Speech outcome after intravelar veloplasty

OBJECTIVE

Cleft lip and palate is the main craniofacial malformation in France. Many surgical techniques had been described to restore cleft palate. In this study, we evaluate phonation in a homogeneous series of patient with isolated unilateral non-syndromic cleft lip and palate before (and after) alveolar cleft closure, operated according to our surgical protocol.

METHODS

We included retrospectively 71 patients with isolated non-syndromic unilateral cleft lip and palate (UCLP), operated in our department from 2009 to 2013. All patients underwent the same surgical protocol: modified Millard cheilorhinoplasty (from 5 to 9-month-old); direct hard palatal closure (from 12 to 20-month-old); alveolar cleft closure with cancellous iliac bone graft (from 4 to 6-year-old). The phonation and clinical statute were evaluated before and after alveolar cleft closure. Fistula rate and speech evaluation were recorded.

RESULTS

The rate of oronasal fistula was 12.7%. About phonation, 76% and 86% of patients were competent or borderline competent respectively before and after gingivoperiostoplasty.

CONCLUSION

This surgical protocol provided speech results in patients with isolated unilateral non-syndromic cleft lip and palate. The gingivoperiostoplasty improved the speech intelligibility.

The use of three-dimensional reconstructions of CT scans to evaluate anomalies of hyoid bone in Pierre Robin sequence: A retrospective study

AIM

The aim of the study was to investigate hyoid bone anomalies in patients with Pierre Robin sequence (PRS) compared to the control group, using computed tomography (CT) examination and three-dimensional reconstruction of the hyoid bone and mandible.

METHODS

A retrospective study was performed of patients between birth and 12 months old with isolated PRS (i-PRS) and syndromic PRS (ni-PRS), who had undergone CT examination, and whose results were compared to the control group of the same age. DICOM data was processed to highlight bone tissue. The mandible and hyoid bones were the main targets of the three-dimensional reconstruction. The study outcomes were the analysis of hyoid bone ossification, volume, and position (distance between hyoid and mandibular symphysis). Univariate and multivariate statistical analyses were performed with α=0.05 as level of significance.

RESULTS

The study sample included 29 i-PRS and 21 ni-PRS patients, while 43 infants in the control group. Hyoid ossification was present in 26/50 (52%) PRS patients (14 i-PRS; 12 ni-PRS) but in 31/43 controls (72%). Statistical analysis showed that absence of hyoid ossification was significantly associated with the diagnosis of PRS (P<0.05). Only ni-PRS patients showed a significant reduction of the distance between hyoid and mandible compared to the control group (P<0.001). Hyoid volume was significantly lower only in the ni-PRS group than in controls (P<0.001).

CONCLUSION

I-PRS and ni-PRS patients differ both etiologically and clinically. Ni-PRS patients confirmed their worst clinical condition than i-PRS with severe anomalies of hyoid development, helping for their ontogeny classification.

[Secondary nasal surgery with cleft palates]

Residual nasal deformity in patients with cleft palate remains the main demand of these patients. Performing primary nasal surgery has significantly improved the results. However, it is still often necessary to improve the nasal morphology. Respect of tissues during primary surgery is essential and allows easier secondary corrections. Anatomical reconstruction greatly facilitates the treatment of secondary deformities. Do not hesitate in case of major labionasales sequelae, to make revision, according to the rules of primary surgery, of the entire lip and nose.

Maxillary shape after primary cleft closure and before alveolar bone graft in two different management protocols: A comparative morphometric study

AIM AND SCOPE

Result assessment in cleft surgery is a technical challenge and requires the development of dedicated morphometric tools. Two cohorts of patients managed according to two different protocols were assessed at similar ages and their palatal shape was compared using geometric morphometrics.

MATERIAL AND METHODS

Ten patients (protocol No. 1) benefited from early lip closure (1-3 months) and secondary combined soft and hard palate closure (6-9 months); 11 patients (protocol No. 2) benefited from later combined lip and soft palate closure (6 months) followed by hard palate closure (18 months). Cone-Beam Computed Tomography (CBCT) images were acquired at 5 years of age and palatal shapes were compared between protocols No. 1 and No. 2 using geometric morphometrics.

RESULTS

Protocols No. 1 and No. 2 had a significantly different timing in their surgical steps but were assessed at a similar age (5 years). The inter-canine distance was significantly narrower in protocol No. 1. Geometric morphometrics showed that the premaxillary region was located more inferiorly in protocol No. 1.

CONCLUSION

Functional approaches to cleft surgery (protocol No. 2) allow obtaining larger inter-canine distances and more anatomical premaxillary positions at 5 years of age when compared to protocols involving early lip closure (protocol No. 1). This is the first study comparing the intermediate results of two cleft management protocols using 3D CBCT data and geometric morphometrics. Similar assessments at the end of puberty are required in order to compare the long-term benefits of functional protocols.

[Facial trauma and injury in children]

