Extended Complex Temporomandibular Joint Reconstructions Exploiting Virtual Surgical Planning, Navigation Assistance, and Custom-Made Prosthesis: A Comprehensive Protocol and Workflow

Background: Alloplastic temporomandibular joint (TMJ) replacement is a well-established procedure in maxillo-facial surgery. However, the surgical management of large excision in this area requires complex reconstruction beyond the standard TMJ prosthesis. Objective: This study aims to describe the design and the consequential application of a protocol which involves the use of computer-assisted surgery tools to best face complex TMJ reconstruction (TMJR). Preoperative accurate study of every single case and intraoperative check of the surgical act are nowadays essential to perform such delicate surgical procedures. Materials and Methods: The study is a retrospective and single institution case series. The various processes of the management and planning of extended TMJ reconstruction (eTMJR) are extensively described, from the preoperative clinical evaluation, imaging acquisition protocols and virtual surgical planning (VSP), focusing also on the intraoperative transfer of VSP using navigation and surgical guides. Results: We included nine patients with different pathologies which were candidates for eTMJR. Overall, the application of our protocol and workflow permitted the reduction of complications and pain, and the improvement of the maximum interincisal opening (MIO) of the patients, restoring patients’ masticatory function and esthetics. Conclusions: The eTMJR should be considered as a safe and reliable surgical management modality in selected patients with large temporomandibular joint and skull base (TMJ-SB) lesions. An accurate preoperative protocol and workflow is essential to perform such insidious and complex reconstruction. However, more extensive studies on this type of device have to be conducted in order to validate its real usefulness and indications

The Use of Artificial Intelligence Algorithms in the Prognosis and Detection of Lymph Node Involvement in Head and Neck Cancer and Possible Impact in the Development of Personalized Therapeutic Strategy: A Systematic Review

Given the increasingly important role that the use of artificial intelligence algorithms is taking on in the medical field today (especially in oncology), the purpose of this systematic review is to analyze the main reports on such algorithms applied for the prognostic evaluation of patients with head and neck malignancies. The objective of this paper is to examine the currently available literature in the field of artificial intelligence applied to head and neck oncology, particularly in the prognostic evaluation of the patient with this kind of tumor, by means of a systematic review. The paper exposes an overview of the applications of artificial intelligence in deriving prognostic information related to the prediction of survival and recurrence and how these data may have a potential impact on the choice of therapeutic strategy, making it increasingly personalized. This systematic review was written following the PRISMA 2020 guidelines

A case report of chondrocalcinosis of the temporomandibular joint: Surgical management and literature review

Background: Chondrocalcinosis is a metabolic disorder characterized by non-infectious joint inflammation with intra- or periarticular calcification. Temporomandibular (TMJ) chondrocalcinosis is rare and not usually included in the differential diagnosis of TMJ and facial pain disorders. Case report: A 67-year-old woman presented with a calcified mass in the right TMJ between the condyle and glenoid fossa, eroding into the floor of the middle cranial fossa due to calcium pyrophosphate deposition in the TMJ. She underwent surgical excision of the mass with immediate econstruction with a custom-made prosthesis. On follow-up, there was complete clinical resolution, with no evidence of recurrence. Literature related to surgical treatment of chondrocalcinosis of TMJ and its treatment was reviewed. Surgery is the most commonly used treatment. A custom-made device allowed us to bridge the defect caused by the destructive disease process. Conclusion: Custom-made prostheses can be considered a safe and effective solution in erosive forms of chondrocalcinosis, replacing the TMJ to restore functionality and correct the anatomical defect

Double osseous flaps for simultaneous midfacial and mandible reconstruction: Automation in surgical complexity within an entirely computerized workflow

