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Patologie della base-cranica anteriore con Piezosurgery
No full text.PIEZOSURGERY®
Stato dell’arte e prospettive
Chirurgia Cranio Facciale Neurochirurgi
Commentary to: An aggressive ameloblastic fibroma in a 9‐year‐old child treated with buccal fat graft
No full textBenign odontogenic tumors comprise a complex
group of lesions described in the 2005 WHO
classification based on the presence of odontogenic
epithelium, odontogenic ectomesenchyme, or
both. Ameloblastic fibroma (AF) is defined in
WHO classification as “neoplasm composed of
proliferating odontogenic epithelium embedded in
a cellular ectomesenchymal tissue that resembles
dental papilla, and with varying degrees of inductive
change and dental hard tissue formation. Both the
epithelial and the connective tissue components of
AF are neoplastic.[1] The neoplastic nature of AF
is supported by reports of recurrence after surgery
and by cases of malignant transformation from a
pre‐existing AF.[2,3] AF is a rather uncommon tumor,
accounting for only 2.5% of all odontogenic tumors.
AF raises at any age, ranging from 6 months to
42 years (mean 3.6-15.5 years); it does not show
sex predilection. The lesion occurs in nearly 50‐80%
of cases in posterior areas of the mandible, molar,
or premolar locations as well. About 25% of AF
are associated with permanent tooth eruption
disturbances and impacted tooth, affecting several
teeth too.[4] The rare extraosseous and soft tissue
localization of the lesion is defined “peripheral AF”.
The initial and small lesions are asymptomatic,
whereas large and advanced ones lead to swelling
and jawbone deformities.[2,5] The dimension and
growth of the lesion are not related with patient’s
complain, and the neoformation is frequently
discovered accidentally during a simple dental
radiological examination.[4]
AF may appear radiographically as a well‐defined
uni or multilocular radiolucent lesion, giving rise
to expansion of the cortex, associated or not with
the crown of an unerupted tooth.[2,3,5] Differential
diagnosis may involve dentigerous cyst and
ameloblastoma on a radiological point of view.[4,6]
Tumor size varies from 1 to 8.5 cm.[3,5] Amina
et al. described an exceptionally large AF localized
in the upper jaw, unlike the most common site in the
posterior mandible.[7]
AF exhibits a slower clinical growth than, for
example, an unicystic ameloblastoma, and it does
not demonstrate an infiltrative pattern among
trabeculae of the surrounding bone. It produces
a enlargement of jawbone through a gradual
expansion of cortex so that bony surface appears
intraoperatively smooth.[4,5]
Conservative or extensive (radical) approaches
over AF treatment are advocated by different
authors. In consideration of the innocuous behavior
of the lesion, several authors proposed a meticulous
enucleation or curettage as the initial treatment,
keeping a block resection for recurrence.[5]
Recurrence rate after surgery is a controversial
issue, and it is estimated between 18.3 and
43.5%.[2,3] Residual tumor left at the time of curettage
or enucleation gives rise to recurrence, and this
induce some authors to advocate a more extensive
surgery as first removal of the lesion. Zallen and
coworkers recommends, in detail, a wide excision of
the tumor unless a significant cosmetic deformity is
produced.[3]
Detection of residual tumor and early recurrence
is possible through a long‐term postoperative
control. The follow‐up management does not have
a well‐defined protocol. Pereira plans to see the
patient twice a year and to obtain TC/OPT on yearly
basis for 2 years; any suspicion of recurrence needs
earlier clinical and radiological control.[8] Long‐term
follow‐up carried out by different authors report no
recurrence after conservative procedure (enucleations
and curettage).[2,3,5] Recurrence of AF may potentially
occur as the malignant histological counterpart,
i.e., as an ameloblastic fibrosarcoma.
Ameloblastic fibrosarcoma develops de novo or
in recurrent fibro‐odontoma or AF. The malignant
transformation in an ameloblastic fibrosarcoma
is rare, even though 30‐45% of ameloblastitc
has developed in pre‐existing or recurrent AF or
in ameloblastic fibro‐odotomas.[9] Ameloblastic
fibrosarcoma does not give rise to metastasis and
is associated with a high recurrence rate (35%)
and 20% of patients have died because of
disease within 3 months to 19 years. Most of
these patients had undergone a curettage or an enucleation at the same site 1‐10 years before
the malignant transformation.[9] In ameloblastic
fibrosarcoma transformation the mesenchymal
component becomes malignant, while the epithelial
component does not show signs of malignant
transformation.[5] The mesenchymal part may show
a step‐wise progression to malignancy, making
difficult to differentiate ameloblastic fibrosarcoma
from AF. Immunoistochemical studies (Ki‐65, p53,
PCNA) are useful for identifying the malignancy.[9
Retrospective analysis of orbital floor fracture: our clinical experience
No full textAim. This retrospective study aimed at investigating
indications, surgical approaches, and the materials
used for orbital floor reconstructions, as well as the
clinical followup, particularly with regard to postoperative complications.
