outcomes of this study reveal that poor oral hygiene practices and compliance by patients who underwent maxillofacial reconstruction with FFF are significantly associated with peri-implant disease.

CLINICAL RELEVANCE

Findings of the present study underline the need by clinicians for a careful assessment, in reference to a specific implant therapy, of patient's prosthetic accessibility for oral hygiene procedures.

Sequencing in Orthognathic Bimaxillary Surgery: Which Jaw Should Be Operated First? A Scoping Review

Bimaxillary orthognathic surgery is widely used for the correction of dentoskeletal deformities. Surgery sequencing (maxilla or mandible first) remains debated, and guidelines and consensus are lacking. This scoping review summarizes the state of the art and compares the advantages and disadvantages of both approaches. The review was conducted following PRISMA-ScR guidelines. Three electronic databases (PubMed, Scopus, Web of Science) were searched using the PICO protocol and key words in orthognathic surgical sequencing. Four reviewers screened the records independently, and disagreement was resolved by consensus. A total of 23 records met the inclusion criteria. The advantages and disadvantages of the two approaches were compared and assessed for accuracy of reporting. Within the limitations of the present study, available evidence for the intrinsic advantages and the accuracy of the mandible-first sequence supports the choice of this approach in most cases. Nevertheless, each clinical case needs to be evaluated individually, as no dogmatic recommendations can be given for sequencing in bimaxillary orthognathic surgery.

Reply to Mattei et al. Jacob Disease, Osteochondroma of the Coronoid Process, Coronoid Process Hyperplasia or Langenbeck Disease: The Big Jumble. Comment on "Raccampo et al. Jacob's Disease: Case Series, Extensive Literature Review and Classification Proposal. J. Clin. Med. 2023, 12, 938"

As authors of the text, we can only thank Mattei et al. [...].

Accuracy of virtual surgical planning in bimaxillary orthognathic surgery with mandible first sequence: A retrospective study

The aim of this study was to verify treatment accuracy using virtual surgical planning (VSP) with a mandible-first sequence and strict surgical protocol to determine what surgical and methodological factors might influence outcomes. VSP transfer accuracy was evaluated retrospectively through a modified method involving voxel-based superimposition in patients who had undergone bimaxillary surgery with a mandible-first sequence to correct dentoskeletal deformities. Data analysis showed that the movements planned and those executed were substantially equivalent (p < 0.01), with the exception of mandibular and maxillary sagittal movements that were 0.72 ± 0.90 mm and 1.41 ± 1.04 mm smaller, respectively, than planned. This study showed that a mandible-first sequence is accurate for transferring virtual surgical planning intraoperatively. There are several factors involved in the proper transfer of virtual planning beyond the software, such as surgical technique and sequencing. Inaccurate sagittal movements and maxillary repositioning seem to depend mainly on surgical factors.

Stem Cell Fate and Immunomodulation Promote Bone Regeneration via Composite Bio-Oss®/AviteneTM Biomaterial

Bone defects in maxillofacial regions lead to noticeable deformity and dysfunctions. Therefore, the use of biomaterials/scaffolds for maxillofacial bone regrowth has been attracting great interest from many surgical specialties and experts. Many approaches have been devised in order to create an optimal bone scaffold capable of achieving desirable degrees of bone integration and osteogenesis. Osteogenesis represents a complex physiological process involving multiple cooperating systems. A tight relationship between the immune and skeletal systems has lately been established using the concept of “osteoimmunology,” since various molecules, particularly those regulating immunological and inflammatory processes, are shared. Inflammatory mediators are now being implicated in bone remodeling, according to new scientific data. In this study, a profiler PCR array was employed to evaluate the expression of cytokines and chemokines in human adipose derived-mesenchymal stem cells (hASCs) cultured on porous hydroxylapatite (HA)/Collagen derived Bio-Oss®/Avitene scaffolds, up to day 21. In hASCs grown on the Bio-Oss®/Avitene biomaterial, 12 differentially expressed genes (DEGs) were found to be up-regulated, together with 12 DEG down-regulated. Chemokine CCL2, which affects bone metabolism, tested down-regulated. Interestingly, the Bio-Oss®/Avitene induced the down-regulation of pro-inflammatory inter-leukin IL-6. In conclusion, our investigation carried out on the Bio-Oss®/Avitene scaffold indicates that it could be successfully employed in maxillofacial surgery. Indeed, this composite material has the advantage of being customized on the basis of the individual patients favoring a novel personalized medicine approach.

Mandibular recontouring with polyetheretherketone (PEEK) patient-specific implants

The definition of the mandibular angle profile is a common challenge for oral and maxillofacial surgeons. Accurate diagnosis and treatment planning are mandatory in order to properly manage soft and hard tissues. The use of several biomaterials is described in the literature. The present paper reports the treatment of a defect in the right mandibular angle in otomandibular syndrome sequelae by positioning polyetheretherketone (PEEK) patient-specific implants (PSI) in a 25-year-old patient who previously underwent orthognathic surgery. Satisfactory aesthetic results were achieved with no complications 12 months after surgery. Considering its advantageous physical properties and the low rate of postoperative complications reported in the literature, PEEK can increase the treatment options for recontouring not only the upper third and the middle third of the face, but also of the lower third, in particular in cases of large three-dimensional defects.

Combined orthodontic and surgical open bite correction

OBJECTIVES

To present a clinical description of the team's treatment techniques.

