[Condylar remodelling after temporomandibular joint reconstruction with fibula free flap]. / Remodelage du condyle après reconstruction de l'articulation temporomandibulaire par lambeau libre de fibula.

AIM: Mandibular reconstructions with fibula free flap are commonly used in maxillo-facial surgery; termino-lateral mandibulectomy with reconstruction of the ramus and condylar unit is seldom used. Consequences on the temporomandibular joint remain unclear, and the type of reconstruction is still subject to controversy. METHODS: Six patients were followed after terminal mandibulectomy, reconstructed with fibular free flap. Evaluations of the results were made on functional and radiological criteria. RESULTS: No patient presented functional disturbances due to reconstruction. Remodeling of the neocondyle extremity was weak in adults but important in children, with modification of morphology and architecture of the condyle in children. DISCUSSION: Preservation of the disc is recommended. Many techniques are described to improve congruence, preservation and remodeling of the free extremity of the fibula flap. All give similar results. It seems that the real determinant factors on the quality of the result are age, presence of the disc or not, previous surgery performed, with or without radiotherapy.

[Condylar positioning during mandibular orthognatic surgery]. / Positionnement condylien lors de la chirurgie orthognathique mandibulaire.

Sagittal split osteotomy of the mandible is the most frequently used method in orthognatic surgery. Osteosynthesis was performed with wires in the 1970s. The instability of fixation allowed condyle movements and there was no problem of condylar positioning. The drawback of this technique was that it required a strict intermaxillary fixation for 6 weeks. Osteosynthesis evolved in the 1980s to a rigid and semi-rigid fixation, with no longer any need for an intermaxillary fixation. But accurately determining the condyle position in the fossa is essential when using a rigid fixation, because no spontaneous adaptation is possible. Moreover, an improper condyle positioning is known to increase short term skeletal relapse, inadequate corrections, and a high incidence of temporomandibular joint dysfunctions. Many solutions have been proposed to solve the problem of condylar positioning: manual positioning technique at osteosynthesis, and mechanical or computer assisted devices to control condylar positioning. The repositionable and adjustable miniplates have also been designed to improve condyle positioning, with the possibility of peroperative adjustment.

Lengthening temporalis myoplasty and brain plasticity: a functional magnetic resonance imaging study.

BACKGROUND: Lengthening temporalis myoplasty (LTM) is a technique developed since ten years for facial paralysis. A spontaneous smile is acquired after this surgery explains by brain plasticity and the aim of the study is to confirm this plasticity by functional magnetic resonance imaging. MATERIALS AND METHODS: A functional magnetic resonance imaging (fMRI) was performed at various time points in ten patients who were operated on LTM during one year. RESULTS: Two different areas were found to be involved in chewing and smiling. We observed changes in the areas involved in smiling and chewing three months after surgery, and these changes persisted for at least one year. CONCLUSIONS: Our findings thus confirm that brain plasticity underlies the clinical observation of acquisition of a spontaneous smile.

[Split temporalis muscle flap vascularized by the superficial temporal pedicle]. / Le lambeau de muscle temporal dédoublé vascularisé par le pédicule temporal superficiel.

INTRODUCTION: The temporalis muscle has been used for more than a century for facial reconstruction. But this flap cannot fill defects beyond the midline. Splitting the temporalis muscle in the plane of the tendon insertion allows lengthening the flap and crossing the midline. TECHNICAL NOTE: The scalp incision is followed by a subcutaneous dissection, taking care to spare hair follicles and superficial temporal vessels. Then the temporalis muscle is detached by a strictly subperiosteal dissection and deep temporal pedicles are dissected and ligated. The flap is split in the plane of the insertion tendon up to its distal end. DISCUSSION: This technique allows reconstructing cranio-facial defect beyond the midline with well-vascularized tissue.

[Inferior alveolar nerve block with ropivacaine: effect on nausea and vomiting after mandibular osteotomy]. / Bloc du nerf alvéolaire inférieur par ropivacaïne : effets sur les nausées et vomissements en postopératoires (NVPO) des ostéotomies mandibulaires.

