André Chaine

Management of odontogenic keratocysts of the jaws: A ten-year experience with 120 consecutive lesions

BACKGROUND The treatment of odontogenic keratocyst (OKC) of the jaws remains controversial. The aim of this study was to report the outcome of our conservative treatment protocol for OKC. METHODS We collected data of all OKC patients treated in the Department of Maxillofacial Surgery, Pitié-Salpêtrière University Hospital from 1995 to 2004. Basal cell naevus syndrome (Gorlins syndrome) patients were excluded. Recurrence data was analysed in relation to radiographic features, type of microscopic diagnosis, presence of cortical perforation, and site of involvement. RESULTS One hundred and twenty cysts in 109 patients were examined. OKCs were more frequent in the third and the fourth decades of life (range: 11-79 years, mean: 40 years) and in men (n=71). Most of the lesions were unilocular radiolucencies in the tooth-bearing area and in the posterior part of the mandible. Histologically, 80 lesions showed parakeratosis. Most of the patients underwent uneventful enucleation. Postoperatively, infection occurred in 4 patients, and there was no jaw fracture. Recurrence was found in 28 cysts (26%), of which 7 cysts (6%) had multiple recurrences. There was no significant association between recurrences and radiographic features, histological type, cortical perforation, or site of involvement (P>0.05). Recurrences were common in the first 5 years after the operation. The average follow-up was 86 months since the last operation (range: 18-151 months). CONCLUSIONS Despite the retrospective nature, no control group and a relatively high recurrence rate, our study suggests that enucleation with the aid of computed tomography and adequate postoperative surveillance is a conservative treatment which yields clinically acceptable results. However, the patients must strictly adhere to close follow-ups because recurrences may have serious consequences. Our algorithm for managing OKCs and cyst-like lesions of the jaws is also presented.

Postoperative complications of fibular free flaps in mandibular reconstruction: an analysis of 25 consecutive cases

OBJECTIVE The objective of this study was to analyze complications following fibular free flap (FFF) transfer for mandibular reconstruction using our definition of postoperative complications. STUDY DESIGN Retrospective observational study. PATIENTS AND METHODS This retrospective study presents our 4-year experiences with FFF for mandibular reconstruction by a single microsurgical team. Data were collected through patient record review and clinical evaluation by 2 independent assessors. We defined complications as any unwanted postoperative outcomes that compromised patient care. Early complication occurred within the first 2 weeks postoperatively; late complications occurred afterward. RESULTS Of 25 patients included, 13 patients (56%) experienced complications. Early and late complications occurred in 13 and 9 patients, respectively. These included flap loss, malunion, skin-paddle necrosis, orocutaneous fistula, wound dehiscence, hematoma, soft tissue contracture, intraoral hair growth, facial asymmetry, osteoradionecrosis, donor-site morbidity, and medical complications. Revision surgeries were performed in 10 patients, ranging from wound dressing to flap removal. All but 2 flaps survived, yielding an overall success rate of 92%. Most of the patients were alive without disease (92%) at the end of the study. Average follow-up was 47.2 months (range: 26-77). CONCLUSION Despite the small number of patients, these preliminary data suggest a relatively high frequency of complications following the FFF reconstruction based on our definition. Minor complications are common and should not be neglected because they may lead to devastating consequences. This should also be a part of informed consent for patients. Complications after the FFF transfer await keen evaluation to establish guidelines to improve end results.

A treatment algorithm for managing giant mandibular ameloblastoma: 5-year experiences in a Paris university hospital

AIMS To review our experiences with giant mandibular ameloblastoma (GMA) over a 5-year period, and to formulate a treatment algorithm for managing this tumour. METHODS We retrospectively reviewed all GMA patients who underwent segmental mandibulectomy and immediate free fibular osteoseptocutaneous flap reconstruction (SM-IFFOFR) by a single reconstructive team from 2002 to 2006. All treatment methods and outcomes were analysed. FINDINGS Forty-four ameloblastoma patients were operated upon during this study period. Sixteen cases had GMA, of which 9 patients were included in this series (mean age: 35 years). The defects in the mandible ranged from 7 to 16 cm in length (mean: 12 cm). The average length of the harvested fibula was 11 cm, and the number of osteotomies ranged from 1 to 2. The mean ischemic time was 137 min (range: 90-180 min). Neck recipient vessels were used for flap perfusion in all cases. All but one flaps were viable without any complications, whilst partial skin-island necrosis occurred in 2 patients. Hospital stay was 2 weeks in most of the patients. No tumour recurrence was found during the follow-up period (range: 26-73 months). Dental implants were placed in 2 patients. CONCLUSIONS Despite several limitations of this study, we suggest that a radical approach with the SM-IFFOFR is an effective treatment for GMA. Further well-designed, larger series with longer follow-up periods are still encouraged.

