D. Goga

An arteriovenous fistula of the maxillary artery as a complication of Le Fort I osteotomy

INTRODUCTION The Le Fort I osteotomy, one of the most common techniques used to correct dento-midfacial deformities, is generally considered to be operatively safe. However, sometimes this procedure can lead to fatal vascular complications. MATERIALS AND METHODS This article describes a fifty-year-old woman with a giant facial venous malformation. The patient underwent a Le Fort I osteotomy in order to correct an open bite. The surgery was complicated by the development of an arteriovenous fistula (AVF) between the maxillary artery and the venous malformation, the diagnosis of which was made by ultrasound doppler. Neuroradiological embolisation process of the maxillary artery was performed in order to close the AVF. RESULTS The total fistula obliteration and a Class I occlusion were obtained. CONCLUSIONS The reported case suggests the necessity of a multidisciplinary process (involving both maxillofacial and neuroradiology teams) for the treatment of dento-midfacial deformities in relation to vascular malformations. This modality is the only way to guarantee minimization of morbidity (according to patients expectations).

Tessier number 4 bilateral orbito-facial cleft: a 26-year follow-up.

Orbito-facial number 4 clefts are the rarest craniofacial clefts and only a few cases have been reported. We report a case of a complete bilateral Tessier number 4 cleft, and our approach to surgical correction. We analyse the patients treatment plan over a 26-year follow-up period. We comment on the age at which the first surgical procedure is commonly performed with or without a primary bone graft, as well as the use of the facial plasty technique with interdigitating Z-plasty flaps and rotation-transposition flaps. Closure of the cleft can constitute an emergency when the patients globe is exposed.

Cemento-ossifying fibroma of the mandible.

INTRODUCTION Cemento-ossifying fibroma is a rare benign tumor most often discovered incidentally. CASE REPORT A 72-year-old patient was referred for a subclinical lesion of the mandible. The orthopantomogram showed a well-circumscribed radiolucent osteolytic image, 1 cm in diameter, on the mandibular angle. On CT, the single lesion had a tissue aspect with a peripheral halo without enhancement after contrast injection. A cortical lacuna on the lingual side was noted. Surgical enucleation of the lesion was performed. The pathological examination confirmed the ossifying fibroma. DISCUSSION/CONCLUSION Slow and progressive, cemento-ossifying fibroma is a rare benign tumor that reaches the maxilla and more frequently the mandible. The ossifying and cementifying fibromas are differentiated by their clinical, radiological, and histological findings. The authors discuss the pathogenesis and radiological signs guiding the choice of diagnostic and therapeutic methods. The treatment is surgical with an enucleation or wider resection with bone reconstruction for large fibromas.

Evaluation of skull strength following parietal bone graft harvest.

Background: Parietal bone grafts are commonly used in craniomaxillofacial surgery. The primary aim of this study was to quantify the loss of strength following monocortical parietal bone graft harvest. The secondary aim was to establish a correlation between strength and thickness of calvaria. Methods: Thirty fresh human cadaver heads (nonfrozen, unembalmed heads) were used for this study. Loss of strength was determined by comparing the maximum impact resistance of bone on the donor side versus the intact side, using a precalibrated pendulum Charpy impact testing machine. Thickness was measured using a surgical navigation system with optoelectronic tracking. Results: Loss of strength at the donor site was 36 percent (p = 0.0000000001) for a 40 percent loss of thickness. Although correlation between these two parameters is rather moderate (r = 0.46), it is highly significant (p < 0.0001). Conclusions: Although loss of strength is quite significant, serious complications at the donor site are rare. As shown in this study, these risks are nonnegligible. However, because of strong legal pressure, surgeons must carefully weigh the risks incurred by the patient against the expected benefits, whether immediate or deferred. Therefore, the patient should receive well-documented information before such monocortical parietal bone graft harvest is performed.

