Joël Ferri

Advantages and limitations of the fibula free flap in mandibular reconstruction

PURPOSE The authors analyze the advantages and disadvantages of mandibular reconstruction with a fibula free flap in a retrospective study of 29 cases, and make comparisons with the iliac free flap and the lateral brachial free flap. MATERIAL AND METHODS Twenty-nine patients (22 male, 7 female) aged 5 to 70 years were studied. Functional and esthetic evaluations were performed together with radiologic examination of the bony calluses. RESULTS The fibula free flap has advantages for mandibular reconstruction, such as the length of bone available, low morbidity of the donor site, and the possibility of using a skin paddle. However, there is the disadvantage of not being able to reconstruct large soft tissue defects. In addition, bone vascularization is reduced when a large number of osteotomies are required. CONCLUSION This reconstruction technique is satisfactory for mandibular defects measuring over 20 cm.

Microsurgical reconstruction of the jaw with fibular grafts and implants.

Reconstructive treatments for jaw defects are complex procedures that can combine multiple techniques including fibula free flap (FFF) grafting. The purpose of this retrospective study was to document and share our experience on mandibular and maxillar reconstruction with FFF followed by secondary dental rehabilitation using implant insertion. We reviewed 198 patients treated by FFF grafting for mandibular and/or maxillary defects in our department during the past 11 years (1996-2007). A selection of 30 patients (18 males and 12 females, mean age of 46 y) with adequate criteria (hygiene, motivation, and prognosis) received secondary placement of osseointegrated implants. The implant success was clinically and radiographically evaluated. A total of 105 osseointegrated implants were placed in the grafted fibulas 5 months to 3 years after the reconstruction surgery. Only 4 implants were lost because of peri-implantitis (3 patients) and fibular fracture (1 patient); this corresponds to a 96.2% implant success rate. During the mean follow-up of 76 months, patients satisfaction and functional and aesthetic results were evaluated. Radiologic findings indicated a low crest resorption around the implants despite an unfavorable crown-to-root ratio. The main difficulties in the reconstructions were lack of FFF height, absence of a vestibular groove, limitation of mouth opening, skin paddle thickness, and the reconstruction of surrounding tissues including the lip. Our management strategy is discussed. Prosthetic choice is fundamental to achieving patient-specific solutions. The prostheses used included sealed or screwed bridge, resin-bonded bridge, tooled bar, implant-borne denture, or implant-stabilized dentures. Dental implants may be used even in situations involving an unfavorable crown-to-root ratio and implant position by using milled bar and overdenture. The FFF provides a consistent bone graft that allows a reliable and predictable restoration with dental implants, leading to a satisfactory functional and aesthetic restoration.

Maxillary reconstruction to enable implant insertion: a retrospective study of 181 patients

BackgroundThe purpose of the present study was to evaluate different types of maxillary pre-prosthetic surgery using autogenous bone graft and suggest a guideline for maxillary reconstruction to place implant.Methods181 patients (125 females and 56 males), age range from 16 to 76 years old, were operated at the Maxillo-Facial Service of the Lilles 2 Universitary Hospital Center (Chairman Pr Joël Ferri). Different techniques were used, but always with autogenous bone grafting. 21 patients underwent a Lefort 1 procedure, 139 underwent sinus graft with or without vestibular onlay graft and 21 underwent onlay graft. This surgical procedure was made to allow the insertion of 685 implants.ResultsThe patients were evaluated by clinical and radiological assessment. In the cases of Lefort 1, the rate of successful osteointegration was higher when the implants were placed in the second part of a two stages procedure: 92%, against 81% for one stage. In cases of sinus lift procedure, the rate of implant success was 98%. The infection rate was 3.5%. There was no significant resorption and the type of prosthesis used was a denture retained by a bar or fixed bridge. In cases of onlay graft, the implant insertion success was 97% and there was no infection. The amount of resorption was more significant in the pre-maxilla than in the other areas and the type of prosthesis used was fixed dentures.ConclusionThese observations demonstrate that: the aetiology of the bone defect indicate the type and number of the surgical procedures to re-established good jaws relationship and give the bone conditions to implant insertion successful.Clinical RelevanceA guideline for surgical decision in the maxillary reconstruction for oral rehabilitation by implants may help to prevent failures of osseous resorption disorders and to foresee the investment of the bone in quality and necessary quantity.

