Prefabricated fibula free flap with dental implants for mandibular reconstruction.

Free fibula transplant is routinely used for mandibular reconstruction in head and neck cancer. Dental rehabilitation, the objective of mandibular reconstruction, requires the use of dental implants as supports for fixed or removable dentures. Positioning of fibular bone grafts and implants determines implant osseointegration and the possibilities of dental rehabilitation. Prefabrication of a fibula free flap with dental implants prior to harvesting as a free flap can promote implant osseointegration. The position of the implants must then be precisely planned. Virtual surgery and computer-assisted design and prefabrication techniques are used to plan the reconstruction and then reproduce this planning by means of tailored fibula and mandible cutting guides, thereby ensuring correct positioning of fibular bone fragments and implants. The prefabricated fibula free flap technique requires two surgical procedures (prefabrication and flap transfer) and precise preoperative planning. Prefabricated fibula free flap with dental implants, by improving the quality of osseointegration of the implants before flap transfer, extends the possibilities of prosthetic rehabilitation in complex secondary mandibular reconstructions.

Tongue base reduction with hyoepiglottoplasty: a treatment for severe obstructive sleep apnea.

OBJECTIVE: To describe a surgical procedure for the treatment of severe obstructive sleep apnea syndrome (OSAS), the procedure's indications, and its results. STUDY DESIGN: A retrospective study of 10 male patients with OSAS treated by tongue base reduction with hyoepiglottoplasty (TBRHE) at the Foch Hospital (Suresnes, France) between 1994 and 1997. Patients had a mean body mass index (BMI) of 32 kg/m2, a mean respiratory disturbance index (RDI) of 70 events/h, and a mean minimal oxygen saturation of 78%. They had refused positive airway pressure therapy or wished to discontinue it. METHODS: Subtotal tongue base reduction preceded by lingual neurovascular bundle identification and derouting, epiglottal verticalization, mouth floor horizontalization, and hyoid bone repositioning was performed, associated in some cases to uvulopalatopharyngoplasty (UPPP). Indications were based on a site-related obstruction, on the absence of craniofacial deficiencies, and on the presence of hyolingual abnormalities determined by cephalometry and magnetic resonance imaging. RESULTS: TBRHE associated to UPPP in most cases had an 80% success rate, based on a postoperative RDI below 20 events/h and a reduction of the preoperative RDI of more than 50%. Snoring and excessive daytime sleepiness decreased or disappeared, respectively, in 100% and 90% of the cases. No neurovascular complications occurred. CONCLUSION: TBRHE is a safe procedure for the neurovascular bundle. Associated to a pharyngotomy, it is an effective treatment for severe OSAS attributable to tongue base obstruction. These results require confirmation in a larger series of patients.

[Laryngeal immobility after thyroidectomy]. / Immobilité laryngée post-thyroïdectomie.

One of the most common complications of surgery of the thyroid gland is vocal folds immobility. New advances in its management have been achieved over the last few years. Laryngeal electromyography, stroboscopy, and computerized analysis of the voice help guide diagnosis, allowing differentiation between recurrent nerve paralysis and glottis traumatism due to intubation, and further follow-up of recovery with relevant therapeutic decisions. In case of unilateral vocal fold paralysis, intrafold silicone or injection of autologous fat is more and more routinely used to obtain vocal rehabilitation. In case of bilateral vocal fold paralysis, to avoid tracheotomy, partial posterior cordectomy using laser surgery restores sufficient laryngeal airflow, with minimal vocal sequelae. Early management of these complications by teams of specialists should allow appropriate and less invasive surgery.

[Surgical treatment of chronic snoring. Description and indications]. / Les traitements chirurgicaux de la rhonchopathie chronique. Description et indications.

Chronic rhonchopathy groups all clinical forms of a disease having a common functional sign: snoring. Surgical treatments form part of a therapeutic strategy which includes medical treatment, essentially reduction in body weight, and nocturnal respiratory prosthetic treatments, essentially continuous positive pressure respiration. First intention surgery is an uvulopalatopharyngoplasty (UPP) with or without tonsillectomy. In the severe forms of chronic rhonchopathy, after failure of UPP, major surgery:protrusion mandibular osteotomy or reduction glossectomy can be associated with the other treatments.

