G. Bettega

Évaluation à long terme de l'uranoplastie par greffe de périoste tibial dans la fente labio-maxillo-palatine totale unilatérale. À propos de 51 cas cliniques

Resume But de letudexa0: Le but de cette etude etait doublexa0: evaluer les capacites de la greffe de perioste tibial effectuee dans le cadre du traitement des fentes labio-maxillo-palatines totales unilaterales a favoriser une production osseuse sans interferer de facon majeure sur la croissance maxillaire et apprecier son role a long terme sur l’equilibre des bases osseuses et l’etancheite palatine. Materiel et methodesxa0: Cette etude retrospective porte sur une serie de 51 patients, âges d’au moins 13xa0ans, traites pour une fente labio-maxillo-palatine totale unilaterale selon un protocole associant une cheiloplastie selon le trace de Skoog, a une greffe de perioste tibial selon Stricker entre quatre et sixxa0mois et une staphylorraphie entre huit et 18xa0mois. Les documents qui ont servi a l’etude comportentxa0: les schemas, photographies et descriptions precises de la fente initiale, les moulages des arcades dentaires, les teleradiographies et les panoramiques dentaires realises aux principales etapes du traitement, le suivi orthodontique, orthophonique et otologique. La croissance etait evaluee a l’aide de moulages au cours des six premieres annees puis sur des teleradiographies de profil apres la puberte. L’ossification etait evaluee de facon quantitative sur coupes tomodensitometriques realisees sur une serie de 18 patients. Resultatsxa0: Les resultats confirmentxa0: la realite d’une ossification rapportee a la greffe periostee dans 72xa0% des cas, une croissance squelettique equilibree ou compensee au niveau occlusal dans 85xa0% des cas, ramenant le taux d’osteotomies a 13,7xa0%xa0; l’avantage de la greffe periostee vis-a-vis de l’etancheite palatine, avec un taux relativement faible de fistules a 7,8xa0%. Conclusionxa0: Cette etude autorise les auteurs a proposer une methode d’evaluation des resultats a long terme dans le traitement des fentes et a maintenir la pratique de la greffe periostee dans leur protocole.

La distraction symphysaire : protocole simplifié

INTRODUCTIONnSevere mandibular incisor crowding with bone insufficiency is usually treated by dental extractions and orthodontic management. Symphyseal distraction was proposed to avoid tooth extraction. This technique is still considered as invasive, complex and unsafe. We evaluated symphyseal distraction to clarify its indications, and to suggest a simplified surgical protocol.nnnPATIENTS AND METHODSnSix patients were treated by symphyseal distraction: three with a bone-anchored device and three with a dental anchored one. Pre and postoperative inter-canine measurements and occlusal stability were analyzed.nnnRESULTSnPostoperative inter-canine measurements increased from 3.4 to 6.8mm (mean 5.2mm). All patients were in Angle class I occlusion without complications. Dental anchored device simplified the surgical procedure.nnnDISCUSSIONnSymphyseal distraction with dental anchored device is a simple, efficient and reliable to treat severe transverse mandibular deficiency. The orthodontist can manage the procedure by himself and controls the whole expansion process according to specific requirements.

Article originalLa distraction symphysaire : protocole simplifiéSymphyseal distraction: A simplified procedure

INTRODUCTIONnSevere mandibular incisor crowding with bone insufficiency is usually treated by dental extractions and orthodontic management. Symphyseal distraction was proposed to avoid tooth extraction. This technique is still considered as invasive, complex and unsafe. We evaluated symphyseal distraction to clarify its indications, and to suggest a simplified surgical protocol.nnnPATIENTS AND METHODSnSix patients were treated by symphyseal distraction: three with a bone-anchored device and three with a dental anchored one. Pre and postoperative inter-canine measurements and occlusal stability were analyzed.nnnRESULTSnPostoperative inter-canine measurements increased from 3.4 to 6.8mm (mean 5.2mm). All patients were in Angle class I occlusion without complications. Dental anchored device simplified the surgical procedure.nnnDISCUSSIONnSymphyseal distraction with dental anchored device is a simple, efficient and reliable to treat severe transverse mandibular deficiency. The orthodontist can manage the procedure by himself and controls the whole expansion process according to specific requirements.

