Clinical impact of two types of mandibular retention devices - A CAD/CAM design and a traditional design - On upper airway volume in obstructive sleep apnea patients.

OBJECTIVE: This pilot randomized crossover study evaluated the outcomes of two custom-made mandibular retention devices (MRDs), a computer-aided design (CAD)/computer-aided manufacturing (CAM) device (Narval CC™) and a non-CAD/CAM device (Narval™), on oropharyngeal airway volume in patients with obstructive sleep apnoea (OSA). METHODS: 12 OSA patients were recruited from an University Hospital for MRD therapy with either CAD/CAM or non-CAD/CAM first. A cone-beam computed tomography evaluation (CBCT) and polysomnography assessment was performed during baseline assessment and at the end of each study period. RESULTS: Upper airway volume increased significantly with the CAD/CAM device (7725 +/- 6540 mm3, p = 0.008) but not with the non-CAD/CAM device (3805 +/- 7806 mm3, p = 0.13). The CAD/CAM device was also associated with a significant decrease in AHI (mean AHI after treatment 9.4±6.7 events/h, p = 0.003) and oxygen desaturation index (mean ODI of ≥ 3%/h 11.9 ± 6.8, p = 0.011). Changes in AHI (14.7 +/- 11.7 events/h, p = 0.083) and ODI (15.5 +/- 19.2, p = 0.074) were not statistically significant with the non-CAD/CAM device. The vertical dimension of occlusion increased significantly following treatment with both MRD devices (both p = 0.003), but was significantly less pronounced with the CAD/CAM device (mean difference: -2.7 +/- 1.7 mm, p = 0.003). Final mandibular protrusion after titration was the same with both devices (85%, p = 0.317). CONCLUSION: The CAD/CAM (Narval CCTM) device was associated with a significant increase in upper airway volume that may be caused by a lower degree of vertical separation between the jaws when compared to the non-CAD/CAM design.

Intra-sinusal bone ring concomitant with Le Fort 1 osteotomy: description of a technique.

AIM: To present a technical note on intra-sinusal bone ring concomitant with Le Fort 1 osteotomy. MATERIAL AND METHOD: A 57-year-old man was referred to our Department for full-mouth rehabilitation. Oral examination identified: uncompensated multiple tooth loss and a class 3 skeletal malocclusion. The treatment plan consisted in a Le Fort 1 osteotomy and short-arch dental implant rehabilitation. Intra-sinusal bone ring technique associated with Le Fort 1 osteotomy were carried out under general anaesthesia. RESULT: High primary retention was clinically observed of both the implant and the bone graft. Radiographic follow-up demonstrated satisfactory healing of the graft and implant osseointegration. CONCLUSION: Bone ring technique concomitant with Le Fort 1 osteotomy seems to be appropriate to correct jaw discrepancy associated to a single tooth loss of the upper molar region with residual bone height of at least 3 mm to ensure implant primary stability.

Rituximab as a trigger factor of medication-related osteonecrosis of the jaw. A case report.

Rituximab, an anti-CD20 monoclonal antibody, is an effective treatment for rheumatoid arthritis. Here we report the case of a patient with rheumatoid arthritis, having taken risedronate for 14 months to prevent corticosteroid-induced osteoporosis, more than 2 years ago, who presented osteonecrosis of jaw following herpetic gingivostomatitis two weeks after the beginning of a rituximab treatment associated with her usual anti-rheumatic drugs. Eight weeks later, no bone and/or gum healing was observed and a stage 2 medication-related osteonecrosis of the jaw (MRONJ) was diagnosed. A conservative approach was decided with antiseptic mouth washes, low-level laser treatment (LLLT) and systemic therapy with teriparatide. Complete mucosal coverage was obtained after more two years of follow-up. We suggest that rituximab as immunosuppressant might be a cause or a decompensating factor of MRONJ. Non-surgical periodontal treatment with LLLT and teriparatide are candidates for the treatment of MRONJ.

A retrospective study of pure medial orbital wall fracture management.