Methods. This study comprised 120 patients who underwent surgery for orbital floor fractures between
2001 and 2011. Diagnosis and treatment were based
on both physical examination and orbital CT scan.
Patients were retrospectively analyzed for data, such
as mechanism of injury, classification of fracture, and
complications.
Results. The most common cause of injury was physical assault followed by traffic accidents. Surgery
was performed with a mean delay of 5 days after
the incident. Subciliary lower eyelid incision was the
most common surgical approach to the orbital floor,
followed by mid lower eyelid incision and transconjunctival lower-eyelid approach. For orbital floor reconstruction, collagenous membrane derived from
bovine pericardium (65%) is mainly used, followed
by titanium mesh (35%); 18.0% of patients showed
postoperative complications: 10.0% presented transient hypesthesia, 4.2% transient diplopia, 2.0% enophthalmos, 1% visible scar and 0.8% from scleral
show.
Conclusion. The main goal of this report is to discuss
indications and timing for surgical repair of orbital
floor fracture fractures and other facial fracture. Complications due to surgery are described
Sinonasal tumors with orbital involvement: the combined approach
No full textAdvanced sinonasal tumors often present with orbital involvement. Surgical treatment and radical excision are also possible preserving the eye. Oncological safety and functional outcome of preserved eye are the counterpart in orbital preservation surgery. Irrespectively of the orbital invasion, tumor histology influences the prognosis. Surgical approaches to the orbit in sinonasal tumor are divided in anterior and posterolateral procedures. The combined transfacial and trancranial surgical approach have been well described in the literature for craniofacial resection, when the anterior or medium skull base are involved. Multidisciplinary collaboration with microscopic and/or endoscopic control have improved surgical technique to extirpate tumors extended to dura, spehenopalatine area and pterygomaxilmary fissure, infratemporal fossa, roof of nasopharynx and apex of orbit. We describe the multiphase combined surgical approach whit maxillofacial, otolaryngology and neurosurgical collaboration in sinonasal tumor treatment
Lateral, Hemimandibular, Anterior.
No full textMaintaining projection and support of the lower face and planning for endosseous dental implant positioning require bony reconstruction of the mandible when a major defect occurred. To completely restore the anterior mandible, it is necessary to overcome the limited height of the fibula compared to the native symphyseal and parasymphyseal region; adequate bone height is a precondition for dental implant planning. Intraoral tissue reconstruction and a myofascial lining can also be performed with myofascial fibula flap or with simple/folded skin island of fibula flap. For the largest defects, a double flap (fibula osteocutaneous flap externally, radial forearm fasciocutaneous or vertical rectus abdominis myocutaneous intraorally) may be required. We briefly describe the mandibular reconstructive principles through fibula flap related to specific defects, referring to the classification proposed by Cordeiro et al
Technique
No full textThe aim of maxillary or mandibular reconstruction must be to restore not only aesthetics but also complete oral function. Cortical bone thickness, height, and bicortical structure of the fibula shaft is ideal for long-term implant-borne prosthetic rehabilitation. Fibular cortical thickness is superior with respect to the iliac crest or the scapula crest. The efficacy of dental implants placed into free fibula flaps for orofacial reconstruction has been thoroughly proved. Some authors have reported the possibility of inserting implants into the free fibula flap during the primary reconstruction. The major disadvantage of immediate implant insertion concerns the high possibility of misalignment of the fixtures. The use of oral implants in irradiated tissue is not considered to be contraindicated. The timing of the implantation procedure, with regard to the effects of irradiation on the jawbone, remains inconclusive for lack of scientific evidence. Typically, dental implants are placed 6–12 months after radiation therapy. The fibula flap is commonly harvested as osteocutaneous flap, so that a skin paddle is harvested with the fibula bone graft. The skin paddle is bulky, much thicker than the gingiva, not fixed to the bone by the periosteum, and not keratinized. Several techniques are used in soft-tissue management after a fibula vascularized graft, such as skin graft, mucosa graft, or biological membranes
BONE GRAFT SUBSTITUTES IN MAXILLO-FACIAL SURGERY
Full text linkBiomaterials for reconstruction of bony defects of the skull comprise of osteosynthetic materials applied after osteotomies or traumatic fractures and materials to fill bony defects which result from malformation, trauma or tumour resections. Other applications concern functional augmentations for dental implants or aesthetic augmentations in the facial region. The wide range of biomaterials available on the market, together with lack of established criteria to guide the use of a specific biomaterial in a particular application, has resulted in different surgeons using different materials, with no uniformity in clinical application. The optimal biomaterial that meets every requirement (e.g. biocompatibility, stability, intraoperative fitting, product safety, low costs etc.) does not exist. The different material types are (autogenic) bone and many alloplastics such as metals, ceramics, plastics and composites. We discuss our clinical experience in the use of biomaterials for craniofacial application and we present our experience with some experimental laboratory studies . Based on literature review, we present guidelines for use of different biomaterials in maxillo-facial surgery
Basic and advanced endoscopic sinus surgery course: open and endoscopic cadaver dissection techniques and live surgery.