Temporomandibular joint dysfunction and orthognathic surgery: a retrospective study

BackgroundRelations between maxillo-mandibular deformities and TMJ disorders have been the object of different studies in medical literature and there are various opinions concerning the alteration of TMJ dysfunction after orthognathic surgery. The purpose of the present study was to evaluate TMJ disorders changes before and after orthognathic surgery, and to assess the risk of creating new TMJ symptoms on asymptomatic patients.MethodsA questionnaire was sent to 176 patients operated at the Maxillo-Facial Service of the Lilles 2 Universitary Hospital Center (Chairman Pr Joël Ferri) from 01.01.2006 to 01.01.2008. 57 patients (35 females and 22 males), age range from 16 to 65 years old, filled the questionnaire. The prevalence and the results on pain, sounds, clicking, joint locking, limited mouth opening, and tenseness were evaluated comparing different subgroups of patients.ResultsTMJ symptoms were significantly reduced after treatment for patients with pre-operative symptoms. The overall subjective treatment outcome was: improvement for 80.0% of patients, no change for 16.4% of patients, and an increase of symptoms for 3.6% of them. Thus, most patients were very satisfied with the results. However the appearance of new onset of TMJ symptoms is common. There was no statistical difference in the prevalence of preoperative TMJ symptoms and on postoperative results in class II compared to class III patients.ConclusionsThese observations demonstrate that: there is a high prevalence of TMJ disorders in dysgnathic patients; most of patients with preoperative TMJ signs and symptoms can improve TMJ dysfunction and pain levels can be reduced by orthognathic treatment; a percentage of dysgnathic patients who were preoperatively asymptomatic can develop TMJ disorders after surgery but this risk is low.

Facial morphology changes after total maxillary setback osteotomy.

PURPOSE To evaluate the morphologic outcome after total maxillary setback osteotomy (TMSO) in dentofacial Class II deformity patients with marked upper jaw prognathism. PATIENTS AND METHODS The assessments of 9 patients before and after TMSO were compared. The evaluation was based upon x-ray superimpositions and standardized photographic comparison. TMSO was performed through a conventional Le Fort I operation with resection of the inferior end of the pterygoid processes. RESULTS All patients presented with marked upper jaw prognathism initially and have had a bimaxillary surgery with a mean maxillary setback of 3.1 mm. All patients ended in Class I occlusion after at least 1-year of follow-up. An opening of the nasolabial angle (mean 8.9 degrees) was noted for all but 2 patients. At the same time, the suborbital profile was nicely modified as a result of substantial heightening of the prezygomatic soft tissues in all patients, even without vertical maxillary intrusion. CONCLUSIONS These results challenge the notion of unavoidable facial alteration commonly associated with upper setbacks. TMSO allows combining satisfactory functional and cosmetic results for a number of carefully selected patients. Pronounced maxillary protrusion with acute nasolabial angle is a prerequisite. The release of the deforming strains of the dysmorphosis upon the midface will improve the suborbital profile. Bimaxillary surgery is recommended to leverage the setback and the opening of the naso-labial angle.

Masseter myosin heavy chain composition varies with mandibular asymmetry.

Human jaw dysmorphologies are frequent and often affect young patients, resulting in malocclusion of teeth and inappropriate jaw relationships. Treatment is performed by means of orthodontics with orthognathic surgery as required. Mandibular asymmetry is one of the most frequent dysmorphologies, but in many cases, the specific cause is unknown. In healthy patients who were undergoing orthognathic surgery for correction of malocclusion, we tested the hypothesis that masseter muscle phenotype composition, which determines contractile properties, was different between sides in patients with mandibular asymmetry but not in those without mandibular asymmetry. After cephalometric analysis, 50 patients from whom we obtained samples of both right and left masseter muscles were separated into 2 groups: with or without mandibular lateral deviation. Samples were immunostained with myosin-isoform-specific antibodies to identify 4 skeletal muscle fiber types, and their fiber areas and proportions were measured. Two-tailed Wilcoxon test for paired samples was used to compare the 4 fiber-type compositions by means of percent occupancy and mean fiber area on both sides. Patients with mandibular asymmetry were associated with a significant increase of type II fiber occupancy (P = 0.0035) on the same side as the deviation. This finding that masseter muscle phenotype is significantly linked to mandibular asymmetry is of relevance to physiotherapeutic and surgical managements of jaw discrepancies and merits further investigation in the light of its possible role in the etiology of this condition.

