Effectiveness of immune checkpoint inhibitors in the treatment of kidney cancer oral metastasis. A case report.

Oral cavity metastasis from renal cell carcinoma is rare with poor prognosis. Recently immune checkpoint inhibitors (ICIs) have shown promising outcomes in the treatment of advanced RCC. Herein, we report a case of palatal lesion mimicking vascular tumor in a 60-year-old woman with locally advanced kidney cancer (T3aN0M0). She underwent an excisional biopsy, and histopathological examinations revealed an oral metastasis from clear cell renal cell carcinoma (ccRCC). The patient was treated with a combination of two ICIs with nivolumab, a programmed death 1 (PD-1), and ipilimumab, a cytotoxic T-lymphocyte-associated antigen 4 (CTLA4). After 3 cycles of systemic immunotherapy, the palate was completely well healed and after 13 months of follow-up, there was no evidence of recurrence. Regarding treatments, radical surgery is often recommended due to a high local control in case of solitary lesions or oligo-metastases. However, this option therapy is associated with a poor quality of life. To the best of our knowledge, this is the first case to suggest the benefits of ICIs in the treatment of oral metastases from ccRCC. Combining ICIs with conservative surgery could be another treatment option for oral metastasis in patients with renal cell carcinoma.

An epidemiologic retrospective study of maxillofacial traumatology in the elderly.

INTRODUCTION: The elderly population, which is more active than before, is increasingly suffering from trauma (loss of reflexes and systemic pathologic conditions). Surgical management may be more controversial due to the potential consequences of general anesthesia and the sometimes negligible consequences of functional management. The main objective of this study was to analyze the causes and location of facial fractures in subjects older than 65 years. The secondary objective was to evaluate the management of these fractures (surgical or functional) according to comorbidities. MATERIAL & METHODS: In this retrospective study (over a five-year period), we analyzed the causes and management of facial fractures in patients aged over 65 years, and the medical history of each patient was investigated. RESULTS: One hundred and nineteen patients with 198 facial fractures were included. The main cause of fractures was a fall (50%). The zygomatic region (39.9%) and mandible (27.8%) were the sites of the most frequent fractures. Comorbidities were found in 84.9% of patients, the majority of which were cardiovascular diseases (82.3%). 75.8% of fractures were treated surgically and 4.8% of patients had complications. DISCUSSION: This work is a help to understanding the causes and consequences of facial trauma in the elderly population. The management of these facial fractures requires a multidisciplinary assessment, taking into account the patient's medical history and evaluating the risks and benefits of a surgical procedure with general anesthesia.

Intraoperative cone beam assessment after reduction of zygomatic fractures helps in taking a decision on associated orbital floor fractures.

INTRODUCTION: Orbital floor fracture (OFF) are frequently associated with zygomatic fractures (ZF). The reduction of the ZF may modify the features of the associated OFF. Intraoperative cone beam CT (CBCT) has shown diagnostic performance of OFF. The aim of our study was to evaluate how intraoperative CBCT control made after the reduction of ZF may help to take a decision on the associated OFF. MATERIAL AND METHOD: Patients with a unilateral displaced ZF associated with an OFF were consecutively included during a 3-year period. Intraoperative CBCT, systematically performed after reduction of the ZF, allowed to decide if the OFF needed reconstruction. The preoperative estimation made on MDCT and the intraoperative decision regarding the OFF were compared. RESULTS: Fifty-nine consecutive patients could be included in the study. Nineteen OFF were presumed to be surgical indications on the preoperative MDCT but only 16 indications were confirmed on the intraoperative CBCT, meaning that 3 OFF behaved favorably during the ZF reduction. Forty orbital floor fractures were presumed to be non-surgical on the preoperative MDCT but 6 of them worsened during ZF reduction and became surgical indications. Overall, the intraoperative CBCT control had an impact on 9 (15.3%) of the OFF. CONCLUSION: Our study showed that OFF after ZF reduction may evolve favorably or, on the contrary, get worse in 15% of the cases. Surgical indication on an OFF can therefore be confirmed intraoperatively. This allows to avoid under-treatment in the patients where the OFF worsens after ZF reduction and over-treatment in the patient where the OFF reduces after ZF.

Significant decrease of facial cellulitis admissions during COVID-19 lockdown in France: A multicentric comparative study.

