CT scan study of the mandibular nerve intra-mandibular path.

INTRODUCTION: It is mandatory to know the anatomic path of the mandibular nerve and its intra-mandibular connections for numerous odontology, stomatology, and maxillofacial surgical procedures. We present a computed tomography study of the mandibular nerve intra-mandibular path. PATIENTS AND METHOD: The computed tomography of 14 mandibles was performed (vestibulo-lingual cross-section) and four landmarks were defined behind the mental foramen. At each landmark, we measured the distance between the alveolar canal and the two cortical layers in the vestibulo-lingual plane, and the distance between the alveolar canal and the alveolar crest, and the inferior border of the mandible in the vertical plane. RESULTS: In the vestibulo-lingual plane, the mandibular nerve is located close to the vestibular cortical layer, then to the lingual cortical before it exits. In the crestal plane, it is located at the superior third of the inferior border of the mandible. DISCUSSION: In spite of anatomical variability, there is a globally common path which means that the utmost caution should be taken by performing systematic imaging before undertaking any surgery close to the nerve.

[Gingivoperiosteoplasty associated to bone graft: radiological evaluation]. / Gingivopériostoplasties associées à une greffe osseuse : évaluation radiologique.

INTRODUCTION: Gingivoperiosteoplasty associated to bone graft is part of a therapeutic strategy applied to the first 20 years of a patient's life. Management is pluridisciplinary. Most authors recommend a bone graft in mixed dentition at the end of premaxillary growth. Retroalveolar and panoramic radiography are the most often used to assess the bone height of the grafted site. We retrospectively studied the radiographies of 57 alveolar grafts in 44 patients. MATERIAL AND METHODS: Between 1999 and 2005, 44 patients underwent gingivoperiosteoplasty associated to bone graft. Thirteen underwent bilateral reconstruction. The surgical interventions were performed by the same surgeon. One year after surgery, the panoramic radiographies were analyzed by a single expert. The bone height compared to roots of adjacent teeth was classified in four grades. Grades 1 and 2 were considered as satisfactory or good and grades 3 and 4 not satisfactory and an indication for a new bone graft. In case of bilateral cleft, each side was analyzed independently. RESULTS: Grades 1 and 2 accounted for 84.2% of grafts. There was no statistical difference in alveolar bone height between patients presenting with agenesis of the lateral incisive. Eighty-one percent of patients grafted with mixed dentition (66% of the cases) had satisfactory results (35% of grade 1 and 46% of grade 2). Patients operated on after 15 years (n=15) had good results in 75% of the cases, 33% were bilateral cleft patients. There was no statistical difference between patients operated on early and those with delayed surgery. DISCUSSION: Radiological results for gingivoperiosteoplasty associated to bone graft are satisfactory. The procedure is easy, cheap, and reproducible. Evaluation with panoramic radiography is not as accurate as with the Denta Scan. CT scan is not used systematically to follow up alveolar cleft palate in children so as to limit irradiation. Volumetric tomography (cone beam) may be the best assessment.

[Assessment of the systematic preoperative insertion of an intra-aortic counterpulsation balloon in patients at high operative risk for coronary artery surgery]. / Bilan de la mise en place systématique d'un ballon de contre-pulsion intra-aortique pré-opératoire chez les coronariens à haut risque chirurgical.

The authors report their experience with pre-operative percutaneous balloon counterpulsation in 75 patients considered to be at high operative risk for coronary artery surgery, mainly because of unstable angina refractory to maximum medical therapy. The criteria to define high surgical risk are reported. The results and the vascular risk in relation to this technique are estimated. Two patients died during the operation, 12 died during the early postoperative phase without any improvement following intra-aortic balloon pumping. The rate and severity of complications of percutaneous insertion of intra-aortic balloon counterpulsation are low and seem to be related to pre-existing arteriosclerosis. The stabilizing effect of this pre-operative insertion on angina, refractory to medical treatment, seems to be justifiable in patients presenting one of the defined criteria.

[Clinical and ossification outcome of custom-made hydroxyapatite prothese for large skull defect]. / Tolérance clinique et degré d'ossification des cranioplasties en hydroxyapatite de larges défects osseux.