Facial traumas are common in children but often unconsidered. Facial injury is responsible of impressive bleeding because of the rich vascularization of the face; this bleeding is often underestimated because of the immediate arterial vasoconstriction that is very strong for children. The blood volume is 80ml/kg for a newborn, with a total of 250ml, reaching 70ml/kg at one year of age. The evaluation must be rigorously performed due to the risk of a sudden decompensation. Regarding the wounds, the primary repair must be performed directly neat or optimal in case of damaged tissues. The rule is to keep maximum of the integrity and to limit debridement. Careful repair often requires general anesthesia, especially in young children, to facilitate a perfect joining of the edges and of the mucocutaneous lines. Losses of substance should be treated by directed cicatrization. Flaps are never performed in children as a first intention for reasons developed below. Given the elasticity of the facial skeleton, fractures require a brutal shock to occur, but the clinical signs can be misleading. For instance, too specific and sometimes ignored, fractures can show weakly symptomatic signs : the fractures of the condylar and the orbital floor, with their respective complication that are temporomandibular bone ankylosis and definitive diplopia. Possible children abuse should be suspected in case of different age lesions and discrepancies between the told story and types of injuries. Once the vital urgency is eliminated, the orbital emergency should be first considered in facial traumas within the ophthalmology specialty because wounds and contusions of the globe are often under-evaluated and threaten the vision. The second emergency is the orbital floor fracture in its 'trapdoor' type, specific to the child. Combined with a motionless eye and uncontrollable vomiting, this is the second true urgency because it involves the prognosis of the oculomotricity and requires emergency surgery. Finally, dental trauma should not be overlooked because of their functional and aesthetic consequences. Primary cicatrization is usually rapid but scars remain inflammatory during a long time. The risk of hypertrophy exists in case of contusions and lacerations associated with wounds but also during puberty and in some locations. Age interfere with the result because growth will either improve or worsen the initial result, depending on the location and mechanism. The secondary specialized and prolonged managing and monitoring is capital on the functional, aesthetic and psychological points of view.

[Functional treatment of children subcondylar fractures: An axiographic assessment]

INTRODUCTION

Subcondylar fractures are common in children. Occlusion disorders resulting from these fractures in deciduous or mixed dentition do not have as much impact as in adults due to alveolar adaption possibilities. Functional treatment allows for good functional results, but does not treat the dynamic shortening of the ramus. The objective of this study was to evaluate the axiographic condylar slope changes after subcondylar fracture in children.

MATERIALS AND METHODS

A prospective study was conducted from 2010 to 2015, including all the under-18 patients presenting with a subcondylar fracture. Examination by mean of a Quick Axis axiograph measured the length of propulsion and the condylar inclination on both sides. The main evaluation criterion was the amount of condylar inclination decrease on the fractured side.

RESULTS

Twelve patients (mean age: 10.42; 5-16) were included. Eleven children had a loss of condylar inclination on the fractured side without occlusion disorders at 33.2 months on average (3-144 months) after the initial trauma. Only one patient had symmetric axiographies without loss of condylar inclination on the fractured side.

DISCUSSION

Dynamic shortening of the ramus on the side of the subcondylar fracture is consistent at short and medium terms in children. Surgical treatment may be the solution for avoiding this dynamic disorder of the mandible and should be evaluated.

Anatomical study of the course of the inferior alveolar nerve in craniofacial microsomia using three-dimensional computed tomography: correlation with the Pruzansky classification

Dysmorphogenesis of the mandible complicates assessment of the course of the inferior alveolar nerve in patients with craniofacial microsomia. Our aim in the present study was to correlate the anatomical description of the course with the Pruzansky classification (which indicates the severity of hemifacial microsomia), in the mandibles of 22 affected patients using 3-dimensional computed tomography (CT). We measured the distance between fixed landmarks on the normal and the microsomic sides. The normal sides served as controls. In the group of five patients with type I disease, we found no significant differences between the unaffected and the microsomic side. In the nine patients with Pruzansky type II disease morphological views of the course showed a between-side difference in the length of the bony canal and the height of the mandibular ramus. In the five patients with Pruzansky type III disease, there was no bony canal. Three-dimensional CT analysis may be of value in plotting the course of the inferior alveolar nerve and assisting the surgeon in mandibular osteotomy or distraction osteogenesis.

Intraosseous haemangioma: semantic and medical confusion

The literature is rich in case reports of intraosseous haemangioma, although most of these are actually cases of venous or capillary malformations. To illustrate this confusion in terminology, we present three cases of slow-flow vascular malformations misnamed as intraosseous haemangioma. A retrospective study of children diagnosed with intraosseous haemangioma was conducted. Clinical and radiological data were evaluated. Histopathological examinations and immunohistochemical studies were redone by three independent pathologists to classify the lesions according to the International Society for the Study of Vascular Anomalies (ISSVA) and World Health Organization (WHO) classifications. Three children who had presented with jaw haemangiomas were identified. Computed tomography scan patterns were not specific. All tumours were GLUT-1-negative and D2-40-negative. The lesions were classified as central haemangiomas according to the WHO, and as slow-flow malformations according to the ISSVA. The classification of vascular anomalies is based on clinical, radiological, and histological differences between vascular tumours and malformations. Based on this classification, the evolution of the lesion can be predicted and adequate treatment applied. The binary ISSVA classification is widely accepted and should be applied for all vascular lesions.

[Wiedemann-Beckwith syndrome: a new approach for reduction glossoplasty using Ultracision(®)]

INTRODUCTION

A reduction glossectomy may be complicated by tongue and mouth floor edema and extend the recovery time for a normal tongue function. We performed reduction glossectomy using Ultracision(®), an ultrasonic vibrating device, so as to limit these complications.

TECHNICAL NOTE

We performed a keyhole glossoplasty under general anesthesia. The initial tongue incision was performed with a cold scalpel, then the glossectomy was continued with Ultracision(®) only. We also used CURVED SHEARS(®). We evaluated our preliminary results with 3 patients presenting with Wiedemann-Beckwith syndrome.

CONCLUSION

Ultracision(®) is a useful tool for intra-oral surgery, and should soon be more frequently used. It is an alternative to electrocautery for this type of surgery.

[Orbital congenital nevi: Principles of treatment about 51 cases]

INTRODUCTION

The incidence of congenital nevi is one over 20,000 newborns per year, 14 % of them are located in the head and neck area. Nevi of the orbital region are particularly difficult to handle on the aesthetic and functional side. The objectives of this study were to conduct an analysis of different clinical presentations of congenital nevi of the eyelid orbital region in children to establish a treatment algorithm.

MATERIEL AND METHODS

We realised a bi-centric retrospective study including 51 children with orbito-palpebral congenital nevi. We analysed the different clinical presentations, their treatments and their results.

