XXV Congresso Nazionale
Collegio dei Docenti Universitari
di discipline Odontostomatologiche
CHIRURGIA MAXILLO FACCIALE
Conservative surgical management of a large
maxillary intrasinus ameloblastoma with
adi-pose bichat bulla flap
B. Poletti de chaurand, g. Patianna, a. Bianco, l. casula, r. Vinci
Oral and Maxillofacial Department, Vita-Salute San Raffaele University, Milan, Italy
BacKgroUND: “ameloblastoma” descends from the early english word “amel”, meaning enamel, plus the greek word “blastos”, meaning germ. it is a rare tumor of odontogenic epithelium and can cause severe abnormalities of the face and jaw. it is rarely malignant or metastatic. there are six different histopathological variants of ameloblastoma: desmoplastic, granular cell, plexiform, follicular, acanthomatous and basal cell. one-third of ameloblastomas are plexiform, one-third are follicular. considering their growing capacity without being symptomatic in mostly of all the clinical cases, the purpose of this study was to report a case of a large intrasinus ameloblas-toma and to stress the importance of a conservative treatment. MetHoDS: We report a case of a 52 year old italian female who was referred to the oral and Maxillofacial department of San raffaele institute. the patient was asymptomatic. Pre-operative ortopantomography disclosed a well corticated radiolucent lesion approximately 5x5cm on the right maxilla. the presence of the osteolytic lesion was confirmed by a ct. in order to expose the entire lesion, a trap door was created by ostectomy and the surgical enucleation of the ameloblastoma was performed without including the nearby implant. an adi-pose Bichat bulla flap was performed to allow an appropriate and primary healing closure.
reSUltS: the histological examination revealed a basal cell type ameloblastoma. the patient has referred no post-operative pain and the lesion healed without any complication. there has been no signs of recurrence or metastasis within a period of six months after the operation, but the patient con-tinues under observation.
coNclUSioNS: a systematic review of the literature of the basal cell ameloblastoma was made too. till date only 10 cases of basal cell ameloblastoma has been reported in literature out of which nine described a non-conservative treatment with par-tial maxillectomy or mandibulectomy. Due to a lack of orga-nization of the studies present in literature and a poor strength of evidences, in order to better understand the best surgical approach to perform, randomized clinical trials based on treat-ment modality and histological subtypes are necessary. the recurrence rates of basal cell ameloblastoma have not been reported due to the limitation in the number of cases. on the available information the basal cell variant needs an appropriate diagnosis based not only on clinical and radiological appear-ance but also on histopathologic analysis. Follow up should occur at regular intervals for at least 10 years because 50% of all ameloblastoma recurrences occur within 5 years postopera-tively. long-term follow-up after surgery is strongly recom-mended also to establish the recurrence rate.
Primary intraosseous squamous cell carcinoma
M. Vasselli 1, a. camurri Piloni 1, r. rizzo 1, r. Bussani 2, g.
tirelli 3, M. Maglione 1
1ASUITS, SC Clinica di Chirurgia Maxillofacciale e
Odontos-tomatologica; 2ASUITS, SC Clinica Otorinolaringoiatrica; 3
AS-UITS, SC Anatomia ed Istologia Patologica
BacKgroUND: the aim of this work is reporting a rare case of Primary intraosseous squamous cell carcinoma that is a cyst-like lesions in the mandible rarely develop into malig-nancies, and the reported incidence is between 0.3 and 2%. the case here described is a rare case of primary intraosseous squamous cell carcinoma of the mandible arising from an odontogenic cysts.
MetHoDS: a 80-year-old male with history of diabetes type ii, chronic renal insufficiency and cardiac issues, was referred to trieste University Maggiore Hospital (trieste, italy), with acute pain in the left retromolars area. at the moment of the first visit was reported also a Warthin’s tumor affecting the left parotid gland. an initial examina-tion revealed extra oral swelling without paresthesia of the omolateral Nai. Following an intraoral examination, the oral mucosa was edematous, percussion pain was expe-rienced on the lower left second molar. Panoramic radi-ography revealed a retained lower left third molar and an irregular radiolucent area between the lower left second molar and a mandibular angle with mostly clear margins based on the bidimensional radiology. in addition com-puter tomography revealed diffuse bone resorption and an extensive loss of cortical bone on the lingual side. During the surgery aimed to remove the second and third lower left molars, a biopsy was performed and the pathological diagnosis was of a squamous cell carcinoma arising from the epithelial lining of the odontogenic cyst. computed tomography with contrast agent was performed that showed a primitive neoformation located into the horizontal branch of the left mandible eroding both the cortical and lingual walls and it extends from the lower left retromolar region towards the omolateral lower cuspid, infiltrating the buc-cinator and medial pterygoid muscles. to the patient has been proposed a segmented mandibulectomy with later-ocervical radical neck dissection associated with plastic reconstruction using the fibula and radial flap. During the surgical procedure it was assessed that was not possible to use the fibula flap.
reSUltS: the histopathological analysis showed a pri-mary squamous cell carcinoma staged as follows: pg2. c2. t4a. N1.
coNclUSioNS: Primary intraosseous squamous cell carci-noma has a predilection for adult men, occurs most frequently in the mandible and is associated mainly with an odontogenic cyst. Surgery alone or combined therapy of surgery and radia-tion are the most common approach. Following enuclearadia-tion of a cystic jaw lesion, the entire surgical specimen should be examined histopathologically.
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patients with a propensity for the head and neck. Mcc occurs mainly in immunosuppressed patients and its clinical prog-nosis is very poor. these tumors tend to local invasiveness, recurrence and to distant metastasization. Merkel cells are afferent sensory receptors found in the basal layer of the epi-dermidis that function as mechanoreceptors. recent studies have questioned the theory that Mcc originates in Merkel cells, originally described as ”tactile epithelial cells” by Friedrich Sigmund Merkel in 1875. Mcc and Merkel cell polyomavirus (McPyV) association has been observed by numerous studies and it seems to be linked approximately in 80% of the cases. evermore, the presence of Mcc associated with an increased risk of non-Hodgkin lymphoma (NHl) or chronic lymphocytic leukemia (cll) occurrence has been highlighted in the last years. Mcc incidence varies between 0.1 and 0.88 per 100.000 person-years. We present the case of a 71-year-old male patient with a history of Malt lymphoma occurring 5 years earlier that was referred to our hospital for a painless swollen mass in the right parotid region. Parotid gland lesion was clinically related to progressive Malt lymphoma and only surgical enu-cleoresection demonstrated Mcc diagnosis.
