Orbital in juries in wartime: Historical study from Paul Tessier's work in Iran.

INTRODUCTION: Paul Tessier was a leading French oculoplastic surgeon who took part in several surgical missions in Iran to manage victims of the Iraq-Iran conflict in the late 1980's and early 1990's. METHODS: We collected the records of 322 patients who underwent surgical procedures for the management of wartime injuries by Paul Tessier's team in Iran from 1990 to 1993. We also report one of the most representative cases of orbital reconstruction performed by Tessier. RESULTS: Mean age at the time of trauma was 20.65±7.04 years (range: 2--62). Craniofacial CT-scans were available for 54 patients. The bones of the upper third of the face and the orbital contents were affected in 124/322 patients (38.50%). Soft-tissue lesions of the upper third included 13 frontal lacerations (4.04%), 60 orbital injuries (18.63%) and 95 uni- or bilateral enucleations (29.50%). Thirty-nine uni- or bilateral lid injuries (12.11%) and 8 tear duct injuries (2.48%) were reported. A specific case of orbital reconstruction using antero-internal and posterior iliac bone grafts was reported as a representative example of Tessier's techniques. CONCLUSION: This study highlights the challenges of orbital reconstruction in wartime injuries and provides insights on the work of one of the most renowned surgeons in this field.

[Anterior mandibular bone grafts by sub-mental approach]. / Greffes osseuses mandibulaires antérieures par voie sous-mentonnière.

INTRODUCTION: Some cases of totally edentulous mandibles are associated with extreme osseous resorption which do not allow the placement of dental implants, even in the symphysis area. We present a bone graft technique performed by mean of a submental approach. TECHNICAL NOTE: The reconstruction is performed under general anesthesia by mean of calvarial bone bone grafts affixed on the superior face and occasionally on the inferior face of the mandibular symphysis, between the mental foramens. The approach is a conventional sub-mental approach that exposes the entire symphysal region. Four patients (aged 61 to 81) have been operated according to this technic. There was no postoperative complication. Mean bone increase was 9.3mm. Nineteen implants were inserted (4.75 implants per patient). No implant have been lost. The scare was inconspicuous. DISCUSSION: This technique is indicated for cases with extreme bone resorption. It allows the reconstruction of the mandibular symphysis, without an intraoral approach and thus with minimized risk of bone graft exposure. Postoperative courses are uneventful. This technique is therefore indicated for elderly patients who complain about ill-fitting dentures.

[Reconstruction of the atrophic edentulous maxilla for implant placement]. / Reconstruction pré-implantaire du maxillaire atrophique.

INTRODUCTION: Extreme maxillary atrophy results from partial or total maxillary bone defect, affecting the alveolar and basal segments. The residual bone is only a few millimeters high and does not allow retention of dental prostheses (complete edentulation), or placing implants. Bone reconstruction with cranial bone grafts usually allows obtaining enough bone volume in a single step to place implants for prosthetic rehabilitation, 3 months later. TECHNICAL NOTE: Reconstruction begins by inserting bone grafts on the sinus floor. The pre-maxilla is then rebuilt with bone grafts placed on the nose floor then on the palate and vestibule. The premolar and molar sectors are rebuilt last with vestibular and palatine bone grafts assembled and stabilized by screws, or steel wire rings, and reinforced on their deep portion with diploe sheets. DISCUSSION: Extreme maxillary atrophy reconstruction with cranial bone grafts is a reliable technique with reproducible results and few complications (sinusitis, bone sequester). Nevertheless, it requires strong experience to adequately perform harvesting and reconstruction.

[Pre-implant posterior mandibular reconstruction]. / Reconstruction pré-implantaire du secteur mandibulaire postérieur.

