Osteomyelitis of the jaw: time to rethink the bone sampling strategy?

This work aims at describing the diversity of osteomyelitis of the jaw (OJ) and at assessing the relevance of a new method designed to avoid salivary contamination during bone sampling in order to improve microbiological analysis and clinical decision-making. We reviewed medical and microbiological data of patients with a suspected OJ based on clinical and/or CT-scan signs and at least one bone sample made for microbiological analysis. During the study period, a new procedure for intraoral bone sampling was elaborated by surgeons and infectious diseases specialists authoring this article (based on stratified samples, cleaning of the surgical site and change of instruments between each sample). A comparison of the microbiological analyses between the two procedures was performed. From 2012 to 2017, 56 patients were included. Median age was 58 years (11-90), sex ratio: 1.24. Main risk factors were having a dental disease (n = 24) or cancer (n = 21). Nineteen patients with the new sample procedure were compared to 37 patients with standard procedure, especially non-cancer patients (n = 16 and 19, respectively). With the new procedure, a median of 3 (1-7) microorganisms per sample was recovered, vs. 7 (1-14) with the former (p < 0.001), a significant decrease of the microbial density was observed for all types of microbes, especially in deeper samples and cultures were more frequently sterile. The way sampling is managed deeply influences microbiological analysis. This strategy facilitates the distinction between pathogens and contaminants and should constitute the first step toward an evidence-based antimicrobial strategy for OJ.

Multicenter prospective micro-costing study evaluating mandibular free-flap reconstruction.

Free-flap mandibular reconstruction is a highly specialized procedure associated with severe complications necessitating re-interventions and re-hospitalizations. This surgery is expensive in terms of health workers' time, equipment, medical devices and drugs. Our main objective was to assess the direct hospital cost generated by osseocutaneous free-flap surgery in a multicentric prospective micro-costing study. Direct medical costs evaluated from a hospital perspective were assessed using a micro-costing method from the first consultation with the surgeon until the patient returns home, thus confirming the success or failure of the free-flap procedure. The mean total cost for free-flap intervention was 34,009€ (5151-119,604€), the most expensive item being the duration of hospital bed occupation, representing 30-90% of the total cost. In the event of complications, the mean cost increased by 77.3%, due primarily to hospitalization in ICU and the conventional unit. This surgery is effective and provides good results but remains highly complex and costly.

[Masticatory apparatus disorder: how can rehabilitation treatment help?] / Dysfonction de l'appareil manducateur : apport de la prise en charge rééducative.

INTRODUCTION: The temporomandibular joint is highly adaptive and masticatory apparatus disorders (MAD) can occur when its ability to adapt is overwhelmed. Occlusal etiologies were long pinpointed as the sole culprits. However, a consensus now exists which minimizes their involvement. It is recognized that the etiology of MAD is multifactorial, combining occlusal problems, parafunctions, postural anomalies, orofacial dyspraxia and stress. MATERIALS AND METHODS: In this article, the authors review the role of physiotherapy in managing these pathologies. RESULTS: While it remains essential to treat the symptoms in order to relieve pain, optimum treatment requires the underlying pathogenic mechanisms to be identified. Rehabilitation treatment, therefore, offers a physiotherapy-based approach providing an etiological solution. By reeducating function, physiotherapy produces lasting results. DISCUSSION: Given the multifactorial nature of MAD etiologies, maxillofacial rehabilitation is an indispensible ally for odontologists or orthodontists adopting a multidisciplinary approach in their treatment of this disorder.

Polyetheretherketone (PEEK) for medical applications.

Polyetheretherketone (PEEK) is a polyaromatic semi-crystalline thermoplastic polymer with mechanical properties favorable for bio-medical applications. Polyetheretherketone forms: PEEK-LT1, PEEK-LT2, and PEEK-LT3 have already been applied in different surgical fields: spine surgery, orthopedic surgery, maxillo-facial surgery etc. Synthesis of PEEK composites broadens the physicochemical and mechanical properties of PEEK materials. To improve their osteoinductive and antimicrobial capabilities, different types of functionalization of PEEK surfaces and changes in PEEK structure were proposed. PEEK based materials are becoming an important group of biomaterials used for bone and cartilage replacement as well as in a large number of diverse medical fields. The current paper describes the structural changes and the surface functionalization of PEEK materials and their most common biomedical applications. The possibility to use these materials in 3D printing process could increase the scientific interest and their future development as well.

Median cleft of the upper lip: A new classification to guide treatment decisions.