[Retrospective cephalometric analysis for surgically treated obstructive sleep apnea: therapeutic deductions]. / Analyse céphalométrique rétrospective dans les syndromes d'apnées du sommeil sévères traités par chirurgie. Déductions thérapeutiques.

PURPOSE OF THE STUDY: The goal of surgical treatment for severe sleep apnea syndrome is to alleviate the upper airway obstruction. The narrowing site must be precisely determined during the preoperative evaluation to ensure success. We suggest that cephalometric analysis using a lateral cephalic radiograph to evaluate bony structures combined with magnetic resonance imaging (MRI) to study soft tissues may achieve this goal. The purpose of this study was to determine the role of two different cephalometric analysis systems for determining surgical strategy and to underline factors predictive of success for different surgical procedures. MATERIALS AND METHOD: We prospectively studied 73 sleep apnea patients. The preoperative evaluation included MRI and two different cephalometric analyses on a lateral cephalic radiograph: Tweed's and Delaire's analyses. Three surgical techniques were performed: mandibular osteotomy and geni tubercule advancement, maxillo-mandibular advancement and tongue base reduction with hypoepiglottoplasty via a cervical approach. RESULTS: Tweed's analysis appeared to underestimate maxillo-mandibular deficiencies compared with Delaire's analysis; the later seemed to be more sensitive. MRI did not prove to be useful in predicting surgical outcome. MRI was non-contributive in our preoperative evaluation. DISCUSSION: We suggest a new surgical strategy using two procedures: maxillo-mandibular advancement and tongue base reduction. Indications are based on the results of two cephalometric analyses (Tweed and Delaire) and the measurement of the oropharyngeal surface.

[Surgical treatment of severe sleep apnea syndrome by maxillomandibular advancing or mental tranposition]. / Traitement chirurgical du syndrome d'apnées du sommeil sévère par avancée maxillo-mandibulaire ou par transposition génienne.

Surgery of the facial skeleton or the tongue may be envisaged in case of failure of continuous positive pressure ventilation for severe sleep apnea syndrome defined by a apnea-hyponea index greater than 30/h. We present here our results in patients treated by maxillo-mandibular advancing and mental transposition. We define the surgical indications. Between January 1993 and June 1997, 41 patients, mean age 49 years, with severe sleep apnea syndrome (mean apnea-hyponea index =58.5/h) were treated by maxillo-mandibular advancing (21 cases) or mental transposition (20 cases) depending on the cephalometric work-up including lateral teleradiography and sagittal magnetic resonance imaging of the tongue. Functional outcome was good in both groups. Objective success (postoperative apnea-hyponea index <20) was 70.5 % after bimaxillary advancing (mean apnea-hypopnea index =17), but only 25 % after mental transposition (mean apnea-hyponea index =44.5). Maxillomandibular advancing is a major procedure which can be effective in sleep apnea patients with severe craniofacial skeletal anomalies. Its applications in apneic patients with no skeletal anomaly remains a subject of debate. Conversely, there would appear to be very few indications for mental transposition.

[Tracheal anastomosis: monofilament absorbable suture versus monofilament non-absorbable suture. Experimental study in rats]. / Anastomose trachéale: fil monofilament résorbable versus non résorbable. Etude expérimentale chez le rat.

OBJECTIVES: When tracheal stenosis is symptomatic, the treatment may consist of surgical resection and anastomosis. A multifilament absorbable suture is usually used. The aim of this experimental work on rats was to study the benefits of using a monofilament absorbable suture with high initial resistance. MATERIAL AND METHODS: We compared Ethilon, a nylon monofilament non-absorbable suture (MNA), with Monocryl, a polyglecaprone 25 (P25) monofilament absorbable suture (MA). The sutures were used for tracheal anastomosis on 16 rats. P25 has a high initial strength but its intra-tissular disappearance is fast. Animals were killed at 1, 2 and 3 months. Anastomoses were studied by optical microscopy and histological analysis. RESULTS: At 3 months no disunity or stenosis was seen with the MA. With the MNA, a modification of the tracheal transverse section and a stenosis were observed. The histological examination showed an initial important inflammatory cell reaction with the MA and at 3 months, a surgery-free like tracheal aspect. At 3 months the rats with MNA had a persistent foreign body cell reaction. CONCLUSION: Good results obtained by using P25 could be due to high initial resistance of the suture protecting the anastomosis. The semi-fast absorption of the suture avoided persistent inflammatory cell reaction. Confirmation of these results by working on larger animals and tracheal anastomosis under tension could allow the use of this suture on human beings, in this instance.

