The sphenomandibular ligament: an anatomical obstacle to ramus lengthening

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.     

Un corps étranger orbitaire insolite

Introduction

Foreign bodies in the orbit are rare. They can generate more or less serious complications depending on their nature and size. We report an exceptional case of a bulky foreign body in the orbit (the tip of a pen), which did not lead to any complication.

Observation

A 13-year-old child presented with a right orbital trauma caused by a pen. He consulted 3 months later when a small palpebral swelling appeared. The CT scan showed the presence of a foreign body on the orbital floor. Wound debridement allowed extracting the tip of a pen measuring 3.5 cm without any complication. There were no postoperative complications.

Discussion

The originality of this observation is two-fold; the singularity of the foreign body and its total harmlessness in spite of its large size. However, orbital trauma and a secondary orbital syndrome must lead to emergency imaging.     

What is Piezosurgery? Two-years experience in craniomaxillofacial surgery

INTRODUCTION: Piezosurgery is a new surgical technique used in dentistry to section hard tissues without damaging adjacent soft tissues. We hypothesized that such a device could also be useful in craniofacial and orthognathic surgery. MATERIAL AND METHOD: An ultrasonic device (Mectron) was employed in different craniofacial surgical procedures: a) to perform 144 Le Fort I osteotomies, 140 palatal expansions after Le Fort I osteotomies, and 134 bilateral sagittal osteotomies; b) to perform a Le Fort III osteotomy for treatment of Crouzon syndrome in 2 patients; c) to perform 5 segmental osteotomies and 3 osteotomies of the inferior edge of the mandible for facial asymmetry; d) to perform 12 cases of unicortical calvarial bone grafting; e) to remove the superior orbital roof in 20 cases of craniofaciostenosis and the frontal bone in 5 cases; f) to remove the external wall of the orbit or the anterior and posterior wall of the frontal sinuses in 10 cases of orbital cavity tumors; g) to approach the skull base through the frontal sinuses in 4 cases. Integrity of soft tissues and surgical time were evaluated. RESULTS: Analysis of the results showed that Piezosurgery: a) allows very precise cutting; b) avoids bone cutting using an osteotome; c) spares soft tissue such as brain, dura-mater, palatal mucosa, and the inferior alveolar nerve; d) increases the time of bone cutting but not the overall operative time because of the absence of soft tissue protection. DISCUSSION: Piezosurgery is a new technical procedure, which can be advantageous for bone cutting in many situations, sparing adjacent soft tissues such as brain, palatal mucosa, and the inferior alveolar nerve from any damage. The device's lack of power appears to be a minor problem compared with the advantages.     

Adénome pléomorphe géant de la parotide

Introduction

Slow evolution pleomorphic parotid adenoma may be diagnosed late. These giant tumors have a functional, esthetic, and social impact. They raise prognostic issues because of the risk of degeneration. We present a case of a giant pleomorphic adenoma involving the parotid glands and try to explain the reasons for the diagnostic delay and describe therapeutic specificities.

Case report

A 54 year-old male patient consulted for swelling of the parotid region slowly evolving over the last 10 years. This lesion had been unsuccessfully treated by conventional methods. A painless 20 cm long plurinodular mass was located in the right lateral cervical region. Its consistence was heterogeneous. The CT scan revealed a heterogeneous tumor with hyperdense and hypodense areas without any associate lesions. A total conservative parotidectomy was performed; the anatomopathological examination confirmed the diagnosis of a pleomorphic adenoma, weighing 1.2 kg for a diameter of 19 cm, without malignant degeneration. The postoperative evolution was uneventful.

Discussion

The recommended treatment for giant parotid adenoma is total conservative parotidectomy. Besides its functional and esthetic impact, the giant parotid adenoma is at high risk of malignant degeneration. Documentation on the nature of the lesion, its evolutive potential, and an early surgical management could limit its incidence.     

Predictive factors of third molar eruption

Introduction

We studied the prognosis of upper and lower third molar evolution.

Patients and methods

Seventy-eight patients were included after a clinical examination, dental casts, panoramic and lateral cephalometric radiographs on inclusion (T1) and two years after (T2). Five parameters were studied: retromolar space (RMS) between the third molar (M3) and the anterior ridge of the ramus; RMS/M3 crown diameter ratio, distances (PTV-M₁) and (X_i-Mi₂); and third molar angle with occlusal plane.