MATERIALS AND METHODS

In Part 1, 30 patients underwent segmental maxillary orthodontics, multisegment Le Fort I, and bilateral sagittal osteotomies of the mandible. Part 1 reported excellent occlusal stability at a mean follow-up of 49.43 months (range, 36-92 months). Cases presented in Part 2 were selected based on availability of excellent technique photographs. The same techniques described in Part 2 cases were used on all Part 1 patients.

RESULTS

The coordination of arch widths and forms, overbite, overjet, and maxillary curve of Spee corrections were stable using the team protocols for orthodontic and surgical treatment.

CONCLUSIONS

In the study group, long-term three-dimensionally stable occlusal results were achieved. To duplicate these results, specific orthodontic preparation, intraoperative surgical steps, and postsurgical steps must be carefully planned and executed. These steps are described in this article, Part 2.

Combined orthodontic and surgical open bite correction

OBJECTIVES

To examine the stability of combined surgical and orthodontic bite correction with emphasis on open-bite closure. All study patients were treated with strict and consistent orthodontic and surgical protocols.

MATERIALS AND METHODS

Study inclusion required all patients to have anterior open bites, maxillary accentuated curve of Spee, 36-month minimum follow-up, and no temporomandibular joint pathology. Thirty patients met the inclusion/exclusion criteria. Importantly, segmental upper arch orthodontic preparation (performed by EG) was used. Surgery consisted of a multisegment Le Fort I (MSLFI) combined with a bilateral sagittal osteotomies (BSSO). Surgery was performed (by ADA and LT) at the Department of Dentistry and Maxillofacial Surgery of the University of Verona, Italy.

RESULTS

The long-term open bite and overjet relapse were not statistically significant. The mean transverse relapse of the upper and lower molars was statistically significant. Of great importance, the upper and lower arch widths narrowed together, maintaining intercuspation of the posterior dentition which prevented anterior open bites from developing.

CONCLUSIONS

This study revealed stability of three-dimensional occlusal correction including anterior open bite. Stable open bite closure was achieved by using rigid protocols for orthodontic preparation, surgical techniques, surgical follow-up, and orthodontic finishing.

Genetics and Epigenetics of Bone Remodeling and Metabolic Bone Diseases

Bone metabolism consists of a balance between bone formation and bone resorption, which is mediated by osteoblast and osteoclast activity, respectively. In order to ensure bone plasticity, the bone remodeling process needs to function properly. Mesenchymal stem cells differentiate into the osteoblast lineage by activating different signaling pathways, including transforming growth factor β (TGF-β)/bone morphogenic protein (BMP) and the Wingless/Int-1 (Wnt)/β-catenin pathways. Recent data indicate that bone remodeling processes are also epigenetically regulated by DNA methylation, histone post-translational modifications, and non-coding RNA expressions, such as micro-RNAs, long non-coding RNAs, and circular RNAs. Mutations and dysfunctions in pathways regulating the osteoblast differentiation might influence the bone remodeling process, ultimately leading to a large variety of metabolic bone diseases. In this review, we aim to summarize and describe the genetics and epigenetics of the bone remodeling process. Moreover, the current findings behind the genetics of metabolic bone diseases are also reported.

Transconjunctival and Subciliary Approach in the Treatment of Orbital Fractures: A Study on Oculoplastic Complication

(1) Background: The aim of the present study was to compare lower eyelid post-operative complications, such as ectropion, entropion, and scleral show of orbital floor fractures, associated to the subciliary vs transconjunctival approaches. (2) Materials and Methods: A retrospective comparative study of patients who underwent surgery for orbital fractures by means of a transconjunctival or a subciliary approach at the Clinic of Dentistry and Maxillofacial Surgery of the University of Verona from January 2013 through September 2018 was designed. Data related to the trauma and to surgical procedures were retrieved, as well as a series of anthropometric parameters extrapolated from standardized photographs. Statistical analysis was performed on the outcomes. (3) Results: 33 patients underwent surgery by means of a transconjunctival approach and 36 patients by means of a subciliary approach. Ectropion was observed to a greater extent in the subciliary group, however the difference resulted to be not statistically significant. Patients in which osteosynthesis devices were used presented with a greater incidence of scleral show with respect to the remaining patients. No statistically significant difference was observed for any of the parameters taken into account. (4) Conclusions: Since the two approaches does not seem to be associated with remarkable differences in terms of outcomes, the choice of technique should be tailored to the patient’s features and the surgeon’s experience.

Complications related to zygomatic implants placement: A retrospective evaluation with 5 years follow-up

This retrospective study assessed zygoma implants in patients treated for upper maxilla extreme atrophy, trauma, cleft palate, or failed reconstruction. The implants were placed using Quad (4 zygoma implants) or mixed (zygoma and conventional implants in premaxilla) surgical technique, with intra-sinus or extra-sinus approach, followed by immediate or deferred loading. Clinical and radiographic evaluations were carried out at 5-year follow-up from loading. Implant survival, symptoms and signs of sinusitis, radiological alterations in terms of mucosal thickening or obliteration of the maxillary sinuses, oroantral communications, and peri-implant soft tissues were examined. A total of 42 patients, with 116 zygoma implants, were included in the study. The cumulative survival rate was 97.41%. One zygomatic bone fracture was assessed. Eight patients reported sinusitis, and two showed oro-antral communications. A comparison between mean pre- and post-operative Lund-Mackay scores showed a statistically significant increase of sino-nasal disease in the post-operative scores (p = 0.0019). Mucositis and gingival recession was observed in 21 and 8 implants respectively. Average recession was 2.52 ± 2.35 mm. According to our results, placement of zygoma implants has proved to be a predictable procedure, with a lower rate of severe complications compared to other treatment options in extreme upper jaw atrophy.