During the 2020 coronavirus pandemic, a lockdown was imposed in France during the first wave. An apparent decrease in incidence of cellulitis of odontogenic origin was noticed then. This study aimed to compare the incidence of cellulitis during this extraordinary period with the same period in 2018 and 2019, based on retrospective multicentric data. All maxillofacial surgery departments in French public hospitals were contacted. Responders were asked to include all patients admitted for the surgical drainage of a head and neck abscess of odontogenic origin during the first 2020 lockdown period, and in a similar time frame in 2018 and 2019 (control group), based on screening the French diagnostic and therapeutic classification of medical acts. We report a 44% significant nationwide decrease in the incidence of admissions for cellulitis. There were 187 patients in 2020 for 334 and 333 patients in 2018/2019 respectively. The reasons to explain this finding are hypothetical (organizational reasons leading to earlier management, patients' fear to seek for medical management, usual excess in surgical indications or concomitant decrease of non-steroidal anti-inflammatory drugs delivery). Whatever the explanation, it would be of great interest to find it out in order to improve the prevention of cellulitis.

[Abdominoplasties: Do we still need to drain in 2021?] / Abdominoplasties : faut-il encore les drainer en 2021 ?

OBJECTIVE: The purpose of this study was to consider the use of drainage when performing an abdominoplasty with regards to postoperative complications for two groups of patients. PATIENTS AND METHOD: From January 1st 2017 to December 31th 2019, 215 patients underwent an abdominoplasty in our institution. In this retrospective, comparative, single institution study, patients were divided into two groups: "drainage" D (n=162) when suction completed abdominoplasty, "no drainage" ND (n=53) when suction didn't completed abdominoplasty. Early and distant complications were retrieved for each group and compared. RESULTS: There was no significant difference between the two groups concerning the occurrence of seroma postoperatively (8% of patients in group D and 11.3% of patients in group AD). The drainage group D experienced more seroma's punctures (2,3± 1,0) and the mean of punctured fluid was higher (386,5ml±350,4ml) compared to the no drainage group ND (1,3+- 0,5 number of punctures with a mean punctured fluid of 165,8mL± 224,2mL). The mean hospital stay was shorter for group ND (2,9± 1,8 days) than for group D (4,4+- 1,7 days), P<0,0001. CONCLUSION: Performing an abdominoplasty with quilting suture but drainless doesn't seem to increase postoperative complications statistically. The authors recommend, under the guise of a quilting suture, not to systematically drain the abdominoplasties and to reserve this technique for patients at risk of complications (high BMI, significant weight loss and co-morbidities).

Which experimental models and explorations to use in regenerative endodontics? A comprehensive review on standard practices.

Since the discovery of dental pulp stem cells, a lot of teams have expressed an interest in dental pulp regeneration. Many approaches, experimental models and biological explorations have been developed, each including the use of stem cells and scaffolds with the final goal being clinical application in humans. In this review, the authors' objective was to compare the experimental models and strategies used for the development of biomaterials for tissue engineering of dental pulp with stem cells. Electronic queries were conducted on PubMed using the following terms: pulp regeneration, scaffold, stem cells, tissue engineering and biomaterial. The extracted data included the following information: the strategy envisaged, the type of stem cells, the experimental models, the exploration or analysis methods, the cytotoxicity or viability or proliferation cellular tests, the tests of scaffold antibacterial properties and take into account the vascularization of the regenerated dental pulp. From the 71 selected articles, 59% focused on the "cell-transplantation" strategy, 82% used in vitro experimentation, 58% in vivo animal models and only one described an in vivo in situ human clinical study. 87% used dental pulp stem cells. A majority of the studies reported histology (75%) and immunohistochemistry explorations (66%). 73% mentioned the use of cytotoxicity, proliferation or viability tests. 48% took vascularization into account but only 6% studied the antibacterial properties of the scaffolds. This article gives an overview of the methods used to regenerate dental pulp from stem cells and should help researchers create the best development strategies for research in this field.

Surgical approach of ectopic maxillary third molar avulsion: Systematic review and meta-analysis.

Ectopic maxillary third molars (EMTM) are extracted mainly by the Caldwell-Luc technique but also by nasal endoscopy. There is currently no consensus on the treatment of this eruption and its management is heterogeneous and multidisciplinary. Two literature searches were performed with no time restrictions via Pubmed. In the first, we used the keywords "ectopic AND third molar" and in the second the keywords "dentigerous cyst AND ectopic third molar". For both articles, epidemiological, symptomatic, radiological and surgical data were recorded. Overall, 33 eligible articles were identified involving 39 cases of EMTM. 79% of patients were symptomatic. 87% of the teeth were associated with a dental cyst. In only 13% of cases was the location of the tooth in the sinus specified in the three planes of the space. Surgery was performed in 77% of patients by the Caldwell-Luc technique, by nasal endoscopy in 10% and by the Le Fort I approach in 3%. The indications for avulsion of EMTM are symptomatic patients or asymptomatic patients with an associated cyst. The intra-sinusal location of the tooth is not a factor in the choice of technique used, which depends rather on the individual skills of the surgeon. Although for a trained operator the Le Fort I osteotomy is an easy procedure, its interest in the treatment of EMTM is limited owing to the rare but potentially severe complications involved.

