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International audience; Spontaneous regeneration of bone tissue after mandibular resection is rare in adults, although it does often take place in children. Periosteum conservation appears to play a major role in this healing process. We here report regarding a 5-year-old boy who exhibited a large mandibular trabecular juvenile ossifying fibroma. The lesion was treated by mandibulectomy, with careful preservation of the periosteal layer and immediate reconstruction with a costal graft by an intraoral approach. Monitoring over the course of a year revealed spontaneous mandibular regeneration, and it allowed for a series of measurements of the graft to be made. During this follow-up period, the mandibular height increased from 41.5% to 75.2% (P = 0.0008) of the height of the unaffected mandibular height, while the width grew from 34.4% to 82.8% (P = 0.0078) of the width of the healthy side, thus demonstrating the importance of a conservative approach regarding the periosteum in such situations. The costal graft acted as a support for bone regeneration by immobilizing the remaining bone fragments and by preventing soft-tissue prolapse.

Hypertrophy of the masticatory muscles most commonly affects the masseter. Less common cases of isolated or associated temporalis hypertrophy are also reported. Parafunctional habits, and more precisely bruxism, can favor the onset of the hypertrophy. This condition is generally idiopathic and can require both medical and/or surgical management.A 29-year-old patient was referred to our department for an asymmetric swelling of the masticatory muscles. Physical examination revealed a bilateral hypertrophy of the masticatory muscles, predominantly affecting the right temporalis and the left masseter. Major bruxism was assessed by premature dental wearing. The additional examinations confirmed the isolated muscle hypertrophy. Benign asymmetric hypertrophy of the masticatory muscles promoted by bruxism was diagnosed. Treatment with injections of type A botulinum toxin was conducted in association with a splint and relaxation. Its effectiveness has been observed at six months.Few cases of unilateral or bilateral temporalis hypertrophy have been reported, added to the more common isolated masseter muscles hypertrophy. The diagnosis requires to rule out secondary hypertrophies and tumors using Magnetic Resonance Imaging. The condition is thought to be favoured by parafunctional habits such as bruxism. The conservative treatment consists in reducing the volume of the masticatory muscles using intramuscular injections of type A botulinum toxin. Other potential conservative treatments are wearing splints and muscle relaxant drugs. Surgical procedures aiming to reduce the muscle volume and/or the bone volume (mandibular gonioplasty) can be proposed.

The pigmentation patterns of facial skin of 354 healthy Chinese women aged 18-80 years were investigated clinically and instrumentally. Chromasphere(®) was used to acquire pictures from the cheeks of subjects. Facial skin tone was described by L* parameter from the L,a,b system as well as Individual Typology Angle (ITA). Results show that skin tone becomes significantly darker along the life span. Both size of hyper-pigmented spots and their contrast with surrounding skin were found increased with age. As additional study, 40 women from these 354 subjects were asked to apply daily a whitening cosmetic product for a 2-month period. Such application led to a significantly lighter skin tone, although this study was not vehicle controlled and we cannot exclude that the increase in L* observed was in some part because of cumulative effects of previously used whitening products, there was an association with lighter skin tone as assessed through both instrumental measurements and self-perception by most subjects.

The facial skin of 354 women, aged 18-80, living in Shanghai, was investigated over two successive 6-month periods, summer and winter. Results from clinical assessments indicate that aging signs, such as wrinkling and sagging, are unaffected over such period. However, physical measurements revealed alterations in some functional criteria of the skin, such as sebum output, skin colour, melanin content of pigmented spots, skin hydration, all being increased during summer. The relationships between all criteria, as well as technical or applied inferences/consequences from this study, are discussed.