Median cleft of the upper lip (MCL) is a specific and rare entity on the spectrum of facial clefts. MCL have different clinical expressions and can be either isolated or part of multiple malformations. Confusion still exists regarding the explanation and classification of MCL; some cases have been reported in the literature, but no studies carried out a complete review of the literature. This study reviewed cases of MCL in 2 French units and conducted a systematic review of the literature, in order to derive a new classification. Fourteen patients with MCL in the 2 units and 195 cases in the literature were reviewed. They involved complete (42%), incomplete (49%), and minor forms (9%). Epidemiological and clinical data were collected, from which a classification was derived, based on the type of cleft and its belonging to other syndrome(s). Three main groups were distinguished, namely, isolated MCL, MCL within craniofacial malformations, and MCL with extrafacial malformations. Each group and subgroup was associated with a prognosis and led to specific management. This study reviewed all of the various forms of MCL and their associated anomalies, in order to have a global view of MCL and to derive a useful classification scheme to guide management of care.

A New Rat Model for Translational Research in Bone Regeneration.

The European Union (EU) directive 2010/63/EU on the protection of animals used for scientific purpose focused on reducing the number of animals and refinement of breeding. Animal studies are necessary to protect human health. Lots of animal models exist to study bone regeneration, but a reliable, well reproducible, and relatively inexpensive model with the possibility for multiple testing in the same animal is still missing. Rats may serve as good models for this due to the small animal size and good cost/benefit ratio. The present study aimed to develop a novel rat caudal vertebrae critical size defect model for bone regeneration and implant osseointegration studies The study was performed using Wistar rats with weight from 380 to 450 g. An incision was made on the dorsal side of the tail. After skin and muscles retractions, the vertebrae were exposed. Critical size defects for bone tissue engineering or implant placements for titanium body experiments were possible in each of the first four caudal vertebrae. Micro-computed tomography (CT) and histology were used to detect bone growth. There was no bone formation in the defects after 1 or 2 months of healing. When a calcium phosphate biomaterial was used (Bio-Oss®; Geistlich Pharma AG, Wolhusen, Switzerland), a good stability of the material in the defect was noted and bone growth was visible after 1 or 2 months. Results based on implant placement showed good primary stability after 3 months of healing. MicroCT showed integrated implant position through the vertebra. These results suggest that the rat caudal vertebrae may serve as a good new model for studying bone regeneration and implant osseointegration with the possibility of multiple testing within the same experimental animal and the potential to decrease number of experimental animals.

Sprayed cells and polyelectrolyte films for biomaterial functionalization: the influence of physical PLL-PGA film treatments on dental pulp cell behavior.

Further development of biomaterials is expected as advanced therapeutic products must be compliant to good manufacturing practice regulations. A spraying method for building-up polyelectrolyte films followed by the deposition of dental pulp cells by spraying is presented. Physical treatments of UV irradiation and a drying/wetting process are applied to the system. Structural changes and elasticity modifications of the obtained coatings are revealed by atomic force microscopy and by Raman spectroscopy. This procedure results in thicker, rougher and stiffer film. The initially ordered structure composed of mainly α helices is transformed into random/ß-structures. The treatment enhanced dental pulp cell adhesion and proliferation, suggesting that this system is promising for medical applications.

Dermal flaps in breast reduction: prospective study in 100 breasts.

The most common complication of breast reduction with inverted T-scar technique is wound dehiscence at the junction of the vertical and horizontal sutures. In this study, a technique involving three triangular dermal flaps is presented with the results for healing in the junctional T zone. Fifty women were included in a comparative, single-center randomized double-blind prospective study to evaluate the efficiency of the three-triangular dermal-flap technique in healing in the junctional T zone. All patients were seen for follow-up at 7 days, 14 days, 21 days, 28 days, 35 days, 42 days, and 49 days after surgery to evaluate primary healing in the T zone. Average healing time was 19.7 days in the triangular-skin-flap series and 25.48 days in the control series, with a statistically significant difference (p < 0.01). One patient in the triangular-skin-flap series experienced dehiscence in the T zone (2%) versus eight patients (16%) in the control series. A statistically significant difference was noted (p = 0.012). This technique is based on the association of two principles. First, ischemia on the edges as well as skin necrosis is limited by suturing the two superior skin flaps rather than directly suturing the cutaneous angles. In addition, this technique brings an underlying dermal support. Second, the inferior flap width allows fixing two sutures laterally to limit the central tension. This easy technique does not lengthen total operative time and significantly improves healing time. It is applicable to all breast reductions with inverted T scars.

Extramandibular position of the inferior alveolar nerve. Analysis and review of the literature.

We report a highly unusual case of unilateral absence of the mental foramen, with the inferior alveolar nerve exiting the mandible via an orifice situated on the lateral surface of the angle of the mandible. However, the teeth on this side of the dental arch had normal sensitivity, and the mandible had grown correctly. Despite the absence of intraosseous course, the inferior alveolar nerve seems to keep its neural and guide roles.