No full textThis course originates from the close collaboration
experienced and established over many years between the
three professionals most involved in the surgical treatment
of lesions of the anterior skull base. We believe, and the
results have proved us right, that the achievement of the best
treatment in such complex anatomical regions can be born
only from an accurate preoperative study, the realization of
several surgical procedures and the care of every detail during
the post-operative period carried out in a close collaboration
among Otolaryngologists, Maxilo-Facial surgeons and
Neurosurgeons. The relatively recent introduction of
endoscopic surgery and the huge expansion of the latter has
further expanded the possibilities of collaboration.
On the other hand those who want to approach to this type of
pathologies necessarily have to know not only the techniques
and possibilities of endoscopy but also the open techniques
which are essential to face certain situations or clinical
manifestations.
The experience of many years of shared work between two
surgical university schools with great traditions such as
Modena and Verona besides a personal friendship established
over time has enabled us both to joint the three specialties
and to create a group that is inspired by the same principles
Il trattamento del collo cN0 nel carcinoma della lingua
No full textRisulta universalmente riconosciuta l’importanza oncologica dello svuotamento laterocervicale terapeutico (therapeutic neck dissection - TND) in caso di evidenza clinica o radiologica di metastasi linfonodali. Lo svuotamento elettivo (elective neck dissection - END), nel caso la stadiazione clinica di malattia risulti essere T1-T2/cN0, rimane invece uno degli argomenti più dibattuti degli ultimi cinquant’anni per ragioni legate alla morbilità chirurgica della procedura di dissezione chirurgica latero-cervicale (Kokemueller et al., 2002; Carlson et al., 2006). Attualmente si possono fondamentalmente individuare due scuole di pensiero: una che sostiene la necessità di eseguire lo svuotamento laterocervicale elettivo in unico tempo con la resezione del tumore primario e l’altra che propone la strategia del watchful waiting (attento monitoraggio). Da una parte il 60-80 % dei cN0 trattati risulta privo di metastasi occulte, e pertanto appare essere iper-trattato, ovvero gravato da una maggiore morbilità data da un secondo sito chirurgico al collo (cicatrici cutanee, asimmetria laterocervicale, possibile paresi del labbro inferiore e, in particolare, dolore e perdita di funzionalità della spalla con anche pesanti ripercussioni sulla qualità di vita dei pazienti) . D’altra parte gli esami diagnostici attualmente disponibili non consentono di identificare con sufficiente certezza le metastasi linfonodali; circa il 20-40 % dei colli cN0 operati risultano in seguito avere delle metastasi occulte ed andrebbero inevitabilmente incontro a recidiva latero-cervicale di malattia, se venisse applicata la teoria del watchful waiting. Sempre a supporto dell’intervento elettivo di svuotamento laterocervicale, diversi lavori dimostrano una migliore sopravvivenza e una minor frequenza di recidive in caso di svuotamento elettivo rispetto a quello terapeutico. Finalmente, un ampio studio prospettico randomizzato condotto su 500 pazienti con carcinoma squamo-cellulare T1-T2 del cavo orale dal Professor Anil D'Cruz supporta l’importanza dello svuotamento elettivo. Questo lavoro è stato presentato al congresso annuale dell’ASCO (American Society of Clinical Oncology) e pubblicato nel New England Journal of Medicine nel 2015 (D’Cruz et al., 2015). Secondo lo studio, nei 3 anni osservati, lo svuotamento laterocervicale elettivo (END) aumenta l’overall survival del 12,5% ed il disease free-survival de 23.6% rispetto allo svuotamento terapeutico (TND). Lo stesso lavora dimostra che l’unico fattore realmente legato ad una maggior probabilità di riscontro di metastasi linfonodali sembra essere una profondità del T maggiore di 3 mm, parametro verificabile solo con l’esame istologico del pezzo operatorio e quindi argomento non applicabile