PURPOSE: To describe the clinical presentation of isolated medial orbital wall fractures, the duration of symptoms and their management. METHODS: Retrospective study of 60 orbits of 60 patients over 18 years of age with isolated medial wall fractures of the orbit at the facial and trauma center of the Pitié-Salpêtrière university hospital of Paris between June 2012 and November 2015. Diplopia, enophthalmos and limitation of extraocular muscle movements were investigated. The location of the fractures was confirmed with three-dimensional computed tomography. Intraocular trauma was ruled out. Incomplete data were excluded. RESULTS: Eighty-three patients were identified (June 2012-November 2015). Sixty patients (39 males and 21 females) had a complete medical record. The mean age was 37 years, ranging from 18 to 75 years. Assault was the most common cause in 45 patients (75%), followed by sports accidents in 8 patients (13%), motor vehicle accidents in 6 patients (10%), and a fall in 1 patient. On presentation, 51 patients (85%) had no symptoms. Diplopia was present in 9 patients (15%). Four of them (6.7%) had associated enophthalmos. The diplopia resolved spontaneously in 5 patients (5.5%) and persisted more than 2 weeks in 4 patients (6.7%), for whom surgical intervention was recommended. Only 4 patients (6.7%) were managed surgically due to the presence of combined persistent diplopia and enophthalmos. The mean time from trauma to surgery was 18 days (15-45 days). At the 45-day postoperative follow-up, persistent diplopia was present in 1 patient out of the four treated surgically, with no residual enophthalmos. Fifty-six patients were managed conservatively. CONCLUSION: Asymptomatic fractures do not require surgical repair, and conservative management is adequate. Such fractures heal on their own without any consequences.

Routine screening for HIV, hepatitis B virus and hepatitis C virus in individuals undergoing oral and maxillofacial surgery.

OBJECTIVES: Given the effectiveness of treatment of HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, there are considerable benefits associated with determining HIV/HBV/HCV status. We evaluated the feasibility and acceptability of systematic screening and subsequent care in an oral and maxillofacial surgery department. METHODS: The anaesthesiologists proposed screening for HIV, HBV and HCV to all individuals of unknown infection status undergoing surgery between 19 April 2016 and 19 April 2017. The endpoints were the rates of test offer, acceptance/refusal and new diagnoses. Seropositive individuals were referred to infectious disease specialists. Associations between age, sex or surgery type and test offer (eligible individuals) or acceptance/refusal (those offered testing) were investigated. RESULTS: Of the 1407 individuals attending the department, 1322 were eligible for inclusion in the study. Testing was proposed to 899 individuals [68%; 95% confidence interval (CI) 65-71%], 831 of whom accepted the offer (92.4%; 95% CI 90.5-94.1%). Results were obtained for 787 individuals (41 samples were uncollected and three were invalid). Age was the only factor associated with test offer in multivariable analysis [odds ratio (OR) 0.90; 95% CI 0.84-0.97, per additional 10 years], and no factor was associated with acceptance. Of the five, three and eight individuals testing positive for HIV, HBV and HCV, four, two and one patient, respectively, reported prior knowledge of seropositivity. The new diagnosis rate was 0.13% (95% CI 0-0.7%) for HIV and HBV, and 0.89% (95% CI 0.36-1.82%) for HCV [three positive polymerase chain reaction (PCR) tests]. All individuals newly diagnosed with HIV or HCV infection received specific antiviral treatment. CONCLUSIONS: Rates of screening offer and acceptance were high. Substantial screening resources are required to decrease the impact of the hidden epidemics of HIV, HBV and HCV infections.

Long-term effectiveness and side effects of mandibular advancement devices on dental and skeletal parameters.

INTRODUCTION: Continuous positive airways pressure, generally used to treat obstructive sleep apnea-hypopnea syndrome (OSAHS), is not tolerated well by many patients. An alternative is to treat OSAHS with mandibular advancement devices (MAD). This research assesses the long term (> 2 years) effectiveness and the side effects on dental and skeletal parameters of these devices. MATERIAL AND METHODS: We selected 24 patients with moderate to severe OSAHS. All were treated with MADs for at least 2 years. We gathered cephalometric teleradiographs in centric relation and sleep recordings before and after the patients were treated. We evaluated the patients' apnea-hypopnea indexes (AHI) as well as their Epworth sleepiness scale (ESS) scores. We measured the inclination of the central incisors and the positions of the upper and lower jaws. RESULTS: Mandibular advancement devices were used for more than 2 years (3.9 ± 1.9 years). We observed a statistically significant decrease of the patients' AHI and their ESS scores. We also observed a modification of the inclination of the lower central incisors (+0.521; P = 0.047) and of the position of the maxilla (-0.287; P = 0.039). DISCUSSION: We demonstrated the clinical effectiveness of mandibular advancement devices for treating OSAHS, with a very low rate of side effects on dental and skeletal positions.

Synovial chondromatosis of the temporomandibular joint: Report and analysis of 12 cases.

