Reconstruction of the orbitozygomatic framework: State of the art and perspectives.

The reconstruction of the whole orbitozygomatic framework (OZF) is complex and can be encountered in cases of congenital midface deformity, after tumor ablative surgery and in severe facial trauma. Nowadays, surgeon has a wide range of available techniques that have continually grown over the past years, optimizing the surgical management and the aesthetical outcomes. Among them, the autologous bone graft (ABG) remains one of the most suitable options : ABG is easy to harvest and has optimal biological properties for bone healing. It can be tailored to the patient anatomy thanks to the recent advances in computer-assisted surgery. However, substantial drawbacks remain such as the early resorption of the non-vascularized graft, the need of a donor site and its potential morbidity. Alloplastic reconstruction is another option that can resolve both the resorption issue and the donor site morbidity. Moreover, the 3D-printing technologies also allows the manufacturing of patient specific implants. However, alloplastic materials have a variable success, especially due to the high risk of infection or exposure. Consequently, regenerative medicine is a promising field that aims to find a procedure without the disadvantages of ABG or alloplastic based reconstructions, but displaying similar or even higher success rate. Indeed, recent tissue engineering strategies have demonstrated encouraging results for bone regeneration using natural or synthetic biomaterials, patient cells and synthetic bioactive substances. The objective of this review is to present the etiologies of OZF defect, the available reconstruction procedures as well as the current state of the research.

Tongue reconstruction after oncological resection: Analysis of the functional outcomes.

The curative management of oral squamous cell carcinoma can be responsible for swallowing and/or speech impairments. In this study, we analyzed the functional outcomes in patients who underwent an oncological resection and a primary reconstruction of the tongue and/or of the floor of the mouth (TFM). We also investigated the predictive factors for poor functional outcomes. This retrospective study included operated patients from October 2013 to May 2021 at the TOURS University Hospital. We assessed the functional results two years after the completion of the cancer treatment with self-administered questionnaires quantifying swallowing and speech disorders. Thirty-three patients were included and reconstructed with antebrachial free flap (N = 16), local flap (N = 8) or Biodesign ® membrane (N = 9). A higher proportion of pT1 tumor was observed in patient who had a Biodesign-based reconstruction (p = 0.001). There was no significant difference between the groups in terms of postoperative complications or for the duration of enteral feeding. The 21 patients who had an adjuvant radiation therapy had no significant more altered functions. Functional scores were significantly higher in the free flap reconstruction group (DHI =24 and SHI=21) (p = 0.008). No predictive factors for poor outcomes were observed. The repair of TFM defects must be adapted to the resection size. The reconstruction techniques allow to get acceptable functional outcomes even for the greater tumors or in case of radiation therapy. Further research would be required to better identify the predictive factors for poor outcomes.

Surgical Management of Hypertelorism: The 3D Animated Technical Note.

The hypertelorism surgery is a complex procedure requiring a long learning curve. Even though the box osteotomy technique is well described in literature, its representation is generally based on texts and illustrations that do not really give a 3-dimensional or a dynamic point of views. The authors present a 3-dimensional animated video, Supplemental Digital Content 1, http://links.lww.com/SCS/E561 showing the craniofacial osteotomies and focusing on the critical points to correct hypertelorism.

Standardized and axially vascularized calcium phosphate-based implants for segmental mandibular defects: A promising proof of concept.