[A new technique of gene transposition in the surgical treatment of sleep apnea syndrome]. / Nouvelle technique de transposition génienne dans le traitement chirurgical du syndrome d'apnée du sommeil.

Pharyngotomy appears to be insufficient for the treatment of severe sleep apnea. For patients who refuse or abandon mechanical ventilatory assistance, surgery can be used to widen the retrobasilingual space adapting it to the cephalometric profile defined by cineradiography and MRI in combination with velopharyngeal plasty. For patients with no maxillomandibular or lingual malformation, the pharyngotomy can be combined with an anterior transposition of the genial insertions of the tongue without rotation. A method different from that described by Riley and Powel is proposed. The details of the surgical procedure are exposed. The operation is indicated in snorers with sleep apnoea with an Apnea Index Superior to 30 who refuse nocturnal ventilatory assistance and who do not have a hypertrophied tongue (Surface less than 30 cm2) or maxillomandibular retroposition.

[Hypoglossal nerve in its intralingual trajectory: anatomy and clinical implications]. / Le nerf hypoglosse dans son trajet intralingual. Etude anatomique et applications cliniques.

There is little literature on the intralingual trajectory of the hypoglosal nerve. We performed an anatomical dissection on 6 cadavers and completed our study with histological examinations. The 12th cranial nerve enters the lower part of the tongue laterally, reaching the anterior border of the hypoglossal muscle where it follows the ascending lingual artery medially to terminate anteriorly to the lingual V. Its terminal branches spread out horizontally in each half of the tongue. There is a paramedial branch, found in all cases, which projects downwardly, posteriorly and medially at the basilingual portion of the genioglossal muscle. These anatomic findings indicate that basiglossectomy removing the entire base of the tongue can be performed without functional sequelae. A certain degree of somatotopy is also found with specific fibers reaching the protractor and retractor muscles. This nerve distribution supports attempts at selective electrical stimulation of the hypoglossal nerve with the aim of dilating the upper airways in patients with sleep apnea syndrome.

[Tongue base reduction with hyoid-epiglottoplasty. A surgical alternative in severe sleep apnea syndromes]. / Basiglossectomie avec hyo-épiglottoplastie. Une alternative chirurgicale pour les syndromes d'apnées du sommeil sévères.

We present preliminary results and indications of tongue base reduction with hyo-epiglottoplasty for the treatment of severe obstructive sleep apnea syndrome (OSAS) due to isolated hyolingual abnormalities. The procedure consists in a subtotal resection of the tongue base after identification and derouting of the lingual neurovascular bundle. Hypopharyngeal enlargement, epiglottis verticalization, floor of the mouth tension and hyoid bone repositioning are also performed during the procedure. 14 severe OSAS male patients (mean apnea-hypopnea index of 71) were treated in our institution from November 1992 to February 1996. Indications were determined after a cephalometric analysis and a magnetic resonance imaging evaluation. Results were evaluated on clinical and polysomnographic criteria. No neurovascular complications occurred. Clinical results were excellent but success rate based on polysomnography was 50%. These preliminary results led us to change some of the steps in the technique. We also identified a predictive factor of success on the cephalometrics: an oropharyngeal area greater than 25 cm2.

[Physiopathologic value of cephalometric teleradiography study and magnetic resonance imaging in sleep apnea syndromes. Therapeutic deductions]. / Intérêt physio-pathologique d'une étude céphalométrique par téléradiographie et IRM dans le syndrome d'apnée du sommeil. Déductions thérapeutiques.

A cephalometric study was carried out on 98 patients assigned to 3 groups including 48 patients with sleep apnea, 25 patients with chronic rhonchopathy without apnea, and 25 controls, respectively. 44 patients benefited from lateral teleroentgenographic investigations and 54 had sagittal-median NMR sections visualized. Various distance, angle and area measurements were obtained. The authors found that anomalies were the more severe that snoring was associated with sleep apnea. These arguments speak for an evolutional character of the disease. The various cephalometric anomalies were primarily related to the hyoglossal apparatus, more rarely to the maxillary-mandibular basal bones. After this analysis, the authors propose a therapeutic strategy for the management of chronic snoring associated with sleep apnea.