Mandibular nerve block can improve intraoperative inferior alveolar nerve visualization during sagittal split mandibular osteotomy

INTRODUCTION The main procedure specific complication of sagittal split osteotomy of the mandibular ramus (SSOMR) is inferior alveolar nerve (IAN) injury. This can be produced by poor intraoperative visibility of the IAN due to bone bleeding. In our centre, mandibular nerve blocks (MNBs) are usually performed for intra- and post-operative analgesia. We observed that MNB seems to decrease intraoperative bleeding and thus to improve IAN visibility. Our study was performed to evaluate the effect of MNB on intraoperative bleeding during SSOMR and, secondarily, on the duration of this procedure. MATERIAL AND METHODS Patients scheduled for bilateral SSOMR under general anaesthesia were prospectively randomized into two groups. The Block group received bilateral MNB (5 mL ropivacaine 0.5% for each block) and the Control group sham MNBs (bilateral cutaneous puncture, without block). The operations were carried out under a standardised general anaesthetic. Post-operatively, the surgeon, blinded to group allocation, assessed intraoperative bone bleeding using a Numerical Rating Scale (NRS) (0: no bleeding, perfect visibility to 100: major bleeding, no visibility). Osteotomy duration, intraoperative anaesthetic requirements, and pain score in the recovery room were also recorded. Results are expressed as median [25-75th percentiles]. RESULTS Nineteen patients were included in each group. Osteotomy under MNB had a decreased intraoperative bone bleeding score compared with controls (20 [0-40] versus 55 [20-80], p=0.0002). They had a dry surgical field more frequently (29% versus 5%, p=0.01), and a shorter mean time for the osteotomy (15 [12.25-17.75] versus 17.5 [15-21]min, p=0.009). Block patients had reduced intraoperative opioid consumption (770 [678-1430] versus 2310 [1908-3058]mcg of remifentanil, p=0.0001), and lower pain scores in the recovery room (0 [0-2] versus 3 [1-5], p=0.12). CONCLUSION MNB decreases intraoperative bone bleeding during SSOMR under general anaesthesia. Three hypotheses to explain this result are discussed.

Coloration noire des os du crâne et de la face

INTRODUCTION We report the case of a patient with a craniofacial black bone disease. This was discovered accidentally during a coronal approach. CASE REPORT A 38-year-old patient was referred to our unit for facial palsy having appeared 10 years before. Rehabilitation of the facial palsy was performed with a lengthening temporal myoplasty and lengthening of the upper eyelid elevator. An unusual black color of the skull was observed at incision of the coronal approach. Subperiostal dissection of skull and malars confirmed the presence of a black bone disease. A postoperative history revealed minocycline intake (200mg per day) during 3 years. DISCUSSION This craniofacial black bone disease was caused by minocycline intake. The originality of this case is to see directly the entire craniofacial skeleton black. This abnormal pigmentation may affect various organs or tissues. Bone pigmentation is irreversible unlike that of the mouth mucosa or of the skin. This abnormal pigmentation is usually discovered accidentally.

Stabilité du greffon et des implants après greffe osseuse du sinus maxillaire : Étude rétrospective de 44 cas

Objectif Objectiver la fiabilite de la technique de greffe osseuse du maxillaire et la stabilite de l’implantation apres greffe, en effectuant une comparaison de nos resultats a ceux de la litterature. Materiel et methodes Nous avons mene une etude retrospective a partir de 44 cas de greffe osseuse du sinus maxillaire, operes entre 1998 et 2002. Le greffon etait autologue dans 31 cas, et un melange d’os autologue et de biomateriau dans 13 cas. Cent douze implants ont ete poses sur les sites greffes, avec une moyenne de 2,5 implants par greffes. L’evaluation a porte sur la morbidite du site receveur, l’integration et la stabilite du greffon osseux ainsi que la stabilite du systeme implantaire sur greffe. Resultats Le taux de reussite des greffes est de 97,8 %. Il y a eu un seul echec, tous les autres cas ont pu etre implantes. Sur les 112 implants poses, 2 ont ete perdus. Discussion Nos resultats sont comparables a ceux de la litterature. Cette etude objective la fiabilite de la technique de greffe osseuse au sinus maxillaire, et l’equivalence des resultats entre greffe autologue et biomateriaux associes a l’os autologue.OBJECTIVES We assessed the reliability of maxillary bone grafting and implant stability, comparing our results with reports in the literature. MATERIAL AND METHODS This retrospective series included 44 patients who underwent maxillary sinus bone grafting between 1998 and 2002. An analogous graft was used for 31 patients and a combination autologous-bone substitute graft for 13. One hundred twelve dental implants were positioned at the grafting site (2.5 implants per graft). We assessed recipient site morbidity, bone graft integration and stability, and stability of the implants. RESULTS Bone grafting was successful in 97.8% of patients. There was one failure. Two of the 112 implants failed. DISCUSSION Our results are comparable with those in the literature. This study demonstrated the reliability of maxillary bone grafting with equivalent results using autologous bone and combination autologous bone-bone substitute.