The reconstruction of massive segmental mandibular bone defects (SMDs) remains challenging even today; the current gold standard in human clinics being vascularized bone transplantation (VBT). As alternative to this onerous approach, bone tissue engineering strategies have been widely investigated. However, they displayed limited clinical success, particularly in failing to address the essential problem of quick vascularization of the implant. Although routinely used in clinics, the insertion of intrinsic vascularization in bioengineered constructs for the rapid formation of a feeding angiosome remains uncommon. In a clinically relevant model (sheep), a custom calcium phosphate-based bioceramic soaked with autologous bone marrow and perfused by an arteriovenous loop was tested to regenerate a massive SMD and was compared to VBT (clinical standard). Animals did not support well the VBT treatment, and the study was aborted 2 weeks after surgery due to ethical and animal welfare considerations. SMD regeneration was successful with the custom vascularized bone construct. Implants were well osseointegrated and vascularized after only 3 months of implantation and totally entrapped in lamellar bone after 12 months; a healthy yellow bone marrow filled the remaining space. STATEMENT OF SIGNIFICANCE: Regenerative medicine struggles with the generation of large functional bone volume. Among them segmental mandibular defects are particularly challenging to restore. The standard of care, based on bone free flaps, still displays ethical and technical drawbacks (e.g., donor site morbidity). Modern engineering technologies (e.g., 3D printing, digital chain) were combined to relevant surgical techniques to provide a pre-clinical proof of concept, investigating for the benefits of such a strategy in bone-related regenerative field. Results proved that a synthetic-biologics-free approach is able to regenerate a critical size segmental mandibular defect of 15 cm3 in a relevant preclinical model, mimicking real life scenarii of segmental mandibular defect, with a full physiological regeneration of the defect after 12 months.

Computer-Assisted Frontofacial Monobloc Advancement and Facial Bipartition for Pfeiffer Syndrome: Surgical Technique.

BACKGROUND: In patients with Pfeiffer syndrome, several corrections are required to correct facial retrusion, maxillary deficiency, or even hypertelorism. The frontofacial monobloc advancement (FFMA) and the facial bipartition (FB) are the gold standard surgeries. We present the correction of this deformity using a simultaneous computer-assisted FFMA and FB. METHODS: The 3-dimensional surgical planning defined the virtual correction and bone-cutting guide in view of the FFMA and FB. Coronal and intraoral approaches were combined to perform the osteotomies. Four internal distractors were also placed for the postoperative distraction osteogenesis. RESULTS: We reported 2 cases of computer-assisted surgery with satisfying outcomes. The sagittal deficiency (fronto-facial retrusion) was corrected by FFMA and the transversal abnormality (i.e., hypertelorism and maxillary deficiency) by the FB, then followed by an internal distraction osteogenesis. CONCLUSIONS: Computer-assisted surgery is helpful and a reliable option for the management of complex faciocraniosynostosis such as hypertelorism and frontofacial retrusion.

Management of post enucleation socket syndrome patients - A retrospective study.

The aim of this retrospective monocentric study was to report the outcomes following the correction of post enucleation socket syndrome (PESS) as well as the factors predicting for a multistep management. Patients were included, if they had received surgery to manage PESS. Demographics and patient history were collected. The symptoms of PESS were clinically rated by the same surgeon and ocularist, preoperatively and after each procedure. The surgery was considered as successful when no PESS clinical symptoms were observed. A prognostic study was performed to investigate the surgical outcomes. RESULTS: Thirty-six patients were included and eight of them had their PESS corrected after the first surgery. In the multivariate analysis (MVA), the deep upper lid sulcus symptom remained the main significant factor associated with an incomplete correction after the first surgery (OR 45.5, IC 95% (3.481-594.6), p = 0.004). For further corrections, the ptosis was the only significant prognostic factor requiring several surgeries (p = 0.005). At the end of the management, 94.4% of the patients had satisfying outcomes. CONCLUSIONS: The management of a PESS involves the correction of both the orbital cavity and the soft tissues. Although its correction is complex and time consuming in the majority of cases, the patients should be informed that the final cosmetic outcomes remain good at the expense of several surgeries.

An Extrudable Partially Demineralized Allogeneic Bone Paste Exhibits a Similar Bone Healing Capacity as the "Gold Standard" Bone Graft.

Autologous bone grafts (BGs) remain the reference grafting technique in various clinical contexts of bone grafting procedures despite their numerous peri- and post-operative limitations. The use of allogeneic bone is a viable option for overcoming these limitations, as it is reliable and it has been widely utilized in various forms for decades. However, the lack of versatility of conventional allogeneic BGs (e.g., blocks, powders) limits their potential for use with irregular or hard-to-reach bone defects. In this context, a ready- and easy-to-use partially demineralized allogeneic BG in a paste form has been developed, with the aim of facilitating such bone grafting procedures. The regenerative properties of this bone paste (BP) was assessed and compared to that of a syngeneic BG in a pre-clinical model of intramembranous bone healing in critical size defects in rat calvaria. The microcomputed tridimensional quantifications and the histological observations at 7 weeks after the implantation revealed that the in vivo bone regeneration of critical-size defects (CSDs) filled with the BP was similar to syngeneic bone grafts (BGs). Thus, this ready-to-use, injectable, and moldable partially demineralized allogeneic BP, displaying equivalent bone healing capacity than the "gold standard," may be of particular clinical relevance in the context of oral and maxillofacial bone reconstructions.