INTRODUCTION: Our objective was to evaluate the contribution of bilateral inferior alveolar nerve block (BIANB) in patients before mandibular sagittal osteotomy for postoperative pain management, consumption of opioids, treatment of nausea and vomiting. MATERIALS AND METHODS: We included 30 patients undergoing mandibular sagittal osteotomy in a prospective, randomized, double blind study. The first group of patients (n=14) underwent a standard procedure (general anesthesia with postoperative morphine treatment). The second group of patients (n=16) underwent BIANB before surgery, in addition to the standard procedure. The postsurgical management was evaluated every four hours for the first 24hours, according to the following criteria: postoperative nausea and vomiting (PONV), visual analogue scale (VAS) assessment of pain, consumption of morphine (cumulative dose) and antiemetic drugs, and need for releasing inter-maxillary blockage. RESULTS: PONV was significantly less frequent in the second group (6.3 % versus 42.9 %, P=0.031). The frequency of releasing inter-maxillary blockage and the consumption of antiemetic drugs were not significantly different in the two groups. The mean VAS pain score was significantly lower in the second group (1.6 versus 0.9 avec P=0.045). There was no significant difference in cumulative morphine requirements between the two groups at 24hours. DISCUSSION: BIANB during mandibular osteotomy increases the patient comfort by decreasing PONV and improving postsurgical analgesia.

[Implant insertion in distracted bone for reconstruction after gunshot injury]. / Pose d'implants en os distracté chez les patients reconstruits après traumatisme balistique.

Distraction osteogenesis is a tissue engineering technique with two clinical applications in maxillofacial surgery: alveolar distraction and basal bone distraction. Even if it appears to be a binding and major surgery, distraction osteogenesis applied to facial bone, and especially to the mandible, has the great advantage of producing a pluritissular reconstruction of ideal quality and quantity, suitable for the ultimate goal of dental implant rehabilitation management. This technique had some drawbacks due to technical constraints related to the material. Distraction osteogenesis is well placed in the armamentarium of reconstructive surgery techniques for bone defects caused by trauma or tumor. It allows rapid restoration of adequate physiological conditions for mandibular dental implant placement. We reviewed the various modifications of this technique.

["Double barrel" free fibula flap and vascular risk. A national investigation in France]. / Lambeau libre de péroné en « double barre ¼ et risque vasculaire. Enquête nationale.

INTRODUCTION: The free fibula flap is the most commonly used flap for mandibular reconstruction thanks to its multiple advantages. Its main drawback is the thin width of the bone section. The "double barrel" fibula flap is a solution to this problem allowing reconstruction of both basilar and alveolar ridges for a stable prosthetic dental rehabilitation. The authors wanted to assess its use, in France, to evaluate its reliability, and to determine its indications. PATIENTS AND METHODS: The authors sent a questionnaire to the 25 French Maxillo-Facial University Hospital Departments. Questions concerned the surgical technique, its indications, and the operative results, between January 2002 and December 2007. RESULTS: Out of the 18 teams who answered, 16 used a free fibula flap for mandibular reconstruction but only seven used the double barrel technique, for a total of 24 double barrel reconstructions. Only one total necrosis was reported. The indications for double barrel fibula flap were nearly all for corpus reconstruction and the operating overtime was less than one hour. DISCUSSION: The international literature review analysis gives results which compare to French ones, with a weak rate of necrosis despite the intermediate rectangular ostectomy. This technique may be recommended especially since it does not increase the operative time much and it improves dental restoration.

[Repair of palatal fistulae in cleft patients]. / Fermeture des fistules palatines séquellaires de fentes.

OBJECTIVES: Treatment of oronasal fistulae in cleft patients remains a surgical challenge because of its high failure rate. The authors report the results of an aggressive surgical technique using the total elevation of palatal mucoperiosteum, even for small fistulae. METHODS: This approach was used on twelve consecutive patients, from five to 33 years of age, presenting with a Pittsburgh classification type IV palatal fistulae. The surgical procedure was total elevation of the hard palate mucoperiosteum starting from the dental sulcus combined with sealed double layer sutures. Clinical and photographical control was made at least 6 months after to detect a possible relapse. RESULTS: The success rate was 100%. No relapsing fistula was observed with follow-up ranging from 6 to 36 months. DISCUSSION: This technique allows wide exposure and safe closure of the nasal layer. It is simple and leaves no raw bone surface exposed and no additional scar. The authors think it can be used in all type IV fistulae less than 1cm wide. Several other surgical techniques have been described to close palatal fistulae: local turnover flaps, pedicled flaps from adjacent oral tissue, tongue flaps, tissue expansion, and even free flaps. Obturator prostheses have also been used. The technique we report, even if more aggressive, seems to be more reliable with fewer relapse and sequelae.