Results

They were noted at T1 and T2. The gain of retromolar space from T1 to T2 reached 1.2 to 2.2 mm without extraction, 2 to 2.7 mm with PM extraction, and 4.5 to 6.8 mm with M1 extraction. The “RMS/M3 diameter” ratio increased in the maxilla from 0.6 to 0.8 and from 0.5 to 0.8 in the mandible (P = 0.01) between T1 and T2. PTV-M1 increased significantly from 17.1 to 19.9 mm (P < 0.001), and Xi-M2i increased significantly from 18.5 to 22.4 mm (P < 0.001) between T1 and T2.

Discussion

The extraction of premolars has little influence on the variation of the retromolar space; conversely first molar extraction increases that space. Prognosis techniques for the evolution of third molars are helpful when considering avulsion.     

Teaching and practice patterns of lateral osteotomies for rhinoplasty

Purpose

Lateral osteotomies are important during rhinoplasty and represent a challenging technique that otolaryngology and plastic surgery trainees must learn. The approaches for osteotomies are difficult to teach as they are accomplished through tactile feedback. Trends in teaching and practice patterns of lateral osteotomies are poorly described in the literature, and this study aims to fill this knowledge gap.

The influence of the Le Fort I osteotomy on nasal airway resistance

Pre- and postoperative rhinomanometric measurements were done on 13 patients by whom a Le Fort I osteotomy was performed. The claim that Le Fort I osteotomies may produce deleterious respiratory effects in the form of an increase in nasal airway resistance was investigated. The results are discussed.     

Chirurgie endoscopique d’un fibro-odontome améloblastique mandibulaire

Introduction

Ameloblastic fibro-odontoma is a rare mixed odontogenic tumor. It occurs predominantly in children and young adults. This article reports a case of ameloblastic fibro-odontoma affecting a young boy who was treated by endoscopy.

Case report

An 11-month-old child was admitted for a right mandibular rapidly growing mass. Computed tomography confirmed the presence of a large radiopaque mass on the right mandible containing compartmented tooth-germs. A biopsy exeresis was performed to completely remove the tumor with an endonasal endoscope. The histological diagnosis was an ameloblastic fibro-odontoma.

Discussion

We performed the enucleation with a nasal endoscope to make sure that the entire lesion had been removed. Bone resection was minimal which should decrease the risk of growth disorders. The ameloblastic fibro-odontoma is a rare mixed odontogenic tumor usually asymptomatic and slow growing. Histopathology proves the diagnosis. The treatment is curettage, preserving the adjacent teeth.     

Medial proximal tibia donor site: contribution to alveolar cleft repair in children

Introduction

Cancellous bone is the best material for alveolar cleft repair (or secondary alveolar cleft repair). It is usually harvested from the iliac bone but morbidity of this donor site is high. Among the other possible donor sites the tibial harvesting procedure seems safe with lower morbidity. The authors assessed the medio-proximal tibial harvesting procedure on a consecutive series of 55 children having undergone secondary alveoloplasty.

Patients and method

An individual questionnaire was used to assess retrospectively the intensity and duration of postoperative pain, functional impotence, possible late complications, and scar length. Postoperative tibial in frontal and profile radiographs were used to assess corticotomy diameter, the distance between corticotomy and growth plate, and local complications.

Results

The mean patient age was nine years. No complications were reported. Sixty nine percent of patients complained of postoperative pain with an average intensity of four out of 10 for a period of 17 days. Sixty five percent of patients complained of discomfort in walking for an average of 12 days. The average scar length was 10 mm. Two patients (3.6%) presented with sequels two years after surgery, residual scar pain for one, and painless ectopic tibial ossification next to the sampling site for the other.

Discussion

The medio-proximal tibial site bone harvesting morbidity is low. The surgical procedure is easy, rapid, and safe. The amount of cancellous bone collected is sufficient for two simultaneous alveolar defect grafts. This site seems especially well adapted for secondary alveoloplasty in children.     