INTRODUCTION: We present a literature reviewed of pre-implant posterior mandible reconstruction, and report our experience with 107 patients exclusively reconstructed with cranial bone grafts. MATERIAL AND METHODS: Over a period of 15 years, 167 patients presenting with sometimes extremely severe bone resorption were grafted using various techniques depending on the type of resorption. RESULTS: The mean bone augmentation was 7.83 mm vertically and 7.16 mm horizontally respectively for patients with vertical and horizontal resorption. It was 6.66 mm vertically and 8.11 mm horizontally for patients with combined horizontal and vertical resorption. The postoperative complications were: mental nerve dysesthesia in 6.5% of patients, graft exposure in 1.8%, and ± complete graft resorption in 4.2%. Implant placement was possible 3 months after reconstruction and bridge placement 6 months after reconstruction. DISCUSSION: The posterior mandible is the most difficult area to reconstruct, according to our experience. The vertical expansion technique, called "sandwich" osteotomy, frequently cannot be used. Alveolar distraction has a lot of drawbacks: patient constraints, uncertain outcome, and high risk of complications. Guided bone regeneration is restricted to small deficits. The onlay graft technique is poorly documented although it has many assets as demonstrated by our study. It may be used in any situation, even the most severe cases, except for rare cases of reduced occlusal space.

[The sphenomandibular ligament: an anatomical obstacle to ramus lengthening]. / Le ligament sphénomandibulaire, obstacle anatomique à l'allongement du ramus.

INTRODUCTION: The sphenomandibular ligament is strong and its insertion below the medial cut of the sagittal split osteotomy explains that it is a barrier to the mobilization of the distal segment. It is the main obstacle to ramus lengthening. We describe the disinsertion technique with an anatomical dissection. SURGICAL TECHNIQUE: After sagittal split ramus osteotomy, we verify that a stable occlusion has been achieved without straining. In case of resistance, a 90° angled periosteal rugine is introduced below the periosteum, against the medial cortex. It is used to detach the last fibers of the medial pterygoid muscle under visual control, and it is carefully moved to the lingula to detach the anterior sphenomandibular ligament insertion. DISCUSSION: In case of a very short ramus, there is hypoplasia of soft tissues, especially the pterygomasseteric sling, and the stylomandibular ligaments are short. This is why it seems necessary to release the sphenomandibular ligament in all forms of ramus lengthening.

Autogenous bone grafts and bone substitutes--tools and techniques: I. A 20,000-case experience in maxillofacial and craniofacial surgery.

Alloplastic bone substitutes can be used to alter facial contour. In contrast, autogenous bone grafts have a successful 80-year history of restoring facial contour as well as the basic functional support of the craniofacial skeleton. The traditional procedures for harvesting and using autogenous bone grafts are not obsolete. During the past 30 years, the techniques have been refined and new sources have been found, such as calvarial grafts. New tools were required and have been designed to make harvesting of grafts easier and faster for the surgeon and safer and less expensive for the patient. Four short articles under the heading of "Techniques and Tools" are presented addressing the harvesting of (1) iliac, (2) costal, (3) tibial, and (4) calvarial grafts. These articles are based on the experience of six surgeons using the same technique and instruments in more than 20,000 autogenous bone grafting procedures. (These figures represent the group experience as of 2001. Since then, one of the junior coauthors has retired, but the remaining five continue to harvest autogenous bone grafts on a regular basis. So, the group experience as of 2004 is in the range of 23,000 procedures). The-senior surgeon's experience of 9500 procedures spans a period of 50 years (from 1946 to 1996). For the other surgeons (10,500 procedures combined), the collection period was 25 years (from 1975 to 2000).

[Bone graft healing]. / La cicatrisation des greffes osseuses.

Bone graft healing involves an invasive process where vessels and cells penetrate the graft material to enable neoformation of bone. The origin of the material and its intrinsic properties and morphology are factors which affect its resorption and replacement. The first step involve formation of bone via the osteoconductive properties of the graft. For autologous bone, graft resorption enables secondarly release of preserved bone proteins, favoring a process of osteo-induction which contributes to remodelling and graft replacement by neoformed bone.

[Oto-mandibular dysplasias: indications for conventional osteotomies and costochondral graft]. / Place de la chirurgie orthognathique conventionnelle et de la greffe costale dans les dysplasies oto-mandibulaires.

Conventional osteotomies and bone grafts are still indicated in the treatment of otomandibular dysplasia. Results are achieved rapidly with a minimum of discomfort for the patient. In the mild cases, a complete correction can be obtained in a single operation.

[Dental implant complications]. / Complications des implants dentaires.

Failure of osseointegration and mechanical accidents are the most common complications of dental implants. The functional prognosis is preserved in any case. Most of these complications can be avoided by a careful patient selection, a strict surgical phase and restorative procedures realized by competent practitioners.