RESULTS

Nineteen underwent direct suture excision; three a total skin graft; 15 a combination of treatments, among them four underwent tissular expansion and 14 patients were not operated and clinically followed-up. The average follow-up time was 6.6 years. In 33 cases residual nevic area was still present. The postoperative sequelae were: dyschromia (n=17), anatomical deformation of the eye (n=10), nevi outbreaks (n=8), internal canthus deformation (n=5) and ectropion (n=1).

CONCLUSION

The results of our study show that therapeutic abstention is preferred when the aesthetic wrong is accepted by the patient and when there is not a higher risk of malignant degeneration. In order to minimise the risk of postoperative sequelae, we propose a therapeutic algorithm for the management of congenital orbital nevi.

Beckwith-Wiedemann syndrome: growth pattern and tumor risk according to molecular mechanism, and guidelines for tumor surveillance

BACKGROUND

Beckwith-Wiedemann syndrome (BWS) is an overgrowth syndrome associated with an increased risk of pediatric tumors. The underlying molecular abnormalities may be genetic (CDKN1C mutations or 11p15 paternal uniparental isodisomy, pUPD) or epigenetic (imprinting center region 1, ICR1, gain of methylation, ICR1 GOM, or ICR2 loss of methylation, ICR2 LOM).

AIM

We aimed to describe a cohort of 407 BWS patients with molecular defects of the 11p15 domain followed prospectively after molecular diagnosis.

RESULTS

Birth weight and length were significantly higher in patients with ICR1 GOM than in the other groups. ICR2 LOM and CDKN1C mutations were associated with a higher prevalence of exomphalos. Mean adult height (regardless of molecular subtype, n = 35) was 1.8 ± 1.2 SDS, with 18 patients having a final height above +2 SDS. The prevalence of tumors was 8.6% in the whole population; 28.6 and 17.3% of the patients with ICR1 GOM (all Wilms tumors) and 11p15 pUPD, respectively, developed a tumor during infancy. Conversely, the prevalence of tumors in patients with ICR2 LOM and CDKN1C mutations were 3.1 and 8.8%, respectively, with no Wilms tumors.

CONCLUSION

Based on these results for a large cohort, we formulated guidelines for the follow-up of these patients according to the molecular subtype of BWS.

[Prenatal diagnosis of cleft lip with or without cleft palate: retrospective study and review]

OBJECTIVES

To evaluate the management of prenatally diagnosed cleft lip with or without cleft palate and the immediate postnatal outcome.

MATERIAL AND METHODS

Retrospective study of all cases of cleft lip with or without cleft palate referred to our fetal medicine unit, between January 2005 and January 2011. The anatomical type of cleft, associated malformations, and the postnatal outcome were reviewed.

RESULTS

Forty-three cases of fetal cleft lip with or without cleft palate were reviewed. The mean gestational age at diagnosis was 24 weeks ± 4. The postnatal distribution of clefts was: 30 cleft lip and palate (70%) and 13 cleft lip (30%). The prenatal diagnosis of the cleft type was exact in 27 cases (62.8%). Nine cases had associated anomalies (21%), detected prenatally in three cases (37.5%). There was no karyotypical abnormality. Six pregnancies were terminated (14%). The immediate postnatal outcome was comparable with unselected newborns.

CONCLUSION

The prenatal diagnosis of cleft lip with or without cleft palate is correct, with two thirds of exact diagnoses. Large clefts palate are the best detected. Associated malformations cannot always be diagnosed by prenatal ultrasound, but have to be searched for because they modify the fetal outcome.

[Pediatric keratocystic odontogenic tumor and nevoid basal cell carcinoma syndrome. Predictive factors for recurrence and aggressiveness]

INTRODUCTION

Keratocystic odontogenic tumors (KOT), as complications in Nevoid Basal Cell Carcinoma Syndrome (NBCCS), occur early (before 20 years of age) and are usually more aggressive. The aim of this retrospective study was to determine the clinical, histological, and genetic phenotype, of these lesions and to define predictive features of aggressiveness.

PATIENTS AND METHODS

We retrospectively studied five patients presenting with one or several KOT with NBCCS. We collected their clinical, radiological, and therapeutic data, rate of recurrence or new localization. Anatomopathological examinations were reviewed systematically. Somatic PTCH, SMO and SMAD 4 sequencing were completed.

RESULTS

The average age at diagnosis was 11.2 years. The average number of KOT was 3.2 most often located in the molar region. All the cysts were enucleated. Anatomopathological examination revealed the presence of satellite cysts and daughter cysts and epithelial expansion in more than 80% of cases. No somatic mutation was observed among KOT.

DISCUSSION

KOT develop in the first 10 years, in patients presenting with NBCCS, and recurrence is observed in the second and third decade. KOT are typically aggressive and have a tendency to recur, especially in patients with NBCCS. Anatomopathological examination may be predictive of the lesion's aggressiveness. Understanding the genetic and immunological mechanisms should open the way for new medical treatment.

[Children orbital floor fracture: retrospective study, about 34 cases]

INTRODUCTION

Orbital fractures represent 30 % of children facial fractures. Nausea and vomiting are more predictive of entrapment than local trauma stigmatisms. Entrapment and diplopia are more frequent in adults. Delay for surgery is unclear in literature varying from 6 hours to days. The aim of this study is to summarise the aspects of orbital floor fractures in children with regard to clinical and radiological presentation, management, and outcomes.

PATIENTS AND METHODS

We conducted a retrospective study including 34 children presenting isolated orbital floor fracture. Clinical, radiological, ophthalmological, surgical data and outcomes were analyzed.

RESULTS

Mean age was 9.4 years. In 15% of cases, no local stigmatism of trauma was present. Entrapment fracture was the most frequent, with 81% of fat or muscles entrapment. In all, 27% of the patient had residual diplopia. Residual diplopia developed after trap-door fracture with muscle entrapment and a more than 24 hours delay for surgery.

