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Resume Introduction L’osteotomie de Le Fort I est une intervention de chirurgie orthognathique classique. Les rapports vasculaires des maxillaires exposent a des complications vasculaires graves. Nous avons collige les complications vasculaires des osteotomies de Le Fort I operees dans le service. Nous en decrivons les aspects diagnostiques et therapeutiques et discutons les moyens de prevention. Patients et methode Cette etude retrospective couvre les osteotomies de Le Fort I operees dans notre unite de 1998 a 2007. Les complications vasculaires graves ont ete definies comme des complications hemorragiques ou ischemiques postoperatoires suffisamment severes pour declencher une procedure specifique. Resultats Neuf cent seize dossiers ont ete analyses (39 % d’hommes et 61 % de femmes ; âge moyen : 24,4 ans ; extremes : 13 et 59 ans), Cinq patients ont presente une complication hemorragique grave. Il n’y a pas eu d’accident ischemique. Trois episodes hemorragiques sont survenus dans la phase postoperatoire immediate. Deux episodes hemorragiques sont survenus de maniere retardee, avec un diagnostic angiographique de pseudo-anevrisme. Le traitement a ete une embolisation hyperselective. Discussion Les complications vasculaires des osteotomies de Le Fort I sont rares (0,55 % dans notre serie). Ce sont majoritairement des accidents hemorragiques. La radiologie interventionnelle est la methode diagnostique et therapeutique de choix.

Aim: To compare the outcome of various surgical approaches of orbital decompression in patients with Graves' orbitopathy (GO) receiving surgery for disfiguring proptosis.Method: Data forms and questionnaires from consecutive, euthyroid patients with inactive GO who had undergone orbital decompression for disfiguring proptosis in 11 European centres were analysed.Results: Eighteen different (combinations of) approaches were used, the swinging eyelid approach being the most popular followed by the coronal and transconjunctival approaches. The average proptosis reduction for all decompressions was 5.0 (SD 2.1) mm. After three-wall decompression the proptosis reduction was significantly greater than after two-wall decompression. Additional fat removal resulted in greater proptosis reduction. Complications were rare, the most frequent being worsening of motility, occurring more frequently after coronal decompression. The average change in quality of life (QOL) in the appearance arm of the GO-QOL questionnaire was 20.5 (SD 24.8) points.Conclusions: In Europe, a wide range of surgical approaches is used to reduce disfiguring proptosis in patients with GO. The extent of proptosis reduction depends on the number of walls removed and whether or not fat is removed. Serious complications are infrequent. Worsening of ocular motility is still a major complication, but was rare in this series after the swinging eyelid approach.

Summary Introduction The use of resorbable materials in orthognathic surgery is presently the object of numerous clinical and experimental studies. Their main drawbacks are their lack of rigidity and induced chronic inflammatory reactions. The purpose of this study was to propose and to test an original system of hybrid osteosynthesis associating a single titanium plate with three resorbable plates in Le Fort I osteotomies in the absence of maxillary expansion, or two titanium plates with two resorbable plates in case of maxillary expansion. Methods Our retrospective study concerned 28 patients operated between 2002 and 2005. A clinical follow-up of over one year detected the specific complications of the hybrid system and a cephalometric study analyzed the secondary relapse 5 months after surgery. These results were compared to the literature. Results One case of mobility and a case of instability of the jaw were observed, along with 5 cases of local chronic inflammatory reaction. The radiological results found a secondary sub-clinical relapse. The removal of the titanium material under local anesthesia was performed without difficulties in ambulatory care, which avoided a new hospitalization for the patient and a new general anesthesia. Discussion The hybrid system allowed obtaining a postoperative stability of the jaw comparable to that obtained by the exclusive use of titanium plates with an acceptable morbidity. This method of osteosynthesis combined the advantages of the resorbable material (removal of titanium plates under local anesthesia) and of titanium material (stability of the procedure). However this method requires a good experience of working with resorbable material, a good follow-up, and cooperative patients. These encouraging results urge us to extend the indications to mandibular sagittal osteotomy and to bi-maxillary osteotomies.

