[Noma]. / Le Noma.

Noma is a necrotizing ulcerative stomatitis known since Antiquity. It occurs mostly in poor countries, the Sahel countries being the most affected. Each year, several hundred thousand cases are reported. Noma affects especially malnourished children who are less than 6 years old and rarely adults with acquired immunodeficiency (HIV, cancer). Ulcerative lesion is occurring rapidly due to the production of endotoxins by bacteria from oral commensal, telluric and animal origin. Necrotic debridement leads to huge defects: loss of soft tissue (skin, nerves, vessels, eye), bone (maxilla, mandible) and teeth. Death occurs rapidly in a few weeks in 80 % of the cases. In case of survival, the consequences are functional, aesthetic, psychological and social. The goal of the treatment in the acute phase is the patient's survival and the fight against limited mouth opening. The management of the phase of sequela is an anaesthetic, surgical and physiotherapy challenge. Its purpose is the social reintegration of the patient.

Reconstruction of large mandibular and surrounding soft-tissue defects using distraction with bone transport.

Reconstruction of large bone and soft-tissue defects of the inferior third of the face is possible using various surgical techniques. Patients who require these procedures need to be in good general health, may have sequelae linked to donor sites, and require several interventions to achieve good aesthetic and functional results. The aim of this study was to report outcomes in patients with large mandibular and soft-tissue defects treated using osteogenic distraction with bone transport. Between 2001 and 2008, 14 patients had distraction with bone transport. Most patients were men (92.1%). The mean age was 43.1 years. The average mandibular bone reconstruction was 13.6 cm. The mean duration of distraction was 2.3 months. No infections occurred, and in all cases reconstruction of soft tissues was obtained. Two patients had non-union and underwent reconstruction using an iliac bone graft. Patients with sufficient bone height (57.1%) had dental implants. 44 implants were inserted, two of which were lost. 36 implants were activated. Six patients had satisfactory oral rehabilitation with implant-supported prostheses. Osteogenic distraction with bone transport allows total or partial restoration of oral function, provides an acceptable appearance, and enables patients to resume a reasonable quality of life.

Mandibular reconstruction using induced membranes with autologous cancellous bone graft and HA-betaTCP: animal model study and preliminary results in patients.

Providing an acceptable quality of life for patients after reconstruction of mandibular segmental defects is challenging because the surgical techniques available have limitations. The authors evaluated two-stage mandibular reconstruction in rabbits and provide preliminary results in humans. 21 rabbits underwent bilateral segmental mandibulectomy and the defect was filled with methylmethacrylate. The methylmethacrylate was removed after 4 weeks and an iliac autograft performed on the right-hand side and an autogenous graft with hydroxyapatite and triphasic calcium phosphate (HA-betaTCP) on the left-hand side. Four patients with severe mandibular osteoradionecrosis underwent a two-stage reconstruction. No clinical or paraclinical complications were noted. Hematoxylin-eosin-saffron staining revealed an induced membrane lining the cavity of all samples with dense vascularity. Decalcified, undecalcified and histomorphometric analysis showed new bone formation in the biomaterial and the autograft. Calcium uptake was higher inside the new cortical bone, notably at sites with HA-betaTCP. CT scans at 6 months showed that two patients had a favorable outcome with cortico-cancellous bone. Microscopic and immunochemical analysis confirmed the experimental data. This study demonstrates the feasibility of mandibular reconstruction using the induced membranes technique. This technique is efficient, and the results would be better in non-irradiated patients with good general health.

[Psychological impact of alveolar mandibular distraction]. / Impact psychologique de la distraction alvéolaire mandibulaire.