A partially demineralized allogeneic bone graft: in vitro osteogenic potential and preclinical evaluation in two different intramembranous bone healing models.

In skeletal surgical procedures, bone regeneration in irregular and hard-to-reach areas may present clinical challenges. In order to overcome the limitations of traditional autologous bone grafts and bone substitutes, an extrudable and easy-to-handle innovative partially demineralized allogenic bone graft in the form of a paste has been developed. In this study, the regenerative potential of this paste was assessed and compared to its clinically used precursor form allogenic bone particles. Compared to the particular bone graft, the bone paste allowed better attachment of human mesenchymal stromal cells and their commitment towards the osteoblastic lineage, and it induced a pro-regenerative phenotype of human monocytes/macrophages. The bone paste also supported bone healing in vivo in a guide bone regeneration model and, more interestingly, exhibited a substantial bone-forming ability when implanted in a critical-size defect model in rat calvaria. Thus, these findings indicate that this novel partially demineralized allogeneic bone paste that combines substantial bone healing properties and rapid and ease-of-use may be a promising alternative to allogeneic bone grafts for bone regeneration in several clinical contexts of oral and maxillofacial bone grafting.

Combined proteomic and transcriptomic approaches reveal externalized keratin 8 as a potential therapeutic target involved in invasiveness of head and neck cancers.

Keratin 8 (K8) expressed at the surface of cancer cells, referred as externalized K8 (eK8), has been observed in a variety of carcinoma cell lines. K8 has been previously reported to be expressed in poorly differentiated head and neck squamous cell carcinoma (HNSCC); however, its role during the invasive phase of upper aerodigestive tract tumorigenesis is unknown. Cohorts of HNSCC tumors for protein and mRNA expression and panel of cell lines were used for investigation. K8 was found to be externalized in a majority of HNSCC cell lines. Among the two main K8 protein isoforms only the 54 kDa was found to be present at the plasma membrane of HNSCC cells. The plasminogen-induced invasion of HNSCC cells was inhibited by the anti-eK8 D-A10 antagonist monoclonal antibody. Overexpression of K8 mRNA and protein were both correlated with tumor aggressive features and poor outcome. The effect of eK8 neutralization on invasion, its presence exclusively in cancer cells and the association of K8 expression with aggressive features and poor clinical outcome in HNSCC unravel eK8 as key player in invasion and a promising therapeutic target in HNSCC.

How Accurate Is Computer-Assisted Orbital Hypertelorism Surgery? Comparison of the Three-Dimensional Surgical Planning with the Postoperative Outcomes.

Importance: Surgery of orbital hypertelorism (ORH) remains an imprecise surgical procedure depending on the experience and habits of the craniofacial surgical teams. Computer-assisted surgery (CAS) has developed dramatically in craniofacial surgery, but there is no current study assessing its accuracy for ORH surgery. Objective: This study aimed to assess the input of CAS and especially the accuracy of the cutting guide-based procedures. The authors presented the computer-assisted box osteotomy or facial bipartition techniques and compared the preoperative surgical planning with the postoperative results. Design, Setting, and Participants: A monocentric retrospective study included the patients who underwent surgical correction of ORH from 2016 to 2019 at the University Hospital Center of Tours, France. All the patients had a computer-assisted orbital hypertelorism surgery (CAOHS) using cutting guides and tailored fixation plates. Of 10 patients included, 7 were treated by box osteotomies and 3 by facial bipartitions. Intervention: Each patient had a preoperative computed tomography (CT) scan enabling a virtual simulation of the reconstruction and the manufacturing of patient-specific cutting guides and customized osteosynthesis plates. The postoperative CT scans were compared with the three-dimensional (3D) virtual simulation using the distances between the sagittal plane and orbital and infraorbital reference points, and from the measurement of the orbital advancement (i.e., 10 reference measurements). Results: All patients had satisfactory clinical and aesthetical outcomes with a mean interorbital distance of 22.8 ± 2.8 mm. The postoperative measurements were significantly higher than for the surgical planning (p < 0.0001). The average absolute differences between the 3D virtual planning and the postoperative CT scans were <1.30, 1.90, and 0.80 mm for the orbital, infraorbital, and orbital advancement measurements, respectively. The overall accuracy of the CAOHS (root mean square deviation) was 1.39 mm. Conclusions: The use of computer-assisted design and computer-aided manufacturing device, such as cutting guides and tailored plates, facilitates the bony surgical correction of ORH using box osteotomy or facial bipartition and allows for valuable, reproducible, and satisfactory clinical outcomes.