Head and neck lesions of Kimura's disease: Exclusion of human herpesvirus-8 and Epstein-Barr virus by in situ hybridisation and polymerase chain reaction. An immunohistochemical study *

INTRODUCTION Kimuras disease (KD) is a chronic inflammatory disorder, characterised by tumour-like lesions in the head and neck region, producing salivary gland nodules and lymph node enlargement. Many authors suggest that KD is a reactive immunological disorder; however, its aetiology remains unknown. AIMS To study immunohistochemical characteristics of head and neck lesions of KD (H&N-KD) and to investigate the possible role of human herpesvirus-8 (HHV-8) and Epstein-Barr virus (EBV) in the development of H&N-KD. PATIENTS AND METHODS This study enrolled five H&N-KD specimens from three patients treated between 1995 and 2005 at Pitié-Salpêtrière University Hospital, Paris, France. Immunohistochemical studies were performed on formalin-fixed, paraffin-embedded tissue. HHV-8 DNA was determined by polymerase chain reaction (PCR) analysis, whilst EBV sequences were identified by PCR and in situ hybridisation. RESULTS The immunohistochemical studies revealed CD20+ germinal centres with prominent staining of CD23+ dendritic reticular cells, surrounded by numerous interfollicular CD3+, and CD4+ or CD8+ T-cells. Factor VIII-related antigen, CD31 and CD34 occurred in the thin-walled blood vessels. The reactivity of CD1a, HHV-8 and EBV-associated latent membrane protein 1-EBV (LMP1-EBV) were negative, and in situ hybridisation confirmed the lack of EBV DNA. No patient recalled an external insult or chronic irritation. CONCLUSIONS The results of this study indicate the reactive nature of H&N-KD (or a subset of H&N-KD), and it is unlikely that HHV-8 and EBV play a role in the pathogenesis of the lesion. However, the patients in this series did not have previous history of trauma or chronic irritation; thus, a neoplastic origin could not be excluded. Further multicentre studies based on more specimens are warranted.

An asymptomatic radiolucent lesion of the maxilla

CLINICOPATHOLOGIC CONFERENCE A 45-year-old Caucasian woman was referred to our maxillofacial surgery department for evaluation and management of an asymptomatic radiolucent lesion of the left posterior maxilla that had been discovered incidentally on routine dental examination. Her medical history was otherwise unremarkable. Clinically, no pain, tenderness, or swelling were noted in the involved area, and the skin over the lesion appeared normal. There was no history of sensory deficit, visual disturbance, or nasal obstruction. No enlarged lymph nodes were palpable in the neck. Intraoral examination did not reveal any obvious abnormalities. Although the left maxillary first molar had incomplete root canal therapy, the tooth had been

Ewing's sarcoma of jaw bones in adult patients: 10-year experiences in a Paris university hospital

INTRODUCTION Despite using aggressive treatment, patients with Ewings sarcoma (ES) always show a high recurrence and a low survival rate. Ki-67 has been used widely in surgical oncology. PATIENTS AND METHODS This case report identified the Ki-67 expression in jaw bone ES from 4 adult patients operated upon between 1996 and 2005 in Pitié-Salpêtrière University Hospital, Paris, France. The clinical data of each patient was also reviewed. RESULTS Ki-67 reactivity was found in 3 cases. Two of 4 patients with 50% and 80% of Ki-67 positive tumour cells had local relapse at 5 years and 8 months after treatments, respectively. Furthermore, the patient with 80% Ki-67 expression exhibited resistance to chemotherapy and died a year after resection. The other 2 cases revealed no evidence of recurrence and metastasis to date. CONCLUSION Ki-67 expression is likely to be associated with tumour recurrence and poor prognosis in jaw bone ES in adult patients. This marker probably helps surgeons to plan and employ appropriate treatment and/or surveillance for each patient; however, the number of cases in this series is very limited. A large-scale, prospective study is, therefore, required to confirm our suggestion.

Statins: a new pharmacological agent for free flap surgery?

Microvascular free tissue transfer has become the standard for reconstruction in head and neck oncological surgery. Several pharmacological agents have been used in order to increase the success rate of this surgery, but there is currently no consensus for an ideal drug. We review the literature concerning the complications encountered in free flap surgery related to the ischaemia-reperfusion injury and detail the effects of statins relevant to this endothelial dysfunction. Statins, because of their pleiotropic effects such as preservation of vascular tone, anticoagulation and anti-inflammatory properties, appear to be useful in free flap surgery. This study highlights the benefits of statins in order to increase the success rate and the quality of the free flap. They should be included in the perioperative strategy, especially in patients with cardiovascular risk factors. A protocol is presented.

Pathology Quiz Case 1. Keratocystic odontogenic tumor (KCOT).

A 29-YEAR-OLD WHITE WOMAN PRESENTED with pain and swelling of the left cheek that had begun a few months before. Thirteen years earlier, a surgeon in an outside hospital had enucleated a radicular cyst (apical inflammatory cyst) in the same area. The patient’s medical and family histories were noncontributory. A head and neck examination revealed no abnormalities other than the swelling of the left cheek, with mild fever and purulent drainage at the upper left posterior oral vestibule. Cortical perforation, along with pain and tenderness, was found during the intraoral palpation. All neighboring teeth were vital, and other dental abnormalities were absent. A panoramic film revealed a unilocular radiolucent lesion at the left maxillary tuberosity involving a root of the left upper second molar. However, the outline of the lesions was unclear because of overlapping of other structures, such as the maxillary sinus (Figure 1). The destruction of the left zygomaticomaxillary buttress and the cloudiness of the left maxillary antrum were noticed in a Water radiograph. Noncontrast computed tomography with a bone algorithm demonstrated a 2.3 2.8-cm spaceoccupying lesion in the left maxilla, extending from the tuberosity to the zygomatic arch and the orbital floor. The inflamed left maxillary sinus and oroantral communication were found in the area of the left upper third molar. It was impossible to differentiate benign sinus secretions from cystic mass on the computed tomograms (Figure 2 and Figure 3). The patient elected to undergo enucleation of the lesion via an intraoral vestibular approach with preservation of the maxillary walls, orbital floor, and zygomatic arch. Histologic examination of the hematoxylin-eosin–stained tissue demonstrated a cystic lesion lined by parakeratinized stratified squamous epithelium (Figure 4). What is your diagnosis?