In vitro investigation of fluorescence of carious dentin observed with a Soprolife® camera.

OBJECTIVES: Our aim was to determine the origin of the red fluorescence of carious dentine observed with the Soprolife® camera. METHODS: We conducted in vitro studies to evaluate the origin of the red fluorescence using acids and matrix metalloproteinase (MMP) to mimic caries and methylglycoxal (MGO) to evaluate the effect of glycation reactions on the red fluorescence. In every step of these models, we detected the changes of dentin photonic response with Soprolife® in daylight mode and in treatment mode. A Raman spectroscopy analysis was performed to determine the variations of the dentin organic during the in vitro caries processes. Raman microscopy was performed to identify change in the collagen matrix of dentine. RESULTS: The red fluorescence observed in carious dentine using a Soprolife® camera corresponds to the brownish color observed using daylight. Demineralization using nitric acid induces a loss of the green fluorescence of dentine. The red fluorescence of carious dentine is resistant to acid treatment. Immersion of demineralized dentine in MGO induces a change of color from white to orange-red. This indicates that the Maillard reaction contributes to lesion coloration. Immersion of demineralized dentine in an MMP-1 solution followed by MGO treatment results in a similar red fluorescence. Raman microspectroscopy analysis reveals accumulation of AGE's product in red-colored dentine. CONCLUSIONS: Our results provide important information on the origin of the fluorescence variation of dentine observed with the Soprolife® camera. We demonstrate that the red fluorescence of carious dentine is linked to the accumulation of Advanced Glycation End products (AGE). CLINICAL RELEVANCE: The study provides a new biological basis for the red fluorescence of carious dentine and reinforces the importance of the Soprolife® camera in caries diagnostics.

Use of botulinum toxin type A to improve treatment of facial wounds: a prospective randomised study.

BACKGROUND: The tension vectors acting on the wound edges are transmitted to immature collagen fibres synthesised during the normal healing phase. This accounts for scar widening as well as hypertrophic and hyperpigmented scars. The aim of our study was to evaluate whether early injections of botulinum toxin type A (BTA), which induces temporary muscular paralysis, decreases tension vectors on wound edges and enhances scarring of facial wounds. PATIENTS AND METHODS: Thirty patients with facial wounds were enrolled in this study and randomised into two groups with or without injection of BTA within 72 h postoperatively. BTA was injected into the facial muscles directly or indirectly involved in scar widening. Scars were assessed at a 1-year follow-up visit by patients using the Patient Scar Assessment Scale (PSAS) scale, by an independent evaluator using the Observer Scar Assessment Scale (OSAS) and the Vancouver Scar Scale (VSS), and by a board of six experienced medical specialists using the Visual Analogue Scale (VAS) with standardised photographs. RESULTS: At the 1-year visit, 24 patients were reviewed and six patients were lost to follow-up. No statistically significant differences were found between the two groups for the PSAS, OSAS and VSS scores. However, the median VAS rated by the six evaluators was 8.25 for the botulinum toxin-treated group compared with 6.35 for the control group. This result was statistically different, demonstrating improved scarring with BTA. CONCLUSIONS: Thanks to chemoimmobilisation, injections of BTA appear to improve cosmesis of facial wounds. Accordingly, they would be beneficial for use in young patients for wounds without tissue loss, lying perpendicular to the reduced tension lines of the skin of the face.

Assessment of leakage at the implant-abutment connection using a new gas flow method.

PURPOSE: The aim of this study was to evaluate, with a new gas flow technique, leakage at the implant/abutment junction in systems with four different connections. MATERIALS AND METHODS: Five Branemark System, five One Morse, five Intra-lock System, and five Ankylos Plus implants and abutments were used. A hole was drilled in the apex of each implant to allow gas to flow through the connection from negative to atmospheric pressure. The gas flow was calculated (slope of pressure decrease, in hPa.s-1). Each connection was tested after both manual and key tightening. Statistical analysis was performed on a generalized linear model with repeated measurements. The significance level was set at α=.05. RESULTS: A global significant difference was observed between the various systems (P=.0001). After manual tightening, gas leakage was (Ln[hPa.s-1], means±standard deviations): One Morse: 0.20 (±1.70); Branemark System: -4.56 (±2.61); Intra-lock: -4.31 (±4.17); Ankylos Plus; -7.59 (±0.76). After key tightening, mean values were: One Morse: -2.51 (±2.72); Branemark System: -7.23 (±1.01); Intra-lock: -7.76 (±0.50); Ankylos Plus; -7.73 (±0.62). CONCLUSION: This study confirms that gas flow is an appropriate method to assess connection leakage. Ankylos Plus connection leakage was very low when the assembly was tightened manually. Among conical connection systems, low (Ankylos Plus) and high (One Morse) leakage was observed. This gas flow study suggests, therefore, that connection design is not the most important parameter for implant/abutment connection leakage.