MetHoDS: Ultrasound examination showed a mass in the superficial portion of the right parotid gland (4,0cm x 2,5cm) hypoechoic and homogeneous, fine needle aspiration cytol-ogy (FNac) was performed and revealed a lymphoid neo-plasm, susceptible to immunophenotypic typing. total body computed tomography (ct) was unremarkable and the Pet/ ct with 18-fluorodeoxyglucose (18-FDg) showed increase standardized uptake value (SUV) of the lesion. a contrast-enhancement computed tomography (ct) revealed a 4,6 cm x 2,6 cm homogeneously hyperdense enhanced mass in the superficial lobe of the salivary gland.
reSUltS: Surgical enucleoresection was performed and tumor histological examination demonstrated a deep atypical homogeneous infiltrated of medium large cells with regular round nuclear contours and vesicular to granular chromatin. tumor immunohistochemical analysis revealed positivity for cytokeratin 20 (cK20). in addition, Mccs express early B-cell lineage markers, such as paired box gene 5 (PaX 5) and terminal desoxynucleotidyl transferase (tdt).
coNclUSioNS: tumor immunohistochemical analysis revealed the presence of markers for cK 20, PaX5 and tdt, the last two ones are specific to early B-cells. it is important to define the true origin of Mccs, because the identification of new markers in Mccs could be the starting point for new target therapies.
The use of three-dimensional reconstructions
of CT scan data to evaluate anomalies of hyoid
bone in Pierre Robin sequence: a retrospective
study
S. Barone 1, F. Bennardo 1, K. Belhous 2, M.P. Vazquez 2, V.
abadie 2, a. Picard 2, a. giudice 1, 3
1School of Dentistry, Department of Health Sciences, Magna
Graecia University of Catanzaro, Catanzaro Italy; 2Department
of Maxillo-facial and Plastic Surgery, Necker-Enfants Malades Hospital, Paris Descartes University, Paris, France; 3Unit of
Oral and Maxillofacial Surgery, Magna Graecia University of Catanzaro, Catanzaro, Italy
BacKgroUND: the aim of the study was to investigate hyoid bone anomalies in patients with isolated and syndromic Pierre robin sequence (PrS) compared to the control group, using computed tomography (ct) examination and
three-Frey’s syndrome treatment with botulinum
neurotoxin: our experience
W. colangeli, Novembre, i. Barca, c.e. Boschetti, r. cordaro, a. cirelli, M.g. cristofaro
University “Magna Graecia” of Catanzaro, Department of Ex-perimental and Clinical Medicine, Unit of Oral and Maxillofa-cial Surgery, Catanzaro, Italy
BacKgroUND: Frey’s Syndrome (FS) can occurs after parotid gland surgery or facelift and is characterized by sweating, ery-thema and warm sensation in the parotid gland region after eating certain foods (especially acid foods). this syndrome is caused by the disruption of the auriculotemporal nerve branches, fol-lowed by an aberrant regeneration resulting in a parasympathetic reinervation with sympathetic receptors. Numerous medical and surgical treatments have been proposed to treat this condition, but there are various drawbacks.Botulinum toxin type a intracutane-ous injection is a relatively new treatment modality, and could be considered the gold standard treatment. Frey’s syndrome man-agement with BoNt (botulinum neurotoxin), was first proposed in 1995 by Drobik and laskawi.
MetHoDS: Between January 2012 and December 2016, five patients affected with gustatory sweating were treated with intracutaneous injection of botulinum toxin type a. gustatory sweating and extension of the affected area was assessed by starch-iodine Minor test. Patients ate an orange, provoking the immediate appearance of brownish spots and adjacent erythema, confirming the clinical picture of gustatory sweating. BoNt mean dose 30 U (at a concentration of 2.5 U/0,1 ml) was injected in minor test positive areas. We performed 5 U BoNt injection for cm^2, with a total of six injection for each patient.the potential for this long-delayed clinical presentation should be discussed with the patient before surgery in the parotid gland.
reSUltS: all patients underwent 3 BoNt treatments in 12 months, 1 every 4 months. No adverse effects were observed. Symptomatic improvement was reported a few days after the injection, by all the patients. three weeks after BoNt injection a starch iodine minor test was performed for each patient confirm-ing gustatory sweatconfirm-ing and a flushconfirm-ing improvement.
coNclUSioNS: Various prophylactic and therapeutic surgi-cal strategies have been proposed to minimize the incidence or severity of Frey syndrome following parotidectomy, including temporal fascia grafting, the application of synthetic material to the surgical field at the time of surgery and ligature of the auriculotemporal and chorda tympani nerves.our data suggest that the Botulinum toxin type a intracutaneous injection can be recommended as that of choice in patients affected by Frey’s syndrome because it is an effective, safe, minimally invasive and well-tolerated treatment and can be repeated if symptoms recur, with no loss of efficacy. in managing symptomatic complaints of Frey’s syndrome, BoNt injection, although not definitive therapy can significantly decrease the severity and thus morbid-ity Frey’s syndrome. Surgical management post parotidectomy Frey’s syndrome should be reserved for severe and refractory cases, as there are limited data to support its use.
Metachronous malt lymphoma and mcc: could
the two neoplasms share a common pathogenesis?
i. Barca, W. colangeli, c. tortosa, D. caruso, D. Novembre, a. cirelli, M. g. cristofaro
Department of Experimental and Clinical Medicine “Magna Graecia” University of Catanzaro, Catanzaro, Italy
BacKgroUND: Merkel cell carcinoma (Mcc) is a rare and aggressive cutaneous neuroendocrine carcinoma in older
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an important psychological impact by having the puberty of onset. this work describes surgical management and an over-view of the syndrome. the importance of the knowledge of this rare framework allows to avoid a missed or wrong diagno-sis, translating a more rapid and correct patient management. MetHoDS: in this article we report two infrequent cases, one of classical ascher syndrome, and one with a rare vari-ant of this syndrome involving upper and lower lips. Both patients referred to the Maxillofacial Surgery Unit of the “Magna graecia” University of catanzaro. Surgery was per-formed removing mucosa and structures of submucosal layer (minor salivary glands), by transversal elliptical incision and by blunt dissection. case 1. a 22-year-old man presented at the Maxillofacial Surgery clinic with a asymmetrical upper lip duplication. this abnormality of the upper lips began to be evident during childhood. Upper eyelids bilaterally showed a dropping like a blepharochalasis. No evidence of thyroid goiter was highlighted. case 2. a 27-year-old man presented at the Maxillofacial Surgery clinic with a congenital sym-metrical lip duplication of upper and lower lips that was pre-sent from birth. the upper lips showing a horizontal furrow on mucosal side with mucosal protrusions. He don’t refer to problems other than cosmetic ones. careful clinical evaluation revealed no abnormalities of the oral mucosa or the presence of palpable masses. Face and neck inspection highlighted the presence of blepharocalasis and likely goiter. Blood test and neck’s ultrasound examination confirmed presence of a euthyroid goiter.
