J. Lebeau

Traumatismes faciaux au CHU de Grenoble: Étude épidémiologique de 961 dossiers sur une période de 365 jours

Introduction Les traumatismes faciaux representant 30 % de l’activite du service de chirurgie maxillo-faciale du CHU de Grenoble. Les auteurs ont evalue ce recrutement sur un an par une analyse des facteurs etiologiques, du type de population touchee, des differentes lesions tant squelettiques que tegumentaires, des lesions associees et du delai de prise en charge. Ils ont compare ensuite cette etude avec deux etudes precedentes afin de connaitre l’evolution de la traumatologie faciale en pays de montagne. Materiel et methode Une fiche stereotypee a ete etablie pour chaque patient ; 994 dossiers ont ete analyses, 961 ont ete retenus. Les parametres etudies ont ete la prevalence, l’âge par tranches de 10 ans, le sexe, la repartition mensuelle, les etiologies traumatiques, les types de lesion par secteurs faciaux, les associations morbides et le delai de prise en charge. Resultats La moyenne mensuelle etait de 80 traumatises recus en urgence. Le pic periodique se situait en juillet avec 97 patients. 65,6 % des patients etaient hospitalises en chirurgie maxillo-faciale. L’incidence etait la plus elevee dans la tranche d’âge de 21 a 30 ans (25,4 %). Il y avait 2,7 hommes pour une femme. Les etiologies traumatiques etaient par ordre decroissant le sport (25,8 %), les accidents de la voie publique (23,1 %), les accidents domestiques (17,6 %), les agressions (3,4 %), les accidents de travail (3,4 %), les morsures (3,2 %). Les accidents de montagne representaient 10,5 % de tous les traumatismes et 40,7 % des accidents de sport, 95 % se produisaient aux sports d’hiver. Il y avait 65,5 % de fractures et 34,5 % de lesions des parties molles isolees. Des lesions associees se retrouvaient chez 33,6 % des patients. 67,2 % des blesses ont ete traites en urgence et 86,9 % avant le cinquieme jour post-traumatique. Discussion L’incidence regionale des traumatismes faciaux se manifeste par un recrutement avant tout sportif. Les sports de glisse dominent le recrutement hivernal. Ce n’est pas le cas d’autres series (canadiennes ou australiennes) dans lesquelles le sport ne vient qu’en troisieme ou quatrieme position. Ce recrutement explique que la population la plus touchee est celle des 20 a 30 ans. La comparaison avec nos deux etudes precedentes montre une recrudescence preoccupante des accidents de ski. La grande proportion (33,6 %) de lesions associees temoigne de la violence des chocs. Les 1 035 fractures sont dues a des chocs frontaux dans 77 % des cas. Les 31 morsures ont ete infligees a des enfants dans 82 % des cas. Une organisation specifique du CHU de Grenoble reservant des plages de bloc operatoire pour la traumatologie hivernale a permis de traiter la grande majorite des blesses dans les premiers jours post-traumatiques.INTRODUCTION The purpose of this study was to determine the types of facial injuries treated in a one-year in a maxillo-facial unit operating in a mountainous region. METHODS All patients admitted to the Grenoble University Hospital maxillo-facial unit for a one year period were studied. We noted cause of trauma, age, sex, type and location of fracture, type of soft tissue injury, time between trauma and surgery. RESULTS A total of 994 patients presenting maxillo-facial trauma underwent surgery over one year; 30% of the units maxillo-facial surgical activity. On average, 80 patients were treated for maxillo-facial trauma per month, with a peak of 97 facial injuries in July; 65.6% were hospitalized in the maxillo-facial unit; 25,4% of the injured were aged between 21 and 30 years. Sex-ratio was 2.7M/1F. The most frequent cause was sports injuries (25.8%) followed, in decreasing order, by traffic injuries (23.1%), home injuries (17.6%), fight injuries (3.4%), work injuries (3.4%) and dog bites (3.2%). 10.5% of the injuries occurred in a mountainous setting and 40.7% were sports injuries, 95% of which during practice of winters sports. Injuries included facial fractures (65.5%) with or without soft tissue damage, and soft tissue injuries only (34.5%); 33.6% of the patients had other lesions of the body. 67.2% underwent surgery within the first 24 hours and 86.9% before the fifth day. DISCUSSION Sports accidents are the leading cause of facial trauma in the mountainous regions. Most facial injuries result from ski, surf and other winter sports accidents. Most of the victims were given surgical care within the first 24 hours following the accident.

Oncocytoma of the eyelid: An aggressive benign tumor

OBJECTIVE The authors report the case of an 83-year-old patient with a benign oncocytoma of the inferior eyelid. DESIGN INTERVENTIONal case report. INTERVENTION Treatment consisted of a large orbital exenteration followed by reconstruction with a pedicled temporalis muscle flap. MAIN OUTCOME MEASURES Histologic evaluation and clinical follow-up were measured. RESULTS After a year of follow-up, there was no sign of local recurrence. CONCLUSIONS Oncocytomas, even if benign, must be considered as very aggressive tumors and treated accordingly.

La distraction symphysaire : protocole simplifié

INTRODUCTION Severe 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. PATIENTS AND METHODS Six 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. RESULTS Postoperative 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. DISCUSSION Symphyseal 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

INTRODUCTION Severe 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. PATIENTS AND METHODS Six 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. RESULTS Postoperative 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. DISCUSSION Symphyseal 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.

Gastro-omental free flap in the reconstruction of the unfavourable hypopharyngeal defects: A functional assessment

BACKGROUND Reconstruction flaps following major head and neck cancer surgery should consider the state of tissue at the recipient site. This study presents the cumulative experience of the use of the gastro-omental free flap (GOFF) for pharyngeal reconstruction in cases with unfavourable recipient site conditions. METHODS The GOFF reconstruction procedure and postoperative follow-up are described in details, and the functional results are analysed retrospectively. RESULTS Fifteen patients underwent GOFF reconstruction. Previous treatments included radiotherapy, chemotherapy and surgery. Postoperatively, two patients (13%) developed partial flap necrosis, and four (27%) patients developed fistula and flap stenosis. On the functional level, eight (53%) patients developed oesophageal speech at different levels of audibility, and all patients developed oral alimentation ranging from a mixed diet with supplements to a regular oral diet. CONCLUSIONS The GOFF is characterised by multiple survival advantages that favour its use in the presence of inhospitable recipient site conditions.

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.

INTRODUCTION Cleft 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. PATIENTS AND METHODS Data 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. RESULTS Complications 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. DISCUSSION Complications 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.

Réparation des mutilations du triangle nasolabio-mentonnier. Plasties conventionnelles versus allogreffes

Central-facial mutilations, located within the nose lips and chin triangle, require great quality repairs regarding morphology and function. Plastic surgery history affords the ideas evolution in this field crossing over nose and lips reconstructions, which were the subject of successive reports within our society, in 1994 (nose reconstruction) and 2002 (lips reconstruction). Now a day, following this progress, the plastic surgeon has a large choice of reliable techniques. His choice is dictated by a precise evaluation of the limits of the substance loss to repair, according to a (mapping) classification of the nose-lip and chin triangle. This classification defines three units (nose-labial, bilabial and chin-labial) as reflexion bases to the therapeutic indications. This anatomical and surgical approach was built starting from a retrospective study of 195 central-facial mutilations caused by ballistic damage and dog bites. The results evaluation makes possible to carry out a reflexion on the potential indications regarding allograft as a therapeutic alternative to the traditional reconstructions of this territory.