Évaluation du déficit sensitif du nerf alvéolaire inférieur après ostéotomie mandibulaire

Introduction L’atteinte du nerf alveolaire inferieur (NAI) est une des complications les plus frequentes des osteotomies mandibulaires. La dispersion des resultats publies nous a conduits a etudier l’incidence des troubles sensitifs persistants au-dela de 1 an sur une serie de 40 patients. Materiel et methode Cette etude a concerne 40 patients âges de 14 a 58 ans. Nous avons etudie l’expression subjective des troubles sensitifs par un questionnaire reprenant les differentes fonctions oro-faciales liees au NAI. Nous avons etudie l’expression clinique des troubles sensitifs en testant chez 25 patients les 3 modes de la sensibilite exteroceptive (tact, temperature et douleur). Nous avons applique 4 tests cliniques appropries sur le territoire du nerf mentonnier. Nous avons objective l’atteinte nerveuse par la methode des potentiels evoques somesthesiques (PES) chez 8 patients. Resultats 77 % des patients exprimaient une alteration de leur sensibilite cutanee. Le deficit sensitif n’a ete retrouve aux tests cliniques que dans 60 % des cas. Les PES etaient perturbes chez 64 % des nerfs ayant un deficit clinique et chez 100 % des nerfs n’ayant pas de deficit clinique. Discussion Nous avons retrouve une plus grande incidence de plaintes subjectives que d’atteinte nerveuse. La technique des potentiels evoques somesthesiques donne des resultats interessants pour le diagnostic electro-physiologique de l’atteinte nerveuse. Ses indications pourraient etre elargies aux atteintes traumatiques du nerf alveolaire inferieur, voire pour son interet medico-legal.

Reconstruction d’une perte de substance complexe du maxillaire par transfert de fibula vascularisé après réalisation d’une fistule artério-veineuse par boucle vasculaire saphène

Introduction Lorsqu’une perte de substance osseuse importante necessite un transfert vascularise, la mauvaise qualite des vaisseaux receveurs impose parfois un geste complementaire d’allongement du pedicule vasculaire. Ce geste peut etre realise soit par des pontages veineux soit en preparant le site receveur par une boucle vasculaire. Nous avons utilise avec succes cette derniere technique chez un patient presentant une importante perte de substance pluri-tissulaire maxillaire. Observation Un homme de 39 ans presentait une perte de substance complete du maxillaire a la suite d’un traumatique balistique. Un lambeau libre de fibula etait envisage. Compte tenu de la longueur limitee du pedicule peronier et du caractere cicatriciel de la zone d’anastomoses vasculaires, la reconstruction a ete realisee en 2 temps : d’abord la preparation du site receveur par une boucle saphene, puis 15 jours plus tard le transfert proprement dit. Discussion Cette technique est une alternative aux pontages veineux qui augmentent de maniere significative le risque de thrombose post-operatoire. Les objectifs de la boucle vasculaires sont d’une part de placer les anastomoses vasculaires en territoire sain et d’autre part de les realiser en termino-terminal. Cette technique a surtout ete decrite dans le traitement des pertes de substance post-traumatique des membres, mais elle est applicable a la face notamment en territoire irradie.

Efficacy and safety of embolization in arteriovenous malformations of the extremities and head and neck: a retrospective study of 32 cases

BackgroundDefinitive treatment of arteriovenous malformations (AVMs) consists of complete surgical excision. When not possible, embolization may be performed.ObjectivesWe aimed to evaluate the efficacy and safety of embolization forAVMs of the extremities and head and neck.Materials and methodsThis retrospective study included all patients undergoing embolization for AVMs of skin and soft tissues on the limbs, head and neck, in the University Hospital Center of Tours between January 1996 and December 2009. The main outcome was efficacy, assessed by two independent assessors, as the percentage of AVM devascularized at the end of embolization. Secondary outcomes were patient satisfaction, evolution of symptoms and safety of embolization.ResultsWe included 32 AVMs in 31 patients, for 66 embolizations evaluated. In 18 AVMs (56.3%), devascularization was greater than 75% of the initial vascularization. Efficacy was lower for AVMs of the upper limbs than other body parts (p = 0.003). For 18 patients who could be contacted by telephone, the mean global satisfaction was 6.0 ± 2.7 on a scale of 0 to 10, and 13 (72.2%) reported an improvement of the symptoms linked to the AVM. Severe adverse events were reported after 4 embolizations, all located on the head and neck.ConclusionEmbolization can lead to good devascularization and improve symptoms linked to AVMs, especially in lower limbs. Minor complications are frequent, and severe adverse events may occur, especially after procedures on the head and neck.