reSUltS: Both patients well tolerated surgery. No alteration of sensibility was reported Maintenance of adegue lips pro-file. Both patients achieved great satisfaction for the improve-ment of relational life and facial aesthetics. No recurrence was observed at 1 year of follow-up
coNclUSioNS: the scientific literature actually describes less than 60 cases. Differential diagnosis for asher’s syn-drome should also include vascular tumors, lymphangioma, angioedema, cheilitis granulomatosis, Miescher’s syndrome, salivary gland tumors, inflammatory fibrous hyperplasia, sar-coidosis and plasmacell cheilitis. early diagnosis in ascher’s syndrome prevents therapeutic delays. adequate esthetic correction is possible ande sufficient to bring the patient back to “normality”, with a minimum risk of recurrence. Findings, blepharochalasis, double lips and goiter reported in this case are consistent with diagnosys of ascher syndrome. importance of recognition this signs have to alert surgeon to propose a diagnosis of ascher’s syndrome and so avoid unnecessary investigations and inappropriate surgery.
Intraoral approach to removal of Wharton
duct large sialolith
D. caruso, e. giofrè, D. Novembre, c. tortosa, r. cordaro, c. e. Boschetti, M.g. cristofaro
University “Magna Greacia” of Catanzaro, Department of Ex-perimental and Clinical Medicine, Oral and Maxillofacial Sur-gery Unit, Catanzaro, Italy
BacKgroUND: Sialolith is a calcareous concretion “calculus” in the salivary ducts or glands, frequently sub-mandibulary gland and its duct. the presence of a sialolith predisposes for onset of a scialolithiasis, this is a benign a infectious-inflammatory condition. Based on size and degree of calcification , calcification can be visible at x-ray exami-nations. Patients typically report remitting tumefaction, pain, edema, redness of oral floor and the submandibular dimensional reconstruction of the hyoid bone and mandible.
MetHoDS: a retrospective study was performed of patients between birth and 12 months old with isolated PrS (ns-PrS) and syndromic PrS (s-PrS), who had undergone ct exami-nation and whose results were compared to the control group of the same age. Digital imaging and communications in Medicine (DicoM) data was processed using the Materialise interactive medical image control system (MiMicS) innovation Suite (Materialise, leuven, Belgium) software to highlight bone tissue. the mandible and hyoid bones were the main targets of the three-dimensional reconstruc-tion. the study outcomes were the ossification of the hyoid bone defined by the body’s maturation and distinguished in three degrees: full ossification (correct development of body and greater horns), moderate abnormalities (reduced devel-opment of all or parts of the hyoid bone), severe anomalies (absence of the hyoid bone or significant lack of ossification of its parts); the position of hyoid bone evaluated using the distance between the anterior edge of hyoid bone and posterior edge of the mandible; the volume of the hyoid bone calculated by a specific function of the software after segmentation and 3D reconstruction of the hyoid. Univariate and multivariate statistical analyses were performed with α = 0.05 as level of significance.
reSUltS: Hyoid bone ossification was present in 26 of the 50 PrS patients (14 ns-PrS and 12 s-PrS: 52%) and in 31 infants of the 43 controls (72%). Statistical analysis showed that absence of hyoid bone ossification was significantly asso-ciated with a diagnosis of PrS (p <0.05). Furthermore, com-parison to the control group showed that the syndromic form of PrS had worse development of the hyoid body (p <0.05) than the ns-PrS group did. the mean distance was 21.5 ± 4.9 mm in the PrS group and 25.8 ± 5.5 mm in the control group. only s-PrS patients showed a statistically significant reduc-tion of the distance between hyoid and mandible compared to the control group (p <0.001). the mean value of the volume was 86.8 mm³ in the PrS group and 140.7 mm³ in the control group. the hyoid volume was significantly lower in the s-PrS group than in controls (p <0.001), whereas ns-PrS patients did not differ from the control group (p >0.05).
coNclUSioNS: isolated and syndromic PrS patients dif-fer not only etiologically but also clinically. S-PrS patients confirmed their worst clinical condition with a deeper involve-ment of craniofacial anomalies. Because hyoid bone altera-tions usually result from abnormalities of the second and third branchial arches, s-PrS pathogenesis is not related solely to problems of the first branchial arch from which maxillary bones develop.
Ascher’s syndrome - a rare variant of a rare
syndrome
D. caruso, i. Barca, a. giudice, e. giofrè, a. cirelli, l. Brizzi, M.g. cristofaro
University “Magna Greacia” of Catanzaro, Department of Ex-perimental and Clinical Medicine, Oral and Maxillofacial Sur-gery Unit, Catanzaro, Italy
BacKgroUND: ascher’s syndrome (laffer–ascher syn-drome) is a disease of unknown etiology. it was first described in 1920. typical presentation includes recurrent edema of the upper lip, upper eyelid resulting in a double lip and blepharo-faxase. in 10% of cases, non-toxic idiopathic thyroid enlarge-ment also occurs. in about 5% of cases there is the involve-ment of both the upper and lower lips. this syndrome can have
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same blind operator and records at t0 and t1 have been
col-lected by the same student of Dental School of Department of Surgery, Dentistry, Pediatrics and gynecology of University of Verona. the procedure proposed in this work consists of two different surgical steps. the first step is the endoscopic transnasal intervention, the Functional endoscopic Sinus Surgery (FeSS), in order to treat the sinusitis. the second one is an open intraoral surgical approach in order to remove the osteonecrotic bone. During the intraoral step, the residual oro-antral bone defect is corrected and closed using the Bichat fat pad. these two steps are performed in the same intraopera-tive session.
reSUltS: in t0 the average lund-Mackay ct score was 6.5
and in t1 1.125. t0 average SNot20 value was 74.25 whereas
it decreased to 14 in t1.VaS average at t0 was 7.34 and 0
in all patients in t1. the major potential of this technique is
found in the use of Bichat adipose pad because of its particular anatomical position and composition: 6 ligaments, 1 artery and 2 veins. the high mobility of Bichat pad allows to use it as a rotation flap as well as a revascularized flap.
coNclUSioNS: this work suggests that the combined treatment for odontogenic sinusitis caused by MroNJ might be a valid surgical approach. it could be so possible to treat MroNJ and the consequent sinusitis by a combina-tion of two kind of surgical techniques never matched before. Further evaluations, greater patients enrollment and a longer follow-up could be recommended to confirm these encourag-ing results.
