Limitation of mouth opening can be caused by bony or fibrous ankylosis of the temporomandibular joint as sequela to trauma, infection, autoimmune disease, or failed surgery. Various procedures have been reported for treatment of temporomandibular joint (TMJ) ankylosis; this article aims to describe the diagnostic protocol and the surgical procedures adopted at the department of Maxillo-Facial Surgery of Rome University “La Sapienza”. Between 1980 and 2000, 123 patients affected by TMJ ankylosis came under our observation; 60 of them (25 females and 35 males of 30 years average age) underwent surgery; bilateral TMJ ankylosis was observed in 21 cases, right-sided in 20 cases, left-sided in 19 cases. In 12 cases coronoid processes were involved. Etiopathogenesis was traumatic in 48 cases, septic in 5 cases, auto-immune (RA and seronegative spondyloarthropathies) in 5 cases; after block removing, arthroplasty was performed with pedunculated flap of temporal muscle (10 cases), Silastic material (11 cases), or lyophilized dura mater (2 cases). Simple condylar shaving was used in the remaining 36 cases. All patients under treatment showed a distinctive improvement both in articular functionality and symptoms; secondary surgery was necessary in seven cases due to the onset of articular complications from previous surgery. Silastic removal was necessary in five cases due to its inducement of foreign body granuloma. Follow-up was performed at 12, 24, and 48 months and 5 years postoperatively. In our opinion the gold standard surgery of TMJ ankylosis today is represented by shaving of articular surfaces and subsequent arthroplasty with or without temporal muscle myofascial flap interposition, whereas the use of Silastic as alloplastic material could be associated to an increased persistence of the local symptoms and a higher risk of foreign body granuloma and it may favor ankylosis relapse and hinder rehabilitation.

Composite tissue defects of the mandible and maxilla, after resection of head and neck malignancies, osteoradionecrosis, malformations, or traumas, cause functional and aesthetic problems. Nowadays, microvascular free flaps represent the main choice for the reconstruction of these defects. Among the various flaps proposed, the scapula flap has favorable characteristics that make it suitable for bone, soft tissue, or combined defects. We report 7 cases of reconstruction of complex maxillofacial defects with subscapular system flaps. The patients treated had Romberg syndrome (1 case), malignant tumors (5 cases), and result of previous trauma (1 case). Location of deficit was the maxilla (3 cases), the mandible (2 case), the ethmoidal-maxillary region (1 case) and the upper and middle thirds of the face in the last case. In 2 cases, a parascapular system flap was used; in 5 cases, a composite flap with latissimus dorsi muscle and scapular bone. Neither failure of the harvested flaps nor complications in the donor site were evidenced. A good aesthetic and functional outcome was obtained in all cases. Many free flaps have been proposed for the reconstruction of defects in the maxillofacial region such as fibula, deep circumflex iliac artery, scapula, among the bone flaps; and forearm, rectus abdominis, and anterolateral thigh, among the soft tissue flaps. The choice of the flap to use depends on the length of the bone defect and the amount of soft tissues required. The subscapular system has the advantage of providing different flaps based on the same pedicle. The osteofasciocutaneous scapular free flap, in particular, allows wide mobility of soft tissues (parascapular flap) with respect to its bone component (scapular bone), resulting suitable for defects of large size involving both the soft tissues and the bone. Although the fibula flap and the deep circumflex iliac artery flap remain the first choice for bone reconstructions of the mandible and maxilla, the scapula flap has some features that make its use extremely advantageous in some circumstances. In particular, we advocate the use of the osteomuscular latissimus dorsi-scapula flap for reconstruction of large-volume defects involving the bone and soft tissues, whereas fasciocutaneous parascapular flaps represent a valid alternative to forearm flap and anterolateral thigh flap in the reconstruction of soft tissue defects.

Well-differentiated thyroid carcinoma (WDTC) represents a group of thyroid cancers with excellent prognosis. Age, a well-recognized risk factor for WDTC, has been consistently included in various prognostic scoring systems. An age threshold of 45 years is currently used by the American Joint Cancer Committee-TNM staging system for the risk stratification of patients. This study analyzes the relationship between the patients' age at diagnosis and thyroid cancer-specific survival in a population-based thyroid cancer cohort of 2115 consecutive patients with WDTC, diagnosed during 1970–2010, and evaluates the appropriateness of the currently used age threshold. Oncological outcomes of patients in terms of disease-specific survival (DSS) and disease-free survival (DFS) were calculated by the Kaplan–Meier method, while multivariable analysis was done by the Cox proportional hazard model and proportional hazards regression for sub-distribution of competing risks to assess the independent influence of various prognostic factors. The mean age of the patients was 47.3 years, 76.6% were female and 83.3% had papillary carcinoma. The median follow-up of the cohort was 122.4 months. The DSS and DFS were 95.4 and 92.8% at 10 years and 90.1 and 87.6% at 20 years, respectively. Multivariable analyses confirmed patient's age to be an independent risk factor adversely affecting the DSS but not the DFS. Distant metastasis, incomplete surgical resection, T3/T4 stages, Hürthle cell histology, and male gender were other independent prognostic determinants. The DSS was not independently influenced by age until the age of 55 years. An age threshold of 55 years is better than that of 45 years for risk stratification.