CONCLUSION

Trap-door fracture is frequent in childhood population. Clinical diagnosis can be difficult. However, surgical treatment should be considered before 24 hours to avoid complication as residual diplopia.

[Cutaneous and mucosal graft for labial defect after animal bite in children]

Animal bite is frequently involved in children labial defect. The need for labial surgical repair is to restore anatomy and function. Local and regional flap is usually described for labial reconstructions. Few authors recommend mucosal and skin graft. In the present study, we described skin and mucosal graft for reconstruction of complex labial defect. This surgical technique can be applied in very young children with reasonable expectations of excellent functional and aesthetic outcome.

[Congenital epulis: refrain from surgery. A case report of spontaneous regression]

INTRODUCTION

Congenital epulis is a rare benign tumor that originates from the mucosa of the dental alveolar ridge. Management of congenital epulis is unclear; most authors recommend surgical excision during infancy.

CASE REPORT

We report a case of congenital epulis arising from the anterior mandibular region that was managed conservatively. This epulis did not interfere with breast-feeding or respiration. Subsequently, there was spontaneous involution of the lesion during the 1st year of life.

CONCLUSION

Small and medium congenital epulis (<20mm) exceptionally compromises feeding and might regress spontaneously. Subsequently, conservative treatment should be adopted. Surgical treatment should be indicated only when major feeding or respiratory problems are present or when the clinical diagnosis is uncertain.

Binder phenotype: clinical and etiological heterogeneity of the so-called Binder maxillonasal dysplasia in prenatally diagnosed cases, and review of the literature

OBJECTIVE

Prenatal Binder profile is a well known clinical phenotype, defined by a flat profile without nasal eminence, contrasting with nasal bones of normal length. Binder profile results of a hypoplasia of the nasal pyramid (sometimes referred to as maxillonasal dysplasia). We report 8 fetuses prenatally diagnosed as Binder phenotype, and discuss their postnatal diagnoses.

METHODS

Ultrasonographic detailed measurements in 2D and 3D were done on the 8 fetuses with Binder profile, and were compared with postnatal phenotype.

RESULTS

All fetuses have an association of verticalized nasal bones, abnormal convexity of the maxilla, and some degree of chondrodysplasia punctata. The final diagnoses included fetal warfarin syndrome (one patient), infantile sialic acid storage (one patient), probable Keutel syndrome (one patient), and five unclassifiable types of chondrodysplasia punctata.

CONCLUSION

This series demonstrates the heterogeneity of prenatally diagnosed Binder phenotype, and the presence of chondrodysplasia punctata in all cases. An anomaly of vitamin K metabolism, possibly due to environmental factors, is suspected in these mild chondrodysplasia punctata. We recommend considering early prophylactic vitamin K supplementation in every suspected acquired vitamin K deficiency including incoercible vomiting of the pregnancy.

Maxillary and mandibular distraction osteogenesis in growing patients: lessons learned after 14 years and update on indications

In the past decade, distraction osteogenesis (DO) has become increasingly popular and has opened new therapeutic perspectives for the treatment of numerous congenital and acquired craniofacial skeletal anomalies. However, DO mechanisms still remain unclear and different treatment protocols are applied by different groups. Here the authors use their 14 years-clinical experience to evaluate DO parameters such as maxillary and mandibular DO stability over time, especially in growing patients, DO effects on soft tissues and the correlation between the bone gain and lengthening capabilities of the device. Based on these data, clinical indications and treatment protocols for mandibular and maxillary DO are suggested. The application of DO to the membranous bones of the craniofacial skeleton has opened a new chapter in the surgical treatment of several congenital and acquired craniofacial deformities. Based on this experience, the authors recommend DO indications guidelines in selected cases of hemifacial microsomia, maxillary hypoplasia and narrow mandible with anterior dental crowding.

Les séquelles maxillaires dans les fentes labioalvéolopalatovélaires. Place de la distraction ostéogénique

A high rate of cleft patients present with maxillary hypoplasia. Most of the growth defects concern the anteroposterior axis of the maxilla. Before bone lengthening by distraction osteogenesis, orthognathic surgery was the only alternative treatment for maxillary hypoplasia. Several studies showed the lack of stability after conventional surgery. In this article reviewing the literature concerning all bone lengthening procedures, the authors discuss published data on maxillary distraction osteogenesis by external and internal devices. Indications of distraction in growing children as an interceptive step are discussed.

Les séquelles vélopharyngées des fentes labioalvéolopalatovélaires. Les pharyngoplasties dynamiques types orticochea

Sphincter pharyngoplasty is one of the treatments for velopharyngeal insufficiency, in cleft palate patients. After Hynes, Orticochea described a procedure which became the reference. After studying 2 series of patients treated by two different surgical procedures, it appeared that the speech improvement was nearly the same. Improvement of the results was obtained when the surgical procedure took into account the physiopathology of the velopharyngeal insufficiency. When the velar mobility was weak or absent, but with an effective mobility of lateral pharyngeal walls, a pharyngoplasty with a pharyngeal flap and a superior pedicle was chosen. On the opposite, with an effective velar mobility, sphincter pharyngoplasty was chosen. When both were poor (velar and lateral pharyngeal walls), it seems that using a pharyngeal flap with a velum pushback gave the best result. If hypernasality persisted after pharyngoplasty, a second procedure had to be performed.

Les séquelles vélopharyngées dans les fentes labioalvéolopalatovélaires. Véloplasties et pharyngoplasties par lambeau pharyngé à pédicule supérieur ou inférieur

Velopharyngeal insufficiency remains a sequel of labial-alveolar-velopalatine clefts. It may occur despite a good quality primary repair. A surgical management must be considered as soon as speech therapy is no longer efficient or before any irreversible compensatory speech pattern appears. Thus, surgery should be decided on after consultation between the surgeon and the speech pathologist or speech therapist, when considering that speech therapy has failed. Several surgical techniques are discussed: intravelar veloplasty, Furlow double-opposing Z-plasty, pharyngoplasty using an inferior or superior pedicle flap. Superior pedicle flap surgery is currently the most commonly used technique. For the past twenty years we have used this technique as described by Petit and modified by Malek, because of the excellent speech results. The drawbacks are known and can be contained by a preventive management.