Cephalic tetanus revealed by peripheral facial palsy

Introduction

Cephalic tetanus is a rare presentation of localized tetanus (1 to 3% of localized presentations). It is a very rare cause of peripheral facial palsy.

Observation

We report a case of cephalic tetanus revealed by peripheral facial palsy and trismus.

Discussion

Facial peripheral palsy often appears after trismus. It is very rarely the first symptom of cephalic tetanus, making the diagnosis difficult.     

Ameloblastoma of the jaws. A retrospective analysis from 1994 to 2007

Introduction

Ameloblastomas and keratocysts are the most frequent epithelial odontogenic tumors of the jaws. They have a high recurrence rate. This retrospective study reviews the features of ameloblastomas operated on in our unit from 1994 to 2007.

Patients and methods

The studied parameters were sex, ethnic origin, age at diagnosis, clinical signs, radiographic presentation, site distribution, histological type, treatment, and follow-up records.

Results

One hundred and sixteen patients were included (with 239 surgical samples). The mean age was 36 years, with a majority of Europeans, 60% of multilocular radiolucent lesions with root resorption, mandibular location (93%). Twenty-one percent of the patients presented with an impacted tooth, the third molar in 79% of cases. Fifty percent of the lesions were from 5 to 13 cm in length, 10% longer than 13 cm. The most common histological type was follicular ameloblastoma. Patients were treated by enucleation in 82% of cases and radical mandibular resection with reconstruction in 11% of cases. The follow-up was documented for 96% of the patients with a 44% recurrence rate. Seventy-four percent of patients with a double recurrence presented with a “follicular” ameloblastoma.

Discussion

We prefer a well-performed enucleation which preserves surrounding bone. The high rate of follicular type recurrence should more systematically lead to a combined treatment: periostectomy and tooth extraction. Our data was compared with previously published large series.     

Allogreffe de face et implantologie basale (implant-disques à appuis corticaux)

Introduction

We report a case of total oral rehabilitation with basal implants (cortically anchored disk-design implants) on a patient who received a facial allograft 1 year earlier.

Observation

A 31-year-old patient was suffering from a plexiforme neurofibroma spread into the soft tissues of the oral cavity with huge deformations of the jaws. The operation consisted in pulling out numerous supernumerary impacted teeth, removing unnecessary soft tissues, settling six basal implants in the maxilla and seven in the mandible. The following day, two resin bridges were adjusted and cemented onto the implant abutments. The permanent bridges were settled 2 months and half later. The outcome was still unremarkable 2 years after the implant procedure.

Discussion

This case report raises important issues, notably the relevance of an oral rehabilitation with implant-supported prostheses on an immunosuppressed patient. In this specific case, this was impossible to achieve using removable prostheses. A facial reconstruction with its plastic, functional, and social goals seemed inconsistent without an oral rehabilitation. Even if they have not been published, cases of grafted patients with dental implants are unexceptional. Lastly, this rehabilitation has been planned for a particularly monitored patient. The second important question regards the choice of the basal implantology. This option has been motivated by the possibility to complete the case in one sole operation with provisional prostheses cemented the day after that act like orthopaedic external fixators providing an exceptional primary stability. The cortical anchorage, which was the only reliable on this patient, allowed to avoid bone grafting. Finally, the particular thinness of the implant emergence limits to the minimum the communications between bone and oral cavity. We would like to stress that the only objective of this observation was to document a specific case and possibly to open the way to a scientific study in accordance with the regulations of clinical research.     

Cone beam 3D sialography: preliminary study

Introduction

Stones, stenosis and inflammatory lesions are the main causes of mealtime syndrome. The aim of paraclinical exam is to find the cause of these obstructive symptoms. Ultrasound is often sufficient to confirm the lithiasic origin of salivary gland swelling. Non-lithiasic salivary obstructions are more difficult to diagnose. We studied the feasibility and quality of a new medical imaging device: three-dimensional (3D) sialography using the technique of cone beam with flat panel (CPCT).

Patients and methods

Five patients were included, referred for diagnostic management of non-lithiasic salivary gland parotid colic. It was performed for each patient in the angiography room, conventional sialography and 3D CPCT. Images were compared to conventional sialography.