Reconstruction of anterior scalp defect with V-Y advancement flap pedicled on the temporal fascia superficialis.

Reconstruction of scalp defect can call upon several surgical techniques. Direct joining is used whenever possible, but because of the low laxity of the scalp, other approaches are often required. Several types of autoclosing flaps of the scalp have been described in the literature. In this article, we report the advantages of the island flap pedicled on the superficial temporal fascia, as described by Onishi (2005) in a case report for the reconstruction of an anterior scalp defect.

Spatulated anastomosis with continuous suture in microreconstructive surgery.

In a well-proven criterion standard technique commonly used in cardiovascular surgery for anastomosis, proximal and distal vessels are spatulated to increase the anastomotic surface and improve congruency between the 2 vessels. Anastomosis is performed with continuous suture of the 2 bisected extremities.A review of the current literature has confirmed that our preliminary results were similar to those achieved by surgeons using the simple interrupted suture technique for microsurgical anastomosis.Patency is highly satisfactory with this technique for anastomosis. Moreover, it is a reliable technique requiring shorter total operative time. Hemostasis is easy to control and can be used with vessel diameters as small as 1 mm. For all these reasons, this technique already commonly used in vascular surgery for anastomosis could be interesting in microsurgery as well.

Correlation of images: technique for mandible biomechanics analysis.

Various experimental or physicomathematical methods can be used to calculate the biomechanical behavior of the mandible. In this study, we tested a new tool for the analysis of mandibular surface strain based on the correlation of images. Five fresh explanted human mandibles were placed in a loading device allowing replication of a physiologic biting exercise. Surfaces of the mandibles were prepared with white and black lacquer. Images were recorded by 2 cameras and analyzed with an algorithm to correlate those images. With the Limess Measurement & Software system and VIC 3D software, we obtained data output concerning deformations, strains, and principal strains. This allowed us to confirm strain distribution on the mandibular corpus and to focus on weak points. Image correlation is a new technique to study mandible biomechanics, which provides accurate measurements on a wide bone surface, with high-definition images and without modification of the structure.

Complications of condylar fracture osteosynthesis.

BACKGROUND: Condylar fracture osteosynthesis is today commonly practiced, but only a few studies deal with complications due to plates or screws loosening. METHODS: We made a retrospective analysis of 53 operated condylar fractures treated with different fixation devices from July 2002 to July 2007. We looked for complications and its relationship with the osteosynthesis device used. RESULTS: We found 11.3% complications due to plate fracture, plate torsion, or screw loosening. Those occurred at 2.75 months after surgery on average. DISCUSSION: When performing condyle osteosynthesis, one must keep in mind that plates must be located on the posterior border of the ramus and below the mandibular incisure to respect mastication strains. In our study, the number of plates or the number of screws per plate was not always ideal. Moreover, we started active physiotherapy the day after surgery, which is too early because titanium plates are too weak to support all the mandibular strains. A well-adapted osteosynthesis associated with a progressive load of the temporomandibular joint should limit postoperative plate fracture or torsion.

Oral and maxillofacial surgery: what are the French specificities?

PURPOSE: Oral and maxillofacial surgery has expanded rapidly over the past century. Recognition in France has grown since the first face transplantation in the world performed by Professor Bernard Devauchelle. This speciality, which seems to correspond to a narrow scope of services, actually involves oral, plastic, reconstructive, and cosmetic surgeries of the face. French training for maxillofacial surgeons differs from the Anglo-Saxon course of study. After examining surveys carried out in Great Britain, the United States, and Brazil, the perception of this speciality in the general public and among regular correspondents (general practitioners and dental practitioners) was ascertained. MATERIALS AND METHODS: More than 4,000 questionnaires were sent to health care workers and patients attending dental practices. The returned questionnaires concerning recognition of this profession in France were analyzed. Evaluating awareness of maxillofacial surgery among practitioners and the public was of particular interest because it can overlap with several other specialities (ear, nose, and throat; plastic surgery; odontology). The questionnaire included the 20 items used in other similar studies so the results could be compared. RESULTS: Several fields of expertise were identified in maxillofacial surgery, in particular traumatology, surgery for facial birth defects, and orthognathic surgery. Moreover, dental practitioners were found to be the most regular correspondents of maxillofacial surgeons compared with general practitioners. Compared with Anglo-Saxon and Brazilian peers, French recognition of maxillofacial surgery was better. CONCLUSION: Despite encouraging results, maxillofacial surgery remains a somewhat obscure speciality for health care workers and the general public. Better awareness is necessary for this speciality to become the reference in facial surgery.