[Foreign body granuloma due to Horsley wax®]. / Granulome à corps étrangers sur cire d'Horsley®.

INTRODUCTION: Horsley wax® is an efficient bone haemostatic agent commonly used in bone surgery. But it is non resorbable and surgeons should be aware of possible complications, which can appear many years later. OBSERVATION: We report three cases of foreign body granulomas due to bone wax. A 14-years-old female patient with an Apert syndrome underwent Le Fort III osteotomy and distraction osteogenesis; 3 years later, an inflammatory granuloma appeared in the temporal area. A 23-years-old female patient, traffic accident casualty, complained about pain in the hip 1 year after undergoing cervical spine surgery with iliac bone graft. A 35-years-old female patient underwent rhinoplasty with anterior nasal aperture surgery. She presented with an inflammatory reaction requiring several subsequent surgeries. DISCUSSION: Using Horsley wax® must be performed according to recommendations so as to prevent inflammatory or infectious complications, and to allow good bone healing. Surgeons must mention its use in the surgical report to avoid a delayed diagnosis in case of complications. There are alternatives to bone wax but they are less effective.

[Benign cartilaginous tumors of the jaws]. / Tumeurs cartilagineuses bénignes des mâchoires.

Benign cartilaginous tumors are a rare entity in jaw bones. The histogenesis is still discussed but an embryological hypothesis is suggested. Chondroma, osteochondroma, chondroblastoma and chondromyxoid fibroma are the main benign maxillary cartilaginous tumors.

[Benign bone forming tumors]. / Tumeurs bénignes ostéoformatrices du massif craniofacial.

Benign bone forming tumors typically produce dense bone (osteoma, enostosis) or osteoid tissue (osteoid osteoma, osteoblastoma). Even though these four lesions have distinct characteristics, it is sometimes difficult to tell them apart and to rule out malignant bone forming lesions such as osteosarcoma. The first line treatment is surgical exeresis.

[Management of whole-scalp tumour: the Poncet-Spiegler cylindroma or turban tumour]. / Le cylindrome de Poncet-Spiegler étendu du cuir chevelu ou tumeur en turban: prise en charge chirurgicale.

INTRODUCTION: The Poncet-Spiegler cylindroma (PSC) is a benign annexal cutaneous tumor which preferentially develops on the scalp, neck, or forehead. Localizations may be isolated or multiple and often affect the young adult. The lesions grow progressively. When the scalp is completely involved, it presents as a "turban tumor". Treatment is surgery and may be difficult when the tumor is extended. We report the management of turban tumor. OBSERVATION: A 25 year-old female patient was first treated by partial scalp nodule exeresis and histology documented a PSC. She was lost to follow-up. But 9 years later, she was managed for a turban like PSC. The treatment was a complete scalp exeresis and secondary reconstruction with a skin graft. Follow-up was uneventful with a progressive functional and cosmetic improvement and after 2 years, there was no relapse. DISCUSSION: As for most tumors, management depends on the size of the PSC. An aggressive surgical treatment must be considered if the PSC is extended. In case of turban tumor, total scalp exeresis and secondary reconstruction with a skin graft is recommended.

[The role of Versajet in the surgical treatment of rhinophyma. Case report]. / Intérêt du Versajet dans le traitement chirurgical du rhinophyma. A propos d'un cas.

Rhinophyma is an hypertrophy of the nose occurring primarily in men, from the age of 40, secondary to hyperplasia and fibrosis of sebaceous glands. This pathology is particularly unsightly and sometimes responsible of nasal obstruction. The treatment of this pathology is primarily surgical and the purpose of all techniques is to carry out a decortication. The authors describe one case of surgical treatment of rhinophyma by hydro-dissection using Versajet. After having presented the other possibilities of surgical technics for the treatment of this pathology, the authors compare the advantages and drawbacks of this new technique compared to those described in the international literature.

[The Antia-Buch flap technique in reconstruction of marginal ear defects]. / Le lambeau d'Antia-Buch dans la reconstruction des pertes de substance partielles de l'hélix.

