[Severe vascular complications of Le Fort I osteotomy]. / Complications vasculaires graves de l'ostéotomie de Le Fort I.

INTRODUCTION: Le Fort I osteotomy is a common orthognathic procedure. This surgery presents risk of severe vascular complications because of local anatomy. The aim of our study was to collect data on vascular complications of Le Fort I osteotomies performed in our department, describe the diagnostic and therapeutic aspects, and discuss prevention. PATIENTS AND METHODS: A retrospective analysis was made on the files of patient having undergone Le Fort 1 osteotomy, between 1998 and 2007. Severe vascular complications were recorded, defined as postoperative hemorrhagic or ischemic complications severe enough to require a specific procedure. RESULTS: Nine hundred and sixteen patient files were included (39% male and 61% female patients, mean-age: 24.42 years; range: 13 to 59 years). Five patients presented with severe hemorrhagic complication. There was no ischemic complication. Three hemorrhagic episodes occurred in the immediate postoperative phase. In two cases, delayed hemorrhagic complication occurred, diagnosed as a pseudo-aneurysm by angiography. These were treated by hyperselective embolization. DISCUSSION: Vascular complications of Le Fort I osteotomies are rare (0.55% in our series). They are most frequently hemorrhagic complications.

[A case of aggressive juvenile fibromatosis of the mandible. Review of the literature]. / Un cas de fibromatose juvénile agressive de la mandibule. Revue de la littérature.

We report a new case of aggressive juvenile fibromatosis (A.J.F.) in a 20-month-old girl. The lesion affected the inferior border of the left mandible and the adjacent soft tissues. The child presented with a painless mass, which had grown over a period of 2 months. Radiographs and computed tomographic scan showed a multilacunar bone defect with subcutaneous and gingival involvement. A biopsy was performed, followed by a partial hemimandibulectomy and a costal graft. The surgical specimen measured 4 X 3 X 3 cm. The patient did well 1 year after surgery. 16 cases of A.J.F. have been reported; with ours, 14 are mandibular. A.J.F. is a locally aggressive lesion, which doesn't metastasize. It occurs chiefly in childhood and adolescence from 1 1/2 to 18 years (median 6.5 year-old). Duration of symptoms prior to presentation varies from a few weeks to months. Clinically, it is a firm nodule. Radiographs are non-specific, but 9 cases have poorly defined destruction of the mandibular inferior border. Following a block resection of the tumor (13 cases), there is no recurrence. In this review, we discuss the clinico-pathologic diagnosis of this impressive tumor which is compared with other mandibular fibrous tumors in children.

[Hybrid osteosynthesis in orthognathic surgery: 28 cases of Le Fort I osteotomy]. / Ostéosynthèse hybride en chirurgie orthognathique: 28 cas d'ostéotomie de Le Fort I.

INTRODUCTION: The use of resorbable materials in orthognathic surgery is presently the object of numerous clinical and experimental studies. Their main drawbacks are their lack of rigidity and induced chronic inflammatory reactions. The purpose of this study was to propose and to test an original system of hybrid osteosynthesis associating a single titanium plate with three resorbable plates in Le Fort I osteotomies in the absence of maxillary expansion, or two titanium plates with two resorbable plates in case of maxillary expansion. METHODS: Our retrospective study concerned 28 patients operated between 2002 and 2005. A clinical follow-up of over one year detected the specific complications of the hybrid system and a cephalometric study analyzed the secondary relapse 5 months after surgery. These results were compared to the literature. RESULTS: One case of mobility and a case of instability of the jaw were observed, along with 5 cases of local chronic inflammatory reaction. The radiological results found a secondary sub-clinical relapse. The removal of the titanium material under local anesthesia was performed without difficulties in ambulatory care, which avoided a new hospitalization for the patient and a new general anesthesia. DISCUSSION: The hybrid system allowed obtaining a postoperative stability of the jaw comparable to that obtained by the exclusive use of titanium plates with an acceptable morbidity. This method of osteosynthesis combined the advantages of the resorbable material (removal of titanium plates under local anesthesia) and of titanium material (stability of the procedure). However this method requires a good experience of working with resorbable material, a good follow-up, and cooperative patients. These encouraging results urge us to extend the indications to mandibular sagittal osteotomy and to bi-maxillary osteotomies.