INTRODUCTION: Implant supported dental prostheses are the most up-to-date solution for edentulous patients. This technique requires and adequate bone quantity and quality. Bone distraction may allow compensating for some bone deficit, especially mandibulary. Few studies have been dedicated to how patients adjusted to this therapy (Int J oral Maxillofac Surg 34 [2005] 238-42, Int J oral Maxillofac Surg 36 [2007] 896-9, Med Oral Pathol Oral Cir Bucal 12 [2007] E225-8). We evaluated the psychological impact of alveolar mandibular distraction. PATIENTS AND METHODS: Between 1999 and 2006, 31 patients aged 27 to 70 years underwent vertical alveolar mandibular distraction. Seventeen patients (54.8%) presented with complications. A questionnaire assessed the psychological impact by using notions used in healthcare psychology: perceived stress, perceived control, and social support. RESULTS: Twenty-three answers (74.2% of operated cases) were studied. In 87% of the cases, patients adjusted well the distraction procedure. Eighty-one percent felt no stress. Fifty-seven percent reported light to moderate pain, and 43% found the treatment painful. Confrontation to adverse events was mentioned only in 13% of the cases. In 17% of the cases, there was a slight alteration of sleep. Fifty-seven percent of the patients managed to forget the presence of the distractor. The most difficult stages were insertion of the distractor (48%) and the activation phase (17%). Seventy-one percent of the patients did not find the protocol restraining. The treatment length was not a problem for 65%. Two patients (9%) found it too long. Ninety-one percent of the patients activated the device on their own, for two (9% of the cases) the surgeon activated the device. Ninety-seven percent of the patients found supervision satisfactory. Medical information helped to adjust well to the procedure in 96% of the cases. Forty-three percent of the patients (10 cases) required specific help during the treatment: family support, attending physician, or surgical team. Among these, 70% considered the medical team's contribution as the most beneficial compared to family support, and 30% reported they were the same. For 96% of the patients, the medical team was the major actor of therapeutic success. Twenty-two percent of the patients considered they were partly responsible for treatment results (perceived internal control). Fifty-two percent of the cases reported they would be ready to undergo another distraction protocol if necessary. DISCUSSION: Alveolar mandibular distraction has only a weak psychological impact. It improves the patient's quality of life. It can be suggested that hope for improvement helped patients to better stand treatment. The information received contributed to better adjust to events. This unpredictable situation does not allow the patient to prepare himself and generates stress. Information in necessary before operating, to let the patient assess his own resources and prepare his own psychological adaptation mechanism. It is through this means that we can speak about true "informed consent or refusal".

[Management of maxillary deficiency through distraction osteogenesis. Report of 14 cases]. / La distraction osseuse dans les hypoplasies du maxillaire. A propos de 14 cas cliniques.

Maxillary protraction using elastics has been used routinely in patients with maxillary hypoplasia. Internal devices with bone anchorage allows more control of the distracted callus and more predictable results. The use of distraction splints with internal distractors simultaneously provides more accuracy in maxillary hypoplasia treatment. Three techniques using internal maxillary distractors and distraction splints are exposed for treatment of severe or partial maxillary hypoplasia. Fourteen patients have been treated from 1996 january 1 to 2000 june 30: twelve with a severe maxillary hypoplasia, two with a partial hypoplasia, among them eight in childhood or adolescence. The functionnal and aesthetic results have been satisfactory in all cases. Vertical maxillary hypoplasia treated by internal distractors techniques provides better results than traditionals inlay grafted Lefort I osteotomies. Segmental distractions can also be used in combination with classic orthognatic surgery.

Modified approach for ethmoid and anterior skull base surgery.

The use of combined craniofacial resection is well established for tumors of the ethmoid bone and the anterior aspect of the base of the skull. Mobilization of the medial fronto-orbital ridge improves the transbasal approach and can be performed with a monobloc bone flap. We describe an en bloc bifrontal craniotomy including the supraorbital ridges and the nasal bones. This provides a wider angle of approach to the anterior aspect of the base of the skull than any other method and avoids retraction of the frontal lobes. This type of bone flap procedure can be performed after a wide periosteal dissection in the coronal area of the scalp alone, without facial skin incision.

Approach to the pterygomaxillary space and posterior part of the tongue by lateral stair-step mandibulotomy.

Fifteen patients underwent surgery for retromandibular parotid, pharyngeal, or posterior tongue tumors. Surgical approach to the pterygomaxillary fossa, parapharyngeal space, and posterior tongue was performed by external cervical incision and lateral stair-step mandibulotomy. After resection of the tumors, the mandibular segments were replaced and secured with miniplates. The plates were removed after six weeks whenever postoperative radiation therapy was planned. By reflecting the ascending ramus, this method provides excellent exposure of the concerned areas. It makes unnecessary both incision of the lower lip and intermaxillary fixation with arch bars, thus allowing a quick resumption of oral feeding. A review of 15 patients demonstrated satisfactory results for mandibular function and morphologic appearance, with minimal complications.