Middle meatal antrostomy prevents sinusitis
after zygomatic implants placement
V. Favero 1, a. D’agostino 2, l. trevisiol 2, J. Venco 3, l.
la-naro 1, P. Procacci 4, P.F. Nocini 5
1MD, Clinical Assistant; 2MD, Associate Professor; 3Student,
Dental School; 4MD, Assistant Professor; 5MD, DDS, Full
Pro-fessor and Head of Department, Unit of Maxillo-Facial Surgery and Dentistry - University of Verona, Verona, Italy
BacKgroUND: to evaluate the role of middle meatal antrostomy in preventing the occurrence of maxillary sinusi-tis following zygomatic implants placement. the authors hypothesize that middle meatal antrostomy may help reduce the incidence of this frequent and potentially serious com-plication.
MetHoDS: a prospective longitudinal study on patients enrolled in a single maxillo-facial surgery unit was per-formed. Patients underwent 4 zygomatic implants placement with intrasinusal technique and simultaneous middle meatal antrostomy with endoscopic approach. inclusion criteria were being eligible for extreme maxillary atrophy rehabilitation with zygomatic implants. exclusion criteria were positive personal history for allergic rhinitis, previous sinus surgery, nicotine addiction, or radiological evidence of thickened mucosa or opacification of the maxillary sinuses, evaluated by means of cone beam ct scans. radiologic findings of thickened mucosa or opacification of the maxillary sinuses were evaluated on computed tomograms performed 12 months after surgery using the lund-Mackay Staging System. clinical symptoms were evaluated both preoperatively and postoperatively 12 months after surgery using the Sino-Nasal outcome test-20 (SNot-20), which is a questionnaire evaluating the relevance in eve-ryday life of a series of symptoms that may be related to the health status of paranasal sinuses. the occurrence of intraop-erative shearing of the Schneiderian membrane was recorded. region. large sialoliths can be removed with different types
of approaches, intraoral, extraoral, endoscopic depending on its position, shape and size, as well as on the basis of the surgeon’s experience.
MetHoDS: in this paper we report two cases of large sialolith located in submandibular gland duct removed with intraoral approach, and explain risks and benefits of intraoral approach. the cases described concern two men of 58 and 62 years, both affected by sialolithiasis of the submandandar gland duct, treated at Maxillofacial Surgery Unit of “Magna graecia” University of catanzaro. clinical history of the two patients is practically superimposable, with repeated epi-sodes of tumefaction and pain in submandibular region that increased during meals. clinical diagnosis was confirmed by radiological diagnosis, (echography, orthopantomogra-phy, tc scan). Patients underwent excision of the calcula-tion with intraoral approach in local anesthesia. Surgery was conducted highlighting distal duct tract and dissecting it with the scalpel. Duct cavity was gently dilating until calculus is found, pay attention to point where duct inclines downwards “comma”. the procedure ends with the sialoliths removal and packaging of a “neo-stoma” . Postoperative radiographic evaluation was performed confirming complete sialolith removal. clinical follw-up were performed at 7 days, 1 and 6 months and 1 year.
reSUltS: Procedure was well tolerated, good healing of surgical wound was observed; no infection and well con-trolled pain. Both patients tolerated the procedure well. No hematomas or sialoceles were found in the submandibular and sublingual region. No sequelae were reported to the ductal apparatus of Wharton or lesion of the lingual and / or hypo-glossal nerves. Maintenance of salivary gland activity has been reported in both patients.
coNclUSioNS: We believe that the intraoral approach is a suitable alternative for removal sialoliths of localized also in the proximal portion of the Wharton duct. intraoral approach appears to have a good prognosis without neurological deficit and with the recovery / maintenance of the residual function of the salivary gland.
Medication-related osteonecrosis of the upper
jaw associated with sinusitis: new surgical
com-bined approach with reconstruction by bichat
fat pad
S. orlandi, S. Bonetti, M. Magi, e. Simeoni, M. Marostegan, l. lanaro, F. lonardi, F. Zotti
Department of Surgery, Dentistry, Pediatrics and Gynecology of University of Verona, Verona, Italy
BacKgroUND: to assess the effectiveness of the new com-bined surgical intraoral and endoscopic transnasal approach, associated with immediate maxillary reconstruction by means of facial adipose fat pad, in patients suffering by Medical related osteonecrosis of Jaws (MroNJ) and subsequent odontogenic sinusitis.
MetHoDS: Seven patients eligible for combined intraoral and endoscopic surgery were enrolled in the study from 2014 to 2017. Staging of osteonecrosis and sinusitis was performed according to current guidelines at baseline (Pre-surgery, t0).
evaluation of signs and symptoms of osteonecrosis and sinusi-tis was carried out by using SNot20, VaS scale and lund - Mackay ct Score at baseline and 3 months after surgery (t1).
the cutting-edge surgery procedure was performed by the
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maxillary or mandibular resections for benign or malignant oral tumours and simultaneous microvascular reconstructions with fibula free flaps. 20.8 (8–38) months after the recon-structive surgery 108 dental implants were placed. eighteen patients received a fixed prosthesis while three received an implant-supported overdenture. clinical data as the probing pocket depth, the presence of suppuration and bleeding on probing and the occurrence of hyperplastic tissue formation were collected from medical records and implant bone loss was measured on radiographs to determine survival and suc-cess rates. the possible influence of radiation therapy, the reconstructive technique and the use of soft tissue grafts as prognostic factors were determined.