[Is condylar resorption a contra-indication for surgery?]. / La résorption condylienne contre-indique-t-elle la chirurgie orthognathique?

INTRODUCTION: Idiopathic condylar resorption, often fortuitously discovered when performing orthodontic-surgical assessment, is a clinical entity in itself. There is a significant risk of postoperative degenerating and worsening. Is this sufficient to contra-indicate orthognathic surgery? The authors suggest an answer after studying a series of patients. MATERIAL AND METHOD: A retrospective study of 10 consecutive patients was made from July 1999 to October 2004. The preoperative assessment was triple: clinical, radiological and photographic. At least 6 months of occlusal, radiological and morphological stability was observed before any therapy was initiated. A fixed orthodontic set-up was placed and patients were regularly followed by a speech therapist for parafunctions. Stability of the occlusal correction, acquisition of a more harmonious aesthetic profile, and resolution of joint symptomatology were used to define therapeutic success at one year. RESULTS: All patients were female. Resorption affected the mandibular side of the joint in all cases and the temporal side in 7 cases. Three types of osteotomies were performed: maxillary (N=1), mandibular (N=5), and bibasilar (N=4). Genioplasty was not systematic. Joint symptoms were resolved in all cases. Postoperative occlusion corresponded to the therapeutic project in 9 cases. All patients were aesthetically improved. DISCUSSION: Idiopathic condylar resorption is not a contra-indication for orthognathic surgery. However, this treatment requires meeting and respecting four principles: a minimal delay of 6 months of occlusal, radiological, and morphological stability, an adapted and meticulous surgical technique, early and prolonged parafunction therapy, and a close follow-up of the patients.

[Free fibular flaps in children: morbidity of the donor site and pitfalls to avoid]. / Lambeau libre de fibula chez l'enfant: morbidité du site donneur et piège à éviter.

INTRODUCTION: We report a case of donor site morbidity late after harvesting a free fibular flap for reconstruction of the mandibular symphsis. CASE REPORT: An 8-year-old boy presented a valgus deformity of the ankle 4 years harvesting of a vascularized fibular graft for mandibular reconstruction. The deformation was repaired with a tibial bone slit and pin fixation. The biomechanical result was very satisfactory, allowing normal gait. DISCUSSION: We recall the rules for fibular flap harvesting needed to prevent deformation of the donor site in children aged less than 9 years.

[Growth defects of fibular flaps in children]. / Troubles de croissance des lambeaux fibulaires prélevés chez l'enfant.

BACKGROUND: Mandibular reconstruction with fibula free flap is a challenge in pediatric patients because of the size of the bone and absence of growth without epiphyseal transplantation. CASE REPORT: We report 2 cases of free fibula flap in children for mandibular reconstruction. The 2 patients presented with growth insufficiency of the bone graft after few years of evolution. DISCUSSION: Growth insufficiency was treated with different surgical procedures which were discussed We review the consequences on growth after fibula free flap and the specific indications to achieve epiphyseal fibular growth in children.

[Regarding orthognathic surgery]. / Regards sur la chirurgie orthognathique.

The author scrutinises the evolution of orthognathic surgery for the last twenty years through the different parameters that participate to its origin; esthetic motivation, orthodontico-surgical collaboration, the limitation of widely used technics, a simple surgical solution, the spreading of rigid fixation, the interest of primary or secondary genioplasty, the consideration of ethnic differences,the usefulness of a maxillo-facial chain, the possible retreatment of failures and consideration for the stability of results.

[Congenital midline cervical cleft]. / Bride cervicale médiane congénitale.