[Maxillary sequelae in cleft patients. Causes of maxillary hypoplasia and possible prevention]

Maxillary hypoplasia is frequently observed in cleft patients. Although maxillary retrusion can be a syndromic outcome, the growth failure is also a consequence of the primary surgery of the palate, alveolar cleft, or lip. In this article the authors analyze the impact of primary surgery on the maxillary growth failure and discuss on how to prevent this complication.

Diagnostic anténatal des RICH (rapidlyinvoluting congenital hemangiomas)

INTRODUCTION

Since 1996, vascular anomalies are classified either as tumors or malformations. Infantile hemangioma is the most common vascular tumor. It is an endothelial cellular proliferation, stimulated after birth (10th day) which then slow involves. Congenital hemangioma is a different kind of hemangioma develops prenatally appearing fully grown at birth. Rapidly involuting congenital hemangioma (RICH) generally involutes spontaneously while non involuting congenital hemangioma (NICH) usually requires a surgical procedure. The clinical and radiological aspects of these two tumors differ significantly at birth. Most congenital hemangiomas detected at antenatal ultrasonography, due to their cephalic localization and their size (up to 10 cm) are RICH.

MATERIAL AND METHODS

We report on five vascular tumors detected in utero during the second and third trimesters, and after birth.

RESULTS

There were three boys and two girls. The average size of the RICH was 5 cm (1.8-10 cm). Four were cephalic and one on a lower limb. A doppler examination was available in three patients, and showed fast-flow in two. Prenatal magnetic resonance imaging was available in three patients.

DISCUSSION

The diagnosis of RICH can be suspected on the antenatal ultrasonography. Fast-flow on the doppler examination confirms the diagnosis. It is advisable to repeat the ultrasonography every two to four weeks to reevaluate the possibility of delivery and the fetal cardiac status. In the event of a prenatal vascular tumor the differential diagnosis also includes other congenital tumors. Magnetic resonance imaging would be indicated if there is any doubt about malignancy. Regular follow-up is necessary during the first months to confirm the diagnosis. RICH regress rapidly while the size of malignant tumors increases. A biopsy is necessary to obtain histopatholgical proof.

La chirurgie du cuir chevelu de l’enfant : principes et particularités thérapeutiques

Surgical treatment of the lesions of the scalp in children has specific objectives: excision of an extensive lesion using minimum operative procedures, hiding scar in the hair, correcting a wide and ungraceful scar. We reviewed our experience of 450 cases (1990-2000), and found that most common lesions in childhood were: sebaceous hamartoma, pigmentary naevus, post traumatic alopecia, aplasia cutis congenita and complicated hemangiomas. Different surgical procedures are discussed: excision, tissue expansion, hair grafts. Large excision can be performed before three months of life because of the good laxity of the scalp. Tissue expansion is particularly suited to the scalp. Aplasia cutis congenita is a special condition, with local vascular abnormalities: local flaps are prohibited. Hemangiomas may require early surgical treatment in the event of complications.

Animaux domestiques et accidents chez l'enfant

Young French children have 45,000,000 domestic pets, cats and dogs being widely prevalent (40%). Injuries due to domestic animals, especially bites, in particular from dogs, represent 1.9% of all children's injuries. On the quality of first aid in the field, i.e., whether the treatment is the first line in surgical specialized service or not, if it is a vital emergency, will depend the possibility of immediate complications, which include local superinfection (15%), functionals and further aesthetic sequelae. Some injuries due to large animals carry a polytraumatism, which should be treated like all polytraumatisms, whatever the aetiology. Learning to know and respect animals and their needs should remain the priority of families to avoid unexpected injury. Families also need to take charge of the responsible animal.

Amblyopie et hémangiome orbito-palpébral capillaire chez le jeune enfant : dépistage et évolution pré et post-chirurgicale

PURPOSE

The analysis of visual complications provoked by infantile periocular hemangiomas and the understanding of their evolution before and after surgery.

MATERIAL

and methods: A retrospective study including 30 children (31 eyes) who were operated for a periocular hemangioma with a surgical technique with the aid of ultrasonic scalpel Cavitron. Ophthalmological evaluation before and after surgery included: appreciation of the palpebral occlusion, strabismus, ocular motility, objective refraction and amblyopia.

RESULTS

Surgical operation was performed within an average age of 9.5 months. The excision of periocular hemangiomas was effective on the release of the visual axis and on the amblyopia: 51.7% (16 eyes) of palpebral occlusion before surgery against 6.4% (2 eyes) after surgery and 77.4% (24 eyes) of amblyopia before surgery against 38.7% (12 eyes) after surgery. The anisometropia decreased after surgery. The ocular motility and the strabismus also improved.

CONCLUSION

Surgical excision of periocular hemangiomas with the aid of ultrasonic scalpel is an effective technique presenting few complications. This surgery can be suggested early in infancy. It has a very good result in the release of the visual axis and the astigmatism which aided the reeducation of the amblyopia.

FOXC2 truncating mutation in distichiasis, lymphedema, and cleft palate

We report a family showing autosomal-dominant segregation of upper- and lower-eyelid distichiasis (double row of eyelashes) in seven affected relatives over three generations, in addition to below-knee lymphedema of pubertal onset (lymphoedema proecox) in three. Two children had cleft palate in addition to distichiasis, but without the previously reported association with the Pierre-Robin sequence. Other ophthalmologic anomalies included divergent strabismus and early-onset myopia. This family was found to be completely linked to markers mapped to 16q24.3 and thereby proposed to be allelic to the distichiasis-lymphedema syndrome (DL, MIM 153400), although pterygium colli, congenital heart disease, or facial dysmorphism were not features found here. As FOXC2/FKLH14 mutations were found to underlie DL and diverse hereditary lymphedema conditions, this gene was examined by sequence analysis. An out-of-frame deletion (914-921del) was identified and found to segregate with the disease, further highlighting the phenotypic heterogeneity of lymphedema conditions linked to FOXC2 truncating mutations. Whether such heterogeneity is related to genotype-phenotype correlation, a hypothesis not primarily supported by the apparent loss-of-function mechanism of the mutations, or governed by modifying genes, remains to be determined.