Diagnostic performance of mobile cone beam computed tomography versus conventional multi-detector computed tomography in orbital floor fractures: a study on human specimens.

The aim of this study was to evaluate the diagnostic accuracy of mobile cone beam computed tomography (MCBCT) versus multi-detector computed tomography (MDCT) in orbital floor fractures. Twenty-four fresh cadaver heads were used, and one orbital floor was fractured for each head by transconjunctival approach. MDCT and MCBCT were performed on each of the heads. The images obtained were then analysed independently by eight evaluators. The radiological characteristics of the orbital floor fractures were visualized with good interpretation agreement between the two images. The location of the fracture and enophthalmos were identified in a comparable manner with strong agreement (κ=0.93 and κ=0.85, respectively). Measurements of fatty hernias and bone defects showed a strong correlation between the two imaging modalities (Pearson coefficient between 0.64 and 0.71 and between 0.67 and 0.71, respectively). The fracture limits and the presence of bone fragments, an intrasinus fatty hernia, and a fracture of the associated medial orbital wall were visualized in both examinations with good agreement (κ=0.68, κ=0.51, κ=0.57, and κ=0.46, respectively). The soft tissue study showed superiority for MDCT, with a κ<0.0009. MCBCT showed good diagnostic performance in the study of orbital floor fracture characteristics.

How useful is intraoperative cone beam computed tomography in maxillofacial surgery? An overview of the current literature.

Intraoperative imaging is increasingly used by surgeons and has become an integral part of many surgical procedures. This study was performed to provide an overview of the current literature on the intraoperative use of cone beam computed tomography (CBCT) imaging in maxillofacial surgery. A bibliographic search of PubMed was conducted in March 2020, without time limitation, using "intraoperative imaging" AND "maxillofacial surgery" AND "cone beam computed tomography" as key words. Ninety-one articles were found; after complete reading, 16 articles met the eligibility criteria and were analysed. The results showed that the majority of the indications were related to maxillofacial trauma, particularly zygomaticomaxillary complex fractures. Final verification with intraoperative CBCT before wound closure was the most common use of this device. However, innovative uses of intraoperative CBCT are expanding, such as CBCT coupling with mirror computational planning, and even the combined use of initial intraoperative CBCT acquisition with navigation. Immediate, fast, and easy evaluation of bone repositioning to avoid the need for further surgical revision is the main advantage of this technique. Imaging quality is comparable to that of multi-slice computed tomography, but with lower radiation exposure. Nevertheless, CBCT is still not widely available in maxillofacial centres, probably because of its cost, and perhaps because not everyone is aware of its advantages and versatility, which are reported in this review.

Split-course hypofractionated radiotherapy for aged and frail patients with head and neck cancers. A retrospective study of 75 cases.

PURPOSE: To assess the efficacy and the tolerance of a split course hypofractionated (SCH) radiotherapy (RT) protocol in head and neck cancer (HNC) for eldery and/or unfit patients (pts). PATIENTS AND METHODS: Pts with HNC treated by SCH-RT in two institutions were included retrospectively. The main SCH RT regimen was two courses of 30 grays (Gy)/10 fractions separated by 2-4 weeks, without any systemic therapy. RESULTS: Between February 2012 and January 2019, 75 consecutive patients were analyzed. The median age was 80 years (range: 45.7-98.2) and 53 (70.7%) were men. Sixty-one (81.3%) pts had stage III/IV disease and 54 (72%) had at least two comorbidities. All of them were treated with intensity-modulated radiotherapy. Median follow-up was 10.6 months (range: 3.1-58.3). Local control at 12 and 24 months was 72.8% IC95%[62-85.5] and 51.7% IC95%[38.1-70.1] respectively. Progression free survival (PFS) at 12 and 24 months were 47.7% IC95%[37.4-60.8] and 41% IC95%[15-36.4] respectively, with a median of 11.5 months IC95%[8.9-17]. OS at 12 and 24 months were 60.4% IC95%[50-73.1] and 41% IC95%[30.6-54.9] respectively, with a median of 19.3 months IC95%[11.9-25.8]. Acute and late grade 3 or higher toxicities occurred for 6 (8%) and 3 (4%) pts. CONCLUSION: The present SCH-RT regimen seems effective, well-tolerated and could represent an alternative to palliative strategies for pts deemed unfit for standard exclusive RT.