OBJECTIVE: We had for aim to study the clinical manifestations, diagnostic imaging techniques, histopathological and therapeutic findings of patients presenting with synovial chondromatosis (CS) of the temporomandibular joint (TMJ). MATERIAL AND METHODS: We reviewed the clinical history of all our patients who were diagnosed with CS between 2009 and 2013. RESULTS: We identified 12 cases of TMJ-CS, in 4 male and 8 female patients, with a mean aged of 50.5 years at diagnosis (range: 43-86 years). The average symptom duration prior to diagnosis was 11 months (range: 1-24 months). The most frequent clinical manifestations were joint pain (10 cases), restricted movement (6 cases), and swelling (4 cases). Panoramic radiographs were not contributive. CT scan and MRI findings led to a diagnosis in every case. 2 to 30 foreign bodies with various degrees of aggregation were removed by arthrotomy in our series and synovectomy was performed in all patients. These foreign bodies were in the upper compartment and the articular disk was not affected in 10 cases. A histopathological examination confirmed the diagnosis. The mean postoperative follow-up was 78 months. No case of chondrosarcoma was identified and the recurrence rate was low (1 case). DISCUSSION: The clinical manifestations of TMJ-CS are common and conventional imaging is poorly contributive so that the diagnosis is often late. The delay before diagnosis was an average11 months for our patients given our experience; it was almost twice longer in other series. Arthrotomy and excision of the loose bodies led to confirmation by histopathological analysis. Most of the time, this treatment is sufficient but long term clinical and radiological monitoring is required.

Causes for litigation and risk management in facial surgery: A review of 136 cases.

INTRODUCTION: Malpractice lawsuits in medicine and facial surgery are on the rise and they become an influencing factor in everyday practice for any surgeon. AIM: We aim to analyze the possible causes for litigation in an effort to avoid these claims in the future. MATERIALS: One hundred and thirty litigation cases filed over a 10 year period (2005-2015) were evaluated. METHODS: Depending on the expert's opinion, it was determined whether the lawsuit was due to actual faulty treatment or either a lack of informed consent or discrepancy between the expected and the final result. RESULTS: A total of 136 claims were filed and examined. Dissatisfaction about the esthetic or functional result topped the list with 47% (n = 64) of the cases followed by nerve damage with 20% (n = 27). Medical negligence and failed treatment accounted both for 9% of all cases (n = 12). The list was completed by post-operative complications (n = 11), death (n = 6) and incorrect or late diagnosis (n = 4). In the expert's opinion only in 21 (15%) cases there was actual fault and in the remaining cases litigation was due to lack of informed consent (n = 70; 51%) or a discrepancy between the expected and achieved result (n = 45; 33%). CONCLUSION: A considerable portion of the lawsuits in facial surgery seem to originate out of a lack of communication between physician and patient and not faulty treatment. Efforts in informing the patient about possible side effects, complications and expectations will benefit the physician greatly by minimizing his liability and risk at prosecution.

Anterior pedicle temporalis muscle flap interposition in the treatment of TMJ disorders.

Temporomandibular joint (TMJ) disorders are a common reason for consultation. Failure of medical treatments sometimes leads to the need for one of many surgical alternatives. Our purpose was to evaluate the results of anterior pedicle temporalis muscle flap interposition in the treatment of TMJ disorders. MATERIAL AND METHODS: For this prospective study, we selected 18 patients who underwent TMJ surgery involving the interposition of a temporalis muscle flap according to a standardized technique, between January 1, 2009 and August 31, 2014. CT imaging was performed on all patients prior to surgery. We documented the etiology of TMJ dysfunction, pre and postoperative pain using a visual analogue scale (VAS), pre and postoperative (last consultation) mouth opening, and complications. We used the Wilcoxon test for our statistical analysis. RESULTS: We observed a significant variation in preoperative and postoperative pain and mouth opening, with an average decrease in VAS values of 4.9/10 and an average increase of mouth opening of 11.1mm. No major complications were observed. DISCUSSION: The interposition of an anterior pedicle temporalis muscle flap in the treatment of temporomandibular joint disorder is a simple and effective technique.

Mandibular lymphoma.

INTRODUCTION: B-cell lymphoblastic lymphoma (B-LBL) rarely occurs in the oral cavity (3.5% of all intra-oral malignant tumors). Few cases of B-LBL mandibular bone involvement have been reported. OBSERVATION: We report the case of a 30-year-old female patient presenting with a single swelling of the left mandibular region, having grown for several weeks. Maxillo-facial CT and MRI showed inflammation of soft tissues and muscles without initial signs of osteitis, thus noncontributive to the diagnosis. A biopsy allowed diagnosing an intra-oral bone lymphoblastic lymphoma. The patient was referred to the hematooncology unit for treatment. DISCUSSION: Jaw localization of non Hodgkin's lymphoma is rare. Clinical symptomatology and radiological signs are poorly contributive. The diagnosis relies on a histopathological analysis.