[Angiomatous lips]

After defining vascular malformations and tumors, the authors approach specific problems of these lesions involving the lips. Careful planning and assessment are necessary throughout the clinical course and evolution. Therapeutic management concern the vascular anomaly but the functional, cosmetic and psychological repercussions as well. The rules of surgical treatment are discussed in this labial location. Capillary malformations can be treated by pulsed dye laser for the skin involvement, but sometimes by reconstructive surgery in case of soft tissue and bony overgrowth. Venous malformations require percutaneous sclerotherapy, partial or total removal surgery, reconstructive surgery, with or without previous embolization, according to the size and functional repercussions. Lymphatic malformations involving the lip are based upon conservative and observing treatment or surgery according to impairment and psychological impact. There is a strong tendency for these lymphatic microcystic malformations to invade and to recur after surgery. The new lasers (diode, Nd Yag) have to be assessed in this area. Arterio-venous malformations are the most severe anomaly. When the lesion is cosmetically and functionally acceptable, the authors propose conservative management waiting for therapeutic progress expected from genetics research. Otherwise management require embolization and complete surgical treatment with lip reconstruction. The first-line treatment of hemangiomas is medical and pharmacological (local medical care, corticosteroids, interferon, vincristine) but surgery may be indicated in three situations. In urgent cases with severe complications surgery is performed after failure of medical management. Early surgery is recommended to prevent functional or cosmetic disturbance or serious psychological distress. Ultrasound dissection (Dissectron) an significantly contribute to the surgical outcome. Late surgery retains its classical cosmetic and functional indications and techniques to treat the residual after-effects. Three key-words dominate the rules of therapeutic management of all types of vascular anomalies: multidisciplinary approach, experience and carefulness.

Melanotic neuroectodermal tumour of infancy involving the orbit and maxilla: surgical management and follow-up strategy

Melanotic neuroectodermal tumour (MNET) of infancy is a rare benign but locally aggressive tumour. We describe our surgical treatment of MNET of the orbital region. There was osteogenic relapse involving the bone of the orbit, 20 days after macroscopically complete excision of the primary tumour when the patient was 12 weeks old. This is only the second report of osteogenic relapse in MNET. The relapse was treated by excision of the involved orbital floor, preserving the orbital periosteum. The tumour has not recurred in 23 months of follow-up. Residual tumour islets may regress spontaneously after incomplete excision of MNET, but the relapse rate is between 15% and 45%. In our opinion, excising a safety margin of a few mm of apparently healthy bone reduces the risk of relapse. In contrast, the orbital contents should be preserved if they are macroscopically normal. Follow-up consisted of frequent physical examinations and CT scans.

[Early surgery of immature hemangiomas with the aid of an ultrasonic scalpel. Apropos of 81 cases]

BACKGROUND

The natural course of immature hemangiomas in infants is well-known. A rapid phase of growth from 6 to 8 months is followed by a period of stability then regression. Since approximately 70% of these immature hemangiomas resolve spontaneously, abstention is generally the rule. The volume or localization of certain lesions may nevertheless have a serious functional or morphological impact.

MATERIAL AND METHODS

This retrospective study included 81 children who underwent surgery between October 1994 and March 2000. The children were aged 2 to 38 months at the time of surgery. Orbital localizations predominated (33 children). The indication for surgery was based on two criteria: risk of a functional impairment or risk of morphological sequela. All children with orbital hemangiomas with a functional risk of amblyopia were initially treated with corticosteroids. Surgery was performed in case of failure. The CAVITRON was used for 77 children and DISSECTRON for 4. These two ultrasound devices allowed easy dissection with little hemorrhage.

RESULTS

There were no peroperative hemorrhagic complications. Few postoperative complications were observed. After resection of the orbital hemangiomas there was little functional impact and the postoperative ophthalmologic examinations were normal within several weeks. Mean follow-up was 12 months after surgery. Use of an ultrasound dissector allowed early and safe treatment of immature hemangiomas.

DISCUSSION

Certain voluminous or poorly localized hemangiomas, particularly on the face, can have a serious function, morphological or psychological impact. Medical treatment is not always active and surgical resection may be required before the development of definitive sequelae. Ultrasound dissection, not previously used in this indication, can contribute significantly to the surgical outcome as demonstrated in these children operated on early. This technique is safe and shortens operative time. In light of these results, we believe early resection of immature hemangiomas should be reevaluated. It should not be considered as a last resort but rather as a complementary treatment.

Possible relationship between the van der Woude syndrome (vWS) locus and nonsyndromic cleft lip with or without cleft palate (NSCL/P)

Cleft lip with or without cleft palate (CL/P) is one of the most common congenital malformations in humans occurring with a birth prevalence of approximately 1:1,000. CL/P may be part of a defined syndrome, sequence or association, although most individual or familial cases present as an isolated (nonsyndromic) malformation (NSCL/P). Inheritance is generally regarded as multigenic although, in some families, NSCL/P seemingly segregates as a monogenic trait. On the other hand, van der Woude syndrome (vWS) is a rare autosomal dominant with cardinal features of lower-lip pits (LLP) and CL/P or cleft palate (alone). Since none of these traits is present in all mutation carriers, some individual or familial vWS cases, especially those lacking LLP, are indiscernible from NSCL/P, raising the question whether allelic variation at the vWS locus could underlie NSCL/P. This question was addressed using parametric linkage (LOD score) analysis in 21 multiplex NSCL/P families based on a tightly linked microsatellite marker (D1S3753), and nonparametric analysis using the transmission/disequilibrium test (GTDT) in 106 NSCL/P triads and selecting markers D1S205, D1S491, and D1S3753. No evidence for linkage of NSCL/P to vWS was found on the 21 families using the LOD score approach. In contrast, TDT yielded a significant P value of 0.04 for D1S205, supporting involvement of vWS in NSCL/P in a complex, modifying/polygenic manner rather than as a monogenic/major disease locus.

