Maxillary and total nasal reconstruction with a scapulo dorsal perforator flap

Facial gunshots injuries remain challenging and present functional and aesthetic problems. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and the maxilla is especially delicate because it requires reconstitution of the facial buttresses, and replacement of bony hard palate, based on occlusion, as well as the restoration of the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue and bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. The scapula dorsal perforator flap is used in the case of a patient to successfully reconstruct the palate, the maxilla and the nasal pyramid in one stage. Free tissue transfer using thoracodorsal perforator flaps and scapula bone free flap have been already described in literature but never to perform the nasal pyramid reconstruction at the same time. Good functional and aesthetic results have been obtained in this case. This article also reviews, through the authors experience and literature, anatomical landmarks, indications, technical surgical tricks, advantages and disadvantages of this flap for palatal, maxillary and nose reconstruction.

Morphology of maxilla in patients with palatally displaced canines

OBJECTIVES

The aim of this study was to investigate the possible relationship between the morphology of maxilla and the palatally displaced canines (PDC).

MATERIALS AND METHODS

In this cross-sectional study, there were 101 patients (45 males, 56 females) aged 12 to 16years, referred to Hamadan school of dentistry in 2014. They were divided into 3 groups: the bilateral PDC (PDCb) group (male=15, female=21), the unilateral PDC (PDCu) group (male=16, female=19), and the control group (male=14, female=16). Five morphology related variables including intermolar width, maxillary arch length, palatal vault depth, palatal intermolar area, and nasal width were measured using CBCT images with Dolphin Imaging software, version 11.5. Statistical analysis was performed with ANOVA and the Dunnett test using SPSS software, version 16.0.

RESULTS

Only the palatal intermolar area and the palatal vault depth values were significantly less in the PDCu and the PDCb groups than those in the control group (the palatal intermolar area: 376.17, 381.93, and 423.75mm², the palatal vault depth: 13.19, 13.42, and 14.59mm; respectively; P<0.05). For all the variables, there was no statistically significant difference between the PDCu and PDCb groups.

CONCLUSION

Decreased palatal vault depth and palatal intermolar area may be correlated with greater chance of palatal displacement of canines. Future prospective studies in mixed dentition patients are needed as a predictive factor to find the probability of PDC.

[Evaluation of healing time of osteochemonecrosis of the jaw after surgery: Single-center retrospective study and review of the literature]

INTRODUCTION

Osteochemonecrosis of the jaw (ONJ) is a chronic ischemic bone exposure. It has an increasing incidence. ONJ is mainly related to bisphosphonate and denosumab therapies in oncologic settings. Healing is considered uncertain ad as occurring slowly. International recommendations suggest to treat ONJ symptomatically in a first attempt. A surgical procedure, potentially aggressive, should be carefully weight up in patients in poor condition and whose life expectancy is often limited. However, surgical treatment seems to allow for a high rate of clinical remission. Postoperative remission periods, when mentioned in the studies, are disparate. The aim of our study was to clarify the remission period of ONJ after surgical management.

METHOD

A retrospective study was conducted on all patients operated for an ONJ at stage 2 and 3 in the Department for Oral and Maxillofacial Surgery - University Hospital of Besançon (France) from January 2006 to September 2015. Healing was defined as complete mucosal closure and asymptomatic site. Stage of the disease, the number and the type of surgery and the time between the last operation and the healing was noticed. These data were compared to an exhaustive review of the literature on PubMed with the following key-words: "osteonecrosis" AND "jaw" AND "surgery" AND "management". Only the articles giving the healing period were included.

RESULTS

Regarding the single-center retrospective study, the files of 23 patients could be included. Fifteen percent of the patients benefited from several procedures under general anesthesia. Twenty percent had a stage 3 ONJ and 80 % had a stage 2 ONJ. Twenty-five interventions were performed on 23 sites in 20 patients. Immediate healing after surgery occurred in 35 % of the patients. At 6 months after surgery, 57 % of the treated areas were healed. Twenty percent of the patients had died. The healing rate did not improve further after 6 months postoperatively. Regarding the review of the literature, 7 articles could be included. The mean postoperative healing period was 60.7 % at 6 months, 71.1 % at 12 months and 69.5 % at 18 months.