Enhanced Osteogenic Differentiation of Human Bone Marrow-Derived Mesenchymal Stem Cells by a Hybrid Hydroxylapatite/Collagen Scaffold

Human bone marrow-derived mesenchymal stem cells (hBMSCs) and their derivative enhanced green fluorescent protein (eGFP)-hBMSCs were employed to evaluate an innovative hybrid scaffold composed of granular hydroxylapatite and collagen hemostat (Coll/HA). The cellular morphology/cytoskeleton organization and cell viability were investigated by immunohistochemistry (IHC) and AlamarBlue metabolic assay, respectively. The expression of osteopontin and osteocalcin proteins was analyzed by IHC and ELISA, whereas osteogenic genes were investigated by quantitative PCR (Q-PCR). Cell morphology of eGFP-hBMSCs was indistinguishable from that of parental hBMSCs. The cytoskeleton architecture of hBMSCs grown on the scaffold appeared to be well organized, whereas its integrity remained uninfluenced by the scaffold during the time course. Metabolic activity measured in hBMSCs grown on a biomaterial was increased during the experiments, up to day 21 (p < 0.05). The biomaterial induced the matrix mineralization in hBMSCs. The scaffold favored the expression of osteogenic proteins, such as osteocalcin and osteopontin. In hBMSC cultures, the scaffold induced up-regulation in specific genes that are involved in ossification process (BMP2/3, SPP1, SMAD3, and SP7), whereas they showed an up-regulation of MMP9 and MMP10, which play a central role during the skeletal development. hBMSCs were induced to chondrogenic differentiation through up-regulation of COL2A1 gene. Our experiments suggest that the innovative scaffold tested herein provides a good microenvironment for hBMSC adhesion, viability, and osteoinduction. hBMSCs are an excellent in vitro cellular model to assay scaffolds, which can be employed for bone repair and bone tissue engineering.

The effect of subspinal Le Fort I osteotomy and alar cinch suture on nasal widening

The aim of this retrospective study was to evaluate the relationships between upper jaw movements and nasal soft-tissue changes in patients who have undergone subspinal Le Fort I osteotomy combined with alar cinch suture. Single and multivariate linear regression analyses were used to examine the relationships between greatest inter-alar width (GAW) and maxillary advancement, maxillary impaction, and rotational movements. The database of our referral hospital was searched for patients who had undergone upper jaw surgery with a subspinal LFI osteotomy to correct dentoskeletal deformities between April 2012 and June 2016. Thirty-eight of the patients (15 men and 23 women) who were identified were eligible for inclusion. The average change in inter-alar width (ΔGAW) was +1.7 ± 1.2 mm. GAW increased by 0.3 mm (p < 0.0001) for each millimetre of maxillary advancement, and increased by 0.5 mm (p < 0.0001) for each millimetre of maxillary impaction. GAW increased by 0.2 mm for each degree of counterclockwise rotation of the occlusal plane (p < 0.0001). An analysis of our data compared with the current literature confirmed that subspinal Le Fort I combined with alar cinch suture reduced alar base widening.

Hydroxylapatite-collagen hybrid scaffold induces human adipose-derived mesenchymal stem cells to osteogenic differentiation in vitro and bone regrowth in patients

Tissue engineering-based bone graft is an emerging viable treatment modality to repair and regenerate tissues damaged as a result of diseases or injuries. The structure and composition of scaffolds should modulate the classical osteogenic pathways in human stem cells. The osteoinductivity properties of the hydroxylapatite-collagen hybrid scaffold named Coll/Pro Osteon 200 were investigated in an in vitro model of human adipose mesenchymal stem cells (hASCs), whereas the clinical evaluation was carried out in maxillofacial patients. Differentially expressed genes (DEGs) induced by the scaffold were analyzed using the Osteogenesis RT² PCR Array. The osteoinductivity potential of the scaffold was also investigated by studying the alkaline phosphatase (ALP) activity, matrix mineralization, osteocalcin (OCN), and CLEC3B expression protein. Fifty patients who underwent zygomatic augmentation and bimaxillary osteotomy were evaluated clinically, radiologically, and histologically during a 3-year follow-up. Among DEGs, osteogenesis-related genes, including BMP1/2, ALP, BGLAP, SP7, RUNX2, SPP1, and EGFR, which play important roles in osteogenesis, were found to be upregulated. The genes to cartilage condensation SOX9, BMPR1B, and osteoclast cells TNFSF11 were detected upregulated at every time point of the investigation. This scaffold has a high osteoinductivity revealed by the matrix mineralization, ALP activity, OCN, and CLEC3B expression proteins. Clinical evaluation evidences that the biomaterial promotes bone regrowth. Histological results of biopsy specimens from patients showed prominent ossification. Experimental data using the Coll/Pro Osteon 200 indicate that clinical evaluation of bone regrowth in patients, after scaffold implantation, was supported by DEGs implicated in skeletal development as shown in "in vitro" experiments with hASCs.

