[Oral appliances or maxillomandibular advancement osteotomy for severe obstructive sleep apnoea in patients refusing CPAP]. / Orthèse d'avancée mandibulaire ou ostéotomie maxillo-mandibulaire pour le traitement des syndromes d'apnées obstructives du sommeil sévères refusant la PPC.

OBJECTIVES: The management of patients with severe obstructive sleep apnea syndrome (OSAS) refusing or not tolerating continuous positive pressure ventilation (CPAP) remains problematic. We evaluated the effectiveness of oral appliances and of maxillomandibular advancement osteotomy. METHODS: One hundred and two patients with severe OSAS were included between 2001 and 2006. Maxillo-mandibular advancement osteotomy was proposed to patients less than 60 years of age, non obese and without comorbidities. The other patients were treated with oral appliances. All patients underwent polysomnography at 3 months. RESULTS: Group A: 25 patients with mean apnea-hypopnea index (AHI) at 45/h were treated by maxillo-mandibular advancement. Three months after the surgery, AHI had decreased from 45 to 7. The success rate was 89% when AHI was less than 15/h and 74% when AHI was less than 10/h. Sixteen patients performed a polysomnography one year after surgery with similar results. There were no major postoperative complications. Group B: 77 patients with a mean AHI at 41/h were treated with oral appliances. Only 23 patients underwent polysomnography at 3 months. The mean AHI had decreased from 41/h to 22/h. The success rate was 56% when AHI was less than 15/h and 30% when AHI was less than 10/h. DISCUSSION: We are confronted with an increasing number of severe OSAS patients with CPAP failure or intolerance. Surgery for maxillo-mandibular advancement is an effective alternative. However, it is not always indicated or accepted by the patient. So an oral appliance remains a useful therapeutic option despite its moderate success rate.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

[Mandibular advancement surgery in patients with severe obstructive sleep apnea uncontrolled by continuous positive airway pressure. A retrospective review of 25 patients between 1998 and 2004]. / Prise en charge par chirurgie d'avancée des maxillaires des patients porteurs d'un syndrome d'apnées du sommeil sévère en échec d'un traitement par pression positive continue: étude rétrospective de 25 patients entre 1998 et 2004.

INTRODUCTION: Continuous positive airway pressure (CPAP) is ineffective in some patients with obstructive sleep apnoea syndrome (OSAS) and some patients do not tolerate it. This study evaluated the outcomes of maxillo-mandibular advancement in OSAS patients without morbid obesity or severe maxillo-mandibular deformity who had first been treated with CPAP for at least 6 months. METHODS: A retrospective study reporting on the experience of the CHU Toulouse Rangueil sleep disorder centre between 1998 and 2004. We performed polysomnography and cephalometry before and 3 months after surgery. RESULTS: 25 male patients with mean apnoea hypopnoea index at 45/hour (+/-15) were treated by maxillo-mandibular advancement. The mean age of participants was 48 years (+/-7), and the mean body mass index was 28 kg/m2 (+/-3.4). Cephalometry demonstrated a retroposition of the mandible (SNB < 80 degrees +/-5) and narrow linguopharyngeal space (ELP = 8 mm+/-3). 3 months after surgery the apnoea hypopnoea index (AHI) had decreased from 45+/-15 to 7+/-7 (p < 0.0001), the Epworth sleepiness scale decreased from 11+/-5 to 6+/-4 (p < 0.01). The linguopharyngeal space was larger (ELP = 14 mm). Success rate defined as an AHI < 15/hour was 89%, and 74% for an AHI < 10/hour. 16 patients underwent polysomnography one year after surgery. The results were the same. There were no post surgical complications, except for one patient who developed permanent labial hypoesthesia. CONCLUSIONS: Maxillo-mandibular advancement seems to be an effective 2nd line therapy for the treatment of severe OSAS.

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.

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.

[Results of 248 patients with sleep apnea syndrome treated by continuous positive pressure ventilation between 1990 and 1995. A study of compliance and outcome of the apnea-hypopnea index]. / Suivi de 248 patients présentant un syndrome d'apnée du sommeil traités par pression positive continue entre 1990 et 1995. Etude de l'observance et du devenir de l'index d'apnée-hypopnée.