DISCUSSION

Our study shows that the postoperative healing rate of ONJ lies between 57 and 66.7 % at 6 months and that this rate was optimized in the order of 10 % to 12months and stable at 18months postoperatively. The ONJ of our series were partially or fully linked to other drugs than bisphosphonates in 70 % of the cases: 50 % were related to denosumab, alone or in combination and 35 % were related to an association with antiangiogenics, bevacizumab mainly.

[Secondary treatment of cleft lip and palate]

For 18 years our protocol has corrected the cleft lip nose and achieved an intravelar veloplasty at the time of the first operation, leaving the least scaring as possible. No doubt that the best treatment of the sequellae is their prevention: - the oro-nasal fistulas have disappeared; the nostril is almost normal; the continuity of a wide maxillary arch is restored in primary dentition - all that favor a nasal ventilation. This context has changed the nature of the secondary treatment described here. When lip and nose are not good enough we must address the residual deformities with the primary surgery principles. The velopharyngeal insufficiency calls for a velar re-repair and the pharyngeal depth is to be reduced by lipofilling. The rare cases of failure are improved by an Orticochea sphincteroplasty.

[Primary treatment of cleft lip and palate. Its fundamental principles]

If the multiplicity of functional protocols of cleft lip and palate treatment has been bewildering, it is now a source of learning. The lessons we can draw from them assist us to choose the best age for the primary surgery and a chronology that prevents the palate from the worst scaring. Eventually, with 18 years of follow-up, the best functional achievement comes unexpectedly from an ambitious primary rhinoplasty that had till now been condemned. Not only do the patients have good appearance and social integration, but the nasal mode of breathing established at the time of the primary surgery favors a good facial growth without any compromise. Reciprocally, all the interacting functions benefit from a nasal ventilation.

[Maxillary tumor revealing primary hyperparathyroidism]

INTRODUCTION

Primary hyperparathyroidism can infrequently present as a giant cell tumor of the jaw. We report the case of a patient presenting with a giant cell tumor leading to the discovery of a parathyroid adenoma.

OBSERVATION

A 70-year-old male patient consulted for a stiffly swollen right jaw. The radiological assessment revealed osteolytic lesions of the right maxilla. The calcium and phosphate levels were disrupted and the parathyroid hormone level was high. A neck ultrasonography revealed a parathyroid adenoma. The patient underwent excision of the maxillary mass and of the parathyroid adenoma; the outcome was marked by normalization of calcium and phosphate levels.

DISCUSSION

Giant cell tumors unusually reveal primary hyperparathyroidism and their maxillary location is exceptionally rare. The diagnosis is made on parathyroid hormone level and imaging. The treatment is surgical.

[Reconstruction of the atrophic edentulous maxilla for implant placement]

INTRODUCTION

Extreme maxillary atrophy results from partial or total maxillary bone defect, affecting the alveolar and basal segments. The residual bone is only a few millimeters high and does not allow retention of dental prostheses (complete edentulation), or placing implants. Bone reconstruction with cranial bone grafts usually allows obtaining enough bone volume in a single step to place implants for prosthetic rehabilitation, 3 months later.

TECHNICAL NOTE

Reconstruction begins by inserting bone grafts on the sinus floor. The pre-maxilla is then rebuilt with bone grafts placed on the nose floor then on the palate and vestibule. The premolar and molar sectors are rebuilt last with vestibular and palatine bone grafts assembled and stabilized by screws, or steel wire rings, and reinforced on their deep portion with diploe sheets.

DISCUSSION

Extreme maxillary atrophy reconstruction with cranial bone grafts is a reliable technique with reproducible results and few complications (sinusitis, bone sequester). Nevertheless, it requires strong experience to adequately perform harvesting and reconstruction.

[Primary intraosseous mucoepidermoid carcinoma of the jaws]

INTRODUCTION

A mucoepidermoid carcinoma (MEC) is a malignant salivary gland tumor. Its primitive intraosseous maxillary localization is rare. We report a case with a difficult diagnosis.

CASE REPORT

A 42-year-old female patient consulted atypical right sinus area pain. The CT scan revealed a heterogeneous tumor lyzing the right maxillary. The surgical treatment was broad resection. The pathological examination indicated an intramaxillary MEC. The surgical treatment was completed by postoperative radiotherapy.

DISCUSSION

Primary intraosseous MEC of the jaws is rare and often affects the mandible. Its intraosseous maxillary localization is even rarer. Its etiopathogenesis is still unknown. The treatment is usually surgical, and the prognosis is based on histological criteria.