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.

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.

[Surgical devices]. / Dispositif chirurgical.

Surgical devices mean the whole surgical department i.e., working space, useful tools for its good process and respect of its rules for the users. That working space obeys to strict rules relating to its conception, its building or the behaviour of people in that space. Working tools (furniture, material and surgical tools) have to respect requirements of the surgical team and the patients. The local rules respect will warrant optimal quality and efficiency. We will successively present architectural imperative rules and will detail arrangement of the surgeons preparing room and the real surgical space.

[Jaw osteosarcomas]. / Ostéosarcomes des mâchoires.

INTRODUCTION: Osteosarcoma (OS) is the most frequent bone malignant tumor. It is usually found on long bones, 5 to 10% are located on jaws, accounting for 0.5 to 1% of all facial tumors. There is little published data which concerns only few patients. Our aim was to study retrospectively cases of facial bone OS in adults, and to compare our results with published data to suggest an optimal management scheme. PATIENTS AND METHOD: Thirty-three patients were managed for an OS, from January 1997 to January 2007. Fourteen patients with a maxillary and mandibular OS, treated in first-intention in our unit, were included. The following data were analyzed: age; personal history; circumstance of discovery; clinical, functional, and physical signs; loco-regional extension and metastasis radiological investigation. The histological slides were systematically reviewed. The protocol, therapeutic outcome, and follow-up were studied. RESULTS: The mean age at diagnosis was 43. Swelling was the most frequent functional sign. The mean delay before management was 3.4 months. The most frequent radiological presentation was a lytic and hyperdense image. The diagnosis was suggested after CT scan in 57.1% of cases. The biopsy was correlated to the anatomopathological analysis in 78.6% of cases. The most common treatment was surgical exeresis completed by chemotherapy. The 5-year survival rate was 50%. DISCUSSION: Jaw OS are specific because of their localization and specific bone ultrastructure. Their management remains controversial: should they be managed like limb OS or treated more specifically? Neoadjuvant chemotherapy, even if it delays exeresis for 3 months, seems to stop the growth or reduce the tumor. An early anatomopathological analysis of the surgical piece determines adjuvant therapy. The negative prognostic factors are: maxillary localization because of limited exeresis margins, tumoral size, and osteoblastic sub-type.

[Keratocysts (or keratocystic epithelial odontogenic tumors)]. / Kératokystes (ou tumeurs odontogéniques kératokystiques).

The aim of this study was to describe the management of keratocysts based on our own experience and on a large literature review. Keratocysts are benign odontogenic epithelial tumors. The main aspects of this lesion are described (definition, epidemiology, clinic, radiology, histology, treatment, and prognosis). In small intra-osseous tumors, surgical procedure must be as conservative as possible, most often enucleation. In large tumors with destruction of the cortical bone, or with destruction of coronoid process or notch, extensive resection can be indicated, with sometimes a transfacial approach for an accurate control, especially in soft tissues. Strict follow-up is mandatory because of the high risk of recurrence.

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.

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.

[Soft tissue myxoma of the face]. / Tumeurs myxoïdes des tissus mous de la face.

Myxoid tumors are a group of heterogeneous lesions with a voluminous myxoid matrix, which may affect any tissue in the body. The frequency of these tumors depends on their localization. On the face, the localization is most often osseous. In this case, they are odontogenic myxoma. Localization in facial soft tissues is very rare. These tumors are benign but with a high potential for local aggressiveness and recurrence. They must be treated surgically with radical exeresis and long-term follow-up.

[Validating a loading protocol for weakened mandibular models]. / Validation d'un protocole de mise en charge des modèles mandibulaires fragilisés.

INTRODUCTION: The purpose of this study was to validate an experimental model of weakened synthetic mandible loaded in a device simulating masticatory forces by studying the reproducibility of the fracture threshold. MATERIALS AND METHODS: Both sides of five synthetic mandibles were weakened by progressive synthetic bone resection. The synthetic mandibles were submitted, after each resection, to static chewing exercises in the simulator. The threshold fracture was recorded. RESULTS: The fracture threshold mean resection height was 19.33 mm with a percentage of error of 6.72%. DISCUSSION: The low percentage of error allowed us to validate this experimental model. A comparison with other experimental or finite element models confirmed our protocol and results. We plan to apply this protocol to fresh weakened mandibles.

[Post-traumatic taste and smell disorders: forensic aspects]. / Dysosmies et dysgueusies post-traumatiques: aspects médicolégaux.

The impact of anosmia or ageusia may be considerable for some occupations. Expert assessment shows how difficult it is to prove the diagnosis. A specialist is usually needed to demonstrate the asserted disorder. Damage compensation is based on the patient's occupation and coverage.

[Jaw osteonecrosis induced by oral biphosphonates: 12 cases]. / Ostéonécroses des mâchoires induites par les biphosphonates oraux: 12 cas.