Introduction Idiopathic condylar resorption, often fortuitously discovered when performing orthodontic-surgical assessment, is a clinical entity in itself. There is a significant risk of postoperative degenerating and worsening. Is this sufficient to contra-indicate orthognathic surgery? The authors suggest an answer after studying a series of patients. Material and method A retrospective study of 10 consecutive patients was made from July 1999 to October 2004. The preoperative assessment was triple: clinical, radiological and photographic. At least 6 months of occlusal, radiological and morphological stability was observed before any therapy was initiated. A fixed orthodontic set-up was placed and patients were regularly followed by a speech therapist for parafunctions. Stability of the occlusal correction, acquisition of a more harmonious aesthetic profile, and resolution of joint symptomatology were used to define therapeutic success at one year. Results All patients were female. Resorption affected the mandibular side of the joint in all cases and the temporal side in 7 cases. Three types of osteotomies were performed: maxillary (N=1), mandibular (N=5), and bibasilar (N=4). Genioplasty was not systematic. Joint symptoms were resolved in all cases. Postoperative occlusion corresponded to the therapeutic project in 9 cases. All patients were aesthetically improved. Discussion Idiopathic condylar resorption is not a contra-indication for orthognathic surgery. However, this treatment requires meeting and respecting four principles: a minimal delay of 6 months of occlusal, radiological, and morphological stability, an adapted and meticulous surgical technique, early and prolonged parafunction therapy, and a close follow-up of the patients.

Introduction La reconstruction mandibulaire par lambeau de fibula chez l’enfant de moins de 10 ans est difficile du fait du petit calibre osseux et de l’absence de croissance faute de prelevement concomitant de centre de croissance. Observation Les auteurs presentent 2 cas d’enfants ayant beneficie d’un lambeau libre de fibula pour reconstruire une perte de substance interruptrice de la mandibule. Ces 2 patients ont presente des troubles de croissance du greffon fibulaire dans les differents plans de l’espace. Ces deformations ont necessite la realisation de distraction osseuse ou de greffon d’apposition. Discussion La correction de ces troubles de croissance peut faire appel a differentes techniques qui sont discutees – dans le plan sagittal : distraction chirurgicale ; – dans le plan vertical : distraction verticale en U ; – au maximum, realisation d’un second lambeau libre en apposition sur le premier. Les possibilites de transfert d’un centre de croissance sont discutees.

Graves' ophthalmopathy is a complex orbital condition with a controversial pathogenesis. It is the clinical expression of a discordance between the inextensible orbit and hypertrophic muscular and fatty elements within the orbit responding to immunological stimulation. The relationship between the orbital and its content can be improved by surgical expansion which increases the useful volume of the orbit. This procedure can be combined with lipectomy to decrease the volume of the orbital contents. We briefly recall the history of surgical decompression techniques and present our experience with Graves' ophthalmopathy patients.