The most recommended technique for the management of patients with a difficult airway is fiberoptic intubation (FOI). The aim of this study was to compare propofol and sevoflurane for FOI performance in patients who were difficult to intubate.Seventy-eight patients scheduled for maxillo-facial surgery were included in this prospective, randomized study. The airway was topically anesthetized with lidocaine 5% before performance of FOI with propofol TCI (group P) or sevoflurane (group S). The following parameters were recorded: rate of success, duration of the induction and of the FOI, BIS and PETCO2 values. A visual analogic scale (VAS) was used to monitor the technical difficulties as well as the recall of patients and their satisfaction. The respiratory and hemodynamic complications were also evaluated.Induction and procedure duration were significantly shorter in group S compared with group P. The rate of successful FOI was not different: 38 cases (97%) in group P and 35 cases (90%) in group S. No significant differences were observed between groups regarding BIS values and VAS values for technical difficulties and for patient recall and satisfaction. The incidence of hypertension or tachycardia was significantly higher in group S compared with group P. The incidence of respiratory complications was not significantly different between the groups, but three patients experienced obstructive dyspnea with hypoxemia.Propofol and sevoflurane provide a high success rate for the performance of FOI in patients who are difficult to intubate.

Cemento-osseous dysplasia is a benign fibro-osseous lesion of the jaws. Its complications are very rare.A panoramic x-ray was made to complete the pre-radiotherapy oral assessment of a 71-year-old female patient presenting with lung adenocarcinoma. This revealed a periapical fibro-osseous lesion on tooth n° 46. She had presented with a similar lesion on tooth n° 36, 16 years before. This had been treated by extraction and alveolar curettage. No surgical treatment was suggested for this recurrence on tooth n° 46.The diagnosis of focal cemento-osseous dysplasia is usually made on radiological and clinical data. The risk for transition to a florid form is unknown. Exeresis surgery before radiotherapy is discussed.

The authors propose a protocol to avoid bleeding complications in patients with bleeding disorders.When a general anesthesia or trunk nerve infiltration is indicated, clotting factor concentrates are to be used in patients with severe bleeding disorders. Desmopressin is to be used in patients with mild bleeding disorders but who are good responders and in patients with thrombopathy. An antifibrinolytic treatment and a fibrin glue are also used. Ninety-six patients underwent 107 extractions with this protocol.Only two patients had bleeding complications requiring an additional treatment.In case of bleeding disorders, the treatment depends on disease severity and type of anesthesia. A general treatment (clotting factor concentrates or desmopressin) is indicated with general anesthesia and with local anesthesia in severe bleeding disorders, but not absolutely necessary with local anesthesia in mild bleeding disorders. However, desmopressin can used in all good responders.

The odontogenic keratocyst (OKC) is unique among odontogenic cysts of the jaws, especially because of the high risk of recurrence. Epidemiological studies demonstrate male predominance and the most common location in the mandible. We reviewed our own experience with eight patients and data in the literature, focusing on very large mandibular keratocysts. We reviewed the clinical, radiological, and histological elements required for the positive and differential diagnosis. CT scans should be performed for very large cysts due to their superiority over plain x-rays, both for treatment planning and follow-up. Surgical treatment is indicated. The choice remains controversial between radical and conservative approach. We prefer conservative treatment. Problems concerning bone healing, recurrence and follow-up are also discussed.

We report a case of predominantly facial neurofibromatosis type I in a 7-year-old girl, exposing the difficulties encountered in surgical management. Infiltration of facial soft tissues by plexiform neurofibroma is difficult to control. Resection of large areas of facial skin is unconceivable, facial functions must be preserved. Orbitocranial surgery is reserved for orbital manifestations of neurofibromatosis with osseous sphenoid dysplasia and pulsatile exophthalmos. Despite progress in tumor imaging and surgery, facial neurofibromatosis remains a challenge for the surgeon. We discuss surgical technique and indications for surgery in these cases.

Radiation therapy, either alone or combined with surgery is a cornerstone in the treatment of oral cavity tumors. Target volumes to be treated with external beam radiation must take under consideration the initial tumor location, providing information on satellites lymph nodes to be irradiated as well. Modern imaging, with emphasis on CT scan with injection, is now mandatory for a better analysis of initial lesions including both tumor location and invaded lymph nodes. Tumor volumes based on clinical examination and CT scan analysis might be divided in two groups. First, volumes susceptible to receive a prophylactic irradiation for an hypothetical microscopic spread (CTV) to be treated with a prophylactic dose; second, volumes including lesions visible clinically or on CT scan that should receive a higher radiation dose (GTV). Clinical tolerance will largely be depending upon radiation-induced mucositis, impairing food intake. Radiation techniques aiming at normal tissues preservation should be used, including devices allowing keeping an open mouth during radiation delivery.