Results

None of catheterization failure or side effects were observed in five patients. 3D CPCT sialography enabled to view gland ducts until their fifth or sixth division. Compared to conventional sialography, 3D CPCT improves signal and contrast to noise ratio.

Discussion

This technique allows an anatomic resolution and signal/noise ratio unmatched. It also allows to reduce metallics artefacts. Its main drawback is those associated with ductal catheterization, exposure to ionizing radiation and potential allergy to iodinated contrast agents.     

Dix-huit cas de dysplasie fibreuse craniofaciale

Introduction

Fibrous dysplasia or Jaffe Lischtenstein's disease is sporadic and rare bone affection, mainly observed in young adults. It is characterized by a bone maturation disorder that can affect one or several bones. Fibrous dysplasia is relatively rare in the craniofacial region, (only 20% of all locations). The authors analyzed the epidemiological, anatomoclinical and evolutive features of fibrous dysplasia in a Tunisian population.

Material and method

The authors retrospectively studied 18 cases of craniofacial fibrous dysplasia, diagnosed at the pathology department of the Sousse F. Hached hospital, beween1990 and 2005.

Results

Most craniofacial dysplasia cases were monostotic (94% of cases). One case was polyostotic. The maxilla and the mandible were the most frequent locations (83.3%). The patients’ mean age was 28.6 years, ranging from 6 to 30 years. The sex ratio was 3.5 in favor of women. Follow-up ranged from one month to 10 years with an average of 26.4 months. One case of sarcomatous transformation was observed.

Discussion

The authors noted epidemiological discrepancies compared to what was usually reported, especially concerning the strong female predominance, the frequency of maxillary and mandibular locations and the predominance of monostotic presentations. Larger series are needed to validate these observations.     

Intractable epistaxis in Osler-Rendu-Weber syndrome

Introduction

Osler-Rendu-Weber syndrome is an inherited disorder characterized by mucocutaneous and visceral telangiectasia. It is often revealed by recurrent epistaxis. It is sometimes profuse and intractable. Hemostasis may be problematic.

Case study

A 61-year-old male patient presented with severe epistaxis due to Osler-Rendu-Weber syndrome. Embolization of the external carotid branches was needed for hemostasis.

Discussion

Embolization of external carotid artery branches can be an effective therapeutic alternative when usual treatments fail.     

Juvenile nasopharyngeal angiofibroma.

This is a retrospective study of 17 patients with juvenile nasopharyngeal angiofibroma treated from 1983 to 1996. Patients with Stage I or II disease according to the Fisch classification system were treated surgically by a transpalatal approach. One patient underwent a Le Fort I osteotomy and down-fracture approach for access. Three patients underwent combined transpalatal and lateral rhinotomy for access, whereas one underwent a transcervical double mandibular osteotomy to facilitate the exposure. A patient with Stage IV disease underwent a combined subcranial frontonasal osteotomy plus a Le Fort I osteotomy for access to a massive angiofibroma. Initial surgical management prevented recurrence in 79% of patients. Two patients with intracranial extension were treated with primary irradiation therapy; their tumours became asymptomatic. Preoperative angiography and embolization were used to treat all surgical candidates. The use of newer craniofacial or subcranial techniques and infratemporal fossa approaches with osteotomies can provide access to large angiofibromas even when there is skull base or intracranial involvement. Surgical exposure may also be enhanced by the use of the Le Fort I osteotomy and down-fracture approaches.     

Histological analysis of dental follicles after unerupted mandibular third molar extraction

Introduction

The extraction of third mandibular tooth germ (M3) is often prophylactic to avoid orthodontic treatment relapse and to prevent infectious or tumoral diseases developing from the dental sac. The purpose of this study was to screen for early histopathological modification of dental follicles (inflammatory, infiltration, or epithelial metaplasia) after extraction of third mandibular tooth germ (M3) on asymptomatic patients. The secondary objective was to study the proliferative activity of the epithelium by dosing the anti Ki-67 antibody.

Patients and method

Twenty dental follicles extracted from 12 boys and eight girls between 14 and 18 years of age were examined under phototonic microscopy. The proliferative activity of the epithelium was assessed by immuno-histochemistry.