Clinical Management of Acinic Cell Carcinoma of the Lacrimal Gland

To report a case of acinic cell carcinoma occurred in the lacrimal gland. A 59-year-old man was admitted because of sudden blurring of vision, progressive proptosis of the left eye, and mild double vision in left and down directions of the gaze (Hess-Lancaster test). His medical history detailed controlled bilateral keratoconus and open angle glaucoma. On examination, the best corrected visual acuity decreased from 8/20 till 1/50 in one week. There was a swelling of the left upper eyelid. A hard and tender mass was palpated in the superior temporal left orbit. Ultrasound scan showed an extraconal solid mass, situated in the superior lateral corner of the orbit. Computed tomography and magnetic resonance imaging (MRI) revealed a mass of two centimeters in diameter, with round well-defined outline, within the lacrimal gland. We performed an enucleoresection of the mass, via a coronal approach and a lateral orbitotomy by a piezosurgical device. The lesion appeared nodular, brownish, measuring about 2 × 1.5 cm. Histopathological findings were consistent with acinic cell carcinoma with a microcystic, focally papillary-cystic growth of pattern. Follow-up MRI outcomes led to removal of the residual lacrimal gland for suspicion of recurrence. No tumor recurrences where detected at 7-year follow-up.

Does Middle Meatal Antrostomy Prevent the Onset of Maxillary Sinusitis After Zygomatic Implant Placement?

PURPOSE

To evaluate the role of middle meatal antrostomy in preventing the onset of maxillary sinusitis after placement of zygomatic implants. We hypothesized that middle meatal antrostomy might reduce the incidence of this complication.

MATERIALS AND METHODS

A prospective longitudinal study was performed of patients who had undergone placement of 4 zygomatic implants and concurrent middle meatal antrostomy with an endoscopic approach at the maxillofacial surgery unit of Verona University. The radiological results of the maxillary sinuses were evaluated on computed tomography scans performed 12 months after surgery using the Lund-Mackay staging system. Clinical symptoms were evaluated both preoperatively and 12 months after surgery using the Sino-Nasal Outcome Test-20 (SNOT-20). Intraoperative violation of the Schneiderian membrane was also assessed. The outcomes from the present study were compared with historical controls.

RESULTS

The sample included 13 patients, 26 maxillary sinuses with negative radiologic findings of sinonasal pathologic features, and 52 zygomatic implants. A moderate increase was found in radiologic findings of sinonasal pathologic features postoperatively compared with preoperatively, with mucosal hypertrophy in 3 maxillary sinuses (11.5%). The incidence and severity of mucosal hypertrophy was significantly lower than the outcomes of the historical controls. The average preoperative SNOT-20 score was 13.45, and the postoperative SNOT-20 score was 1.18. The Schneiderian membrane was pierced in 13 sinuses in 9 patients.

CONCLUSIONS

Shrinkage of the ostiomeatal complex seems to play a fundamental role in the onset of sinonasal pathologic features after zygomatic implant placement compared with implant-related causes. Although functional endoscopic sinus surgery is a supplementary surgical method in implant placement, it seems to provide statistically significant improvement in the health of the sinonasal system. Perforation of the Schneiderian membrane does not appear to correlate with the onset of sinus opacification and sinonasal symptoms.

Innovative Biomaterials for Bone Regrowth

The regenerative medicine, a new discipline that merges biological sciences and the fundamental of engineering to develop biological substitutes, has greatly benefited from recent advances in the material engineering and the role of stem cells in tissue regeneration. Regenerative medicine strategies, involving the combination of biomaterials/scaffolds, cells, and bioactive agents, have been of great interest especially for the repair of damaged bone and bone regrowth. In the last few years, the life expectancy of our population has progressively increased. Aging has highlighted the need for intervention on human bone with biocompatible materials that show high performance for the regeneration of the bone, efficiently and in a short time. In this review, the different aspects of tissue engineering applied to bone engineering were taken into consideration. The first part of this review introduces the bone cellular biology/molecular genetics. Data on biomaterials, stem cells, and specific growth factors for the bone regrowth are reported in this review.

Human adipose stem cells induced to osteogenic differentiation by an innovative collagen/hydroxylapatite hybrid scaffold

Novel biomaterials are of paramount importance for bone regrowth. In this study, we investigated human adipose stem cells (hASCs) for osteogenic, osteoconductivity, and osteoinductivity effects of an innovative collagen/hydroxylapatite hybrid scaffold. In hASCs that were grown on this scaffold, osteogenic genes were analyzed for their expression profiles, together with adhesion and extracellular matrix genes. In hASC integrins, basement membrane constituents and collagens were up-regulated, together with cell proliferation. In addition, expression of osteopontin and activated focal adhesion kinase was studied at the protein level. Our in vitro data indicate that hASCs, together with hybrid biomaterial, is an important model of study to investigate in vitro bone induction.-Mazzoni, E., D'Agostino, A., Manfrini, M., Maniero, S., Puozzo, A., Bassi, E., Marsico, S., Fortini, C., Trevisiol, L., Patergnani, S., Tognon, M. Human adipose stem cells induced to osteogenic differentiation by an innovative collagen/hydroxylapatite hybrid scaffold.

Is the Retromandibular Transparotid Approach a Reliable Option for the Surgical Treatment of Condylar Fractures?

PURPOSE

This study evaluated the outcomes and complications of the surgical treatment of condylar fractures by the retromandibular transparotid approach. The authors hypothesized that such an approach would be safe and reliable for the treatment of most condylar fractures.

