Jacques-Charles Bertrand

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.

Rhinoplasty: an outcome research.

Background: A bicentric, prospective cohort study was performed to assess the outcome of rhinoplasties from the patient’s perspective. Methods: Fifty-eight patients scheduled for rhinoplasty from two different hospitals (public and private) were examined before and after surgery using the Rhinoplasty Outcomes Evaluation, a specific validated assessment scale. For statistical analysis, paired Student’s t test and the Mann-Whitney test were applied. Student’s t test was used to compare preoperative and postoperative scores. Results: The scores of both the cosmetic and the posttraumatic patients were significantly improved by rhinoplasty (p < 0.0001). There was no significant difference when the authors compared the improvement scores of subgroups ranged by age, sex, primary versus secondary rhinoplasty, time between first consultation and surgery, posttraumatic versus non–posttraumatic patients, and functional versus nonfunctional indications. Conclusions: Whatever the type of initial demand (posttraumatic, cosmetic, or functional), rhinoplasty significantly increased Rhinoplasty Outcomes Evaluation scores. The study design did not allow the authors to determine subgroups of patients more able to obtain an important improvement score.

Depression, anxiety and quality of life: outcome 9 months after facial cosmetic surgery

OBJECTIVE The request for cosmetic surgery is of a psychological nature. Very few studies have quantitatively assessed whether or not this psychological need was actually satisfied, and more precisely, which psychic components were satisfied. MATERIAL AND METHODS This is a multicentric, prospective cohort study. One hundred and three patients scheduled for facial cosmetic surgery from three different hospitals were examined before and after surgery using four assessment scales validated using European populations. The Montgomery and Asberg depression rating scale (MADRS) measured the existence and intensity of depression, the self-assessment test of thoughts in social interaction (SISST) measured the positive or inhibitory thoughts in the context of social relationships, and the European quality of life 5 dimensions (EQ-5D) (generic test) measured the quality of life. In addition, a semi-directive interview was specially created by our team. For statistical analysis, ANOVA and Students t test were applied. RESULTS Twenty-four patients were lost to follow-up. Although the initial MADRS index was high (p<0.05), it did not change after surgery (p>0.1). SISST+ (positive thoughts): the social anxiety of the individual examined was significantly greater than that of the control group (p<0.005) and improved after surgery (p<0.01). The SISST- (inhibitory thoughts) did not change (p>0.1). The EQ-5D visual analogue scale (VAS) did not reveal any difference (p>0.1) while the descriptive EQ-5D demonstrated over-representation of anxiety/depression (p<0.01), and an improvement of this (p<0.05) postoperatively. The mean subjective satisfaction index was 8.1 (scale of 1-10) without sharing any influence of the complications suffered (65% of the patients made self-assessments). CONCLUSION The best indications for facial cosmetic surgery seem to be a lack of self-confidence associated with a desire for social interaction, and a request focused on a specific physical feature. The results presented add documentary confirmation to the impression shared by the majority of cosmetic surgeons. However, it was also confirmed that cosmetic surgery is not limited to its technical components, but remains a medical act which must consider the overall effect on the whole patient.

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.

Cinegammography and 3-D emission tomoscintigraphy for evaluation of revascularized mandibular bone grafts: a preliminary report

The following reports a study conducted to investigate a scintigraphic monitoring procedure for bone free flap in mandibular reconstruction. This procedure is based on the one hand, on vascular and bone cinegammography, and on the other hand, on vascular and bone 3-D tomoscintigraphy. We used a prospective cohort study design. All patients who underwent free flap mandibular reconstruction from April 1993 to April 1998 in the Salpêtrière University Hospital, France (20 cases) have been evaluated in relation to this scintigraphic procedure. Vascular and bone scintigraphy were performed within the second week after surgery during 2 consecutive days. All images were read by one author (J.- Y. B.), who did not know the skin status of the flap. The results were compared with the viability of revascularized bone grafts as evaluated by the skin status and Greenberg classification based on bone radiographs three months after reconstruction. Vascular cinegammography seems to be closely related to anastomosis patency. Bone cinegammography gives appreciable information on bone viability. 3-D vascular tomoscintigraphy remains difficult to interpret. 3-D bone tomoscintigraphy gives precise information on the viability of the different segments of the bone flap. These results suggest that vascular and bone 3-D tomoscintigraphy coupled with cinegammography have an excellent prognostic value. In the event of partial failure it can give information on the location of the impaired patency and on the osseous fragment which has lost any viability.

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.

Psychological care for maxillofacial trauma patients: a preliminary survey of oral and maxillofacial surgeons.

INTRODUCTION Psychological morbidities are major complications following maxillofacial injuries. The aim of this study was to assess self-evaluation of oral and maxillofacial surgeons on posttraumatic psychological care. METHODS Using a cross-sectional study design, we enrolled a sample of surgeons in 261 oral and maxillofacial surgery (OMFS) departments in the United States, United Kingdom and France. A self-administered e-mail questionnaire was used to evaluate knowledge, attitude and practice of the surgeons regarding psychological problems in maxillofacial injury patients, and their collaboration with psychological personnel. Appropriate descriptive and univariate statistics were computed, and P<0.05 was considered statistically significant. RESULTS The response rate was 28.1% (112 of 398), but we included only 100 respondents from 107 OMS units. 60% of the surgeons disclosed a moderate or high level of relevant knowledge. Only 28 OMS departments (26.2%) had intra-service psychological staff (commonly in France [P<0.05]), and five surgeons revealed considerable deficits in access to psychological care. Frequent reasons for patient referral to psychological staff were depression, body dysmorphic disorder, posttraumatic stress disorder, suicidal idea, anxiety and behavioural changes. Eighty-eight surgeons linked patients non-compliance with changes or difficulties in practice, and 58 surgeons experienced it already. CONCLUSIONS Despite several limitations, the results of this study suggest that oral and maxillofacial surgeons have a great interest and experience in posttraumatic psychological problems. Psychological professionals in charge will improve surgical care quality. Well-designed studies with larger sample size are desirable to confirm our results. Ethical issues of maxillofacial trauma care are also discussed.

Do temperature and atmospheric pressure affect the incidence of serious odontogenic infection

OBJECTIVE The purpose of this study was to investigate the popular belief that the incidence of odontogenic cellulitis is weather-related. Two meteorologic parameters were examined: temperature and atmospheric pressure. STUDY DESIGN To test the hypothesis being studied, a retrospective cohort study design was used. Medical reports of all patients with serious odontogenic cellulitis who were treated at the Salpêtrière University Hospital between January 1, 1995, and December 31, 1995, (a total of 301 cases) were evaluated in relation to the weather. Hypothesizing that the incidence of odontogenic cellulitis was constant over a period of 1 year, the authors calculated the probability of observed incidence for each month over a 12-month period. The mean number of cases of odontogenic cellulitis (+/- standard error of the mean) for days on which (1) the temperature was within the same 2 degrees -C (3.6 degrees -F) interval and (2) the atmospheric pressure was within the same 3-hPa (2.25-mmHg) interval was also calculated. RESULTS When the monthly incidence of odontogenic cellulitis and either the average temperature or the average atmospheric pressure for each month were examined together, fluctuation in the former seemed to be independent of the latter. Similarly, when we calculated the mean number of cases of odontogenic cellulitis for several intervals of temperature and atmospheric pressure without taking the calendar into account, no direct relationship could be observed. CONCLUSION The results of the study suggest that the occurrence of odontogenic cellulitis is not influenced by the weather, at least insofar as weather is measured by temperature and atmospheric pressure.