Between 1990 and 1995, 369 patients were investigated for obstructive sleep apnea syndrome (OSAS) by polysomnography. Among them, 248 patients with a mean Apnea-Hyponea index (AHI) of 37.7 per hour were treated by nasal continuous positive airway pressure (n-CPAP). Mean follow up was 39.5 +/- 20.4 months. In this group, 23 patients (9.2%) refused nCPAP immediately or after the first night and 39 (15.7%) gave up later. 15 patients (6%) died during the period of the study. The cumulative compliance reached 70% at 72 months. Non compliant patients usually gave up n-CPAP before the end of the first year. We compared the group of 150 patients always treated at the date of 31/12/95 with the group of 62 patients who refused nCPAP initially or gave up later. There was no difference in clinical parameters or polysomnographic data between the two groups. In 94 patients treated by nCPAP for more than a year we evaluated the outcome of AHI by a polysomnography performed after 72 hours of nCPAP cessation. Mean AHI of the group at this time was 38.2 +/- 20.3/h and was well correlated with the initial index (r = 0.41, p < 0.0001). However for 28 patients (29.7%) we observed, at the time of this second AHI determination, a variation (plus or minus) of at least 50% of the index. 6 patients, without any significative weigth loss, had an AHI below 5/h at this second determination. In this small group nCPAP was interrupted for 6 to 12 months, then another polysomnography was performed. At this time mean AHI was 42.4/h and clinical symptoms had reappeared in all patients. This study demonstrated that compliance to nCPAP in OSAS patients is good. No clinical or polysomnographic factors allow to predict non compliance. AHI is not modified by long term treatment with nCPAP.

[Osirix: free and open-source software for medical imagery]. / Osirix: logiciel libre d'imagerie médicale.

Osirix is a tool for diagnostic imagery, teaching and research tasks, which presents many possible applications in maxillofacial and oral surgery. It is a free and open-source software developed on Mac OS X (Apple) by Dr Antoine Rosset and Dr Osman Ratib, in the department of radiology and medical computing of Geneva (Switzerland).

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.

[Evulsion of the optic nerve, a diagnosis to be recognised!]. / L'avulsion du nerf optique, un diagnostic à connaître!

INTRODUCTION: Evulsion of the optic nerve is a rare but serious injury. It occurs generally after an ocular contusion and may cause blindness. CASE: We report the case of a 53-year-old woman who presented with a blunt ocular trauma after having been punched by her husband. Initial examination of the left eye was impossible due to a major palpebral oedema. A CT scan of the orbit revealed a thickened optic nerve. No improvement was noted. DISCUSSION: Optic nerve avulsion is often caused by sudden and forceful rotation of the eye with tearing of the optic nerve as its globe entry level. The diagnosis can be confirmed by examination of the ocular fundus or by medical imaging such as CT scan of the orbital cavity as in our case report. The prognosis is usually poor.

[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.

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.

Pseudoaneurysm of internal carotid artery following mandibular reconstruction treated by covered stent.

SUMMARY: We describe the case of a 68-year-old woman who had a mandibular titanium plate reconstruction following surgery for a parotid carcinoma. Fifteen months later she presented bleeding episodes related to a pseudoaneurysm of the internal carotid artery located just above the bulb. This was probably related to the weakening of the arterial wall following friction with the mandibular plate and radiotherapy.We successfully obliterated this pseudoaneurysm using a covered stent. This rare diagnosis should be evoked in case of bleeding following a mandibular reconstruction. Stenting is an effective treatment strategy obviating the need for open surgery.

[The value of lidocaine-prilocaine cream in the surgery of detached ears]. / Intérêt de la crème de lidocaïne-prilocaïne dans la chirurgie des oreilles décollées.