Introduction Premiere cause des exophtalmies de l’adulte, l’ophtalmopathie basedowienne est une pathologie orbitaire complexe dont la physiopathologie reste un sujet de controverses. Decrite il y a plus de 150 ans, sa presentation clinique extremement heterogene et ses rapports troubles avec l’endocrinopathie qui l’accompagne destabilisent le praticien. Deux formes particulieres de cette pathologie sont a envisager, selon que l’on considere la phase active ou sequellaire de l’ophtalmopathie. Les traitements souvent empiriques et purement symptomatiques proposes aux patients sont le reflet de la profonde meconnaissance des mecanismes de cette pathologie. Materiel et methode Nous presentons l’analyse retrospective d’une serie de 30 patients pris en charge entre 1991 et 2002. Tous les patients presentaient un tableau clinique d’ophtalmopathie basedowienne de gravite variable et ont beneficie du meme geste de decompression orbitaire chirurgicale. Resultats Le stade moyen de l’OB (Classification NOSPECS) des patients au moment de la chirurgie etait de 4,5 (extremes : II-VI). Le stade moyen post-operatoire etait de 2,4 (extremes : 0-5). La comparaison des grades moyens d’OB a montre une amelioration significative de la protrusion oculaire : 1,55 (extremes : 1-2) en post-operatoire contre 2,4 en pre-operatoire. Parmi les patients presentant une neuropathie optique (Stade VI, n = 12), 83 % des patients (10/12) ont presente une normalisation des PEV avec normalisation ou franche amelioration de l’acuite visuelle dans les 3 mois post-operatoires. La diplopie est restee inchangee dans 45 % des cas (5/11), elle s’est amelioree dans 45 % des cas (5/11) et elle s’est aggravee dans 1 cas. La regression clinique de l’exophtalmie, quelle que soit son intensite de depart, a ete notee dans 93 % des cas, a 6 mois post-operatoire. Tous les patients ont presente une amelioration globale de la position de repos des paupieres. Discussion Nous basant sur cette experience clinique, nous analysons l’approche globale de cette maladie a la lumiere des dernieres avancees dans ce domaine, principalement representees par le concept d’activite de la pathologie, veritable guide diagnostique et therapeutique. Enfin, nous montrons l’interet d’une consultation multidisciplinaire reunissant medecin endocrinologue, chirurgien maxillo-facial et ophtalmologiste pour progresser dans la comprehension et la prise en charge de l’ophtalmopathie basedowienne.

Introduction L’osteoradionecrose reste d’actualite avec un traitement qui entraine parfois une perte de substance mandibulaire dont la reconstruction est difficile. Le but de l’etude etait d’evaluer la fiabilite et l’apport des lambeaux osseux dans la reconstruction mandibulaire apres osteoradionecrose. Materiel et methode Cette etude retrospective a concerne tous les patients ayant beneficie d’une reconstruction mandibulaire apres osteoradionecrose entre 1989 et 2002. 25 reconstructions mandibulaires ont ete realisees sur 23 patients : 16 lambeaux de fibula, 5 serrato-costaux, 1 brachial externe, 1condyle femoral interne et 2 lambeaux pedicules de grand pectoral arme. Resultats Il y a eu 2 complications majeures (8 %) avec perte d’un lambeau de fibula et d’un lambeau de condyle femoral interne. Il y a eu 42 % de complications mineures. Il y a toujours eu une amelioration des symptomes et de la qualite de vie. Discussion Le lambeau de fibula apparait etre une technique de choix pour la reconstruction mandibulaire immediate ou differee. Le lambeau serrato-costal a ensuite notre preference comme alternative ou comme lambeau de rattrapage.

Le remodelage condylien est un processus physiologique permettant a l’articulation temporo-mandibulaire (ATM) d’adapter en permanence sa forme et sa structure aux modifications de son environnement biomecanique. Il est base sur l’interaction entre les contraintes mecaniques supportees par l’ATM et les capacites adaptatives du condyle. La chirurgie orthognathique induit des contraintes mecaniques parfois importantes au niveau des ATM, le remodelage condylien physiologique laissant alors la place au phenomene de resorption condylienne. La repercussion condylienne de la chirurgie des maxillaires est un processus complexe, mal elucide, et qui peut prendre des formes cliniques extremement variables. Il s’agit en particulier d’une etiologie reconnue de recidives post-operatoires. La presentation de deux cas cliniques permet de discuter les diverses hypotheses etiopathogeniques de ce processus ainsi que les facteurs predisposants potentiels au phenomene de resorption condylienne apres chirurgie orthognathique.