MATERIALS AND METHODS

A retrospective evaluation of patients who underwent surgical reduction of a condylar fracture from January 2012 to December 2014 at the Clinic of Dentistry and Maxillofacial Surgery of the University Hospital of Verona (Verona, Italy) was performed. Inclusion criteria were having undergone surgical treatment of condylar fractures with a retromandibular transparotid approach and the availability of computed tomograms of the preoperative and postoperative facial skeleton with a minimum follow-up of 1 year. Static and dynamic occlusal function, temporomandibular joint health status, presence of neurologic impairments, and esthetic outcomes were evaluated in all patients.

RESULTS

The sample was composed of 25 patients. Preinjury occlusion and temporomandibular joint health were restored in most patients. Esthetic outcomes were deemed satisfactory by clinicians and patients. Neither permanent neurologic impairments nor major postoperative complications were observed.

CONCLUSIONS

According to the results of the present study, the retromandibular transparotid approach is a viable and safe approach for the surgical treatment of condylar fractures.

Quadruple zygomatic implants supported rehabilitation in failed maxillary bone reconstruction

Extreme atrophy of the jaws constitutes a challenge for maxillofacial surgeons. The technique involving Le Fort I osteotomy, bone grafting, and endosseous implants remains the gold standard treatment for class V and class VI atrophy of the maxilla. As severe maxillary atrophy is associated to impaired microvascularization of overlying soft tissues, reconstruction using vascularized free fibula flaps together with endosseous implants is one of the possible treatment plans. When this approach fails, however, retreating these patients using traditional techniques often proves unsatisfactory. This study outlines our clinical experience with full-arch zygoma implant-supported prosthetic rehabilitation to treat severe atrophic maxilla following failure of strategies including multiple Le Fort I procedures or vascularized free fibular flaps.

Rehabilitation of a complex midfacial defect by means of a zygoma-implant-supported prosthesis and nasal epithesis: a novel technique

Purpose

Several authors have described zygoma implants as a reliable surgical option to rehabilitate severe maxillary defects in case of extreme atrophy or oncological resections. The aim of this study is to report a new technical approach to the rehabilitation of a complex oronasal defect by means of a zygoma-implant-supported full-arch dental prosthesis combined with a nasal epithesis.

Patients and methods

The patient presented with a subtotal bilateral maxillectomy and total rhinectomy defect because of a squamous cell carcinoma of the nose. No reconstructive surgery was performed because of the high risk of recurrence; moreover, the patient refused any secondary procedure. After surgery, the patient presented a wide palatal defect associated to the absence of the nasal pyramid. Zygoma-retained prostheses are well documented, and they offer good anchorage in rehabilitating wide defects after oncological surgery and a good chance for patients to improve their quality of life. We hereby describe two prosthetic devices rehabilitating two iatrogenic defects by means of a single intraoral implant-supported bar extending throughout the oronasal communication, thus offering nasal epithesis anchorage.

Results

At 1-year follow-up after functional prosthetic loading, no implant failure has been reported. Clinical and radiological follow-up showed no sign of nasal infection or peri-implantitis. The patient reported a sensitive improvement of his quality of life.

Conclusions

Simultaneous oral and nasal rehabilitation of complex oronasal defects with zygoma-implant-supported dental prosthesis and nasal epithesis represents a reliable surgical technique. According to this clinical report, the above-mentioned technique seems to be a valuable treatment option as it is safe, reliable and easy to handle for both surgeon and patient.

Are Zygomatic Implants Associated With Maxillary Sinusitis?

PURPOSE

The purpose of the present study was to analyze the relation between zygomatic implants and symptomatic and radiologic modifications of the maxillary sinuses.

MATERIALS AND METHODS

A retrospective cohort study of patients who underwent zygomatic implant rehabilitation at the Clinic of Dentistry and Maxillofacial Surgery of the University of Verona from January 2005 through May 2014 was designed. The primary predictor variable was time (pre- vs postoperative). Concerning outcome variables, radiologic findings of thickened mucosa or opacification of the maxillary sinuses were evaluated on computed tomograms using the Lund-Mackay Staging System. Clinical symptoms were evaluated using the Sino-Nasal Outcome Test-20 (SNOT-20). The parameters assessed underwent descriptive statistical analysis.

RESULTS

The sample was composed of 41 patients (mean age, 54 yr; 61% women). Preoperatively, 12% had sinus findings. Postoperatively, 46% had sinus findings (P = .0001 by McNemar paired test). Preoperatively, 12% had a SNOT-20 score higher than 11. Postoperatively, 15% had a SNOT-20 score higher than 11 (P = 1 by McNemar paired test).

CONCLUSIONS

In accordance with data in the literature data, placement of zygomatic implants does not seem to be associated with severe rhinosinusitis complications. However, in a considerable number of patients, asymptomatic radiologic alterations of the paranasal sinuses were observed. Therefore, it is important to plan assessments of the prosthetic and peri-implant components of the procedure and the postoperative homeostasis of the maxillary sinuses.

Hydroxyapatite/Collagen Composite Is a Reliable Material for Malar Augmentation

PURPOSE

To evaluate the long-term results of cheekbone augmentation using porous hydroxyapatite granules mixed with microfibrillar collagen in a large group of patients.

MATERIALS AND METHODS

Four hundred thirty patients who underwent zygomatic augmentation and intermaxillary osteotomy were evaluated clinically, radiologically, and histologically.