per far cadere l’indicazione ad uno svuotamento elettivo. In conclusione dobbiamo considerare che circa un terzo dei pazienti con carcinoma squamocellulare orale presenta tuttora (nonostante le nuove metodiche di imaging) metastasi linfonodali occulte alla diagnosi, e che, se non trattati chirurgicamente al collo durante l’asportazione del T, hanno possibilità di dover essere rioperati a livello latero-cervicale in un secondo tempo, con una minor prospettiva di controllo locoregionale della malattia ed una peggiore prognosi, considerati il maggior volume linfonodale e la possibile invasione extranodale. Quindi, nonostante il rischio di complicanze legate allo svuotamento laterocervicale (nello studio menzionato riguardano comunque solo il 5 % dei pazienti), al momento rimane indicato intervenire in maniera elettiva nei colli cN0. Riteniamo giustificato osservare questa pratica terapeutica perlomeno fino allo sviluppo di metodiche di imaging in grado di garantire una precoce diagnosi di metastasi occulte laterocervicali. Più precisamente lo svuotamento selettivo del collo è indicato nei pazienti con carcinoma squamoso del cavo orale senza evidenza clinica o radiologica di coinvolgimento linfonodale (N0), con un rischio di metastasi occulta del 15% - 20% e per i quali la chirurgia è il trattamento indicato per il tumore primitivo. Considerata l’anatomia del drenaggio linfatico della lingua che abbiamo riportato, ne segue che per i casi cN0 con carcinoma della lingua si esegua lo svuotamento sovraomoioideo elettivo (END), con dissezione del I-II-III livello linfonodale al di sopra del muscolo omoioideo
COMPOSITE CUSTOM-MADE BONE GRAFTS (SMARTBONE® ON DEMANDTM) FOR A LARGE SPHENO-ORBITAL RECONSTRUCTION
Full text linkThe treatment of anterior and lateral skull base tumors has always constituted a complex surgical challenge: extensive bony demolitions produce aesthetic deformities that need accurate reconstructions. Indeed, highly destructive procedures increased the need to introduce new reconstructive techniques. Wide defects, e.g. those involving more than a single orbital wall, have to be reconstructed with solid tissues such as autologus grafts or alloplastic materials. Surgical visual limits may reduce the possibility to properly repair the three-dimensional bony architecture of the craniofacial skeleton: because of the nonlinear nature of the bone in the craniofacial skeleton, even small degrees of error can lead to poor outcomes.
Here we investigated the innovative application of custom-made bone grafts in a case of skull base reconstructive surgery, a technique that is not previously reported. Innovations applied to this case were multiple: basing on high resolution patient’s CT scans, virtual surgery and computer-aided design were used to plan resection; contralateral disease-free skull base was used as a reference and mirroring technique was used to create the ideal grafts, which were then manufactured accordingly using the new composite custom-made bone grafts (SmartBone® on DemandTM). SmartBone® is shaping resistant and offers high tenacity to screws and surgical fixation manoeuvres, because it is produced by combining bovine mineral bone structures with biopolymers and cell nutrients (polysaccharides).
The patient underwent resection of a meningioma in the spheno-orbital-temporal region. The neurosurgeon resected the meningeal involved district, which was then reconstructed with a collagenous membrane. SmartBone® on DemandTM were then very precisely grafted into destination site. During follow-up, nor cerebrospinal fluid leakage nor intracranial infection were registered. Postoperative CT scans showed excellent stability and integration of all bone grafts; postoperative morphological results are satisfactory.
Outcomes confirm the high reliability and accuracy of virtual surgical planning and grafts design, which, together with SmartBone® high performances, allow producing very precise and stable custom-made grafts and, finally, addressing the previously unmet needs in skull base reconstructive surgery
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