[One step surgery for severe African endocrine exophtalmia: clinical case]. / Chirurgie en un temps d'une exophtalmie basedowienne africaine sévère: présentation d'un cas clinique.

INTRODUCTION: The association hyperthyroidism-exophtalmia is pathognomonic of the Graves disease. Classically, the treatment is based on a pluridisciplinary step-by-step approach with a precise chronology. In some African places, these optimal conditions are not present. When confronted to such particular situations, it can be proposed to treat surgically at the same time the endocrine disease and the ophthalmologic complications. OBSERVATION: The authors report the case of a 42-year-old women suffering of a great thyreotoxic goiter with severe bilateral exophtalmia, treated by thyroidectomy and orbital decompression in the same session with a good result after 18 months. DISCUSSION: This non-conventional approach can be useful in particular situations when the medical environment is not optimal. It permits the radical treatment of their disease and improves the prognosis of patients with poor capacities for survey.

[A novel miniplate model for maxillary osteotomies]. / Nouveau modèle de miniplaques pour les ostéotomies maxillaires.

INTRODUCTION: The use of miniplates in orthognatic surgery, and especially for Le Fort I osteotomies, has brought great improvement in technical aspects, postoperative evolution, and long-term stability. Nevertheless, accurate modelling of theses plates remains problematic because the right balance between malleability and rigidity is hard to determine. This is why we designed an original new miniplate model. The aim of this study was to assess our new model in clinical settings. MATERIAL AND METHOD: This novel plate was made of two lateral sockets with two holes on each side, linked by a central bar, 1mm thick like the plate. Three lengths were available. A mechanical study proved that this plate was stronger than a 0.6 millimeter thick plate and that its adaptability was much superior to that of a common 1-mm thick plate. We retrospectively studied 180 patients having undergone a Le Fort I osteotomy with or without mandibular osteotomy. Follow-up ranged from 6 to 12 months. Congenital abnormalities were excluded. RESULTS: Bone healing was achieved without any complication in due time for all but two patients. In one case, a plate fracture was observed. In the other case, a slight mobility of the upper jaw appeared after removal of the device. No intolerance was observed. DISCUSSION: This novel miniplate seems to be improved when compared to other available devices. Rigid osteosynthesis of a Le Fort I osteotomy can be problematic because of the repositioning gap and the variable anatomy of the maxilla. The device must be rigid enough, inconspicuous, and well tolerated. Only three plate lengths are necessary to treat all cases, which reduces cost and storage. The only requirement is to mandatorily insert four plates every time. Removal of the plates does not seem necessary.

Outcomes of orbital decompression using surgical navigation in thyroid-associated ophthalmopathy.

Thyroid-associated ophthalmopathy can result in proptosis. In such cases, orbital decompression surgery is often warranted to reduce the adverse impact on patient quality of life. Due to the anatomical complexity of the orbit, navigation can be of considerable assistance during orbital decompression. The objective of this study was to evaluate the benefits of using a surgical navigation device in orbital decompression surgery. A retrospective study was performed based on patients who underwent decompression surgery with (N+) or without (N-) a navigation device between 1997 and 2017. Included patients had undergone unilateral or bilateral orbital decompression by resection of the orbital floor and medial wall of the orbit. Criteria assessed were the presence of debilitating postoperative diplopia, postoperative proptosis reduction, symmetry of protrusion of the eyeballs, and the duration of surgery. Three hundred and fifty eyes were analysed (191 patients): 205 in the N+ group and 145 in the N- group. Use of the surgical navigation system resulted in a greater proptosis reduction, and this result was statistically significant for the right eyeball (P=0.03). The surgical navigation system had no effect on symmetry of protrusion of the eyeballs or on postoperative diplopia. Setting up the navigation device increased the duration of surgery by 40 minutes on average.

Temporomandibular joint arthroplasty for osteoarthrosis: A series of 24 patients that received a uni- or bilateral inter-positional silicone sheet.