INTRODUCTION: The aim of this study was to evaluate the results of ear defect reconstruction using the Antia-Buch flap technique and to compare it to other techniques described in international literature. MATERIALS AND METHODS: We performed 19 Antia-Buch flaps between November 1998 and November 2002: 15 cases after neoplastic treatment and four post-traumatic cases. Defect ranged between 15 and 40 mm. Between 30 and 40 mm, we used Fata's modification. The final assessment took into account patient satisfaction, cosmetic aspect of reconstruction assessed by the medical team, the presence of a notch at the helical rim and the degree of microtia. RESULTS: All ear reconstructions were successful. No complications were reported. Fata's modification was used for eight patients. All the patients were satisfied with the result in spite of a systematic microtia. The cosmetic aspect was considered as good for 16 patients, average for three. Nine patients presented with a notch at the helical rim. DISCUSSION: Reconstruction using the Antia-Buch flap is a simple and fast operative technique performed in a single operation under local anesthesia. It allows for a harmonious reconstruction of the helix and auricle with a tissue of same nature, and only a tiny cicatricial ransom, systematic microtia and frequent notch on the helical rim.

[Labial sequels after uni- and bilateral cleft lip repair]. / Les séquelles labiales dans les fentes uni- et bilatérales.

Children born with labial-alveolar-velopalatine clefts must be managed by multidisciplinary teams in order to decrease the frequency and the importance of sequels, by implementing a true therapeutic strategy. It is indeed easier to avoid a secondary deformation than to correct it. Labial sequels are often associated to nasal sequels, and are managed in a single surgical intervention, with total revision of the cheilorhinoplasty. Some less important labial deformities can be corrected without total and simultaneous revision of the lip-nose complex. The goal of correction is functional and aesthetic, and the choice of the moment depends mainly on the psychological impact of the deformation for the child, and his motivation for reoperation.

[Salivary nitrates. New perspectives concerning the physiological function of saliva]. / Les nitrates salivaires. Nouvellesperspectives concernant les fonctions physiologiques de la salive.

For many years, nitrate ions have been thought to be "toxic agents", but scientific reality seems very different. The source of nitrate ions is double: exogenous and endogenous, and the metabolism of nitrates is partly salivary. The strong concentration of nitrate ions in saliva has many beneficial physiological effects. Salivary nitrate has anti-infectious effects on the oral cavity and all along the digestive tract. They give cardiovascular protection, are instrumental in the adaptive relaxation of the stomach by acting on smooth stomach muscles and have a protective action on the gastric mucosa.

[Nasal reconstruction with a three-staged forehead flap: assessment of 16 cases]. / Reconstruction nasale par lambeau frontal en trois temps: évaluation de 16 cas.

INTRODUCTION: We report our experience in 16 patients with a three-staged forehead flap, described by Millard (1974) and Burguet (1992) for nasal reconstruction. We wanted to determine whether the three-stage procedure improves the quality of the final aesthetic result. MATERIALS AND METHODS: Sixteen patients underwent forehead flap nasal reconstruction between June 2002 and February 2005. Reconstruction was performed in three stages, a first stage for the transfer of the forehead flap on the nose, a second stage where the pediculized forehead flap was thinned (day 15) and a third stage for division of the pedicle (day 30). The quality of the final aesthetic result of nasal reconstruction was evaluated 6 months postoperatively, by the patient (patient's satisfaction with the nasal reconstruction [4 points]) and by the surgical team according to the thickness of the flap (3 points), integration of the scars (1 point), color of the flap (1 point) and the redefinition of the natural contour of the nose (1 point). A final 10-point score was used to assess the quality of the result: very good (score above 8), good (score from 7 to 8), average (score from 5 to 7) and poor (score less than 5). RESULTS: Sixteen nasal reconstructions were followed to completion. Outcome was considered very good in ten (62.5%), good in three (18.7%) and fair in three (18.7%). DISCUSSION: Use of the three-stage procedure for forehead flap nasal reconstruction improved the contour of the flap by aggressive defatting of the still pediculized flap, and thus improving the final aesthetic result. Traditionally two stages are used for frontal flaps, with pedicle division at the first stage. This refinement must not be excessive because of the risk of necrosis, the frontal flap often requiring latter defatting. In the three-stage technique thinning is performed at the second stage on a vascularised, bipediculized flap, which makes it possible to obtain the desired refinement without excessive vascular risk.

