Thomas Schouman

Histological features and management of a mandibular Gorham disease: a case report and review of maxillofacial cases in the literature

Gorham disease (GD) is a rare osteolysis without sex, race, or age predilection, affecting bones in different regions. Based on clinical, histological, and molecular features, diagnosis is difficult and required exclusion of neoplastic, inflammatory, infectious, and endocrinologic disease. Etiology is still unknown. We report the case of a 36-year-old man suffering from severe progressive osteolysis located at the mandible. Histology showed massive osteolysis without malignant cells. Immunohistochemistry revealed thin-walled vessels and lymphatic ducts. These investigations lead to diagnosis of GD. Radical surgical treatment was followed by bisphophonate therapy. Recurrence occurred 4 months after surgery and alphaa-interferon therapy permitted remission. To support this case report, we reviewed the 41 maxillofacial cases published in the literature since 1928. Jaw is the main location; histology mostly shows hemangioma-like proliferation. Immune disorders are usually advanced as a cause although physiopathology is unknown. Therefore, appropriate treatment is controversial. Antiosteoclastic drugs are usually proposed in addition to surgery, but immunomodulating drugs and radiation therapy should also be considered in the treatment.

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.

Osteosarcomas of the mandible: Are they different from other tumor sites?

BACKGROUND Osteosarcomas of the mandible (MOS) affect 1/10 million persons/year, mostly the young adult. Due to lack of specific data, the treatment of MOS is extrapolated from that of extragnathic OS but varies widely between institutions. MATERIALS AND METHODS We aimed at providing a focused description of MOS histologies and grades through the English literature, at determining the evidence-based role of chemotherapy, of adjuvant radiation therapy and the potential of reconstructive surgery tailored through modern pre-operative multi-modal imaging. RESULTS The estimated proportion of high grade MOS was 58%. However, low-grade MOS may be underestimated as they are mostly reported as case reports. The intermediate grade was hardly found in the literature. Estimated weighted-mean proportions of chondroblastic and osteoblastic MOS were 37% and 46%, respectively. Multimodal imaging modalities including MRI has a great potential for accurate pre-operative assessment of tumor extensions into bone and soft tissues. Surgery is the mainstay of treatment and margins the most important factor. The role of neoadjuvant chemotherapy in treating occult systemic metastases and in increasing the probability of clear margins is controversial, as well as the histology-dependent response to chemotherapy. The role of adjuvant radiotherapy (mostly proposed for positive margins) and/or adjuvant chemotherapy is still controversial. Crude survival is around 77% and local control around 67%. Local failure is the main cause of death in MOS compared to extragnathic sites.

[How to avoid research misconduct - recommendations for surgeons]

Research misconduct is defined by the Royal College of Physicians of Edinburgh as any behaviour by a researcher, whether intentional or not, that fails to scrupulously respect high scientific and ethical standards. Various types of research misconduct include fabrication or falsification of data, plagiarism, problematic data presentation or analysis, failure to obtain ethical approval by a research ethics committee or to obtain the subjects informed consent, inappropriate claims of authorship, duplicated publication, and undisclosed conflicts of interest. These can result in patient injury, deterioration of the patient-physician relationship, loss of public trust in biomedical research, as well as pollution/degradation of the medical literature. Surgical research malfeasance has been underreported, and no practical guidelines for good research and publication have appeared to date in French surgical journals. In an attempt to uphold the scientific integrity of our profession, we discuss research misconduct and emphasise preventive measures and considerations for surgeons.

Distraction osteogenesis versus fibula free flap for mandibular reconstruction after gunshot injury: socioeconomic and technical comparisons.

Background: Since the birth of maxillofacial surgery, ballistic injuries are a real challenge for surgeons. For more than 20 years, fibula free flap (FFF) became the criterion standard for mandibular reconstructions. But FFF is not always the perfect answer for mandibular reconstruction, and a technique named distraction osteogenesis (DO) was raised. The purposes of this study are to estimate the financial cost and reattempt for the patient each techniques in our experience to determine the best-choice criteria for mandibular reconstruction after gunshot injury. Methods: We performed a retrospective study over the last 15 years, including 15 patients with a mandibular ballistic injury. Ten patients were treated with FFF, and 5 with DO. We evaluated the complications and morbidity encountered with each technique. We also decided to estimate the cost of different rehabilitations, including the cost of the device and hospitalization. Results: In our study, the global cost of the DO protocol appears as not more expensive than the FFF one. Postoperative complications encountered during the FFF protocols were related to donor-site morbidity. The DO patient had pseudoarthrosis, mucosa irritation, or local infection. Discussion: Our study demonstrated both the economic and technical interest of DO compared with the FFF for mandibular reconstruction. Thus, nowadays, DO appears as an alternative to the FFF for mandibular reconstruction, the main decisional criterion being the evaluation of the tissues dilapidated during the initial traumatism, but social environment of the patient shall also be considered.