PURPOSE: To evaluate mid-term results from using a silicone sheet for inter-positional arthroplasty in moderate or severe cases of osteoarthrosis of the temporo-mandibular joint (TMJ). To also determine any remaining indications from this method. PATIENTS AND METHODS: This retrospective study included patients that underwent surgery between 2008 and 2016. Pre- and post-operative mouth opening (MO), according to inter-incisal distance (mm) and pain score (PS: 0=no pain to 4=very severe pain) were recorded for 24 patients. Patients were divided according to thickness of the silicone sheet (group A: 1.0 mm, group B: 1.5 mm). RESULTS: The cohort included 22 females (92%). Mean age at surgery was 55 years±13 (26-80). Mean length of follow-up was 26 months±24 (6-80). Mean improvement in MO was 8.2 mm (+33%) and of PS was 1.7 (-68%). MO was not improved for two patients and worsened for one. PS score improved for all patients. No statistical difference was found between groups A and B. There was also a tendency for degradation of outcomes over time. CONCLUSION: The poor reputation of prosthetic discoplasty was not as evident in our series, even though anatomical and functional status seemed to deteriorate over time. This is because total-joint prosthetic replacement is often proposed instead. However, for elderly or fragile patients that have severe pain, and regarding cost-benefit aspects, conventional arthroplasty can still be discussed, especially since French national health-care insurance does not yet support TMJ prosthetic replacement for osteoarthrosis.

Intra-operative quantification of the surgical gesture in orbital surgery: application to the proptosis reduction.

BACKGROUND: Proptosis is characterized by a protrusion of the eyeball due to an increase of the orbital tissue volume. To recover a normal eyeball positioning, the most frequent surgical technique consists in the osteotomy of orbital walls combined with a loading on the eyeball to initiate tissue decompression. The first biomechanical models dealing with proptosis reduction, validated in one patient, have been previously proposed by the authors. METHODS: This paper proposed an experimental method to quantify the intra-operative clinical gesture in proptosis reduction, and the pilot study concerned one clinical case. The eyeball's backward displacement was measured by an optical 3D localizer and the load applied by the surgeon was simultaneously measured by a custom-made force gauge. Quasi-static stiffness of the intra-orbital content was evaluated. FINDINGS: The average values for the whole experiment was 16 N (SD: 3N) for the force exerted by the surgeon and 9 mm (SD: 4mm) for the eyeball backward displacement. The averaged quasi-static stiffness of the orbital content was evaluated to 2.4N/mm (SD: 1.2) and showed a global decrease of 45% post-operatively. INTERPRETATION: The protocol and the associated custom-designed devices allowed loads, induced displacements and macroscopic stiffness of the orbital content to be measured intra-operatively. The clinical relevance has been demonstrated in a pilot study. To our knowledge, no study has been published allowing the clinical gesture in proptosis reduction to be quantified intra-operatively. Associating an enlarged database and validated patient-related predictive models will reinforce the surgical efficiency and patient comfort contributing to diagnosis and intra-operative guidance.

Maxillofacial intraoral distraction osteogenesis followed by elastic traction in cleft maxillary deformity.

We present a case of severe maxillary hypoplasia in a 16 years old cleft patient treated by distraction osteogenesis maxillary advancement. Initial evaluation showed vertical and antero-posterior maxillary deficiencies, and a Class III malocclusion. Two intraoral distractors (Zurich Pediatric Maxillary Distractor, KLS Martin, Tuttlingen, Germany) were placed in a high Le Fort I osteotomy. An initial advancement of 11 mm was obtained, but the resulting occlusion was unsatisfactory (end-to-end occlusion). The consolidation period was reduced to 3 weeks to allow the mechanical manipulation of the newly formed bone with Class III elastics. An additional advancement of 3 mm, caused by elastic orthodontic traction produced both normal skeletal relationship and satisfactory occlusion. This observation shows that it is possible to carry on a skeletal maxillary displacement by interdental elastics before the complete fusion of the callus. After 12 months of postoperative follow-up no osseous relapse could be detected and the occlusal result was stable.

Evaluation of gingival microcirculation by a laser-Doppler flowmeter. Preliminary results.

Up to now, only qualitative studies have been performed on gingival microcirculation whereas quantitative methods have been used in animal experiments, by the injection of microspheres for instance. The authors had the opportunity of using a Laser-Doppler Flowmeter (LDF) which had already served to explore the cutaneous microvascular blood flow. At first, it was necessary to modify an occlusal splint for good immobilisation of the probe on the gingival mucosa. Then they made a study on twenty healthy students with measurements of red cell velocity in superficial maxillary gingival mucosa. Each subject was tested twice at an interval of one-month. A statistical analysis shows very good reproducibility of the tests, especially for the pulsative velocity, despite a rather high variability between the subjects. The haemodynamic parameters (heart rate, systolic or diastolic blood pressure) do not seem to have a significant influence on the values obtained. The LDF is a very good instrument for the evaluation of gingival microvascular flow, as has been demonstrated for cutaneous microcirculation. A wide range of applications can be considered for this sensitive and harmless technique.

Craniofacial differences according to the body mass index of patients with obstructive sleep apnoea syndrome: cephalometric study in 85 patients.