reSUltS: the mean follow-up after implant insertion was 90.2 (20–204) months. the implant survival rate was 97.2% at the 12-month follow-up, 86.5% at 60 months, and 79.3% at 120 months. the rate of implant success was 95.4% at the 12-month follow-up, 73.5% at 60 months, and 64.7% at 120 months. implant failure was more common in patients that had implants placed after they underwent radiation ther-apy (p = 0.001) versus those who did not. Peri-implant bone loss ranged from a minimum of 0.5 mm to a maximum of 8.1 mm (mean 2.2±1 mm) at the 10-year follow-up. Peri-implant probing depth measures ranged from a minimum of 2 mm to a maximum of 9 mm (mean 3.8±2 mm). Peri-implant hyperplasic tissue was identified in 20.3% of the surviving implants at the 10-year follow-up and its presence impacted the rate of peri-implant bone loss. connective tissue and skin grafts positively influenced both survival and success of implants and reduced the risk of peri-implant hyperplastic tissue formation.
coNclUSioNS: the overall implant survival rate was acceptable. However, a relevant number of implants was identified as unsuccessful at a long-term follow-up. the use of soft tissue grafts can be considered a reliable procedure to significantly improve the long-term outcomes.
reSUltS: Preliminary results of the study are referring to 11 patients. 9 patients were female and 2 patients were male. Mean age was 57 years. Mucosal thickening was found in a single maxillary sinus. average preoperative SNot-20 score was 13. average post-operative SNot-20 score was 4. Schneiderian membrane was sheared in 10 sinuses (6 patients).
coNclUSioNS: the radiological evidence of postopera-tive maxillary sinus opacification or mucosal thickening was remarkably low when compared to historical controls per-formed in the same unit and to the current findings in the literature. the SNot-20 score decreased in the majority of patients and increased in none. Narrowing of the ostiomeatal complex may play a pivotal role in the occurence of maxillary sinusitis following zygomatic implants placement. Middle meatal antrostomy seems to be an effective prophylactic maneuver in the prevention of this complication.
Long-term outcomes of dental implants in
oncologic patients reconstructed with fibula
free flaps
g. Pellegrino 1, a. tarsitano 1, a. Ferri 1, g. corinaldesi 1, a.
Bianchi 1, l. Montebugnoli 2, c. Marchetti 3
1Oral of Maxillofacial Surgery Department, University of
Bo-logna, BoBo-logna, Italy; 2Section of Oral Science, University of
Bologna, Bologna, Italy; 3Maxillo-facial Surgery and Oral and
Maxillofacial Division, DIBINEM, University of Bologna, Bo-logna, Italy
BacKgroUND: the aim of this retrospective study was to evaluate the long-term survival and success rates of implants placed in patients who underwent mandibular or maxillary reconstruction with a fibula free flap and the influence of vari-ables as radiotherapy and surgical techniques.
MetHoDS: Between 1998 and 2015, 21 patients underwent
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CHIRURGIA ORALE
Influence of maxillary sinus width on new bone
formation after transcrestal sinus floor
eleva-tion: a prospective histologic and
histomorpho-metric study
c. Stacchi 1, t. lombardi 2, a. rapani 1, F. Berton 1, g.
Perinet-ti 1, t. traini 3, r. Di lenarda 1
1Department of Medical, Surgical and Health Sciences,
Univer-sity of Trieste, Trieste, Italy; 2Private Practice, Cassano allo
Io-nio, Italy; 3Department of Medical, Oral and Biotechnological
Sciences, University of Chieti-Pescara, Chieti, Italy
BacKgroUnD: the aim of this multicenter prospective study was to analyze clinically and histologically the influ-ence of bucco-palatal sinus width on new bone formation after transcrestal sinus floor elevation (tSFe).
MethoDS: Patients needing maxillary sinus augmenta-tion (residual crest height <5 mm) were treated with tSFe without simultaneous implant insertion. the crestal access through the sinus floor was performed by using calibrat-ed drills with stops (Mica, Megagen implant co. ltd, gyeongbuk, South Korea) and, after checking Schneiderian membrane integrity, sinus was grafted by condensing grad-ual increments of xenogeneic granules (Smartbone, iBi Sa, Mezzovico-vira, Switzerland), until a minimum height of 10 mm was obtained (comprising the residual bone crest). Six months later, bone-core biopsies were retrieved from implant insertion sites by using trephine drills in order to perform histological and histomorphometric analyses. histological slides were multistained with ladewig fibrin stain, toluidine blue/azure ii counterstained with acid fuchsine or double stained with toluidine blue/pironine g at 1% and azure ii. Sinus width (SW) between buccal and palatal walls at 10-mm level (comprising the residual alveolar crest) and number of sinus bone walls in contact with the graft (Wgc) (2: graft in contact with both lateral and medial walls; 1: graft in contact with lateral or medial wall; 0; graft not in contact with both lateral and medial bone walls) were measured on post-operative cone beam computed tomography by two independent calibrated exam-iners. Differences in nFB among cases grouped according to either SW (as <12 mm, 12-15 mm and >15 mm) or Wgc (as 0-wall, 1-wall and 2-wall) were evaluated by means of one-way analysis of variance (anova), followed by Bonferroni-corrected independent sample t-test. Finally, forward multiple linear regression was performed to iden-tify other variables influencing nFB (age, gender, smoking habits, history of periodontitis, residual crestal height). reSUltS: Fifty consecutive patients (25 males and 25 females, age range between 31 and 84, mean 58.3 ±9.8, 13 smokers, 37 no smokers) were enrolled in this study and underwent tSFe procedures. Six patients dropped out from the study (three for membrane perforation, one for post-oper-ative infection, two for late dissemination of the biomaterial) and forty-four patients were included in the final analysis. Mean percentage of nFB at 6 months was 21.2 ±16.9% (range
0-62.1%). Multivariate analysis showed a strong negative correlation between SW and nFB (r2=0.793), and a strong
positive correlation between Wgc and nFB (r2=0.781).
Furthermore, when SW was stratified into three groups (<12 mm, 12 to 15 mm, and >15 mm), nFB percentages after six months of healing (36%, 13% and 3%, respectively) resulted significantly different (p<0.0001).
conclUSionS: This study represented the first statisti-cally significant confirmation based on histomorphometric data that nFB after tSFe was strongly influenced by sinus bucco-palatal width, being a predictable outcome only in narrow sinus cavities (SW <12 mm, measured between buc-cal and palatal walls at 10-mm level, comprising the residual alveolar crest). During pre-surgical planning, bucco-palatal sinus width should be regarded as a crucial parameter when choosing sinus floor elevation with transcrestal approach as a treatment option.