The Leishmania/HIV co-infection has emerged as a result of the increasing overlap between leishmaniasis (mainly visceral, more rarely cutaneous) and AIDS, which is due to the spread of the AIDS pandemic to rural areas and that of visceral leishmaniasis to suburban areas. Cases of co-infection have so far been reported from 33 countries around the world, most of the cases have been notified in south-western Europe. 1,627 cases have been notified from Spain, France, Italy and Portugal. While Leishmania/HIV co-infection is increasing in eastern Africa, cases of co-infection are expected to diminish in South-western Europe due to the new highly active anti-retroviral therapy (HAART). In 1998, a world wide WHO/UNAIDS surveillance network was established, which now includes 28 member institutions. In south-western Europe, the surveillance system based on 16 institutions is now well established. The systematic use of standardized and recently computerized case-report forms, the central international registry at WHO headquarters, and finally the use of a geographic information system (GIS) for mapping and monitoring co-infections have improved the overall quality of epidemiological data gathering. All member institutions of the network report to WHO on an annual basis. World wide information is analysed and periodically disseminated through international publications. The GIS integrates epidemiological and demographic data sets and allows for the mapping of co-infection cases down to locality level. The system can be used to easily visualise and analyse the spatial distribution of co-infection cases and to permit monitoring of the evolution of the distribution of the cases over time. The risk of co-infected patients, as carriers of Leishmania in the blood, to be a source of infection for the sandfly, has been recently confirmed. Moreover intravenous drug users also transmit the disease through the sharing of needles.

Ewing's sarcoma is the second most common malignant bone tumor of childhood, yet it is a rare tumor. Primary maxillary localization is unusual and occur in only 1-2% of cases, mostly in the mandible. The prognosis of Ewing's sarcoma has been improving considerably since the introduction of combined modality treatment. The estimated overall survival at 4 years is 75%. It is widely accepted that prompt chemotherapy is necessary to treat occult micrometastasis, present in over 80% of cases at time of diagnosis, and to reduce the tumor size. Prognostic factors correlated with a poor overall survival are large tumor size and poor histologic response to initial chemotherapy. Adequate local control of Ewing's sarcoma can be achieved after chemotherapy, with radical or conservative surgery and radiotherapy. Surgery was recommended whenever possible. Radiation dosage and fields are based upon the quality of surgery and histological response to chemotherapy. Concern has been raised, however, regarding deleterious late effects of radiation in this young population. Conservative surgery and reconstruction are often used to improve functional outcome. We report four cases of Ewing's sarcoma localized to jaw bone and mandible, successfully treated by combined modality treatment.

A madreporic coral graft was used for orbital floor reconstruction following facial trauma. This report presents a multicentric study of 83 patients with a follow-up period of 15 to 24 months. The results of this study indicate no significant rejection or infection opposed to so many synthetic implants outcome. The radiological follow-up demonstrates a partially resorption of the implant within about 2 years and its replacements by new bone. Coral implant was used to correct enophthalmos or diplopia due to enlarged orbital dimensions. It was technically easy to insert and its anatomic shape does not require to be fashioned before use. Its inflexibility allows to bridge large bone defects and this implant should be considered as an attractive alternative to autogenous grafts, avoiding a second surgical site, in reconstructing orbital floor fractures.

Though clinic examination gives us much information, radiology still is essential in head trauma. Many standard radiographic projections have been described in the past and yet since the eighties it appears that C.T. scanner (C.T.) has become absolutely necessary to a great number of us. In fact, C.T. is indispensable when there is a matter of vital urgency or when a functional problem appears (diplopia). But most of the time high quality standard radiographic projections are sufficient. We have selected five radiographic projections: the occipito-mental's such as Mahoney's or Blondeau or Louisette, the submento-vertical's, the rotated occipito-mental's. For each of these radiographic projections we have specified the angular definition, the realization techniques, the criterions of quality and the results. The use of conventional radiology gives us images of which the quality is high enough to allow a precise topographical diagnosis and is far cheaper than C.T. So we can assert that standard radiographic projections are necessary and sufficient and that the use of C.T. becomes indispensable only in the few cases of diplopia or enophthalmia or complicated maxillary fracture. In the case of a lateral head trauma, our strategy of radiographic exploration will be represented as indicated on picture n degrees 20.