Tailored Three-Dimensionally Printed Triply Periodic Calcium Phosphate Implants: A Preclinical Study for Craniofacial Bone Repair.

Finding alternative strategies for the regeneration of craniofacial bone defects (CSD), such as combining a synthetic ephemeral calcium phosphate (CaP) implant and/or active substances and cells, would contribute to solving this reconstructive roadblock. However, CaP's architectural features (i.e., architecture and composition) still need to be tailored, and the use of processed stem cells and synthetic active substances (e.g., recombinant human bone morphogenetic protein 2) drastically limits the clinical application of such approaches. Focusing on solutions that are directly transposable to the clinical setting, biphasic calcium phosphate (BCP) and carbonated hydroxyapatite (CHA) 3D-printed disks with a triply periodic minimal structure (TPMS) were implanted in calvarial critical-sized defects (rat model) with or without addition of total bone marrow (TBM). Bone regeneration within the defect was evaluated, and the outcomes were compared to a standard-care procedure based on BCP granules soaked with TBM (positive control). After 7 weeks, de novo bone formation was significantly greater in the CHA disks + TBM group than in the positive controls (3.33 mm3 and 2.15 mm3, respectively, P=0.04). These encouraging results indicate that both CHA and TPMS architectures are potentially advantageous in the repair of CSDs and that this one-step procedure warrants further clinical investigation.

Cameriere's third molar maturity index in assessing age of majority: a study of a French sample.

Forensic age estimation is a challenging field in forensic sciences because of the increase of migratory flows. Medicolegal age assessment is a key point because it has many implications for authorities. Dental age estimation is an essential part of the global age assessment. The aim of this study was to evaluate and test the accuracy of Cameriere's cutoff values of the third molar maturity index (I3M) in assessing legal adult age of 18 years in a French population. The sample was constituted of 431 orthopantomograms performed between January 2014 and August 2017 on patients aged between 14 and 22 years. The reproducibility and repeatability of the method were high. Age distribution gradually decreases as I3M increases in both sexes. 0.08 seemed to be the best I3M cutoff. For females, the sensitivity and specificity of the test were 74.51% and 88.23%, respectively. The sensitivity and specificity for males were 92.19% and 88.35%, respectively. The accuracies were 80.74% for female, 90.57% for male. Estimated post-test probabilities were 0.879 for female and 0.899 for male. To conclude, the specific cutoff value of I3M ˂ 0.08 may be a useful additional tool in discriminating adults and minors in French population.

Surgical treatment of orbital hypertelorism: Historical evolution and development prospects.

Orbital hypertelorism (OR.H) is defined as an abnormal increase in the distance between the two orbits secondary to a skeletal anomaly, and it occurs in association with numerous congenital craniofacial malformations. Since its description by Greig in 1924, OR.H and the associated corrective procedures have captivated many surgeons. Here we present a discussion of the historical evolution of surgery for OR.H and highlight its future prospects. In the mid-twentieth century, only cover-up techniques simulating approximation of the eyes via an optical illusion were used, such as frontonasal skin resection, epicanthal fold surgery, and rhinoplasty. Subsequently, numerous surgeons attempted to correct the deformation using orbitonasal osteotomies via an extracranial approach. However, the outcomes were largely inadequate. Finally, in 1967, Tessier developed an efficient two-stage technique for OR.H correction via an intracranial approach; this technique revolutionized the management of OR.H. In 1970, Converse refined Tessier's procedure by performing a one-stage surgery that preserved olfaction. In 1976, Van Der Meulen developed the facial bipartition technique, which simultaneously corrected maxillary and craniofacial deformities. Box osteotomies and facial bipartition are still used for the correction of OR.H. Using the technological advancements introduced in the early 2000s, several surgeons have attempted to improve these techniques with the use of three-dimensional (3D) surgical planning, preoperative 3D printing, augmented reality-based surgical navigation, and computer assisted surgery using cutting guides. These modern-day practices are rapidly developing and are expected to refine and standardize the surgical correction of OR.H in the future.