[Oto-mandibular dysplasias: genetics and nomenclature of syndromes]

Otomandibular dysplasia are characterised by a combination of anomalies of the ear and the mandible. From the surgical point of vue, facial dysostosis is prominent and focus the attention. For the geneticist it is a group of different entities, familial or sporadic. Familial history, detailed clinical examination looking for extra-facial associated malformations, characteristics of the facial dysostosis, unilaterality or bilaterality and biological or radiological findings allow sometimes to identify a known syndrome. A bilateral and symetric dysostosis with predominant zygomatic and malar hypoplasia suggest the diagnosis of Treacher-Collins or Franceschetti syndrome or mandibulofacial dysostosis, particularly in the presence of positive familial history. Acral anomalies associated with facial dysostosis allow the distinction between Treacher-Collins syndrome and acrofacial dysostosis (Nager and Miller syndromes). Unilateral and bilateral asymmetrical anomalies, namely facioauriculovertebral syndrome, hemifacial microsomia, otomandibular dysostosis, no. 7 cleft, first branchial arch syndrome, Goldenhar syndrome were lumping together by Gorlin in 1990, who proposed to use the term "oculoauriculovertebral spectrum". This classification is the first step before genetic studies, who need homogeneous group of patients. Lastly recurrence risk can be evaluated and genetic counselling can be done only if a precise genetic diagnosis is known.

[Hemifacial microsomia treated with mandibular lengthening using intraoral distractors. On precise indications]

Mandibular hypoplasia in the hemifacial microsomia have largely benefited from distraction techniques especially intraoral. In fact, these techniques are possible in the child, replacing him in a better morphological, psychological and functional configuration. They can redynamise growth and, in any case, diminish secondary distant effects. The authors, from precise criteria, propose a surgical classification to facilitate the therapeutic decision. Intraoral and sometimes bidirectional distraction, whose results are equivalent to external distraction, present numerous advantages that, in the majority of cases, make it preferred now to external distraction. Its three-dimensional (3D) effect on bone and soft tissues and the long term follow-up must be evaluated more objectively, as pre and post-distraction stereolithographic or 3D photogrammetric may get. It must be considered in the child as the first step of skeletic surgery preparing to a facilitated second step orthopedic, orthodontic or orthognathic after puberty. In the young adult, it is in competition with conventional surgery but the slow progressive process, kind with the temporo-mandibular joints, allows in mandibular asymmetries an adaptation having avoided the need for controlateral osteotomy or a bone graft.

Pierre Robin sequence and interstitial deletion 2q32.3-q33.2

Pierre Robin sequence (PRS) consists of the nonrandom association of micrognathia, cleft palate (CP), and glossoptosis. It also includes respiratory and feeding difficulties that appear to be neurogenic rather than mechanical in causation. Genetic determinants are thought to underlie this functional and morphological entity, based on the existence of Mendelian syndromes with PRS, and the rare observations of familial nonsyndromic PRS, in which some of the affected individuals have isolated CP. We report the association of PRS with deletion 2q32.3-q33.2 due to an unbalanced reciprocal translocation 46,XX, t(2;21), del 2(q32.3q33.2), and we refine the deletion interval with regard to YAC probes and polymorphic DNA markers. The deletion was shown to be flanked by D2S369 (telomeric) and D2S315 (centromeric), thus it maps to a recently determined chromosomal region known to be nonrandomly associated with CP. This observation supports the hypothesis for the genetic bases of nonsyndromic PRS, strengthens its possible genetic association with isolated CP, and provides a candidate PRS locus, in chromosomal region 2q32.3-q33.2.

[Mandibular advancement: osteotomy or distraction osteogenesis? A case report]

From an experience in osteogenic distraction techniques acquired since 1993 and facing a case of retromandible, the authors have tried to define the criteria leading them to suggest a distraction rather a classical surgical procedure. The selection of the patient is based upon the age, the significance of the advancement, the asymmetry of the advancement and the former existence of a temporomandibular joint degenerative disease. Monitoring the distraction, in particular with per- and post-distraction orthodontics, remains complicated. The overcorrection and the reduction of recurrences after advancement using distraction remain openly discussed.

"Distraction" of grafted alveolar bone in cleft case using endosseous implant

OBJECTIVE

Presentation of a specific surgical technique of vertical alveolar ridge distraction performed on an alveolar bone graft 1 year after the primary grafting procedure designed to correct a labioalveolar cleft. The graft had not obtained the results desired and presented heavily scarred mucosal tissue.

TECHNIQUE

A dental implant placed within the graft once it has been entirely freed by osteotomies functions as an endless screw. To avoid vascular risk, the alveolar bone graft is detached as a whole along its total height. Consequently, no bone remains above it to provide support for a conventional alveolar distractor. An osteosynthetic miniplate, fastened in a horizontal position beneath the nasal mucosae above the graft, is used to replace the missing bony support and to stabilize the implant, which activates the distraction process.

PATIENT

This study is based on our first clinical case with a follow-up of 18 months at present.

RESULT

A vertical displacement of the entire graft was achieved, including its attached mucosal layer, which repositioned both bone and mucosa on a far better level in the cleft area. Thus, a normal length of abutment was obtained permitting prosthetic rehabilitation based on the same endosseous implant, which was left in place within the graft.