The craniofacial manifestations, together with teleradiographic and cephalometric findings, of Steinert's dystrophy were examined based on a review of the literature and the clinical features of several patients with myotonic dystrophy leading to the diagnosis of Steinert's disease. The prevalence of the functional impairments due to facial deformation varies with the severity of the disease, suggesting early interceptive treatment supported by orthopaedic care and rehabilitation therapy of orofacial functions. Surgery involves bimaxillary osteotomy which can improve mastication and facial morphology. Operative risks should be carefully identified with adequate explorations before surgery.

Trauma to the condylar area is rather frequent and the stomatologist should be capable of performing a standard radiographic exploration. Two incidences performed in the stomatologist's office using a dental tube appear to be essential. The modified Parma and the transorbitary Zimmer incidences are needed for lateral and anteroposterior views respectively. The equipment required for these views are described together with several examples.

The amplitude of buccal opening was limited due to fibrosis of the middle pterygoideus muscle two months after a patient had undergone anaesthesia of the lower dental nerve trunk. Surgery was required. A physiological explanation was attempted based on other cases reported in the literature.

Extensive bleeding is an important complication of dental extractions in haemophiliacs. Based on 26 case reports, the different therapeutic possibilities are discussed. When general or regional anaesthesia is required, protocols can be proposed for coagulation factor supplementation or even treatment with Minirin. In cases with local anaesthesia, substitution is not required. The importance of mandatory local haemostatic measures combined with antifibrinolytic treatment is emphasized.

Case reports of seventeen patients with the Saethre-Chötzen syndrome treated at the Stomatology and Maxillofacial Surgery Clinic, Nantes, France are analyzed, together with clinical and paraclinical signs of this syndrome, included within the framework of the acrocephalosyndactylies. Results of cases reported in the published literature are reviewed and compared with those of the present series. The characteristic craniofacial equilibrium of the Saethre-Chötzen syndrome is discussed, together with findings of a teleradiographic study performed according to Delaire's analysis. A discussion on the differential diagnosis of this syndrome is enlarge to include all acrocephalosyndactylies.

New techniques developed over the last decade use vascularized bone flaps for maxillofacial reconstructive surgery. Indications for use of three recently described flaps (external brachial, fibular, parascapular) are discussed as a function of the regions to be reconstructed. Three clinical cases are presented, each patient having received one type of flap.

The so-called benign lympho-epithelial lesion (BLEL) of the parotid is a rare condition. Its diagnosis is based on histology. For a long time there have been problems with its classification and prognosis: classification since certain cases may be classified as Sjögren's syndrome or as a precursor of the latter, prognosis there may be recurrence, contralateral involvement or progression to non-hodgkin's lymphoma. The authors discuss these factors in 8 cases and propose total parotidectomy with facial nerve preservation as the treatment of choice.

A new non-invasive technique for assessing the efficacy of topical non-steroidal anti-inflammatory drugs (NSAID) in man is proposed. The NSAID are initially applied to the skin under occlusion before inflammation is induced by a methyl nicotinate solution. The inflammatory response is quantified in terms of cutaneous blood flow by a laser Doppler velocimeter (LDV). The efficacy of NSAID preparations is calculated by comparing the responses of the LDV to the methyl nicotinate challenge on the pretreated and the non-treated skin sites. This protocol has been used to investigate the effect of three different NSAID preparations (indomethacin, niflumic acid, palmitoyl collagenic acid) and the influence of the vehicle on the efficacy of indomethacin. The three preparations tested gave positive results but with different amplitudes in response. The efficacy of indomethacin varied with the vehicle used.