Radiographic evaluation of percutaneous transfacial wiring versus open internal fixation for surgical treatment of unstable zygomatic bone fractures.

INTRODUCTION: The fixation of unstable zygomaticomaxillary complex (ZMC) fractures can be achieved by open reduction with rigid internal fixation (ORIF) and/or by closed reduction with percutaneous transfacial Kirschner wire fixation (CRWF). The aim of this study was to tomographically assess the symmetry and the protrusion of the cheekbone with unstable ZMC fractures that had been treated by ORIF vs. CRWF. MATERIALS AND METHODS: Sixty patients exhibiting a surgically unstable tetrapodal ZMC fracture were included in this multicenter retrospective study. The coordinates of 5 landmarks representing the zygomatic protrusion were comparatively studied on the healthy and on the broken side using preoperative and postoperative tridimensional computed tomography (CT) scans or cone beam CT. RESULTS: No significant difference was found in the zygomatic protrusion irrespective of the surgical technique that was used. The zygomatico-maxillary ansa was found to be the most complicated area to reduce, particularly in the frontal plane with both the CRWF and the ORIF technique (p1 = 0.001 and p2 = 0.0009, respectively). There was no difference in terms of the level of complications, while the mean duration of the surgery was significantly less for the CRWF group. CONCLUSION: With good postoperative radiographic outcomes, the CRWF can be proposed as an alternative or in association with the ORIF technique for fixation of tetrapodal fractures of the ZMC.

Is It Safe To Use Frontofacial Monobloc Advancement and Cutting Guides on Adult Patients with Crouzon Syndrome? Introducing 2 Cases on 41- and 56-Year-Old Patients.

BACKGROUND: Patients with Crouzon syndrome are mainly treated in childhood by frontofacial monobloc advancement to avoid ophthalmic, neurologic, and maxillary complications. There is no reported case of surgery on adult patients with Crouzon syndrome in the literature. However, when faced with 2 cases of adult patients showing severe quality of life deterioration, our team decided to make an attempt using monobloc advancement technique. CASE DESCRIPTION: Two women aged 41 and 56 presented with untreated Crouzon syndrome and suffered from exorbitism, intracranial hypertension with chronic headaches, and hypoplastic maxillary. We decided to perform frontofacial monobloc advancement with internal distraction despite their advanced age using planned surgery and cutting guides. Distraction began 7-10 days after surgery and was of 15 mm. Distractors were taken off at 6 months. Surgical treatment corrected chronic headaches, ocular symptoms due to exorbitism, and hypoplastic maxillary. Patients were satisfied with the functional and aesthetic results. We noticed that this heavy surgery was more difficult to bear by these adults than children. CONCLUSIONS: Adults with craniofacial malformations have a lower self-esteem, lower quality of life, and less satisfaction with their facial look as compared with individuals without facial malformations. There is also an increased risk of psychosocial problems. Despite postoperative difficulties and minor complications, our 2 patients were satisfied with the functional and aesthetic results. This led to the conclusion that surgically addressing adult patients with Crouzon syndrome via monobloc advancement is appropriate and secure when performed by a trained team.

Lengthening temporalis myoplasty and reduction of the swallowing oral phase dysfunction in facial palsy patients.