The authors report 3 cases (including 2 recurrences) of congenital median cervical clefts (fold and fistula). Based on a review of the literature, they recall the principal clinical features of these lesions. The modalities and results of surgical treatment are discussed: Z-plasty, musculocutaneous flaps, tissue expansion. The possibility of recurrence after Z-plasty during the first months of life emphasises the importance of regional hypoplasia in certain cases and requires tissue supplementation. The disturbance of mandibular growth may require genioplasty in adolescents.

[Hydroxyapatite in orthognathic surgery. Animal experimentation and clinical applications]. / Hydroxyapatite en chirurgie orthognathique. Expérimentation animale et applications cliniques.

Bone cell conduction can occur within hydroxyapatite, a biocompatible, bioactive, synthetised ceramic material, when it is placed in contact with bone tissue. Results of experimental and clinical studies on maxillary osteotomy incisional lines have confirmed these properties, the quality and stability of the results and the good tolerance of this biomaterial making it a product of choice as a substitute of iliac bone grafts, when no longer indicated in this context.

[A rare cervical malformation syndrome: mento-sternal cleft. Apropos of 4 case reports]. / Un syndrome malformatif cervical rare: la fissure mento-sternale. A propos de 4 observations.

Midline cervical cleft and webbing is a rare congenital anomaly of the neck. A series of 4 cases is reported, among which 2 relapses. The neonatal diagnosis of the deformation leads to a surgical treatment for the first two years, associating excision of the cleft with its underlying fibrous cord, and closure with local plasty (wave-plasty, multiple Z-plasty). However, relapses are possible. They show evidence of a real regional hypoplasia that will require the contribution of tissue. Myo cutaneous flaps are used in 3 cases. The possibility of tissue-expansion is discussed. Mandibular surgery may be necessary at a later stage (genioplasty).

[Amyloid disease and extreme macroglossia. Apropos of a case]. / Maladies amyloïdes et macroglossie extrême. A propos d'un cas.

A case of extreme macroglossia was observed in a patient with amyloid disease and dysglobulinaemia. A medial diamond-shaped glossectomy was required to reduce the size of the tongue. The details of the surgical and anaesthetic procedure are presented. This type of surgery, greatly appreciated by the patient, can only be undertaken after careful preparation. The reported cases are rare and the indication for surgery is difficult due to the unpredictable nature of the local and general clinical course of the disease.

[Le Fort osteotomy. A study of the complications from a review of the literature and from a homogenous series of 50 patients]. / Ostéotomie de Lefort I. Etude des complications à partir d'une revue de la littérature et d'une série homogène de 50 patients.

Since Wassmund in 1927, the Le Fort I osteotomy became a popular procedure in maxillo-facial surgery. Review of the literature is presented with a series of 50 homogenous patients. The authors show that they are few complications of this operation although theoretically may look numerous. The intra and post-operative haemorrhages are infrequent and never alter the vital prognosis. The bony necrosis disappeared since the last technical improvements. The secondary displacement remains a problem which seems less important actually because of the use of plates and screws, and the improved surgeon's skill. So, the Le Fort I osteotomy become a reliable surgery since indications and technical points are respected.

[Visor osteotomy of the mandible in edentulous patients]. / Ostéotomie en visière de la mandibule chez l'édenté.

The use of a sliding osteotomy to reconstruct an incisive block on an edentulous mandible was first described by Frans Harle in 1975. Employed in cases of a flattened widened mandible, when bone material is still present, it supplies an elegant solution to the problem of the anterior stability of inferior total prosthesis. Results of the use of this technique are reported. The problem of the mucoperiosteal cover of the graft after it is slid above the bone base left in place was resolved by performing, with the true osteotomy, a mucous sliding graft completed by a thin skin graft. A slightly different sliding osteotomy is also proposed, in which the mandibular graft is slid in the inverse direction, thus partially correcting the false prognathism of the edentulous patient.

[Late results of the surgical treatment of temporomandibular joint ankylosis in children]. / Résultats tardifs du traitement chirurgical de l'ankylose temporo-mandibulaire de l'enfant.