Medicoeconomic study of microsurgical head and neck reconstructions.

OBJECTIVES: The use of microanastomosed free flaps has become essential in the management of head and neck defects following cancer resection or other causes. However, this surgery is under-rated by the French case-mix based rating procedure. The purpose of this study was to evaluate the cost balance of this type of surgery in a patient cohort managed by free flap head and neck reconstruction in a polyvalent adult head and neck surgery department. MATERIAL AND METHODS: This retrospective study was based on 52 patients divided into two groups undergoing either mandibular or nonmandibular reconstruction. Possible prognostic factors were investigated in patients undergoing mandibular reconstruction. Kaplan-Meier survival analysis was also performed for both groups of patients. The Foch Hospital financial department's analytical accounting data for 2006 and 2007 were used to evaluate the costs related to these patients. A senior surgeon retrospectively reviewed the patients' charts with the Medical Informatics physician in order to optimize the choice of diagnosis-related group (DRG). RESULTS: The mean income generated by mandibular and nonmandibular reconstructions in 2006 and 2007 was 545€/day and 526€/day for hospitalisation including free flap and 828€/day and 818€/day for "satellite" hospitalisations for other procedures related to the reconstruction, respectively. After review of the rating by a senior surgeon, in order to optimize the choice of DRG, the mean income received by the hospital could have been improved by +6%. CONCLUSION: Optimization of procedure and hospital stay rating associated with better collaboration with the Medical Informatics physician are essential in order to continue to provide this major surgery, which is essential for the patient's quality of life. A higher rating of this activity by the French health system is also necessary.

Mandibular osteosclerotic lesion of a parotid salivary duct carcinoma: demonstration of the neural tropism of these tumors.

INTRODUCTION: Salivary duct carcinoma (SDC) is an uncommon entity of salivary gland cancers with a poor prognosis due to local aggressiveness or distant recurrences involving lymph nodes, lung, and long bones, in which secondary lesions are usually osteolytic. The authors report the first case of mandibular SDC, atypical due to its osteosclerotic presentation and its site, attributed to aggressive neural spread of the tumor along the trigeminal nerve. CASE STUDY: This asymptomatic osteosclerotic bone involvement was diagnosed based on pathological enhancement of the trigeminal nerve demonstrated on MRI and was accompanied by facial nerve involvement up to its third intracranial portion. Radical surgery ensured disease control with continued good quality of life at the 4-year follow-up visit. CONCLUSION: Nerve enhancement on MRI and determination of specific tumor markers (HER-2/neu and p53) should be taken into account to evaluate the prognosis of SDC and to propose appropriate surgical treatment.

[Treatment of inveterate unilateral dislocations of the mandible by open repositioning of the condyle and meniscectomy]. / Traitement des luxations invétérées unilatérales de la mandibule par reposition sanglante du condyle et méniscectomie.

A new method for treating inveterate forms of mandibular luxation is described, after a brief review of conventional therapeutic procedures. The route of approach chosen provides wide exposure of the temporo-mandibular joint, the endoarticular approach ensuring protection of pericondylar venous plexuses and of the internal mammary artery by allowing section of the external pterygoid tendon and the performance of a juxta-cervical capsulotomy. Excellent results were obtained in two patients with unilateral inveterate dislocation of the mandible operated upon using this procedure.

[Subcutaneous cervicofacial and mediastinal emphysema complicating tooth extraction: case report]. / Emphysème sous-cutané cervico-facial et médiastinal au cours d'une avulsion dentaire: à propos d'un cas.

Subcutaneous emphysema is a rare and well-known complication of dental procedures. Many cases go unrecognized and resolve spontaneously, while others may require specific surgical management to prevent complications. We present a case of cervicofacial and mediastinal emphysema which occurred during a routine dental procedure and a review of the literature on differential diagnosis and management.

Mandibular nerve: MR versus CT about 10 proved unusual tumors.

10 patients with symptoms of mandibular neuralgia formed the basis of this study. They were studied by both enhanced CT and MRI. MRI, better than CT, easily permits distinction between intrinsic and extrinsic lesions and detects involvement of the cavernous sinus and meninges. Moreover, because of its multiplanar imaging capability, and ability to portray exquisite anatomic details and characteristic tissue signal intensity, MRI is helpful in the evaluation of tumor involvement for biopsy and preoperative planning for these deep tumours.