INTRODUCTION: Facial palsy can cause dysfunction in the oral phase of swallowing. Lengthening temporalis myoplasty is a widely used technique for correction of facial asymmetry in facial palsy. The aim of this study was to determine whether lengthening temporalis myoplasty could reduce the dysfunction in the oral phase of swallowing in patients with facial palsy. MATERIALS AND METHODS: This prospective study enrolled 13 patients undergoing lengthening temporalis myoplasty. Lip continence, bolus residue, and perceived disability before surgery and at 3 months and 6 months after surgery were compared. Lip force was evaluated with a manometric test and drooling with a self-administered questionnaire. Bolus residue was assessed visually. Perceived disability was evaluated using a self-administered questionnaire. RESULTS: Lip force improved significantly (from 58.23 ± 23.35 mmHg to 91.15 ± 18.36 mmHg; p = 0.001). Drooling showed a corresponding reduction, with the score decreasing from 4.31 ± 1.8 to 3 ±â€¯1.41; p = 0.025. A decrease in bolus residue was also noted; the score decreased from 1.39 ± 0.77 to 0.46 ± 0.66; p < 0.001. These changes contributed to a significant reduction in perceived physical disability; the score decreased from 6.15 ± 3.74 to 3.46 ± 5.70; p = 0.004). CONCLUSION: Lengthening temporalis myoplasty, in addition to providing smile reanimation, may also reduce the dysfunction of the oral phase of swallowing in patients with facial palsy.

Contribution of third molar eruption to the estimation of the forensic age of living individuals.

Forensic age estimation of a living individual is frequently performed in clinical forensic medicine. Medicolegal physicians are usually called upon by the authorities to estimate the age of a living person requesting asylum or to determine whether a suspected offender is subject to juvenile or adult criminal law. Dental age is one of the parameters studied to estimate biological age. Several methods are used, and among these, analysis of the eruption of the third molar (M3) on an orthopantomogram (OPG) is one of the common methods. The objective of the study was to analyse the contribution of M3 eruption to age estimation, in particular with regard to the threshold of 18 years of age, in a sample of individuals examined in a French university hospital. The stage of wisdom tooth eruption of all individuals aged between 15 and 24 years, who had an OPG performed between 1 January 2013 and 31 December 2015, was interpreted using a three-stage scoring system. In total, 557 OPGs (340 males and 217 females) were included. None of the stage scores allowed a distinction between minors and majors, for either sex. Overall, 85% of females and 98% of males with four M3s in stage 3 (complete emergence in the occlusal plane) were majors.

Reconstruction of segmental mandibular defects: Current procedures and perspectives.

BACKGROUND: The reconstruction of segmental mandibular defects remains a challenge for the reconstructive surgeon, from both a functional and an esthetic point of view. METHODS: This clinical review examines the different techniques currently in use for mandibular reconstruction as related to a range of etiologies, including the different bone donor sites, the alternatives to free flaps (FFs), as well as the contribution of computer-assisted surgery. Recent progress and the perspectives in bone tissue engineering (BTE) are also discussed. RESULTS: Osseous FF allows reliable and satisfying outcomes. However, locoregional flap, distraction osteogenesis, or even induced membrane techniques are other potential options in less favorable cases. Obtaining an engineered bone with satisfactory mechanical properties and sufficient vascular supply requires further investigations. CONCLUSIONS: Osseous FF procedure remains the gold standard for segmental mandible reconstruction. BTE strategies offer promising alternatives.

Muscle Forehead Flap: Salvage Surgery for Closure of Cutaneous Fistula After Cranioplasty Exposure.

BACKGROUND: Infection and skin fistula are well-known complications after cranioplasty leading to reconstruction exposure and usually requiring new surgical procedure with poor condition for cutaneous closure. We describe 2 cases using muscle forehead flap (MFF) to treat skin fistula and cranioplasty exposure. CASE DESCRIPTION: The first case was a 43-year-old man who underwent a calvarial bone graft of the frontal sinus anterior wall after craniofacial trauma. Three months postoperatively, osteitis of the bone reconstruction and a skin fistula occurred in the median frontal region. The second case was a 37-year-old woman treated for a cingular glioblastoma by 3 surgeries, concomitant chemoradiation therapy, and frontal reconstruction using a titanium plate. She presented a plate exposure associated with cerebrospinal fluid leak and meningitis. Both patients were successfully treated by surgical removal of the frontal cranioplasty and skin closure using MFF. We observed a satisfying cosmetic result with no recurrence of infection or fistula at 12 and 4 months, respectively. CONCLUSIONS: MFF is a surgical option to treat complex cases of cutaneous fistula secondary to cranioplasty exposure of the anterior cranial fossa.