Long-term outcome after surgical treatment of temporomandibular joint ankylosis is not always satisfactory in children. Interposition of a temporalis muscle flap is insufficient to ensure good functional results if the surgical procedure is not followed by careful active and passive physiotherapy. The results can be evaluated only after the child has grown.

[Current status of the treatment of fractures of the mandible in edentulous patients]. / Etat actuel du traitement des fractures de la mandibule chez l'édenté.

Conventional therapy for fractures of the atrophied mandibular arch in edentulous patients, employing surgery followed by the insertion of a prosthesis, gives unsatisfactory results due to the frequency of early or late complications. A strictly surgical approach has therefore been adopted in the maxillofacial Surgical Unit in Lyon. The procedure involves systematic freeing of the fracture lines and their contention, after as complete an anatomical reduction as possible, by means of wire sutures, a miniature plate and screw, or even a rib graft in cases of marked mandibular atrophy. Consolidation without complications can be obtained, followed by the insertion of a prosthesis after a short period of time.

[Double cogenital nasopalatine fistula behind the central and lateral incisors]. / Double fistule congénitale naso-palatine en arrière des incisives centrales et latérales.

A 26-year-old man presenting no clinical manifestations apart from the intermittent flow of nasal secretions into the mouth was found to have a double fistulous tract at the level of the upper central incisors. Fistulography confirmed the presence of a fistula. The nosological place of this congenital lesion remains to be defined.

[A simple technic for the reproduction of radiograph transparencies]. / Technique simple de reproduction des radiographies en diapositives.

An reversible daylight color film associated with 3 filters was used for slide reproduction from radiographs. This simple, rapid, and low-cost technique appears to be particularly suitable for iconographic reproduction for teaching purposes.

[The temporal muscle flap and palatal repair]. / Lambeau de muscle temporal et réparation du palais.

Two edentulous elderly women presented with benign but extensive tumors of middle third of face. The excision necessary for reasons of comfort and hygiene could not be envisaged unless the ineluctable vast palatine breach opened could be immediately repaired by surgery, any prosthetic solution being excluded. The use of a total temporal muscle flap, without zygoma section, provided an effective and comfortable solution to this both delicate and unusual problem. These cases illustrate the interest in the use of temporal muscle flaps in maxillofacial surgery, and their management for the repair of large palatine breaches.

[Facial asymmetry due to hemi-mandibular hypertrophy]. / Asymétrie faciale par hypertrophie hémimandibulaire.

A relatively frequent disorder, hemi-mandibular hypertrophy is today well identified clinically and radiologically. Its expression varies from one case to another but it becomes stabilized at the end of growth. Its etiology is unclear and it can only be corrected surgically: the habitual inclination of the plane of occlusion leads to a bimaxillary action with a tridimensional effect. The results of these osteotomies performed at the same time is stable and dramatic. Although isolated osteotomy of the basilar excess has become a last resort procedure, isolated condylectomy is still an acceptable compromise in toothless patients. The diagnostic approach and result of surgical treatment are analyzed in light of a homogeneous series of 12 cases.

[Excision of ameloblastoma and reconstruction using a mandibular autologous graft]. / Exérèse d'améloblastome et reconstruction par autogreffe mandibulaire.

Three patients with mandibular ameloblastomas were treated by hemimandibulectomy followed by immediate reconstruction by a single-block mandibular homograft prepared at a distance from the operating field and taken from the bone section removed after visual and radiologic control of total tumoral separation. This procedure is simpler and more economic, rapid and reliable that conventional reconstruction using rib or iliac homografts. It is indicated for those limited cases of ameloblastoma or benign bone tumors which, even though possessing similar prognoses by their site (coronal...) or their tendency for recurrence and thus requiring interruptive resection, are sufficiently small to ensure total tumor excision and the recovery of a sufficiently thick bone piece for an ideal homograft. The procedure is of particular interest in the elderly and/or debilitated patients, and may be useful after abusive hemimandibulectomy.