Computer-guided bone lid osteotomy: a case
report
S. giovannini 1, a. Fincato 1, g. Brunello 1, 2, a. Quercia 3, e.
Stellini 1, l. De Stavola 1, S. Sivolella 1
1University of Padua, Department of Neurosciences, Section of
Dentistry, Padua, Italy; 2University of Padua, Department of
Management and Engineering, Vicenza, Italy; 3ULSS 2- Marca
Trevigiana – Regione Veneto
BacKgroUnD: the aim of this paper is to present a case of dentigerous cyst associated with an impacted mandibular third molar successfully treated with computer-guided bone lid technique.
MethoDS: a healthy 46-year-old male patient was referred to our department with an asymptomatic unilocular well-defined radiolucent lesion in the posterior portion of the left mandible associated to a horizontally impacted third molar. the patient underwent a cone-beam computed tomography (cBct) and the bone lid was planned through a computer-aided design (caD) process (3Diagnosys 4.0, 3DieMMe). virtually planned ideal bone osteotomy planes were defined in order to provide an adequate access to the tooth and to avoid damage to anatomical structures. a surgical template was then produced to guide the piezoelectric tips on the planned osteotomy planes. the design of the template was made in such a way as to have both a bone and a dental support on tooth 37. the final guide design, including holes for screwing the guide to the bone, was created with caD software (PlastycaD, 3DieMMe). the surgical guide was produced in medical polyamide by a caM process (3Dfast). the surgery was performed under local anaesthesia and seda-tion. a full-thickness flap was reflected buccally, the polyam-ide surgical gupolyam-ide was inserted and stabilized with a screw. the cystic lesion and the impacted tooth 38 were accessed through a buccal bone lid fashioned using a piezoelectric device (Piezosurgery®, Mectron S.p.a., carasco, italy). the
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tions, then obtained scores were compared.the sample size was calculated by considering the duration of the procedure as the main parameter to evaluate surgical difficulty. Power was set at 80% and alpha at 0.05. a p-value <0.05 was considered as being statistically significant.
reSUltS: one hundred and twenty-four patients were treated by three centres with mandibular third molar extrac-tion, and each tooth was assigned with a score according to JD original and modified classifications. Mean surgical time was 24.1 ±22.2 min, with significant differences among the centres (p=0.001). Surgical time between groups derived from both former and modified JD classifications resulted significantly different (p=0.002 and p=0.001, respectively). in the multivariate analysis, the statistical model including modified JD score was more efficient than the model with original JD score in predicting surgical time (r2=0.204 and
r2=0.126, respectively). although both classifications have
specific items to evaluate the risk of neurologic lesions, in the present study it was not possible to perform any statistical evaluation of this parameter due to the low number of cases with neurological complications: further investigations are needed to answer this issue.
conclUSionS: the modified JD classification resulted as a reliable tool for predicting surgical time of impacted lower third molar extraction: this could be an adjunctive help for the clinician and the patient in the decision making process and to manage a more efficient daily planning both in hos-pital departments and in dental offices. Moreover, the future scientific works on impacted mandibular tooth could benefit of this classification to stratify surgical difficulty in order to standardise recorded data and to analyse them in a more reli-able and predictreli-able way.
Cavernous hemangioma of the oral mucosa: a
rare case report and literature review
F. Di Francesco, S. Ferrara, c. Maietta, r. rullo
Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania “Luigi Vanvitelli”, School of Oral Surgery
BacKgroUnD: hemangioma is considered a benign vas-cular lesion of congenital origin, which develops after abnor-mal proliferation of endothelial cells of blood vessels. the head and neck are commonly affected and the oral cavity is the most frequent site. hemangiomas occur more frequently in the female with a male-female relationship between 1: 3 and 1: 5. the causes of onset are still unknown, but exces-sive muscle contraction, repeated trauma and hormonal fac-tors seem to play a predominant role. in adults, cavernous hemangiomas usually do not regress and have a chronic course with slow and progressive growth. this paper reports a case of buccal cavernous hemangioma, diagnosed on the basis of clinical, instrumental and histopathological findings and treated surgically.
MethoDS: a 20-year-old woman presented with a swell-ing, involving 2/3 of the left anterior part of the buccal mucosa, which has been reported for about 10 years. there were no associated characteristics of pain, fever, difficulty in phonation and swallowing. intraoral examination revealed a single large intramural and non mobile neoformation on the left anterior part of the buccal mucosa. the mucosal surface appeared grainy, bluish-violet in color with well-defined edges and surrounding area was normal appearance. on pal-pation the neoformation had a soft consistency, and blanched tooth was easily extracted without sectioning and the lesion
removed, leaving the inferior alveolar nerve intact. the buc-cal bone lid was returned to its original position and stabilized with a 1.3 mm fixation microplate (Synthes gmbh). Finally, the flap was put back in place and sutured.
reSUltS: any immediate or late complications were record-ed. the histopathological findings were consistent with fol-licular cyst with calcifications of the wall, confirming clinical and radiological pre-surgical diagnosis. Bone healing and any signs of recurrence of cyst were assessed at 6-month clinical and radiographic follow-up.
conclUSionS: in conclusion, the bone lid technique for the removal of dentigerous cysts associated with impacted lower third molars demonstrated to be a safe and reliable tech-nique. this approach provides better access and visibility of the surgical field and allows bone lid repositioning at the end of the surgery, minimizing the loss of bone. even though there is limited literature addressing the effectiveness of custom-ized surgical guides for fashioning osteotomies and for bone harvesting, it seems that an adequate preoperative planning in combination with a computer-guided surgery further simpli-fies the surgical intervention and reduces the risk of damage to anatomical structures. adequate planning of bone pathol-ogy removal through a conservative approach, such the bone lid technique implemented using piezoelectric devices and computer-guided surgery, can allow the “restitution ad inte-grum” of the bone tissue.
A classification for assessing surgical difficulty
in the extraction of mandibular impacted third
molars: description and clinical validation
e. rizzato 1, c. Stacchi 1, P. Daugela 2, F. Berton 1, t.
lom-bardi 3, t. andriulionis 2, g. Perinetti 1, g. Juodzbalys 2, r. Di
lenarda 1
1Department of Medical, Surgical and Health Sciences,
Univer-sity of Trieste, Trieste, Italy; 2Department of Oral and
Maxil-lofacial Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania; 3Private Practice, Cassano allo Ionio, Italy BacKgroUnD: assessment of the surgical difficulty of mandibular impacted third molar extraction is an important part of the pre-surgical analysis, in order to plan correctly both clinical and organisational aspects. Many classifications have been proposed over time, but their accuracy in predicting surgical complexity and risk of intra-operative complications remain questionable. the present prospective study introduc-es and clinically validatintroduc-es a modification of Juodzbalys and Daugela classification (JD), maintaining the original indexes and their evaluation, but with a different interpretation of the final score, in order to improve its effectiveness in predict-ing surgical difficulty of impacted mandibular third molar extraction.