Position paper from the IBRA Symposium on Surgery of the Head – The 2nd International Symposium for Condylar Fracture Osteosynthesis, Marseille, France 2012

BACKGROUND This is a position paper from the 2nd International Bone Research Association (IBRA) Symposium for Condylar Fracture Osteosynthesis 2012 was held at Marseille, succeeding the first congress in Strasbourg, France, in 2007. The goal of this IBRA symposium and this paper was to evaluate current trends and potential changes of treatment strategies for mandibular condylar fractures, which remain controversial over the past decades. METHODS Using a cross-sectional study design, we enrolled the consensus based on the panel of experts and participants in the IBRA Symposium 2012. The outcomes of interest were the panel and electronic votes on management of condylar base, neck and head fractures, and panel votes on endoscopic and paediatric condylar fractures. Appropriate descriptive and univariate statistics were used. RESULTS The consensus derived from 14 experts and 41 participant surgeons, using 12 case scenarios and 27 statements. The experts and participants had similar decision on the treatment of condylar base, neck and head fractures, as well as similar opinion on complications of condylar fracture osteosynthesis. They had a parallel agreement on using open reduction with internal fixation (ORIF) as treatment of choice for condylar base and neck fractures in adults. Endoscopic approaches should be considered for selected cases, such as condylar base fractures with lateral displacement. There was also a growing tendency to perform ORIF in condylar head fractures. The experts also agreed to treat children (>12 years old) in the same way as adults and to consider open reduction in severely displaced and dislocated fractures even in younger children. Nevertheless, non-surgical treatment should be the first choice for children <6 years of age. The decision to perform surgery in children was based on factors influencing facial growth, appropriate age for ORIF, and disagreement to use resorbable materials in children. CONCLUSIONS The experts and participating surgeons had comparable opinion on management of condylar fractures and complications of ORIF. Compared to the first Condylar Fracture Symposium 2007 in Strasbourg, ORIF may now be considered as the gold standard for both condylar base and neck fractures with displacement and dislocation. Although ORIF in condylar head fractures in adults and condylar fractures in children with mixed dentition is highly recommended, but this recommendation requires further investigations.

Complications of calvarial bone harvesting for maxillofacial reconstructions.

Background:For almost a century, autologous bone grafts are the criterion standard for facial skeleton rehabilitations. Progressively, because of its various advantages, calvarial bone imposed as one of the most adapted for craniomaxillofacial reconstructions. Also, calvarial harvesting remains a controversial technique because of its potential complications described in the literature. The aim of this study was to report the precocious and late complications encountered in our practice and to compare them with the previous data of the literature. Methods:We decided to realize a retrospective study over 10 years and 511 cases of calvarial bone harvesting performed in our maxillofacial department. Results:Our results are very clear, reporting some annoying consequences and long-term aesthetic reattempts, but any serious complication. Discussion:According to our experience and previous data of the literature, we described some technical refinements that could improve our technique and reduce its potentials complications. Nevertheless, we think that nowadays calvarial harvesting is the criterion standard for maxillofacial bone grafts, and the complications described in the literature are negligible for experienced operators.

4H syndrome: a rare cause of leukodystrophy.