OBJECTIVE: Cranioplasty is an everyday concern in neurosurgery, especially in decompressive craniectomy cases. Our surgical team uses custom-made hydroxyapatite implants for large and/or complex defects. PATIENTS AND METHOD: Eight patients had a custom-made prosthesis. Each of them has been reviewed by an independent observer. Each patient described his feeling of satisfaction, using a questionnaire, graduated from "A" (really satisfied) to "D" (unsatisfied). Each of them also underwent a CT-scan (helicoidal acquisition, 0.6mm thick for multiplanar reconstruction) to evaluate qualitatively the ossification graduated from "0" (no ossification) to "5" (continuous ossification). Maximal under-prosthetic bone thickness, intra-prosthetic calcic density were also reported. RESULTS: Supervision delay was 43.7 months [6-99 months], average defect surface was 85.5 cm(2) [27.6-137.6 cm(2)], the craniectomy etiologies were intracranial hypertension (seven patients) and calvarial invasion (one patient). Implant tolerance was reparted in "A" score (50%) and "B" score (50%). Concerning ossification, six patients (75%) had a score of "2" or less and two patients had a score of "3" or "4". DISCUSSION: Hydroxyapatite custom-made implants for cranioplasty appear to be ideal for good aesthetic and tolerance results, but their ossification is hardly analyzed due to the prosthesis density higher than the bone's density. This is why we recommend them for children and in cases of complex defects such as pterion location.

Gunshot wounds: two cases of midface reconstruction by osteogenic distraction.

BACKGROUND: Reconstruction of the midface is a surgical challenge because of the aesthetic and functional implications that are characteristic of this area. METHODS: We describe two cases of reconstruction after gunshot wounds of the midface by a customized external ostegeognic device (OBL Laboratory). These two patients had mandibular reconstruction by osteogenic distraction by the same technic. RESULTS: Gunshot wounds cause considerable cutaneous, osseous and muscular damage. Reconstruction techniques have to reconstruct all those tissues. DISCUSSION: Reconstruction by osteogenic distraction allows the bone and soft tissues to be simultaneously expanded. This expansion decreases the patchwork effect of free flap reconstruction. An other advantage of reconstructing the soft tissues at the same time by osteogenic distraction is that subsequent bone grafts can be covered, reducing the risks of their exposure.

[Computed tomography study of the lower alveolar intra-mandibular nerve path]. / Etude tomodensitométrique du trajet intra-mandibulaire du nerf alvéolaire inférieur.

INTRODUCTION: It is mandatory to know the anatomic path of the lower alveolar nerve and its intramandibular connections for numerous odontology, stomatology, and maxillofacial surgeries. We present a computed tomography study of the lower alveolar nerve intramandibular path. MATERIAL AND METHOD: The computed tomography of 14 mandibles was performed (vestibulolingual cross-section) and four landmarks were defined behind the mental foramen. At each landmark we measured the distance between the alveolar canal and the two cortical layers in the vestibulolingual plane, and the distance between the alveolar canal and the alveolar crest, and the inferior border of the mandible in the vertical plane. RESULTS: In the vestibulolingual plane, the alveolar nerve is located close to the vestibular cortical layer, then to the lingual cortical before it exits. In the crestal plane, it is located at the superior third of the inferior border of the mandible. DISCUSSION: In spite of anatomical variability, there is a globally common path which must lead to the greatest caution by performing systematic imaging before any surgery close to the nerve.

[Maxillary sequels in labial-alveolar-velopalatine clefts. The role of orthognathic surgery]. / Les séquelles maxillaires dans les fentes labioalvéolopalatovélaires. Place de la chirurgie orthognathique.

Maxillary hypoplasia is a common sequel in cleft lip and palate deformities. After primary surgery to close lip and palate, patients routinely need extensive treatment particularly orthodontic management. With this type of approach, maxillary hypoplasia is less frequent and severe and subsequent orthognathic surgery is efficient in most cases. Without the proper management maxillary hypoplasia may be severe and patients will need a modified management and specific revision. At the end of maxillar growth, the first aim of treatment is to achieve continuity of the maxillary arch with gingivoperiosteoplasty. The transversal insufficiency can then be treated by distraction osteogenesis. Orthodontic treatment should leave place for missing teeth.

[Maxillary sequels in labial-alveolar-velopalatine clefts. Orthodontic management]. / Les séquelles maxillaires dans les fentes labioalvéolopalatovélaires. Prise en charge orthodontique.

Routine othodontic management is unavoidable in all patients with cleft lip and palate after primary surgery. This management combines dental arch alignment with maxillary expansion of the lesser fragment before alveolar bone grafting. To treat dental arch asymmetry, the space of the missing lateral incisor is preserved until the age of dental implant. Otherwise, dento-orthopedic treatment attempts to normalize transversal dental dimension once alveolar bone grafting is done in order to prepare the surgical advancement of the maxilla.