The possibility to obtain a skin anaesthesia using only an ointment may be very usefull for outpatient surgery. Recently available in France, the lidocaine-prilocaine cream give an interesting local anaesthesia. We have used this new presentation as skin preparation before otoplasty for 10 patients. As the local anaesthesia injections are then performed without pain, the comfort of the patient is greatly improved. Furthermore, it is easy to sue and without side-effect. The main disadvantage consists in the action delay of one hour, with the necessity to ask the patient to come earlier.

[Are there still indications for Wassmund's osteotomy?]. / Y a-t-il encore des indications de l'ostéotomie de Wassmund?

The surgical treatment of anterior alveolar protrusion is usually based on the so-called Wassmund osteotomy. Although the anterior occlusal results are always good, the esthetic impact is very often bad, due to the upper lip recession. However, a good statistical evaluation can be achieved concerning cutaneous movements after surgery, as established by many authors and confirmed by a study particularly focused on lip length and nasolabial angle modifications. It seems mandatory to make a profile prediction tracing for each surgical indication to avoid an irreversible esthetic degradation. In fact, the best surgical indication is very often to perform mandibular advancement with or without associated maxillary surgery.

[A superiorly pedicled nasobuccal flap. Its value in the reconstruction of posterior-superior loss of substance of the oral mucosa]. / Lambeau naso-génien à pédicule supérieur. Intérêt dans la reconstruction des pertes de substance postéro-supérieures de la muqueuse buccale.

Superiorly based nasolabial flap is an interesting solution for reconstruction of moderate size maxillary defects. The operative technique and its results are described. Advantages (reliability in flap vascularity, versatility, easiness of elevation) and limits of this procedure for closure maxillary defects are mentioned. Then they are compared to the other reconstructive maxillary techniques.

[Treatment of a case of multiple tooth agenesis: an orthodontic and implant solution]. / Traitement d'un cas d'agénésies dentaires multiples: solution orthodontique et implantaire.

Now, the excellent long term results observed in oral implantology allow use of implants in young people. They change habitual prosthetic indications which need healthy teeth mutilations. The authors present a case of multiple dental agenesis in a young girl. She was treated by orthodontic preparation and implants with a good final result (2 years end treatment follow up).

[A rapid intermaxillary fixation technic]. / Technique rapide de fixation intermaxillaire.

The authors describe a new intermaxillary fixation (IMF) technique. This technique is particularly easy and quick. It needs usual 4/10 or 5/10 steel wire with a small pearl fixed at one extremity. Four wires are used, passed from lingual side to vestibular side, between premolars. Wires are then linked and intermaxillary fixation is performed. Osteosynthesis is realised by intraoral approach. This technique does not allow to maintain IMF during a long postoperative period. Therefore, it should be reserved for cases where miniplate osteosynthesis will be sufficient. It seems interesting to use this technique for monofocal mandibular fractures, in association with rigid miniplate osteosynthesis.

[Ballistic data for plastic surgeons]. / Données balistiques à l'usage des chirurgiens plasticiens.

After a brief review of portable firearms or small caliber guns, the authors discuss various concepts concerning wound ballistics. Kinetic energy plays an important part in the damaging action of bullets, while the concepts of "shock wave" and "stopping power" have been supereded by the definition of wound profiles. These profiles are characteristic of each bullet. Clinically, they take the form of a temporary cavitation zone and a permanent cavity. The reaction of tissues crossed by the bullet largely depend on the elasticity of these tissues and the presence of bone. The concept of high velocity bullets should be abandoned. The phenomenon of cavitation alone and its dramatic clinical consequences should be taken into account and must guide the therapeutic approach.

[Osteosynthesis using micro-plates in fractures of the orbital floor]. / Ostéosynthèse par micro-plaques dans les fractures du plancher de l'orbite.

The exploration of orbital floor in case of blow-out fractures shows frequently only one or two important fragments. This fact leads us to realize osteosyntheses with titanium micro-plates in this kind of fractures. This was done for ten patients by transconjunctival approach. This technic has provided good results, clinically and radiologically. The tolerance of titanium implant was excellent. Therefore, it is unnecessary to preleve bone for grafting or to use biomaterials. Micro-plates ablation is not necessary.