Computational area measurement of orbital floor fractures: reliability, accuracy and rapidity

OBJECTIVE To evaluate the reliability, accuracy and rapidity of a specific computational method for assessing the orbital floor fracture area on a CT scan. METHOD A computer assessment of the area of the fracture, as well as that of the total orbital floor, was determined on CT scans taken from ten patients. The ratio of the fractures area to the orbital floor area was also calculated. The test-retest precision of measurement calculations was estimated using the Intraclass Correlation Coefficient (ICC) and Dahlbergs formula to assess the agreement across observers and across measures. The time needed for the complete assessment was also evaluated. RESULTS The Intraclass Correlation Coefficient across observers was 0.92 [0.85;0.96], and the precision of the measures across observers was 4.9%, according to Dahlbergs formula .The mean time needed to make one measurement was 2 min and 39 s (range, 1 min and 32 s to 4 min and 37 s). CONCLUSION This study demonstrated that (1) the area of the orbital floor fracture can be rapidly and reliably assessed by using a specific computer system directly on CT scan images; (2) this method has the potential of being routinely used to standardize the post-traumatic evaluation of orbital fractures.

Acute compartment syndrome following fibula flap harvest for mandibular reconstruction.

Donor site morbidity for free fibula osteofasciocutaneous flaps has rarely been reported in the literature. We report on a case of acute compartment syndrome (ACS) in a 22-year-old male, following fibula flap harvest for mandibular reconstruction and arising after post-ischemic reperfusion damage. Dissection during this patients surgery was unusually difficult. The skin defect was covered with a loose dressing while waiting for secondary grafting. Intracompartmental pressures measured by the Wick catheter technique confirmed the diagnosis of ACS. ACS is an unexpected complication after fibula flap harvest since the three compartments of the leg are opened during surgery. Only four cases of ACS have been reported in the literature. Analysis of this serious complication might lead to changes in the routine use of the pneumatic tourniquet in some selected cases. New automatic tourniquet systems might also be advantageous in such cases.

Maxillary sinus textiloma: a case report

IntroductionTextilomas have been reported in many locations. We report the first case of textiloma located in the maxillary sinus that mimicked a sinus cyst recurrence on computed tomography images.Case presentationA 60-year-old Caucasian man was referred for persistent infection of the right maxillary sinus. A maxillary sinus benign cyst had been removed three months before. Computed tomography showed a sinus opacity evoking a cyst recurrence. A new operation was planned to remove the cyst by a Caldwell-Luc approach. After excision of very thick fibrous tissue, a compress was discovered in the maxillary sinus. The patient did not present with any sinus infection after the operation.ConclusionThe surgeon should always take into account the possibility of textilomas in a patient with a history of sinus surgery.

Précision des prédictions morphologiques en chirurgie orthognathique. Évaluation d’un procédé de fusion d’images 3D

INTRODUCTION The CT/CBCT data allows for 3D reconstruction of skeletal and untextured soft tissue volume. 3D stereophotogrammetry technology has strongly improved the quality of facial soft tissue surface texture. The combination of these two technologies allows for an accurate and complete reconstruction. The 3D virtual head may be used for orthognatic surgical planning, virtual surgery, and morphological simulation obtained with a software dedicated to the fusion of 3D photogrammetric and radiological images. TECHNICAL NOTE The imaging material include: a multi-slice CT scan or broad field CBCT scan, a 3D photogrammetric camera. The operative image processing protocol includes the following steps: 1) pre- and postoperative CT/CBCT scan and 3D photogrammetric image acquisition; 2) 3D image segmentation and fusion of untextured CT/CBCT skin with the preoperative textured facial soft tissue surface of the 3D photogrammetric scan; 3) image fusion of the pre- and postoperative CT/CBCT data set virtual osteotomies, and 3D photogrammetric soft tissue virtual simulation; 4) fusion of virtual simulated 3D photogrammetric and real postoperative images, and assessment of accuracy using a color-coded scale to measure the differences between the two surfaces.

Chirurgie assistée par dispositifs sur-mesure : reconstruction par lambeau libre de fibula

The reconstruction of jaws with a free fibula flap can be anticipated virtually. The simulation can be transferred to the operating theater using customized devices obtained from computer-assisted design and manufacturing in a complete digital workflow. Several alternatives are available, from cutting guides to customized titanium osteosynthesis plates, to obtain the best accuracy and reproducibility of reconstruction. Moreover, these new processes allow integrating prosthetic planning concomitantly with reconstruction. We present the virtual three-dimensional planning method for jaw reconstruction with a free fibula flap and the various alternatives of surgery guided by customized devices provided by this planning.