[Extra-oral implants: surgical procedures]. / Implants extra-oraux: procédures chirurgicales.

The different extra-oral implant systems (screw and plate fixation) are not compatible. Rigorous surgical procedure (detailed and illustrated here) is mandatory to obtain the best implant osseointegration and epithesis loading 3 months later. Besides surgical procedure, careful bone and peri-abutment suture are required for success.

[Spheno-mandibular ankylosis. A case]. / Ankylose sphéno-mandibulaire. Une observation.

A rare case of spheno-mandibular ankylosis is reported in a 12 year-old child. The patient only complained of a restricted mouth opening; no particular etiologic factors were found to explain what was perhaps a myositis ossificans of the pterygoid muscles. However, neither the anatomic presentation at surgery, nor the histologic findings could confirm this diagnosis. An intra-oral route was chosen for the ankylosis resection, and the reconstruction of the resected upper part of the ramus was performed by a costo-chondral graft. The patient was free of recurrence 3 years after follow up.

[Popliteal pterygium syndrome. A exceptional case]. / Syndrome des ptérygium poplités. Une observation privilégiée.

We report the case of a patient with a popliteal pterygium syndrome, a rare malformation associating, in its complete form, cleft lip and cleft palate, cleft lower lip, intergingival synechia, defects of the genito-urinary tract and popliteal pterygium. Based on this observation and a review of the literature, the phenotypic and genotypic aspects of this malformation were discussed together with adapted therapeutic management and genetic counselling.

[Therapeutic management of traumatic avulsion of permanent teeth]. / Prise en charge thérapeutique des expulsions traumatiques des dents définitives.

Management of avulsed permanent teeth requires perfect knowledge of the different parameters influencing the short and mid-term and above all long-term prognosis. Based on a review of the literature and the analysis of 50 cases cared for in our unit enables us to propose, in accordance with the extra oral delay and the degree of dental maturation, a protocol for the different emergency situations. This clarification emphasizes the contribution of new preserving solutions which allow reimplantation delays up to 24 hours without effect on prognosis.

[A comparison of standard radiographs and "scout-view" radiographs. The value for cephalometric analysis]. / Comparison des télécrânes et des "modes radios". Intérêt pour le bilan céphalométrique.

Is the scout-view as reliable as the standard lateral view for cephalometric analysis? Cephalometric data (Delaire analysis) were obtained in ten patients with CT-scan and standard x-ray for comparison. Qualitative results showed imprecisions for craniofacial contours and soft tissue ptosis. Quantitative results were analyzed statistically and revealed a significantly higher level of error with scout-view tracings. The scout-view does not appear to be as reliable and takes longer to acquire than the standard lateral x-ray: for the pediatric population, it could be a disadvantage.

[Oral aphthae induced by nicorandil. Anatomopathologic aspects. Apropos of a case]. / Aphtose buccale induite par le nicorandil. Aspect anatomopathologique. A propos d'un cas.

Major apthous stomatitis induced by nicorandil is exceptional, the mechanism is still unknown and the histological aspect of these lesions have not been previously reported. Our case reports a man who was treated by nicorandil for coronary artery disease. He was referred for major aphtous stomatitis; one element was biopsied. The histological aspect was an aspecific sialadenitis, with granulous reaction, and without vasculitis or eosinophilic infiltration. We conclude that aphtous stomatitis induced by nicorandil could to be explain by a toxic effect, rather than a toxicallergic or immunologic mechanism.

[Management of cleft lip and palate in university hospital of Rouen]. / Prise en charge des fentes faciales et palatines à la clinique chirurgicale du centre hospitalier universitaire de Rouen.

Cleft lips and cleft palates are managed in the department of Pediatric surgery in Rouen for the last 30 years. From the antenatal diagnosis, the parents got in touch with the surgeon who will coordinate this management. Around thirty new patients are treated every year. The chronology of the treatment is of "classic" manner. The cleft lip is repaired at about 3 weeks of age and the palatoplasty is performed after the age of 1 year. In view to maintain the intimacy of the consultation we did not institute multidisciplinary consultations. The other members of the interdisciplinary team will intervene during the follow up depending on the form of the cleft and the encountered problems. The information and the files circulate freely and are discussed together.