MethoDS: Patients needing a surgical extraction of an impacted mandibular third molar with formed roots were enrolled for the study in three centres. common inclusion and exclusion criteria for oral surgery procedures were applied for eligibility. Surgical procedures were performed follow-ing a standardised approach by one expert surgeon in each centre. Surgical time from flap incision to the complete tooth removal was recorded, together with the technical variables of each intervention (flap design, ostectomy, coronectomy, roots separation) and possible intraoperative complications (e.g. apex fracture, profuse bleeding). extracted third molars were evaluated according to the original and modified JD
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this clinical finding. in the august of 2017, the patient, male, 25 years old, was referred by the oncohematologist because she noted a pigmentation of the hard palate. the patient was affected by cMl since 2005, successfully treated with imatinib, he present a kidney stone in 2015, was previosully treated with ansiolotic therapy. at the time of the objective examination, the patient was in a state of general agitation thinking that the palatal lesion could be of neoplastic origin. For this reason the incisional biopsy (punch 0.5cm) of the palate was programmed under local anesthesia and conscious sedation as the usual protocol (Manani’s protocol). the speci-men was fixed in formalin and sent for histopathological examination, showing melanin deposition below the basal membrane.
reSUltS: given histological examination pattern, the patient’s history and the clinical appearance of the lesion, the diagnosis of pigmentation secondary to the use of imatinib of the mucosa of the hard palate, was formulated. Similarly to what is described in the reports in the literature the risk of developing pigmenting intra-oral is very low even if prob-ably underdiagnosticated because, unfortunately, the intraoral examination is often not performed by non-dentist medical colleagues, contrary to what happened in this case. Moreover, the risk of pigmentations of this type increases if exposure is prolonged over time as in this case.
conclUSionS: this case report describes an infrequent manifestation of side effect related to a drug widely used in the treatment of cMl. the patient was looked not only for his pathology and to the contingent manifestation, but also in its entirety, also offering a pharmacological help to his understandable anxiety. the collaboration between various professional figures involved in order to reach a diagnosis that is not immediate as in this case is fundamental.
Modified surgical extrusion of severely
com-promised teeth for rehabilitative and/or
regen-erative purposes
D. angerame, M. De Biasi, B. Kalaj, M. Maglione
Clinical Department of Medical Science, Surgery and Health, University of Trieste, Trieste, Italy
BacKgroUnD: the present work reports the possible advantages of a modified surgical technique to extrude severely damaged teeth for their early functional and aesthet-ic rehabilitation or to develop the implant site, highlighting the global advantages that this technique provides over the traditional surgical, orthodontic and combined techniques. MethoDS: We report a representative case to present the peculiar technical aspects of a modified surgical technique. an adult woman with an extensively decayed lower second premolar was treated as follows. Under local anaesthesia, an intrasulcular incision was performed on both the buccal and lingual sides; then, vertical releasing incisions were made up to the mucogingival junction. Full-thickness flap elevation was carried out coronally to the mucogingival junction. to allow a firm grip of the forceps on the root, a 3 mm-deep groove was prepared between the root to be extruded and the surrounding bone by using a fine-grit tapered point dia-mond bur mounted on a high-speed handpiece. once luxated with rotational movements without being removed from the alveolar socket, the root was positioned 4-5 mm coronally to the alveolar crest, with the aim of respecting the biologic width and offering adequate ferrule for the final restoration. on compression. Magnetic resonance imaging was used for
diagnosis and volumetric analysis, showing a mass with dis-tinct edges, an isointense signal on t1-weighted images and a hyperintense signal on t2-weighted images. in addition, ecoDoppler method was employed, which did not show any major tributary arterial branch feeding the lesion. Depending on the clinical and instrumental features, a provisional diag-nosis of hemangioma was made. the employed instrumental investigations were fundamental to obtain diagnostic and sur-gical guidelines, and to avoid complications during planned surgery. Under general anesthesia, an intraoral approach was used, as the tumor was located in front of the masseter muscle and on a plane inside the buccinator muscle, below the oral mucosa. the excision of a large hemangioma can lead hemorrhages difficult to manage, especially in cases of hemangiomas of the buccal-masseteric region, which could be fed by a branch of the facial artery. another anatomical-surgical relationship to consider is the one with the Steno’s duct. the excised mass was about 3.5 x 2 x 1.5 cm, showing macroscopically nodular areas with an adipose, spongy and hemorrhagic appearance.
reSUltS: histopathological examination confirmed the definitive diagnosis of cavernous hemangioma. Microscopic examination revealed large sinusoidal spaces covered by flat endothelial cells, interstitial fibroialinosis, the presence of lymphonocytic inflammatory and hemorrhagic foci. Patient follow-up was performed for two years and there was no relapse of the lesion or outcomes involving neuromuscular function.
conclUSionS: although hemangioma is considered one of the most common soft-tissue tumors of the head and neck, it is relatively rare in the oral cavity. the identification of hemangioma is a challenge because these lesions clinically resemble other entities such as other vascular malformations (lymphangioma and varices), pyogenic granuloma, giganto-cellular epulis, and oral carcinoma in its clinical varieties. the treatment is based on several factors such as size, posi-tion, accessibility, depth of invasion, patient age and aesthetic aspects. Most non-surgical treatments have been suggested as watch-and-wait, cryotherapy, laser therapy, isolated embo-lization, sclerosing agents or steroid injection. however, the results of these treatments are controversial, so they are rec-ommended only when surgical treatment is contraindicated. in this case, surgical treatment was preferred, after careful clinical and instrumental analysis.
A rare case of mucosal pigmentation of the
hard palate in a patient taking imatinib
c. Bacci 1, a. angelini 2, M. l. Mariuzzi 1, g. Zanette 1, a.
grigoletto 1, a. cerrato 1, M. cocco 1, M. valente 2
1Oral Medicine, Pathology and Surgery (dott C. Bacci) Clinical
Dentistry, Department of Neurosciences, Padua, Italy; 2
Depart-ment of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
BacKgroUnD: to describe a rare cases of oral mucosal pigmentation due to effect of imatinib.