Introduction: Broad maxillofacial surgical resections involving both the midface and the mandible represent a challenge in terms of reconstruction. Although several papers have explored the possibility of simultaneously using two microsurgical flaps, reports on the implementation of a dual osseous flap strategy are limited, and mainly addressed to static anatomical reconstruction, regardless of functional implications. In particular, there is a lack in the literature of a unifying protocol which illustrates how technology including virtual planning, statistical shape modeling, virtual occlusion, 3D-printing and patient-specific implants can address the functional and accuracy needs required for an optimal reconstruction. Materials and methods: In this paper, the Authors present their preliminary experience in a two-center study, showing how broad maxillofacial defects, requiring a simultaneous reconstruction in both the mandible and the midface, can be successfully reconstructed using the combination of two osseous flaps in an automated sequence in which all steps are anticipately defined in a virtual plan, accounting for the optimal alignment of temporomandibular joint, predicting the final occlusion and defining a mandibular shape according to a statistical shape model. Results: Average RMSE for the iliac bone crest flap was of 3.2 ± 0.36 mm; for the fibula flap, RMSE value was of 2.3 ± 0.65 mm, for patient-specific implants, for mandibular prostheses the average RMSE was 2.46 mm with 0.76 mm standard deviation. Temporomandibular joint function increased when a TMJ prosthesis was placed. Conclusions: Double bone free flap is a valuable resource to reconstruct wide defects that simultaneously involve two thirds of the cranio-maxillo-facial skeleton, but a careful virtual planning study should be always performed before approaching this surgical option

The Transantral Endoscopic Approach: A Portal for Masses of the Inferior Orbit\u2014Improving Surgeons' Experience Through Virtual Endoscopy and Augmented Reality

In the past years, endoscopic techniques have raised an increasing interest to perform minimally invasive accesses to the orbit, resulting in excellent clinical outcomes with inferior morbidities and complication rates. Among endoscopic approaches, the transantral endoscopic approach allows us to create a portal to the orbital floor, representing the most straightforward access to lesions located in the inferior orbital space. However, if endoscopic surgery provides enhanced magnified vision of the anatomy in a bloodless field, then it has several impairments compared with classic open surgery, owing to restricted operative spaces. Virtual surgical planning and anatomical computer-generated models have proved to be of great importance to plan endoscopic surgical approaches, and their role can be widened with the integration of surgical navigation, virtual endoscopy simulation, and augmented reality (AR). This study focuses on the strict conjugation between the technologies that allow the virtualization of surgery in an entirely digital environment, which can be transferred to the patient using intraoperative navigation or to a printed model using AR for pre-surgical analysis. Therefore, the interaction between different software packages and platforms offers a highly predictive preview of the surgical scenario, contributing to increasing orientation, awareness, and effectiveness of maneuvers performed under endoscopic guidance, which can be checked at any time using surgical navigation. In this paper, the authors explore the transantral approach for the excision of masses of the inferior orbital compartment through modern technology. The authors apply this technique for masses located in the inferior orbit and share their clinical results, describing why technological innovation, and, in particular, computer planning, virtual endoscopy, navigation, and AR can contribute to empowering minimally invasive orbital surgery, at the same time offering a valuable and indispensable tool for pre-surgical analysis and training

Redesigning the paradigms of clinical practice for oral and maxillofacial surgery in the era of lockdown for covid-19: From tradition to telesemeiology

The rise of the COVID-19 pandemic has posed new challenges for health care institutions. Restrictions imposed by local governments worldwide have compromised the mobility of patients and decreased the number of physicians in hospitals. Additional requirements in terms of medical staff security further limited the physical contact of doctors with their patients, thereby questioning the traditional methods of clinical examination. Our institution has developed an organization model to translate the essential clinical services into virtual consultation rooms using a telemedicine interface which is commonly available to patients. We provide examples of clinical activity for a maxillofacial surgery department based on teleconsultation. Our experience is summarized and an organization model is drafted in which outpatient consultation offices are translated into virtual room environments. Clinical examples are provided, demonstrating how each subspecialty of oral and maxillofacial surgery can benefit from virtual examinations. The concept of \u201ctelesemeiology\u201d is introduced and a checklist is presented to guide clinicians to perform teleconsultations. This paper is intended to provide an organization model based on telemedicine for maxillofacial surgeons and aims to represent an aid for colleagues who are facing the pandemic in areas where lockdown limits the possibility of a physical examination