Effect of interleukin-1beta on transforming growth factor-beta and bone morphogenetic protein-2 expression in human periodontal ligament and alveolar bone cells in culture: modulation by avocado and soybean unsaponifiables.

BACKGROUND: In periodontal disease, interleukin-1beta (IL-1beta) is responsible for the matrix breakdown through excessive production of degrading enzymes by periodontal ligament fibroblasts and osteoblasts. Transforming growth factor-beta (TGF-beta) plays an important role in tissue regeneration as one of the factors capable of counteracting IL-1beta effects. In this study, we investigated the in vitro effect of avocado and soya unsaponifiables (ASU) on the expression of TGF-beta1, TGF-beta2, and bone morphogenetic protein-2 (BMP-2) by human periodontal ligament (HPL) and human alveolar bone (HAB) cells in the presence of IL-1beta. METHODS: HPL and HAB cells were incubated for 48 hours with ASU (10 microg/ml) in the presence or absence of IL-1beta (10 ng/ml). The steady-state levels of TGF-beta1, TGF-beta2, and BMP-2 mRNAs were determined by Northern blot or reverse transcription-polymerase chain reaction (RT-PCR). The amounts of TGF-beta1 and TGF-beta2 proteins were measured by enzyme-linked immunosorbent assay (ELISA). RESULTS: The data indicated that IL-1beta strongly decreases the expression of TGF-beta1 and TGF-beta2 by HPL cells. ASU were capable of opposing the cytokine effect. In HAB cells, TGF-beta1 and BMP-2 mRNA levels were downregulated by the cytokine. ASU were found to reverse the IL-1beta-inhibiting effect. In contrast, the cytokine stimulated the production of TGF-beta2 in alveolar bone cells, with no significant effect of ASU. CONCLUSIONS: The results indicate that the IL-1beta-driven erosive effect in periodontitis could be enhanced by a decreased expression of members of the TGF-beta family. The ASU stimulation of TGF-beta1, TGF-beta2, and BMP-2 expression may explain their promoting effects in the treatment of periodontal disorders, at least partly. These findings support the hypothesis that ASU could exert a preventive action on the deleterious effects exerted by IL-1beta in periodontal diseases.

[Anhidrotic ectomermal dysplasia (AED): four cases]. / La dysplasie ectodermique anhydrotique: présentation de quatre observations.

INTRODUCTION: Anhidrotic ectodermal dysplasia (AED) or Christ-Siemens-Touraine syndrome is a rare, hereditary genodermatosis, classically X-linked recessive disorder. MATERIAL AND METHODS: [corrected] We report the cases of 3 children and a male adult. RESULTS: The mode of diagnosis, the clinical signs and the therapeutic option are detailed. DISCUSSION: AED is characterized by a malformative state derived from the ectodermal layer of the embryo which results in the triad: anhidrosis (or hypohidrosis), hypotrichosis, anodontia (or hypodontia). Hypohidrosis causes thermoregulation disorders, which in the infant, can be life threatening. It is important to recognize the affection early to avoid accidents of hyperthermia. Once the diagnosis is established, family investigations are necessary to determine whether it is a family form or a new sporadic case. Carrier mothers must be informed of the high risk recurrence for future male infants. Symptomatic maxillo-facial treatment strives to improve masticatory function and facial growth and thus limit the psychological impact and improve patient comfort.

Gunshot wounds: reconstruction of the lower face by osteogenic distraction.

BACKGROUND: Although osteogenic distraction is a well-established technique, the distraction device still needs to be improved, miniaturized, and made lighter, more flexible, and more adaptable for mandibular reconstruction in adults with gunshot wounds. The authors successively used unidirectional and bidirectional devices, followed by a bone transporter with a horseshoe-shaped trammel. The trammel system was then replaced by an endless screw, and finally by a customized endless screw. METHODS: Eleven adult patients with gunshot injuries underwent mandibular reconstruction using osteogenic distraction with an external device. RESULTS: An average bone gain of 79 mm was achieved. No infectious complications were observed. The authors encountered equipment problems during the study, requiring a change of material. The mean duration of mandibular distraction was 3.5 months. CONCLUSIONS: Distraction of bone fragments facilitates the simultaneous expansion of soft tissues, avoiding free or pedicled myocutaneous flaps, for soft-tissue reconstruction. The alveolar ridge with the attached gum is also recreated by distraction, allowing dental reconstruction by osseointegrated implants.