A 24-year-old woman suffered from gait unsteadiness and tetraparesis since childhood. Her medical history was characterized by a normal delivery of non-consanguineous parents. Walking with support was acquired at 10 months. Childhood development was characterized by occurrence of a progressive cerebellar ataxia, short stature, mental development retardation (IQ = 46), and hypodontia (i.e., absence of deciduous teeth eruption and short tooth roots). Walking without support was never acquired. At the age of 14, a partial growth hormone (GH) deficit (insufficient peak of GH in standard condition and with stimulation tests) and an hypogonadotropic hypogonadism [absence of luteinizing hormone (LH) and follicle stimulating hormone (FSH), lack of response to LH-releasing hormone (LH-RH) injection with LH peak at 0.6 UI/l and FSH peak at 1.4 UI/l] were found. Dental panoramic radiographs showed short tooth roots and absence of dental pulp chamber (Fig. 1). At the age of 24, neurological examination observed a severe static and kinetic cerebellar syndrome, spastic tetraparesis, multidirectional nystagmus, vertical down and up-gaze palsy, and mental retardation. Walking perimeter was 10 m with human assistance. Neuro-ophthalmologic examination confirmed vertical gaze palsy, and revealed amblyopia (with visual acuity of 4/10 on both sides), severe myopia, and bilateral temporal papillary atrophy. Nerve conduction studies and electromyography were normal. Neuroimaging performed at 3 Tesla (Philips, Best, The Netherlands) showed marked atrophy of the corpus callosum (reflecting the global white matter (WM) volume) and the cerebellum. In addition, spinal cord atrophy was moderate (data not shown). Myelinated areas including the pyramidal tracts, the internal capsule, the deep cerebellum, and the brainstem were hyperintense relative to cortical grey matter (CGM) on T1-WI and hypomyelinated areas (=rest of the white matter) were diffusely hypointense relative to CGM on T1-W1 (Fig. 2a–c). On T2-FLAIR images, the myelinated area appeared iso/hypointense relative to CGM and the hypomyelinated area appeared diffusively hyperintense relative to CGM (Fig. 2d–f). The pons appeared small with widening of the prepontine cystern, which was probably due to hypomyelinated corticopontine tracts as well as atrophy of crossing cerebellar tracts (Fig. 2a, c, d, f). Single voxel proton-magnetic resonance spectroscopy (HMRS) spectra showed low choline/creatine and N-acetylaspartate/creatine ratios within the left semi-ovale WM, left basal ganglia and pons. A prominent myo-inositol peak was also found within the pons (Fig. 2g). Tractography obtained from a Diffusion O. Outteryck (&) D. Devos L. Hopes P. Vermersch Department of Neurology, Salengro Hospital, Universite Lille Nord de France, CHRU Lille, Rue Emile Laine, 59037 Lille Cedex, France e-mail: Olivier_outteryck@hotmail.com

Condylar hyperplasia: correlation between clinical, radiological, scintigraphic, and histologic features.

PurposeThe objectives of this study were to compare demographic, clinical, radiographic, scintigraphic, and histologic differences between the 2 main types of condylar hyperplasia (CH) and to suggest a new therapeutic management based on such findings. MethodsThis was a retrospective study based on 28 patients who presented either vertical (group 1) or horizontal (group 2) forms of CH and underwent surgical treatment. Every patient had a complete preoperative clinical and radiological examination as well as a single-photon emission computed tomography scan. A histologic analysis of each resected condyle was performed. These various parameters were then compared in the 2 patient groups. ResultsThe mean age at time of the diagnosis was 25.8 years (range, 12–50 years), and there were 22 females and 6 males. Nineteen patients had the vertical form of CH, and 9 had the horizontal form. Scintigraphic analysis showed moderate to extensive radionucleotide uptake in cases with rapid growth. Four cases had negative single-photon emission computed tomography scan uptake, and all were vertical forms, but there was no statistically significant difference between the 2 groups. The histologic analysis showed both a global thickening of the cartilage cap and of the prechondroblastic cells layer with no statistically significant difference between the 2 groups. ConclusionsCondylar hyperplasia is a pathologic condition affecting mainly young females and whose origin remains unknown. Single-photon emission computed tomography scans as an indicator of the rapidity of the disease progress are essential in assessing the condylar hyperplasia and to guide the therapeutic approach.