The Role of Temporomandibular Joint Arthroscopy for Diagnosis and Surgical Management of Synovial Chondromatosis

Objective: We report the experience of our maxillo-facial surgery unit into the diagnostic and the therapeutic role of arthroscopy of temporomandibular joint (TMJ) synovial chondromatosis (SC). Materials and Methods: A series of sixteen patients with an imaging, arthroscopical, and histological diagnosis of SC treated with arthroscopy was selected. The surgeries were conducted in the Department of Maxillo-facial surgery, Academic hospital of Udine, from January 2016 to December 2022. Medical history, clinical examination, imaging, arthroscopical, and histological characteristics were recorded and then reviewed and discussed. Results: Clinical improvement, both in pain and in maximum incisal opening (MIO), were noticed in whole patients. Histologically, according to Milgram’s classification, the sample was fairly homogeneous. Arthroscopic treatment was successful in 87.5% of the patients. Only two cases of SC relapse were registered and were then submitted to open surgery to perform a total sinovectomy. The data collected were used to develop an SC classification proposal based on clinical, radiological (magnetic resonance imaging), arthroscopical, and histopathological characteristics. Conclusions: TMJ arthroscopy must be considered the first line of treatment for SC, leaving open surgery to relapses cases and those cases with extraarticular extension. A univocal classification is essential to best stage and prognostically characterise this pathology

Custom-Made Alloplastic Prosthetic Implant to Treat Temporomandibular Joint Ankylosis in Pediatric Patients: A Case Study

Temporomandibular Joint (TMJ) ankylosis represents a fairly common condition which surgeons need to face. According to Rowe, it can be defined as a restricted functional capacity of the jaw with limited movements owing to bony or fibrous adhesions between the condyle and either glenoid fossa, disc or eminence (or both). It can become a disease which impacts patients' daily life, who suffer from limited mandibular excursion with reduced intercisal opening, anterior open bite, inability to swallow, sleep disorders, and speech problems. In children this may also result in abnormal mandibular and facial growth. In this paper, we deal with the case of a child with an important momolateral ankylosis, previously treated surgically with Costochondral Grafting arthroplasty without success and subsequently treated with a custom-made prosthesis

Outcomes of a Pharmacological Protocol with Pentoxifylline and Tocopherol for the Management of Medication-Related Osteonecrosis of the Jaws (MRONJ): A Randomized Study on 202 Osteoporosis Patients

Medication-related osteonecrosis of the jaws (MRONJ) is a challenging situation in clinics. Previous studies have shown that pentoxifylline combined with tocopherol proved to be beneficial in patients with osteoradionecrosis, due to their antioxidant and antifibrotic properties. The aim of this randomized study was to evaluate the effect of pentoxifylline and tocopherol in patients that had developed MRONJ after tooth extractions. The study population consisted of 202 Stage I MRONJ female patients with an average age of 66.4 ± 8.3 years, who were divided into two groups. The test group (n = 108) received a pharmacological protocol with pentoxifylline and tocopherol (2 months pre-operatively and 6 months post-operatively). The control group (n = 94) had sequestrectomy operations without any pharmacological preparation. The main outcomes were clinical healing of the mucosa after 1 month, and clinical and radiographic healing of the bone lesion at 6 months. In the test group all patients had mucosal healing and there was only one relapse within 6 months. In the control group, in 17% of the patients the mucosa did not heal, 71% of the patients relapsed within two months, and 7% developed infectious complications (such as abscess or phlegmon). After 6 months, the control group patients with persisting issues were prescribed pentoxifylline and tocopherol, as in the test group. At a subsequent follow-up, all those patients healed completely. Patients were monitored for a period of 7.8 ± 0.3 years, during which no relapse or additional problems were reported. As a conclusion, pentoxifylline and tocopherol protocol seems to be beneficial in the management of MRONJ patients