We examined the craniofacial characteristics of patients with obstructive sleep apnoea syndrome (OSAS) and correlated them with the body mass index (BMI (weight (kg) x height (m2)). Eighty-five men with OSAS diagnosed by conventional polysomonography were divided into two groups according to their BMI (< 30 and > or = 30). Cephalometry was analysed by using 31 measurements of the size of the bone structures, their relationships and the size of the airways. The groups were comparable for age and the apnoea-hypopnoea index (mean 49, standard deviation (SD) 23). Patient with a BMI < 30 had a shorter anterior floor of cranial base, a smaller mandible and retroposition of the mandible compared with severly obese patients. These skeletal differences were associated with narrower velopharyngeal and linguopharyngeal spaces. This study sh ows that there is a craniofacial difference between two populations, divided according to their BMI.

Rehabilitation of long-term facial paralysis.

A wide variety or techniques have been developed over the years in an effort to reduce the devastating impact of facial paralysis on the patient. The authors choose to perform hypoglossal-facial nerve anastomosis when facial facial nerve anastomosis, or cross-over, or microvascular muscle transplantation are impossible. Nevertheless, these results appear always insufficient for palpebral occlusion. The authors propose to associate two rehabilitation technique to obtain optimal results. They perform hypoglossal facial nerve anastomosis using the technique modified by U. Fisch, and they associate temporal muscular transfer to improve ocular protection. This association imposes an increased strain on the patient in an effort to undertake double re-education which modifies twice his classic corporeal scheme. The surgical technique are associated after evaluation of the possibility of the patient adherence to the long duration physical therapy.

[Diagnosis and treatment of dysthyroid orbitopathy: a multidisciplinary disease]. / Prise en charge diagnostique et thérapeutique d'une orbitopathie dysthyroïdienne: une affection multidisciplinaire.

Graves' disease is a common autoimmune disorder that can be complicated, especially in smokers, by an orbitopathy which can sometimes jeopardize vision and result in functional sequelae affecting quality of life of these patients. Although the diagnosis of dysthyroid orbitopathy is usually obvious, clinical evaluation must specify the stage of progression (clinical activity score) and severity according to the European Group EUGOGO classification. At first, rapid restoration of the euthyroid state, smoking cessation and simple symptomatic ophthalmic treatment are suggested. In the case of severe or active orbitopathy, oral or intravenous corticosteroid therapy with or without orbital radiation therapy (and even emergency orbital surgery in the case of compressive optic neuropathy) should be implemented. Ultimately, orbital surgery (orbital decompression in cases of exophthalmos), oculomotor surgery (diplopia) or eyelid surgery (retraction) may be required depending on the severity of sequelae. A multidisciplinary approach involving ophthalmologist, endocrinologist and orbital surgeon should facilitate an overall diagnosis and treatment plan for these patients.

[Septic pseudarthrosis of the mandible and endodontic treatment]. / Pseudarthrose septique mandibulaire et traitement endodontique.

INTRODUCTION: Septic pseudarthrosis of the mandible is an uncommon complication with several etiologies. The presence of a tooth next to a fracture site is one of the etiological factors. Conservative management of a tooth in or near the mandibular fracture site is often the issue when treating fracture of a toothed part. OBSERVATION: A 49 year-old male patient was hospitalized in our department for a bifocal fracture of the mandible (right parasymphysis and left sub-condylar). An open reduction internal fixation with plates and screws was performed. The immediate postoperative period was uneventful except for persistent tooth pain in the parasymphyseal fracture site. At 1 postoperative month, the fracture site was stable and signs of consolidation were documented by the panoramic view. A dentist performed root canal treatment on tooth 42, 8 weeks after surgery, because of recurrent complaint by the patient. At 6 months, clinical and radiological examinations revealed mandibular pseudarthrosis. DISCUSSION: This type of pseudarthrosis case is relatively infrequent. It occurs after endodontic treatment of a healthy tooth close to the fracture site (performed after the physiological delay before bone healing). The bacterial colonization of the fracture site could be related to this endodontic treatment. This case raises questions on the need for endodontic treatment of a tooth near a mandibular fracture site.

The vascular system of the upper eyelid. Anatomical study and clinical interest.

Thorough knowledge of the vascular supply is indispensable for repair and oncologic surgery of the eyelids, and has a significant impact on the management of complex defects of this region. This anatomic study was performed with five fresh cadavers after arterial injection of coloured neoprene latex. The distribution of the vascular system of the upper eyelid was examined after dissection and photographic study. It is made up of three arcades: the preseptal arcade, the supratarsal arcade, and the marginal arcade, under the orbicularis oculi muscle. These arcades are supplied by branches of the ophthalmic artery (supraorbital artery, supratrochlear artery and medial palpebral artery) and branches of the facial artery and temporal artery. Small vertical branches arising out of these arcades provide an anastomotic network. This anatomical study aimed to describe the vascular system of the upper eyelid in order to search for constant features and to map the blood supply of the principal upper lid flaps.