De l'histoire des chirurgiens cachés derrière nos instruments du quotidien. Partie 4 : la rhinoplastie.

Many surgical instruments are named after their inventors, acclaimed surgeons of the past, because of their discoveries and their contributions in the field of surgical techniques. However, these daily reminders of history of surgery are often forgotten by the modern practitioners. We propose to review, through a selection of instruments, short biographies of these precursors. This fourth original article will focus on the inventors of rhinoplasty instruments: Joseph, Killian, Aufricht, Cottle and Claoué.

Three-dimensional acquisition technologies for facial soft tissues - Applications and prospects in orthognathic surgery.

The management of patients with dento-maxillofacial deformities is based on assessments of the dental occlusion - facial skeleton - soft tissues triad. As societal demands and surgical practices have evolved, facial soft tissues have moved to the forefront of considerations in orthognathic surgery. Techniques are therefore required to analyze facial soft tissues objectively and reproducibly, for diagnosis, preoperative planning, and follow-up. Several technologies are currently capable of providing three-dimensional (3D) models of the face, either by 3D reconstruction of traditional computed tomography or cone beam computed tomography data, or directly by stereophotogrammetry, laser scanning or structured light scanning. Multimodal image registration techniques allow bone base, dental occlusion and facial soft tissue information to be combined in a 3D virtual patient. Three-dimensional cephalometric analysis of the facial skeleton and skin is now perfectly integrated in virtual planning and is gradually gaining in automation and accuracy. Photorealistic 3D simulations allow optimal soft tissue planning and facilitate physician-patient communication. Finally, these facial modeling techniques facilitate post-operative studies of soft tissues, which generally involve comparisons of volumetric data. There are many research avenues to pursue and technical improvements are to be expected, particularly through the development of big data and artificial intelligence approaches.

Surgical reconstruction of the foramen tympanicum: What is known and how we do it.

Defects affecting the anterior wall of the tympanal bone can result from trauma, infection, neoplasm or previous local surgery. An anatomic variation, namely the persistence of the foramen tympanicum, can also be encountered. When symptomatic, surgical reconstruction may be indicated. The aim of this study was to identify the surgical treatments of symptomatic foramen tympanicum found in the literature and detail our innovative reconstruction technique. A bibliographic research was conducted in PubMed database in March 2020, without time limitation. Papers dealing with surgical management of a foramen tympanicum were included. Data collected were the publication date, the number of patients, their age and gender, the symptoms and the surgical treatment performed. We report, in addition, the case of a symptomatic persistent foramen tympanicum in a 30-year-old man with a follow-up of 18-months. A total of 17 studies (n=23 patients) were included for analysis. The main reconstruction techniques were, in equal proportion, cartilage graft (30%) and insertion of a titanium mesh (30%). We carried out an iliac crest bone graft using a preauricular approach on a patient suffering from chronic tinnitus and fullness in the left ear resulting from a persistent foramen tympanicum, confirmed by clinical and radiological examinations. It allowed the complete resolution of symptoms and no complication such as temporomandibular ankylosis occurred. Based on the review of the literature, we believe this technique has the advantage of providing durable reconstruction thanks to osseointegration.

Gingival Mucosa-Associated Lymphoid Tissue (MALT) lymphoma developed around a mandibular extraosseous dental root canal overfilling: A case report.

Lymphomas are rare pathologies in the oral cavity, representing only 3.5% of malignant tumors. Their typical topography is Waldeyer's lymphatic ring and approximately 8% of all non-Hodgkin lymphomas are mucosa associated lymphoid tissue (MALT) lymphomas. The authors report a rare case of mandibular gingival MALT lymphoma, which developed around an extraosseous dental root canal overfill. This atypical, case of lymphoma indicates that practitioners have to be vigilant and perform a biopsy every time they are confronted with a suspicious chronic lesion in the oral cavity.

The high sub-mandibular approach: Our experience about 496 procedures.