Introduction La stabilite a long terme des classes III squelettiques severes est rarement evaluee dans la litterature. Nous presentons une etude de 12 patients operes entre juin 1995 et decembre 1997 et basee sur l’analyse de superpositions cephalometriques. Materiel et methode 12 patients operes ont ete revus a long terme. Le sex ratio etait equilibre. Le recul moyen etait de 3 ans et 8 mois. L’âge moyen des patients etait de 23 ans. Tous les cas ont beneficie d’une orthodontie pre et post-operatoire ainsi que d’une chirurgie bimaxillaire associant osteotomie de Lefort I et osteotomie sagittale des branches montantes. L’etude des cas etait basee sur l’analyse de superpositions a partir de traces cephalometriques selon Delaire sur les teleradiographies preoperatoire, postoperatoire precoce et postoperatoire tardive. Nous definissions l’instabilite osseuse par un deplacement superieur a 4 mm. La recidive correspond a une perte du resultat fonctionnel et esthetique. Resultat 4 patients (33 %) presentaient une instabilite osseuse. Tous les cas etaient stables a long terme. Discussion Pour preciser l’origine de l’instabilite osseuse, une etude des principaux facteurs d’instabilite est presentee et discute d’apres les donnees de la litterature.

Introduction Les auteurs presentent l’observation d’une complication a long terme au niveau du site donneur d’un lambeau de fibula preleve pour reconstruire une perte de substance interruptrice de la symphyse mandibulaire. Observation A l’âge de 8 ans (4 ans apres l’intervention), l’enfant a presente une deviation en valgus du tiers distal de la jambe qui a necessite la realisation d’une reconstruction peroniere par prelevement d’une baguette osseuse tibiale osteosynthesee par des broches. Cette intervention a permis de corriger le trouble biomecanique et de retrouver une marche normale. Discussion Les auteurs rappellent les regles a respecter afin d’eviter une deformation du site donneur apres prelevement de fibula chez l’enfant de moins de 9 ans.

Background: Low adherence to treatment in Multiple Sclerosis (MS) has been shown to lead to poor health outcomes. Various strategies to improve adherence have been suggested including educative programs, injection devices and dedicated nurse assistance. Objective: To assess the impact of elements of the patient support program on adherence; to explore disease factors affecting adherence; and to determine whether these factors influence the choices of supportive elements. Methods: A prospective, observational cohort study was conducted. MS patients were eligible if they had switched to Interferon beta-1b (IFNB-1b) between 1 and 3 months prior to inclusion. Data were collected at months 6, 12, 18 and 24 after inclusion. Adherence was defined as completion of both study protocol and medication at 24 months. Patients underwent evaluations of disability, quality of life, depression, and coping styles. Results: A total of 1077 patients from 15 countries were included, of which 61.8% were adherent to IFNB-1b after 24-months. Depression, quality of life and autoinjector devices were baseline predictors of adherence at 24-months. Coping styles did not show to have substantial impact on adherence. Lower quality of life increased the probability of choosing supportive elements. Conclusion: The study showed that the usage of autoinjector devices chosen during the study was the strongest predictor of drug adherence of all the supportive elements tested in this study. (C) 2011 Elsevier B.V. All rights reserved.

Over the years, orthognathic surgery has become a mainstay of maxillofacial surgery and is the object of many publications and oral communications. However, in spite of well-established methodology, disparities still exist in France basically concerning the way orthognathic surgery is performed.In relation with the XXXIXth congress of Stomatology and Maxillofacial surgery, a questionnaire was mailed to 100 French maxillofacial surgeons. Questions dealing with some practical points of orthognathic surgery (condylar positioning, osteosynthesis technique, rate of condylar resorption.) were asked.Overall reply rate was 37%. Condylar positioning was performed empirically in 73% of the cases. Mandibular osteosynthesis was achieved by titanium miniplates alone in 70%. Post-operative condylar resorption rate was about 2%. This survey produced numerous astute comments.This survey highlighted the interest of maxillofacial surgeons for practical aspects of orthognathic surgery including the questions of condylar positioning or osteosynthesis technique. These points are instrumental in achieving high-quality surgical result.