The promising impact of molecular profiling on treatment strategies in oral cancers.

Oral squamous cell carcinoma (OSCC) is a major cause of cancer-associated morbidity and mortality. Although OSCC may develop from easily accessible oral preneoplastic lesions (OPLs), no intervention has been reported so far that reduces the rate of malignant transformation. A comprehensive molecular characterization of oral carcinogenesis may help refining treatment strategies both in patients with OPLs and OSCC. Herein, we review main molecular alterations occurring at different steps during oral carcinogenesis and show how molecularly-based medicine and surgery may impact the outcome of OSCC in the future.

The immune microenvironment of HPV-negative oral squamous cell carcinoma from never-smokers and never-drinkers patients suggests higher clinical benefit of IDO1 and PD1/PD-L1 blockade.

BACKGROUND: Never-smokers and never-drinkers patients (NSND) suffering from oral squamous cell carcinoma (OSCC) are epidemiologically different from smokers drinkers (SD). We therefore hypothesized that they harbored distinct targetable molecular alterations. PATIENTS AND METHODS: Data from The Cancer Genome Atlas (TCGA) (discovery set), Gene Expression Omnibus and Centre Léon Bérard (CLB) (three validation sets) with available gene expression profiles of HPV-negative OSCC from NSND and SD were mined. Protein expression profiles and genomic alterations were also analyzed from TCGA, and a functional pathway enrichment analysis was carried out. Formalin-fixed paraffin-embedded samples from 44 OSCC including 20 NSND and 24 SD treated at CLB were retrospectively collected to perform targeted-sequencing of 2559 transcripts (HTG EdgeSeq system), and CD3, CD4, CD8, IDO1, and PD-L1 expression analyses by immunohistochemistry (IHC). Enrichment of a six-gene interferon-γ signature of clinical response to pembrozulimab (PD-1 inhibitor) was evaluated in each sample from all cohorts, using the single sample gene set enrichment analysis method. RESULTS: A total of 854 genes and 29 proteins were found to be differentially expressed between NSND and SD in TCGA. Functional pathway analysis highlighted an overall enrichment for immune-related pathways in OSCC from NSND, especially involving T-cell activation. Interferon-γ response and PD1 signaling were strongly enriched in NSND. IDO1 and PD-L1 were overexpressed and the score of response to pembrolizumab was higher in NSND than in SD, although the mutational load was lower in NSND. IHC analyses in the CLB cohort evidenced IDO1 and PD-L1 overexpression in tumor cells that was associated with a higher rate of tumor-infiltrating T-cells in NSND compared with SD. CONCLUSION: The main biological and actionable difference between OSCC from NSND and SD lies in the immune microenvironment, suggesting a higher clinical benefit of PD-L1 and IDO1 inhibition in OSCC from NSND.

Osteomyelitis of the jaws: A retrospective series of 40 patients.

INTRODUCTION: The caseload of jaw osteomyelitis seem to have decreased considerably over the last fifty years thanks to the progress of oral hygiene, the appearance and the use of antibiotics, and early screening. 'Limited osteitis' remains frequent in general practice (alveolitis after dental extraction), but osteomyelitis is much rarer as evidenced by the lack of current literature and the low number of reported patients in the published series. The aim of this study was to analyze retrospectively all the cases of maxillo-mandibular osteomyelitis treated in a large academic department of Stomatology and Maxillofacial Surgery over a period of 6 years and to compare the results to data from the literature. MATERIAL AND METHOD: All patients diagnosed with maxillo-mandibular osteomyelitis by one of the staff surgeons between January 2009 and December 2015 was included. An epidemiological record (sex, age, ethnic background, risk factors, clinical, origin of disease, imaging and biology, treatments and progression) were collected for each patient. Osteomyelitis cases were classified according to the Zurich Classification System. Results were compared to data from the literature. RESULTS: Forty patients were retained. Three presented acute osteomyelitis, 26 secondary chronic osteomyelitis and 11 a primary chronic osteomyelitis. Osteomyelitis affected predominantly the mandible (87%). Dental origin was found in 90% of cases. Nine patients (22.5%) recovered and 29 (90%) were clinically improved. Ten of the 11 patients with primary chronic osteomyelitis were improved. DISCUSSION: This cohort study is one of the largest series currently available and presents results comparable to those of the literature of the last 25 years.