MethoDS: imatinib (brand names gleevec or glivec) is a tyrosine kinase inhibitor used as first line treatment of chronic myeloid leukaemia (cMl) as stated by national institute for health and care excellence (nice). Prescribing information for imatinib lists the possible side effects, with skin hyper-pigmentation risk as 0.1–1% while oral hyper-pigmentation aren’t mentioned. there are few reports in the literature concerning
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MethoDS: thirty consecutive patients in treatment with oral anticoagulants were selected among the patients attend-ing the Department of Special oral Pathology of the “a.o.U Federico ii di napoli” for multiple dental extractions. the patients were divided into two groups: group a consisted of 15 patients in treatment with noas (7 males and 8 females, mean age 67.47 years), while group B consisted of 15 patients in treatment with warfarin (6 males and 9 females, mean age 69.14 years), showing an INR≤2.5. The inclusion criteria were: direct or indirect anticoagulants taking for heart disease (atrial fibrillation) or vascular disease (pulmonary embolism and deep vein thrombosis); over 60 years of age; need of multiple dental extractions. the exclusion criteria were: liver disease, severe renal failure, disorders of the hemostasis and coagulation, valvular prosthesis, history of prolonged bleed-ing events. the followbleed-ing conditions were applied in both groups: no changes of the current pharmacological therapy, antibiotical prophylaxis, tooth extractions between one and three teeth, use of sutures and hemostatic aids (oxidate cel-lulose). Bleeding evaluation was performed in the immediate post surgical phase (t0), 12 hours later (t1) and 72 hours later (t2). the between-group difference (group a vs. group B) was measured with an analysis of variance (anova) for repeated measurements, with Bonferroni correction. the significance level was set at P<0.05.
reSUltS: Bleeding events were significantly reduced in group a, as compared to group B. Statistically significant difference was found at all the three time points measured (t0: P<0.005, t1: P<0.05; t2: p<0.05).
conclUSionS: this study demonstrated an easier bleed-ing management in patients treated with noas, when com-pared with patients treated with warfarin, after oral surgery procedures.
Grinded teeth as a source of bone graft: a brief
narrative review of the literature
e. ernesti Moro 1, S. giovannini 1, g. Brunello 1, 2, e. Stellini 1,
B. Zavan 3, 4, S. Sivolella 1
1University of Padua, Department of Neurosciences, Section of
Dentistry, Padua, Italy; 2University of Padua, Department of
Management and Engineering, Vicenza, Italy; 3Department of
Biomedical Sciences, University of Padua, Padua, Italy; 4Maria
Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
BacKgroUnD: teeth have been proposed as a source of grafting material for the treatment of alveolar bone defects. the aim of this brief narrative review is to present the differ-ent methodologies for the preparation of autogenous tooth graft: one involves the preparation of the graft at the dental office right after the extraction (chairside), whereas another method involves sending teeth to a tissue bank, where they are prepared according to a precise protocol and then sent back to the dentist for use.
MethoDS: the PubMed database was searched for relevant literature. combinations of the following key words were used as search terms: autogenous[all Fields] anD (“tooth”[MeSh terms] or “tooth”[all Fields] or “teeth”[all Fields]) anD (“bone transplantation”[MeSh terms] or (“bone”[all Fields] anD “transplantation”[all Fields]) or “bone transplantation”[all Fields] or (“bone”[all Fields] anD “grafting”[all Fields]) or “bone grafting”[all Fields]). articles were restricted to those published in english from 2010 to January 2018. a secondary review of the reference lists of these articles was performed. the grey literature was Stabilization of the root was accomplished by triple
compos-ite resin-metal splinting on the buccal, lingual, and occlusal aspects after standard adhesive procedures. one and a half months later, the splint was removed and the final rehabilita-tion performed by means of a convenrehabilita-tional metal-ceramic prosthetic bridge involving partial preparation of the adjacent abutment teeth.
reSUltS: no complications occurred during the follow-up period. During the first postoperative week, the patient complained mild symptoms that were compatible with the limited surgical trauma caused by the intervention. at the time of splint removal, no mobility of the extruded root was present. in this case and in our experience, preparing a groove between the root and the alveolar bone eased the luxation phase and did not jeopardise the healing process of hard and soft tissues, even in case of substantial changes of the original root position.
conclUSionS: the modified surgical extrusion (double minimally invasive full-thickness flap, periradicular groove, rotational luxation movements, root permanence in the alveo-lar socket, extended extrusion and repositioning, triple splint) is a viable option in the restoration of severely compromised single-rooted teeth or in the management of nonrestorable roots. its advantages include limited postoperative symp-toms, low risk of complications, reduced chair-side time, and acceptable aesthetics. Further studies should take into account whether the technique has the potential to be standardised for implant site development, similarly to what can be made with orthodontic extrusion to improve bone and gingival charac-teristics of implant recipient sites.
Bleeding evaluation in oral surgery patients
treated with new oral anticoagulants
a. accarino 1, D.izzo 1, v.P.cozzolino 1, P.nuzzolo 1, r.Bucci 2,
g. de Paolis 3, l.ramaglia 4, P.Bucci 5
1Oral Surgery School, Department of Neurosciences,
Reproduc-tive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy; 2Department of Neurosciences,
Re-productive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy; 3Department of Medicine and
Pharmacy, Dentistry School, University of “Grigore T. Popa”, Iasi, Romania; 4Department of Neurosciences, Reproductive
and Odontostomatological Sciences, University of Naples Fed-erico II, Naples, Italy; 5Department of Neurosciences,
Repro-ductive and Odontostomatological Sciences, University of Na-ples Federico II, NaNa-ples, Italy
BacKgroUnD: in the last few years, new orally admin-istered anticoagulants drugs (noas) have been introduced in the clinical practice for patients that require prolonged use of anticoagulant drugs. three types of noas have been recently approved in the USa and in several european countries, including italy: dabigatran etexilate (Pradaxa®), rivaroxaban (Xarelto®) and apixaban (eliquis®). Several advantages have been reported with noas, such as stable effect at a fixed dose without the necessity to monitor the coagulation with routine laboratory exams (inr), and rapid onset. Furthermore, unlike vitamin K antagonists, noas show a wide therapeutic margin, low drug to drug interactions and no significant food interactions. the use of noas has found several applications in different dentistry specialties, especially in oral surgery patients. the aim of this study is to evaluate the bleeding events after multiple dental extrac-tion in patients taking noas, compared with patients taking conventional anticoagulants (warfarin).
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