Biomedical subjects
Publications and source records attributed to J Lachard.
TMJ arthroscopy is a little invasive and of poor morbidity procedure of both investigation and treatment of temporomandibular pathology. A highly equipped operating room (double instrumentation) together with fine skill and proper knowledge of arthroscopic joint anatomy can easily prevent the rare complications described (articular, vascular, neurologic and otologic).
In four cases, the authors analyse the medical and legal factors which lead the expert to his conclusions in french law, concerning temporo-mandibular joint dysfunction after whiplash injury indemnification. An uncertain direct link between the injury and the damage together with the patient's dental prior state to the accident, lead to retain an incomplete legal imputability. The compensation awarded to the victim will consist of an overvalued extra-patrimonial damage which will eventually be able to balance a low physiological deficit price.
Arthroscopy is an interesting and enlarging technique that visualise the temporomandibular joint and allows surgical technics such as lysis and lavage, prediscal section, retrodiscal cauterisation, oblic protuberance cauterisation, disc suturing or shavering of the articular surfaces.
Diagnostic arthroscopy is reserved to patients who suffer from internal temporo-mandibular joint derangements resisting to conservative treatments. This technique allows an acute diagnostic approach to the intra-articular lesions of the superior compartment.
In 7 cases of mandibular laterognathia caused by condylar hypertrophy, the authors specify the clinical and teleradiological features in adolescents. They emphasize the inadequacy of lateral teleradiography and of its measurements, and the need for three-dimensional investigation. In adolescents, secondary deformations, either spontaneous or therapeutic, are rare, and the treatment preferred is condylectomy based on the study of casts. The immediate results of this techniques are satisfactory. The long-term consequences on growth and temporomandibular pathology have been studied.
Posterolateral segmentary maxillary impaction osteotomy has a role to play in the treatment of gaps between the upper and lower jaws. It has several advantages, especially an uncomplicated postoperative period and the single-maxillary contention it provides. The indication must be established after an articulator assessment in order to take into account the mandibular protrusion caused by autorotation and to prevent a sagittal shift. Associated marginal glossectomy will frequently be required. Similarly, in case of vertical excess, genioplasty for vertical reduction will improve the facial balance. This technique may also be proposed as "pre-prosthetic surgery" in cases of egression in the premolar and molar areas, for which it has shown excellent results.
With reference to a case reported here, the authors emphasize the importance of reducing the length of the ramus of the jaw in rather exceptional forms of gaps between the upper and lower jaws with an increase in the posterior height of the face. This procedure provides more stable results and the patient's gums are no longer revealed when smiling.
We are yielding a case of recurring melanotic neuroectodermal tumor of infancy situated in the premaxilla, with a very quick evolution, haemorrhage, and which has precociously recurred after surgical removal. This tumor is studied on the paraclinical (CT scan, M.I.R.) and on the histological hand (immunohistochemical and ultra-microscopy). This observation is then compared with those of literature in which we find about 200 cases. The neurocristopathic histogenesis is actually doing the unanimity. The prognosis must now be quite reserved because of the recurrences (one case for six) and the possibility of malignant forms, some with metastasis.
The TMJ arthroscopy is an investigation method reserved for those who does not respond to non invasive treatments. The technical aspects of the puncture and the normal arthroscopic anatomy are studied.
Synovial chondromatosis of the temporo-mandibular joint is a rare and mild disorder. Three cases are reported, one with an histological aspect of chondrosarcoma. The evolution is favourable after removing the loose particles and the synovial tissues.
Trapdoor fractures of the floor of the orbit were first described in 1965 by Soll and Poley. The authors discuss the pathology and pathogenic theories for these lesions and present 8 cases. The diagnosis is essentially clinical and is frequently supported by computed tomography when it is performed rapidly. The surgical procedure is designed to release the herniated tissues by lowering the orbital floor so as not to aggravate the constrictive lesions. These fractures constitute surgical emergencies and their prognosis depends on the nature of the tissues incarcerated.
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Injury to the face as a result of firearm wounds differs as a function of whether the injury was due to a bullet or lead shot. In the first case treatment is usually that of a mandibular or maxillary comminuted fracture and is principally orthopedic. In the case of hunting guns the damage is considerable and requires reconstitution of soft tissue with the use of a distant flap (purely cutaneous or musculo-cutaneous), bone repair, when necessary, being by costal or iliac grafts.
The preferred composite flap is the musculocutaneous flap from pectoralis major for repair of loss of mucocutaneous substance due to cancer or injury. In rare indications the musculocutaneous flap from sternocleidomastoid muscle is used. When loss of bone substance combined with a cutaneous or mucosal defect has to be corrected use is made of the bone-muscle-skin flap from pectoralis major to include the 5th rib, or the bone-muscle-skin flap from sternocleidomastoid to include internal portion of clavicle. Reliability on use of these two flaps has led to their application in surgery for mandibular osteoradionecrosis. In addition to allowing repair of bone continuity, the vascular and cellular capacities of the flap provide colonization and rehabilitation of the borders of lost substance with live tissue, as shown by subsequent bone remodelling. Results of statistical analysis of 50 cases are presented.
Kole's operation combines segmental alveolar osteotomy of lower incisor-canine region with a reduction mentoplasty. The procedure usually provides a reduction in height of mentum, sometimes with an advancement, and involves ablation of an intermediate bone fragment. Ablation of lower border as described by Kole too frequently results in an esthetically poor chin. Insertions of platysma and digastric muscles are untouched. The inferior segmental osteotomy separates the lower incisor-canine region, which is displaced upwards or upwards and backwards after extraction of premolars, displacement being maintained by interposition of bone detached during mentoplasty. A reduction glossectomy is almost constantly associated. The best indication for Kole's operation is anterior gaps with or without proalveoli. It is often combined with segmental or total surgery to maxilla. Results are generally stable, especially after mentoplasty, but from the dental aspect pulp mortifications are not rare.
Results of 104 arthrotomography scans with contrast of temporomandibular joints of 71 patients are used to define normal arthrography criteria (15.4% of cases). Reducible anterior displacements represented 28.8% of cases, non-reducible displacements 40.4%, perforations 12.5% (5.8% associated with a reducible luxation, 6.7% with a non-reducible luxation). The failure rate was 2.9%. Arthrography provides important information on articular morphology and dynamics, the state and position of the meniscus and of the posterior brake, and the state of the joint capsule. Performed by an experienced operator it possesses few complications.
Conventional treatment of osteoradionecrosis of mandible is by antibiotics combined if necessary with a hemimandibulectomy. A method is proposed which reduces bone excision to infected and necrotic tissue while respecting mandibular continuity. The bone remaining is covered by a flap taken from a distant region. Five cases treated in this way are reported. When mandibular continuity has to be interrupted to suppress infected foci, immediate repair is performed using an osteo-musculo-cutaneous flap, and six cases treated by this method are reported. A part from their mechanical covering and reconstructing roles these well vascularized flaps improve vitality of tissues they enclose, including the mandibular bone.
Specific features of Delaire's operation when compared with Rosenthal's inferior pedicle pharyngoplasty are described, and phonetic results obtained in a recent series of 10 patients operated upon using the former procedure reported. The excellence of these results is emphasized.