INTRODUCTION: The incidence of jaw osteonecrosis induced by oral or intravenous biphosphonates (BP) has been increasing. Two hundred cases of jaw osteonecrosis induced by oral BP (JONOBP) were reported, with an incidence of 4 % and a prevalence of 1/952. We report 12 cases of JONOBP observed from January 2007 to January 2009. MATERIAL AND METHODS: A pluridisciplinary committee including odontologists, stomatologists, and maxillofacial surgeons from two Paris hospitals was asked to manage patients treated by BP. Twelve patients presenting with JONOBP were included from January 2007 to January 2009. For each of these patients, age, sex, associated co-morbidities, any triggering factor, previous or current combination treatments, the type of BP used, its initial indication, dosage, delay before onset of JONOBP, and delay between first clinical signs and diagnosis were studied. JONOBP localization, stage (American Association of Oral and Maxillofacial Surgeons [AAOMS] classification), clinical and radiological signs, anatomopathological and bacteriological examinations (when performed) were documented. The treatment and evolution were described. RESULTS: Ten women and two men, mean age 65 years (36 to 82 years), were included. BP were taken orally once a week or daily. The mean duration of BP exposure was 39.6±2,4 months (19 to 58 months). The indication for BP was prevention or treatment of osteoporosis in 11 cases and breast with bone metastases in one case. Tooth extraction was the triggering factor in nine cases. The premolar and molar mandibular area was the most often affected. Corticosteroid therapy was combined to BP in half of the cases. There were no clinical, radiological, and histological specific signs. BP treatment was stopped in all patients. Nine patients underwent surgery. Evolution was favorable for nine patients. Six patients were cured, on average 3.8 months after beginning management (one to nine months). Three male patients improved. Three female patients were lost to follow-up. Alendronate was the most frequently implicated (six cases) and risedronate (five cases). Five patients presented with diagnosed or suspected auto-immune conditions. DISCUSSION: The duration of exposure to BP was superior to three years in most cases. The triggering factor was tooth extraction. The mean diagnostic delay was five months. There were more stage 2 and 3 patients, according to the AAOMS classification. They were the most frequent, probably because of the higher number of co-morbidities, especially corticosteroid intake. Patient management complied to Afssaps and AAOMS recommendations. The evolution was favorable for all managed patients.

[Suprafascial dissection of the radial forearm flap]. / Prélèvement suprafascial du lambeau antébrachial radial.

INTRODUCTION: The aim of this study was to assess the efficacy of dissection of radial forearm flap in a superficial plan above the deep fascia to prevent donor site problems. PATIENTS AND METHODS: Eighteen radial forearm flaps were used for orofacial reconstruction: 11 suprafascial flaps and seven infrafascial flaps. We compared in the two groups: flap failure, graft success, tendon adhesions, sensory nerve damage at donor site. RESULTS: We observed one case of flap failure in the infrafascial group and one case in the suprafascial group. With suprafascial elevation flap technique, we noted 100% of grafts integration without tendon adhesion. In infrafascial elevation flap technique, four out of seven patients had delayed healing. DISCUSSION: The suprafascial dissection of free radial forearm flap creates a superior graft recipient bed ensuring early and complete successful graft.

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.

[Vegetable foreign body of the infratemporal fossa: a case report]. / Corps étranger végétal de la fosse infratemporale.

INTRODUCTION: Limited amplitude of mouth opening due to a foreign body in the infratemporal fossa is a rare event. We report a trismus due to a foreign body of vegetable origin located in the infratemporal fossa. OBSERVATION: A 44-year-old female patient presented with a left endobuccal wound made by an oak branch. Limited amplitude of mouth opening was noted on clinical examination. A first CT scan did not reveal any foreign body. Despite an adequate treatment, the patient presented with acute cellulitis. A second CT scan revealed a parapharyngeal and masticatory compartment collection. One month after drainage, the patient spontaneously rejected the vegetable foreign bodies. An MRI better investigated the lesional diagnosis and the patient underwent surgery for the third time. DISCUSSION: Discovering foreign bodies in the infratemporal fossa is unusual. CT scan is a useful but limited tool if foreign bodies are small and/or of weak density. MRI is the reference examination.

[Outcome of oral implants after autogenous bone reconstruction]. / Devenir des implants après chirurgie préimplantaire.

INTRODUCTION: The purpose of this study was to evaluate the implant placement outcome in edentulous patients prosthetically rehabilitated after autogenous bone graft. MATERIAL AND METHOD: Between 2002 and 2006, 75 patients underwent graft surgery, only 64 patients (mean age of 53.8 years) had a complete treatment. Calvarial bone grafts were used in 41 cases, mandible bone in 13 cases, and iliac bone in 13 cases. Grafting techniques were onlay and inlay grafts in the maxilla combined or not with LeFort I osteotomies, and onlay or interposed bone graft in the mandible. Twelve patients presented with complications, wound dehiscence in seven cases and infection in five cases. Twenty-two patients presented with perforation of the sinus mucosa in the course of sinus lift. RESULTS: Three hundred and seventy-nine implants were inserted in 64 patients, 295 in the maxilla and 84 in the mandible. Fifteen implants failed (3.95%), 13 before loading and two after, 10 maxillary implants (3.38%), and five mandibular implants (5.95%). The global implant survival was 96.05% with a mean background of 23.6 months, 88.37% after sinus lift, 83.33% after apposition graft in the mandible and 88.64% in the maxilla. DISCUSSION: These results correlate to current published data.

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.

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.

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.

[Otophyma, zygophyma and giant rhinophyma: a rare association]. / Otophyma, zygophyma et rhinophyma géant : une association rare.

A patient, 64-year-old, is referred for the treatment of a giant rhinophyma. He refused any treatment during eight years. The interest of this case report is the size and the weight of the rhinophyma, the obstruction of the nasal airways and the resulting social disturbance. This exceptional clinical rhinophyma was associated with an otophyma, a zygophyma and ophthalmic disease. To our knowledge, this clinical presentation has never been reported before. The management of the rhinophyma and the otophyma was surgical excision, secondary healing followed by a full thickness skin graft associated to a fullface mechanical dermabrasion.