INTRODUCTION: The potential drawbacks of surgical approaches to neck and base fractures of the mandibular condyle (visible scare, facial nerve injury) are still considered by many surgeons as a brake for open reduction and internal fixation. The aim of our study was to analyze the results in terms of access, scare quality and complications that could be noticed in a 12 years period of time with the use of the high sub-mandibular approach (HSMA) we first described in 2006 for the surgical treatment of neck and base fractures. MATERIAL AND METHOD: All the files of patients operated on for condylar neck and base fractures approached by mean of a HSMA between January 2006 and December 2018 in our department and containing information concerning age, sex, type of fracture, kind of osteosynthesis material, operating time, name of the surgeon, postoperative complication linked to the approach, scare quality at 6 months follow-up at least were included. The skin incision and the dissection planes followed the original publication of Meyer et al. in 2006. RESULTS: 434 patients (sex ratio: 2.06, mean age: 32, 496 approaches) met the inclusion criteria. Following the AO classification, 21.2% of the fractures were classified as neck fractures and 78.8% as base fractures. 97.6% of all fractures were stabilized by mean of a 3D plate (TCP® plate, Medartis, Basel-CH), the remaining ones by mean of a combination of 1.2, 1.5 and 2.0 straight plates. Mean operating time was 40minutes per side. Patients were operated on by senior surgeons in 71.7% of the cases and by trainees under supervision for the others. Concerning the complications linked to the approach, we noticed 11 (2.2%) temporary (0 definitive) paresis of the facial nerve, 1 (0.2%) hematoma and 1 (0.2%) abscess that both needed revision. Scare was hypertrophic or considered as unaesthetic by the patient in 5 cases (1%). DISCUSSION: The HSMA, if performed as initially described, is a safe and quick procedure compared to other cutaneous approaches. It gives access to all base fractures and to most of neck fractures. The very low rate of facial nerve complications is mainly explained by the plane by plane dissection making it very easy to avoid the facial nerve branches or to check them when encountered. The HSMA is particularly suited to the use of TCP plates as the upper holes of these plates, placed horizontally, are easy to reach from below. The HSMA is therefore still our preferred cutaneous approach to the condylar process.

[About history of surgeons hidden behind our daily surgical instruments: Scissors]. / De l'histoire des chirurgiens cachés derrière nos instruments du quotidien. Partie 3 : ciseaux.

Many surgical instruments are named after their inventors, acclaimed surgeons of the past, because of their discoveries and their contributions in the field of surgical techniques. However, these daily reminders of history of surgery are often forgotten by the modern practitioners. We propose to review, through a selection of instruments, short biographies of these precursors. This third original article will focus on the inventors of modern scissors: Mayo, Metzenbaum, Stevens and Lister.

Customized three-dimensionally printed mandibular external fixator.

The advent of customized three-dimensional (3D) printing allows the affordable manufacturing of sophisticated medical devices, thereby providing swift and simple solutions to specific needs in modern healthcare. Meanwhile, certain devices such as industrial mandibular external fixators (EFs) have become less and less available from medical device companies because of decreased indications. What is more, their handling is often complex. The authors report, step by step, the original design and uneventful clinical use of a 3D-printed, customized mandibular EF. This device was designed together with a positioning and drilling guide for the fixation of a septic mandibular pseudarthrosis. It provided an adequate and satisfactory balance between lightness and rigidity. A simple, accurate and safe placement of the EF was achieved thanks to the skin-supported positioner and drilling guide, thereby making the procedure minimally invasive and time-efficient. To our knowledge, this is the first reported clinical use of a 3D-printed, customized mandibular EF to date. Because such 3D technology is becoming increasingly available to a large number of surgeons, the authors believe that the present innovation could become an alternative to reusable standard EFs.

Epidemiology of maxillofacial trauma in the elderly: A European multicenter study.

INTRODUCTION: The progressive aging of European population seems to determine a change in the epidemiology, incidence and etiology of maxillofacial fractures with an increase in the frequency of old patients sustaining craniofacial trauma. The objective of the present study was to assess the demographic variables, causes, and patterns of facial fractures in elderly population (with 70 years or more). MATERIALS AND METHODS: The data from all geriatric patients (70 years or more) with facial fractures between January 1, 2013, and December 31, 2017, were collected. The following data were recorded for each patient: gender, age, voluptuary habits, comorbidities, etiology, site of facial fractures, synchronous body injuries, Facial Injury Severity Score (FISS). RESULTS: A total of 1334 patients (599 male and 735 female patients) were included in the study. Mean age was 79.3 years, and 66% of patients reported one or more comorbidities. The most frequent cause of injury was fall and zygomatic fractures were the most frequently observed injuries. Falls were associated with a low FISS value (P<.005). Concomitant injuries were observed in 27.3% of patients. Falls were associated with the absence of concomitant injuries. The ninth decade (P<.05) and a high FISS score (P<.005) were associated with concomitant body injuries too. CONCLUSIONS: This study confirms the role of falls in the epidemiology of facial trauma in the elderly, but also highlights the frequency of involvement of females, and the high frequency of zygomatic fractures.