Necrotizing sialometaplasia of the parotid gland associated with facial nerve paralysis.

INTRODUCTION: Necrotizing sialometaplasia is a benign inflammatory lesion involving most frequently the minor salivary gland of the hard palate. Involvement of the parotid gland is rare, involvement of the parotid gland associated with facial palsy is exceptional. CASE REPORT: A 56-year-old male patient with Marfan syndrome presented with swelling and inflammation of the left parotid gland associated with progressively complete facial nerve paralysis. CT scan and MRI showed a parotid collection with hyper signal of the nearest tissues associated with erosion of the styloid process. A malignant tumor was suspected. The histological examination of a biopsy showed a lobulocentric process with necrosis, squamous metaplasia, and inflammation. The immunohistochemical examination supported a final diagnosis of necrotizing sialometaplasia. DISCUSSION: Necrotizing sialometaplasia of the parotid gland associated with facial nerve paralysis presents like a malignant neoplasm, both clinically and histologically. Only advanced immunohistochemical examination can really confirm the diagnosis.

Prognostic factors of gingival-alveolar squamous cell carcinoma of the maxilla.

OBJECTIVES: To determine prognostic factors in gingivo-alveolar squamous cell carcinoma of the maxilla (GA-SCC-M), and particularly the prognostic value of both vertical and antero-posterior tumor spread. MATERIAL AND METHODS: Our retrospective study included all naïve-treatment patients treated in our center between 2006 and 2013 for GA-SCC-M. Posterior involvement was considered when the tumor extended behind the mesial side of the first maxillary molar. Spread posterior to the maxillary tuberosity was defined by the spread to at least one of the following structures: pterygomaxillary fissure, pterygoid muscles, and processes. Involvement of the maxillary sinus floor, nasal fossa, and orbital floor was assessed, concerning the vertical spread. RESULTS: A radiological tumor spread to the nasal fossa, maxillary sinus floor, and orbital floor were prognostic factors independently of age, cervical lymph node metastasis and positive margins in multivariate analysis (p < 0.05). Radiological suggested spread tended to be noticeably more predictive of a poor prognosis than histological proven tumoral spread. The prognosis was not significantly different between clinical tumoral spread anteriorly or posteriorly to the first molar (p = 0.46). The prognosis was not worsened, even in case of radiological suggested spread posterior to the maxillary tuberosity (p = 0.09). CONCLUSION: A vertical radiological spread of GA-SCC-M was a prognostic factor but not the extension posteriorly to the maxillary tuberosity. T4b tumors were mostly resectable, proving that a T4b stage was not predictive of unresectability in GA-SCC-M of the maxilla.

[Macrocheilia revealing an acute promyelocytic leukemia]. / Macrochéilie révélant une leucémie aiguë promyélocytaire.

INTRODUCTION: Macrocheilia is a rare presentation for acute promyelocytic leukemia (APL). CASE REPORT: A 18 year-old man was referred to our department for an acute swollen lower lip, multiple swollen cervical lymph nodes and spontaneous gum bleeding. The diagnosis of APL was made and the treatment was rapidly started in an intensive care unit. DISCUSSION: APL is often found because of stomatologic symptoms but macrocheilia is rarely reported. APL is a vital emergency.

[Kimura's disease of the hard palate]. / Localisation palatine d'une maladie de Kimura.

INTRODUCTION: Kimura's disease is an inflammatory and autoimmune disease that is endemic in Middle East and Asian countries but remains rare in Europe. It usually presents as subcutaneous nodules combined with cervical lymphadenopathies in the cervicofacial region. The oral mucosa localization is extremely rare. We report for the first time a case of hard palate localization. OBSERVATION: A 61-year-old male patient from Martinique consulted for a recent median, extensive and poorly defined black area localized on the hard palate. It was painless and did not cause any discomfort. We performed a biopsy to rule out a melanoma. The pathology report led to diagnosing Kimura's disease. The biological parameters, especially the renal status, were normal. A simple medical supervision was prescribed. DISCUSSION: This was the first time Kimura's disease was observed as a pigmented area located on the hard palate. The diagnosis of melanoma first had to be ruled out. The histological and immunohistological parameters are mandatory to make a diagnosis.

Calcified onchocercal nodule in the infratemporal fossa: a rare case.

Onchocerciasis is a parasitic tropical disease that often presents as multiple, superficial nodules. When it is unique and deeply situated, its clinical diagnosis is difficult. We report a case of a calcified onchocercoma that was localised to the infratemporal fossa.