RESULTS

Complications were found in 13 patients (1.56%). There were no relevant radiologic differences in prosthesis volume after 1 month (T1) or after 24 months (T2) in any patient; there were no clinically relevant differences in 110 patients after 36 months. At T1, the prosthesis had a granular structure and the granules had not migrated; at T2, the prosthesis was staunchly adhering to the underlying bone. Over time, the radiopacity of the material increased. Histologic results of 19 biopsy specimens obtained from 8 patients 2 years after the procedure showed prominent ossification with low inflammation, confirming new bone formation over time. According to the visual analog scale, the patients were generally satisfied with the aspects that were considered.

CONCLUSION

Hydroxyapatite and collagen composite used during malarplasty produced a successful outcome. Its main drawback is a learning curve that is longer than for more frequently used implantable biomaterials.

Morphological study of upper airways and long-term follow-up of obstructive sleep apnea syndrome in acromegalic patients

Pathogenesis and long-term outcome of obstructive sleep apnea syndrome (OSAS) in acromegalic patients are still under debate. The aim of the study was to assess the prevalence and long-term follow-up of a series of acromegalic patients with OSAS and to investigate site, degree, and possible causes of upper airway obstruction by morphological study. Cross-sectional and longitudinal study was conducted in 58 acromegalic patients (33 active, 25 controlled) with polysomnography in all subjects, repeated in 25 patients with OSAS, and echocardiography. Morphological study including fiberoptic nasopharyngoscopy with the Müller maneuver (FNMM), magnetic resonance imaging (MRI), with 3-dimensional (3D) elaboration was also performed. The prevalence of OSAS was 58.6 % in the whole series: 63.6 % in the active group and 52 % in the controlled one. Left ventricular hypertrophy was more prevalent in patients with OSAS. OSAS improved in 62.5 % of active patients after achieving hormonal control, whereas it persisted or got worse in 66.6 % of the controlled ones. The uvula and tongue base were the main site of obstruction assessed by FNMM. Uvula diameters obtained by MRI study correlated with the severity of upper airway collapse assessed by FNMM and tongue measure with apnea-hypopnea index (p = 0.044). A greater narrowing and a smaller total volume of upper airways were confirmed by 3D-MRI in patients with more severe OSAS. Uvula and tongue hypertrophy plays a relevant role in the pathogenesis and severity of OSAS. Intensive treatment of acromegaly needs to be promptly adopted in order to reverse it.

Specific Antibodies Reacting with SV40 Large T Antigen Mimotopes in Serum Samples of Healthy Subjects

Simian Virus 40, experimentally assayed in vitro in different animal and human cells and in vivo in rodents, was classified as a small DNA tumor virus. In previous studies, many groups identified Simian Virus 40 sequences in healthy individuals and cancer patients using PCR techniques, whereas others failed to detect the viral sequences in human specimens. These conflicting results prompted us to develop a novel indirect ELISA with synthetic peptides, mimicking Simian Virus 40 capsid viral protein antigens, named mimotopes. This immunologic assay allowed us to investigate the presence of serum antibodies against Simian Virus 40 and to verify whether Simian Virus 40 is circulating in humans. In this investigation two mimotopes from Simian Virus 40 large T antigen, the viral replication protein and oncoprotein, were employed to analyze for specific reactions to human sera antibodies. This indirect ELISA with synthetic peptides from Simian Virus 40 large T antigen was used to assay a new collection of serum samples from healthy subjects. This novel assay revealed that serum antibodies against Simian Virus 40 large T antigen mimotopes are detectable, at low titer, in healthy subjects aged from 18–65 years old. The overall prevalence of reactivity with the two Simian Virus 40 large T antigen peptides was 20%. This new ELISA with two mimotopes of the early viral regions is able to detect in a specific manner Simian Virus 40 large T antigen-antibody responses.

Is Le Fort I Osteotomy Associated With Maxillary Sinusitis?

PURPOSE

The purpose of the present study was to investigate the association between Le Fort I osteotomy and the anatomic, radiologic, and symptomatic modifications of the maxillary sinus.

MATERIALS AND METHODS

Subjects who had undergone Le Fort I osteotomy from January 2008 to December 2013 were enrolled in a retrospective cohort study. The eligibility criteria were the availability of a cone beam computed tomography (CBCT) scan taken before and 12 to 24 months after the procedure. The exclusion criteria were the unavailability of CBCT scans, the use of tobacco, and previous orthognathic procedures. The primary predictor variable was time (pre-vs postoperative). The primary outcome variables were the sinus volume, mucosal thickening, iatrogenic alterations in the sinus anatomy, and rhinosinusitis symptoms, evaluated using the Sino-Nasal Outcome 20-item Test (SNOT-20). Descriptive statistics were computed for each variable, and paired analyses were used to compare the pre- and postoperative values.

RESULTS

The data from 64 subjects (mean age 27; 59.4% were female; median follow-up 32.4 months, range 13 to 66 months) were studied. Postoperatively, 1.6% of the sample (0% preoperatively) had moderate-to-severe and 15.6% (3.1% preoperatively) had mild-to-moderate sinusitis symptoms. The rest of the sample presented with mild to no symptoms. The increase in the SNOT scores after surgery was statistically significant (P = .016). Radiologic evidence of postoperative inflammatory processes affecting the paranasal sinuses was found in 27.3% of the sinuses (9.4% preoperatively). The postoperative Lund-Mackay scores were significantly greater (P = .0005). A 19% decrease was found in the mean postoperative sinus volume, with a 37% incidence of iatrogenic injury.