Ostéonécrose des maxillaires sous bisphosphonates : cinq cas

Introduction Les bisphosphonates ont ete recemment impliques dans des tableaux d’osteonecrose des maxillaires. Nous presentons une etude descriptive de cinq patients. Patients et methode Nous avons traite trois femmes et deux hommes. Deux patients recevaient des bisphosphonates intraveineux pour myelome et les trois autres pour cancer du sein avec metastases osseuses. La chimiotherapie a ete poursuivie, le traitement par bisphosphonates interrompu. Aucun patient n’avait eu de radiotherapie dans la region cervico-faciale. Quatre patients avaient une localisation mandibulaire avec exposition osseuse et un, une localisation maxillaire avec communication bucco-sinusienne. Ils ont tous eu des prelevements a visee histologique et microbiologique. Resultats L’examen histologique montrait une necrose osseuse et eliminait une atteinte tumorale. Quatre biopsies revelaient une infection a Actinomycose. Quatre patients ont eu un curetage osseux. Ils ont tous presente un lâchage precoce des sutures. Discussion Les bisphosphonates ont une activite anti-angiogenique prouvee cliniquement. A long terme, ils sont responsables d’une accumulation de microlesions osseuses. Ces mecanismes expliquent en partie la pathogenie des osteonecroses. Seuls les maxillaires sont touches par cette pathologie, seraient-ils un lieu de fixation privilegie des bisphosphonates ? Dans notre serie d’autres facteurs de risques ont ete retrouves : certains cytotoxiques, les corticoides et l’insuffisance renale chez un patient. D’autre part, la surinfection par Actinomycete semble avoir un role important dans ces tableaux. Le seul traitement efficace est la prevention dentaire avant la mise en route du traitement.

Les altérations morphologiques au cours des syndromes oto-mandibulaires

Otomandibular dysplasia is a congenital malformation defined by a certain degree of temporomandibular or pterygomandibular hypoplasia. The syndrome is characterised by the variability of clinical findings, but the three major features are auricular, mandibular and maxillary hypoplasia. All the laterofacial structures may be affected. The deformity is usually unilateral but bilateral cases exist; a lot of associated malformations have been described. Multiple classification systems have been published. Some of them are very complex, but it is possible to define a simple diagnostic diagram based on ethiopathogenic data. Bilateral involvement affects predominantly the zygoma, and concerns hereditary syndromes. When the mandibular hypoplasia is evident Franceschetti or Goldenhar syndrome is suspected; otherwise Treacher-Collins syndrome is probable. Unilateral cases are not, in general, hereditary and the hypoplasia predominates on the mandible. The difference between hemifacial microsomia or mandibular dysplasia is made by the presence of associated laterofacial deformities.

Maxillary distraction complications in cleft patients.

INTRODUCTIONnCleft lip and palate (CLP) patients often present with a class III malocclusion in connection with a three dimensional maxillary hypoplasia. Twenty-five to 60% of these patients need maxillary advancement. Two solutions are possible: orthognathic surgery and maxillary distraction. The purpose of this study was to evaluate the complications of maxillary distraction in CLP patients.nnnPATIENTS AND METHODSnData was collected from the records of patients treated in our surgery unit between 2000 and 2007. Among the eight patients (four male and four female), five presented with a bilateral CLP, two with a unilateral CLP, and one with a unilateral cleft lip associated to a soft palate cleft. The average age at surgery was 17 years. All underwent a Le Fort I osteotomy with a pterygomaxillary disjunction. An external distractor was used for the first two patients and an internal distractor for the six following patients. After a seven-day latency, activation was implemented at a rate of 1mm twice a day. The average period of consolidation was four months. Maxillary advancement ranged between 7 and 19mm, with an average of 12.6mm. The average follow-up was four years.nnnRESULTSnComplications were noted in seven patients: one intra-operative hemorrhage, one avulsion of a tooth anchored at the pterygoid process during osteotomy, three cases of device dysfunction, two cases of significant pain during activation, one loosening of the orthodontic arch in an external system, two cases of labial ulceration, and one maxillary sinusitis due to migration of a wisdom tooth.nnnDISCUSSIONnComplications of maxillary distraction in CLP patients were very frequent. Most were related to the device and did not interfere with the final result. This must be taken into account when indicating distraction and choosing the device. Two types of complications can occur during distraction: those related to the osteotomy and those related to the device. The complications related to the osteotomy are linked to the cicatricial ground of previous surgery. They are not specific to distraction. The comfort of the internal device is undeniable, but the design of some models must be reviewed to improve their tolerance.

Développement et croissance de la mandibule dans son environnement

A thorough knowledge of mandibular growth is necessary for proper comprehension of growth disorders and malformations affecting the lateral cranio-facial region. The growth mechanisms are complex and multifactorial, the mandible itself is subdivided into two heterogeneous and interdependent segments, as far as growth is concerned. These are the ramus and the corpus. The ramus is interacting with the middle cranial base through the TMJ and the temporo-pterygoid muscle belt. The mandibular body is interacting with the maxilla and the anterior cranial base. Its occlusal role is a function of the adaptive capacity of the alveolodental region.

La dacryo-cysto-rhinostomie par voie externe

La dacryo-cysto-rhinostomie par voie externe est le traitement des obstacles situes sur le trajet du canal lacrymo-nasal. Elle consiste a court-circuiter l’obstacle en realisant une stomie entre le sac lacrymal et la paroi externe de la fosse nasale. Les etapes operatoires comportent : un abord para-canthal, un decollement sous-perioste limite en avant par la crete lacrymale posterieure afin de preserver l’insertion posterieure du ligament canthal medial (et donc la pompe lacrymale), une trepanation osseuse a cheval sur l’os maxillaire et l’unguis, et une stomie par deux lambeaux muqueux. L’intubation bi-canaliculo-nasale est systematique et maintenue pendant 10 a 12 semaines.