Results

Three dental follicles presented with focal epidermoid metaplasia of the epithelium, without odontogenic tumoral proliferation. In all other cases, the cylindrical epithelial cell structure was normal. A mild chronic inflammatory infiltrate was present in 30% of the cases. Immuno-histochemical analysis revealed labeling of very rare epithelial lining cells, slightly more in cases presenting with metaplasia.

Discussion

The prevalence of early morphological changes of dental sac is low. This histo-morphological study does not support the systematic extraction of asymptomatic mandibular tooth germs (M3).     

Jaw osteosarcomas

Introduction

Osteosarcoma (OS) is the most frequent bone malignant tumor. It is usually found on long bones, 5 to 10% are located on jaws, accounting for 0.5 to 1% of all facial tumors. There is little published data which concerns only few patients. Our aim was to study retrospectively cases of facial bone OS in adults, and to compare our results with published data to suggest an optimal management scheme.

Patients and method

Thirty-three patients were managed for an OS, from January 1997 to January 2007. Fourteen patients with a maxillary and mandibular OS, treated in first-intention in our unit, were included. The following data were analyzed: age; personal history; circumstance of discovery; clinical, functional, and physical signs; loco-regional extension and metastasis radiological investigation. The histological slides were systematically reviewed. The protocol, therapeutic outcome, and follow-up were studied.

Results

The mean age at diagnosis was 43. Swelling was the most frequent functional sign. The mean delay before management was 3.4 months. The most frequent radiological presentation was a lytic and hyperdense image. The diagnosis was suggested after CT scan in 57.1% of cases. The biopsy was correlated to the anatomopathological analysis in 78.6% of cases. The most common treatment was surgical exeresis completed by chemotherapy. The 5-year survival rate was 50%.

Discussion

Jaw OS are specific because of their localization and specific bone ultrastructure. Their management remains controversial: should they be managed like limb OS or treated more specifically? Neoadjuvant chemotherapy, even if it delays exeresis for 3 months, seems to stop the growth or reduce the tumor. An early anatomopathological analysis of the surgical piece determines adjuvant therapy. The negative prognostic factors are: maxillary localization because of limited exeresis margins, tumoral size, and osteoblastic sub-type.     

Eine seltene Komplikation nach Le-Fort-I-Osteotomie

Malfunctions of the eustachian tube after Le Fort I osteotomies are rare. A 22-year-old woman was treated by Le Fort I osteotomy for maxillary retrognathism. Postoperatively she developed recurrent tubal malfunction and middle ear effusions on the left side, with no improvement after adenotomy, tonsillectomy, and grommet insertion. In consecutive computed tomography and magnetic resonance imaging scans, a forward dislocation of the left pterygoid hamulus was demonstrated. In addition, damage to the tensor veli palatini muscle was evident. Both postoperative sequelae appear to be responsible for the unilateral tubal dysfunction.     

Jugal swelling revealing acute lymphoblastic leukemia

Introduction

Acute lymphoblastic leukemia (ALL) is the most common hematologic malignancy in children. The clinical presentation at diagnosis is due to bone marrow infiltration or extra-medullary involvement. Maxillofacial localization is very rare in ALL. We report a case of T-ALL revealed by right cheek swelling in a 14-year-old boy.

Case presentation

A 14-year-old boy had presented with a 6 cm right cheek swelling for two months, complicated by pyrexia, cervical adenopathy, and splenomegaly. CT scan revealed a 3 × 7 × 8 cm swelling surrounded by voluminous sub chin, subclavicular, mediastinal, and paratracheal bilateral adenopathies. The biological analyses revealed normocytic anemia, hyperleukocytosis with 83.6% blast cells, neutropenia, and thrombopenia. The biopsy histology and the immuno-histochemical analysis suggested a diffuse small-cell Non-Hodgkin lymphoma (NHL). The myelogram identified a type 1 ALL and immunophenotyping on bone marrow cells suggested phenotype T ALL. The patient was treated according to the MARALL-06 protocol and died on the 17th day of induction, in septic shock.

Discussion

Despite their rare occurrence, ALL should be included in the differential diagnosis of jugal swelling. The evident hematological context should suggest the diagnosis and a myelogram should be performed as soon as possible because the outcome is rapidly fatal.