CONCLUSIONS

The study results indicate that Le Fort I osteotomies can have an important impact on sinus health. The postoperative radiologic evidence of maxillary sinus inflammatory processes and the incidence of rhinosinusitis symptoms and iatrogenic damage in these patients have led us to conclude that CBCT scans and the SNOT-20 questionnaire should be used routinely during postoperative monitoring. Larger long-term studies are warranted to clarify the postoperative outcomes and complications.

Significant association between human osteosarcoma and simian virus 40

BACKGROUND

Simian virus 40 (SV40) has been considered to be an oncogenic viral agent in the development of osteosarcoma (OS), which to the authors' knowledge continues to be of unknown etiology.

METHODS

In the current study, serum samples from patients with OS were investigated with an indirect enzyme-linked immunoadsorbent assay (ELISA) to test for the presence of immunoglobulin G antibodies, which react with SV40 antigens. In ELISA, SV40 antigens were represented by 2 synthetic polypeptides that mimic epitopes of the viral capsid proteins 1 to 3. Additional sera from patients with breast cancer and undifferentiated nasopharyngeal carcinoma as well as healthy subjects were the controls.

RESULTS

Immunologic results suggested that antibodies that react with SV40 mimotopes were more prevalent (44%) in serum samples from patients with OS compared with healthy subjects (17%). The difference in prevalence between these cohorts was statistically significant (P<.001). It is interesting to note that in the patients with OS, significance indicated the difference between OS versus breast cancer (44% vs 15%; P<.001) and OS versus undifferentiated nasopharyngeal carcinoma (44% vs 25%; P<.05).

CONCLUSIONS

The data from the current study indicate an association between OS and SV40. These data could be transferred to clinical applications for innovative therapies to address SV40-positive OS.

Keratocyst, conservative treatment: case report

The odontogenic keratocyst is now designated as a keratocystic odontogenic tumor and is defined as a benign uni- or multicystic, intraosseus tumor of odontogenic origin, with a characteristic lining of parakeratiniezed tumour as a better reflects is neoplastic nature. This case report presents the marsupialization procedure for the treatment of a keratocystic lesion.

Aneurysmal bone cyst of the nasal bone: case report

The aneurysmal bone cyst (ABC) is a solitary, expansile, non-neoplastic bone lesion, described as a distinct clinicopathological entity by Jaffe and Lichtenstein. We report a case of an ABC arising from the nasal bone in a adult male patient treated with complete surgical excision.

Tongue flap to treat a severe case of Miescher's cheilitis granulomatosa

Miescher's cheilitis granulomatosa is the monosymptomatic form of Melkersson-Rosenthal Syndrome. Severe macrocheilitis often causes a functional and esthetical impairment of the lip. Conservative treatment represents the first option to face this rare disease. Unfortunately, medical treatment is often ineffective without any significant result as far as swelling and disfigurement are concerned. Reductive cheiloplasty is indicated in all those patients who have failed to respond to medical treatment. Excision of excess tissue may be obtained by means of several surgical techniques. We report a case of a 55-year-old man affected by severe granulomatous cheilitis refractory to any medical treatment and then treated with the use of tongue flap for the reconstruction of the excised lower lip.

Full vestibular approach in pre-prosthetic surgery: retrospective evaluation of 90 patients and literature review

Atrophy of the jaws could represent a challenge in maxillofacial and oral surgery. The correction of bone defects due to the atrophic process is frequently achieved by means of onlay bone grafting. In the present note, a technique of flap designing to approach the alveolar atrophic crest will be discussed. The primary incision is sculpted in the vestibular aspect of the oral fornix, apically to the mucogengival junction. A full thickness mucosal flap is then lifted to expose the maxillary or mandibular lateral wall, and the alveolar crest is reached after the deglovement of the atrophic edentulous crest. This technique aims to decrease the incidence of dehiscence and consequent infection in the area of bone grafts, in order to provide a feasible and safe procedure to perform bone grafting and preserve the overlying soft tissues. This technique of flap design has been applied on 90 cases (167 sites) to face mild to severe jaw atrophy obtaining good results in comparison with the traditional crestal incision technique.

Calcium sulfate barrier for regeneration of human bone defects. 3 years randomized controlled study

Several experimental studies have been performed in order to evaluate the behavior of different types of biomaterials involved in the process of tissue and bone regeneration. The guided bone regeneration (GBR) principles are applied in the rebuilding of periodontal tissues, damaged by the periodontal inflammatory process. Since the introduction of GBR biological principles, a wide range of materials have been tested and used as a physical barrier. At present, the autogenous material continues to be considered the best choice when reconstruction of bone defects is intended. Calcium phosphate ceramics have been widely applied as bone substitutes, coatings, cements, drug delivery systems and tissue engineering scaffolds due to their resemblance to the mineral portion of the bone tissue, relative ease in processing and good cell attachment. 40 patients (25 males and 15 females) planned to receive bone regeneration procedure were included in the study. 20 patients were treated for bone regeneration using just BondBone, 10 patients using BondBone and a Collagen membrane and the remaining 10 patients with Bone substitute and a collagen membrane. This study has evaluates the bone tissue behavior of calcium sulfate barrier in bone repair in human bone, observing the GBR biological principles. We can conlude that calcium sulfate can work as a completion material, space maintainer, vehicle for a controlled release of certain drugs, associated with other graft materials.