Vascular territories of the tongue: anatomical study and clinical applications.

The goal of this cadaver study has to propose the concept of angiosomes of the tongue (arterial cartography) from the notion of lingual artery segmentation, known in the literature since 1998. Fifteen fresh cadaver heads were used in this study. Four selective ink injections were made in specific location of the lingual artery like the segmentation concept. Three mucosal territories of the tongue were defined and they appear dependent on the precise segments of the lingual artery. The territory of the deep lingual artery is the dorsal side of the tongue, the territory of the sublingual artery is the ventral side and the territory depending of the dorsal artery is the root of tongue. No study was published yet about the vascular territories of the tongue. This study brings an additional knowledge and a review about the vascular risk of the tongue resections. The originality of this study consists of the description of vascular territories of tongue proceeding to different segment of lingual artery, which has not been described in the literature since now. The knowledge of these two notions is useful before every tongue resection, which can compromise the vascularity of the remaining tongue, and at the time of the lingual revascularization, once this vascularity is compromise.

[Neurosensory disorders and functional impairment after bilateral sagittal split osteotomy: role of the anatomical situation of the alveolar pedicle in 76 patients]. / Troubles de la sensibilité consécutifs aux ostéotomies sagittales des branches montantes de la mandibule: rôle de la position du pédicule alvéolaire chez 76 patients.

INTRODUCTION: Bilateral sagittal split osteotomy (BSSO) of the mandibular ramus is the most frequent orthognatic surgery. The risk of neurosensory disorders remains high even their incidence varies according to numerous publications. The anatomical location of the alveolar pedicle seems to be one of the most important factors in these disorders. The aim of this study was to determine its exact role. MATERIAL AND METHOD: We performed a retrospective study on 76 patients and 152 osteotomy sides, all of them operated according to the Epker technique by the same surgeon between 2000 and 2004. For each operative side we noted the position of the inferior alveolar nerve during the split: Type I entirely in the internal cortical bone, Type II partially in the external cortical bone, Type III mostly or completely in the external cortical bone. The neurosensory disorders were recorded during clinical examination and simply classified into two categories: "absent" or "present". The outcome was noted during the postoperative follow-up at D1; D15; M1,5, M6, and M12. After that, it was documented through a written questionnaire or telephone conversation. RESULTS: Since there was no difference between the right and the left sides, the study enclosed all of the operative sides together (152). The anatomical distribution was: 97 Type I (63.8%), 28 Type II (18.4%), and 27 Type III (17.8%). Immediate postoperative neurosensory disorders (D1) occurred on 74.3% of sides, with important significant differences between Type I (64.9%) on one hand, Type II (89.2%) and Type III (92.6%) on the other hand. At one year of follow-up, the rate of neurosensory disorders was 20.4% with also a difference between Type I (13.4%) and Types II and III (35.7% and 29.6%). DISCUSSION: The anatomical location of the alveolar pedicle seems to be important. This study confirms previously published studies and raises the question of CT scan assessment before performing BSSO.

[Decision strategy in orthognathic surgery. Part 2: The esthetic choice in orthognathic surgery--practical applications]. / Stratégie de la décision en chirurgie orthognathique. 2e Partie: Le choix esthétique en chirurgie orthognathique--application pratique.

Even if the functional factors are the most important in the decision, we have always to remember the need of our patient concerning aesthetic improvement. At this moment, the traditional approach based upon morphologic cephalometric analysis (which are frequently discordant) must be substituted by an aesthetic approach. The goal is to obtain a realistic 3D-imaging of the face as it will be after surgery. But it cannot really be achieved yet and we are obliged to work on lateral X-ray cephalograms. The most important at this stage of the decision is not to make a static aesthetic evaluation. It is on the contrary to perform a prospective simulation of the new profile line, as accurate as possible, based upon statistical correlations between soft- and hard-tissues changes. Even if there are some technical problems, even if the results are not currently good enough, the aesthetic prospective analysis allows validation or modulation of the initial functional surgical indication. We can compare for instance the aesthetic results of different amounts of displacements in bimaxillary surgery. Meanwhile, it is sure that the result depends also on the precision of the surgical procedure and on the good functional re-equilibration which is essential for the stability.