Experimental study of a new surgical technique for anatomic remodeling of atrophic socket in maxillary postextraction single implant

Replacement therapy with immediate postextraction single dental implants has gained wider acceptance in clinical practice. However, because bone tissue volume may be insufficient for primary stability and subsequent osteointegration, many dentists prefer delaying implantation 2 or 3 months later, which may lead to greater loss of vestibular bone tissue and worsen postextraction atrophy. To avert these problems, a new surgical technique has been developed that allows immediate loading on postextraction single implants and atrophic socket remodeling. Socket remodeling is known to occur when the extraction site is completely ossified, but, depending on the length of time since tooth extraction, surgical complications may still arise, resulting in suboptimal wound healing of the socket, with unacceptable esthetic and functional outcome.

Mandibular distraction of the body and ramus

With the ever increasing interest in the field of osteodistraction techniques, the mandible is certainly the most studied anatomical site, both experimentally and clinically. Currently, the methods of mandibular distraction can be classified by position (intra- or extraoral), by the direction of distraction and by the site of application (toothborn, boneborn or hybrid fixation). To guarantee good results from the osteodistraction procedure, it is fundamental to have an accurate preoperative plan considering the correct classification and evaluation of the patient combined with a valid project regarding the direction of the distraction vector. One of the most important aspects to consider is the orientation of the distractor, especially if the defect to be corrected is three-dimensional. Regarding the correct planning of the operation, knowing the secondary effects of the distraction on the soft tissues, muscles and nerves, the temporomandibular joint and velopharyngeal functioning is of fundamental importance. It is worth considering particular situations in which osteodistraction is extremely helpful in maxillofacial surgery, for example in the construction of a neocondyle, in bone replacement during oncologic interventions, in obstructive sleep apnea correction and in hemi-mandibular reconstruction.

p63 expression in odontogenic cysts

A total of 123 cases of odontogenic cysts, distributed as follows: 30 follicular (FC), 35 radicular (RC), 53 keratocysts, 1 glandular odontogenic and 4 calcifying odontogenic cysts, were analysed by immunohistochemistry for expression of p63, a component of p53 protein family. In RCs p63 positivity was not only in basal and parabasal layers but also in the intermediate layer and about 1/3 of cases displayed a percentage of stained cells comprised between 0 and <5%, and about 2/3 between >5% and <50%. In FCs positivity was confined to basal and parabasal layers of the epithelium and in the majority of FCs the stained cells were comprised between 0 and <5%. OKCs displayed the most intense and diffuse p63 labeling. In conclusion, these data suggest that p63 expression may be useful to identify cysts type with more aggressive and invasive phenotype supporting the hypothesis of a suprabasal proliferative compartment in OKCs.

p63 overexpression associates with poor prognosis in head and neck squamous cell carcinoma

p63 belongs to a protein family that includes 2 structurally related proteins, p53 and p73. The aim of this study was to investigate the biologic role of p63 in oral tumorigenesis and its possible role as prognostic marker in oral cancer. Ninety-four cases of oral squamous cell carcinoma and 10 cases of normal mucosa were analyzed for p63 expression by immunohistochemistry. Normal oral mucosa showed a basal and parabasal expression of p63. Five (5.3%) cases of oral cancer showed less than 10% of positive tumor cells; in 33 (35.1%) cases the positive tumor cells comprised between 10% and less than 30%, in 36 (38.3%) cases the positive tumor cells comprised between 30% and less than 50%, and in 20 (21.3%) cases the positive tumor cells were more than 50%. There was also a statistically significant correlation between p63 expression and tumor differentiation: p63 expression was amplified in poorly differentiated tumors (P < .05). When analyzed for prognostic significance, patients with perineural infiltration had poorer survival rates than the group with no perineural infiltration (P < .05) and patients with increased p63 expression had poorer survival rates than the group with reduced p63 expression (P < .05). The statistical analysis showed no significant correlation between p63 expression, sex, age, tumor size, staging, recurrence, and metastasis. Cases with diffuse p63 expression were more aggressive and poorly differentiated and related to a poorer prognosis. These data suggest that p63 expression may be useful to identify cases of oral squamous cell carcinoma with more aggressive and invasive phenotype providing novel diagnostic and prognostic information on individual patient survival with oral cancers.

Eagle's syndrome secondary surgical treatment. Report of a case

Eagle's Syndrome is reported to be the symptomatic calcification of the stylohyoid complex. Calcification of the stylohyoid ligament is a relatively common finding in the general population, however only a small percentage of these people presents symptoms. According to the kind of symptoms described by the patients it is possible to recognise two syndromes: the classic one, which occurs after a tonsillectomy, and stylo-carotid artery syndrome, which is independent from a tonsillectomy. The only effective treatment in symptomatic cases is the surgical shortening of the styloid process. The case presented underlines the problems due to the persistence of the calcified caudal portion of the stylohyoid ligament after a first surgical removal. A second surgical treatment is suggested for a complete resection of the calcified ligament which was causing the symptomatology complained by the patient. This patient had previously undergone surgical shortening of the stylohyoid ligament after he was diagnosed as having Eagle's Syndrome, of the styloid-carotid artery type. After a stylohyoidectomy, he still suffered from dysphagia, neck pain and scratching sensation when swallowing. Further surgical treatment was necessary, with the aim of removing the caudal portion of the ligament, which was causing the patient's symptoms. An extra-oral approach was used and, after surgery, the patient was completely relieved of the symptoms. Conventional and three-dimensional CT were performed after surgery, they showed the complete absence of the left calcified stylohyoid ligament.