CONCLUSION

This technique may prove particularly helpful in certain cases in which a primary alveolar bone grafting procedure has produced borderline results. In such cases, on the one hand, neither the reasonably satisfactory volume of the bone graft itself nor the poor quality of its scarred mucosal tissue argue in favor of a secondary grafting procedure. On the other hand, it is impossible to resort to currently available alveolar distracters since our choice of techniques leaves no bone support above the graft.

Analysis of the methylation status of the KCNQ1OT and H19 genes in leukocyte DNA for the diagnosis and prognosis of Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS) is an overgrowth disorder involving developmental abnormalities, tissue and organ hyperplasia and an increased risk of embryonal tumours (most commonly Wilms tumour). This multigenic disorder is caused by dysregulation of the expression of imprinted genes in the 11p15 chromosomal region. Molecular diagnosis of BWS is currently difficult, mostly due to the large spectrum of genetic and epigenetic abnormalities. The other difficulty in managing BWS is the identification of patients at risk of tumour. An imprinted antisense transcript within KCNQ1, called KCNQ1OT (also known as LIT1), was recently shown to be normally expressed from the paternal allele. A loss of imprinting of the KCNQ1OT gene, associated with the loss of maternal allele-specific methylation of the differentially methylated region KvDMR1 has been described in BWS patients. The principal aim of this study was to evaluate the usefulness of KvDMR1 methylation analysis of leukocyte DNA for the diagnosis of BWS. The allelic status of the 11p15 region and the methylation status of the KCNQ1OT and H19 genes were investigated in leukocyte DNA from 97 patients referred for BWS and classified into two groups according to clinical data: complete BWS (CBWS) (n=61) and incomplete BWS (IBWS) (n=36). Fifty-eight (60%) patients (39/61 CBWS and 19/36 IBWS) displayed abnormal demethylation of KvDMR1. In 11 of the 56 informative cases, demethylation of KvDMR1 was related to 11p15 uniparental disomy (UPD) (nine CBWS and two IBWS). Thirteen of the 39 patients with normal methylation of KvDMR1 displayed hypermethylation of the H19 gene. These 13 patients included two siblings with 11p15 trisomy. These results show that analysis of the methylation status of KvDMR1 and the H19 gene in leukocyte DNA is useful in the diagnosis of 11p15-related overgrowth syndromes, resulting in the diagnosis of BWS in more than 70% of investigated patients. We also evaluated clinical and molecular features as prognostic factors for tumour and showed that mosaicism for 11p15 UPD and hypermethylation of the H19 gene in blood cells were associated with an increased risk of tumour.

Assessment of p57(KIP2) gene mutation in Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome (BWS) is an overgrowth disorder involving developmental anomalies, tissue and organ hyperplasia and an increased risk of embryonic tumours (most commonly Wilms' tumour). This multigenic disorder is caused by dysregulation of the expression of imprinted genes in the 11p15 chromosomal region. It may involve paternal uniparental disomy (UPD), loss of imprinting of the IGF2 gene, maternal inherited translocations and trisomy with paternal duplication. Recently, a small proportion of BWS patients has been shown to have a mutation in the paternal imprinted p57(KIP2) gene, which encodes a cyclin-dependent kinase inhibitor and negatively regulates cell proliferation. We screened for p57(KIP2) gene mutations in 21 BWS patients with no 11p15 UPD in leucocyte DNA. All patients had a phenotype typical of BWS. We analysed the entire coding sequence of p57(KIP2), including intron-exon boundaries, by direct sequencing of five PCR-amplified fragments. No mutation was found in the p57(KIP2) gene. Our results are consistent with those of previous studies showing that mutation of p57(KIP2) is infrequent in BWS. Thus, other mechanisms of p57(KIP2) silencing (imprinting errors) and/or other 11p15 genes are probably involved in the pathogenesis of BWS.

[The Wiedemann-Beckwith syndrome and a congenital cataract]

Wiedemann-Beckwith syndrome is a congenital syndrome with characteristic abnormalities: omphalocele, macroglossia, neonatal gigantism, visceromegaly, hemihypertrophy and a predisposition to embryonic tumors. Ophthalmologic abnormalities have not been described with Wiedemann-Beckwith syndrome. The authors report one case of Wiedemann-Beckwith syndrome associated with bilateral congenital cataract. Family studies indicate linkage of the Wiedemann-Beckwith syndrome locus to the marker 11p15,5. The genetics of cataract is heterogenic. Several mutations responsible for congenital cataract have been described. The association of the Wiedemann-Beckwith syndrome and cataract may contribute to the understanding of the genetics of congenital cataract.

Neurophysiological brainstem investigations in isolated Pierre Robin sequence

Polysomnography, electromyography (EMG) of the face, tongue, and soft palate, blink reflexes (BRs), EMG during bottle-feeding, and brainstem auditory evoked responses (BAERs) were performed in 25 newborn babies with isolated Pierre Robin sequence (PRS) to aid in evaluation and management. Obstructive apneas were found in 23/24 patients (the 25th having undergone tracheotomy). Number and duration of central respiratory pauses were always normal, as well as electroencephalographic and clinical organization of sleep stages. EMG recruitment pattern in facial and lingual muscles, and BRs were normal in all cases. EMG recruitment pattern in muscles of the soft palate was normal in 14/25 patients, showed a reduced average amplitude with short-duration and low amplitude motor unit potentials in 10/25, and showed signs of denervation in 1/25. EMG during bottle-feeding showed sucking-swallowing disorders in 20/25 patients. BAERs showed a bilateral conductive impairment with increased latencies and thresholds in 5/19 patients, but with normal and symmetric I-III and I-V interpeak latencies in 19/19. These neurophysiological findings suggest that in isolated PRS a dysfunction of the lingual and pharyngeal motor organization exists without any structural impairment in brainstem nuclei and pathways.

Functional analysis of the intergenic regions of TcP2beta gene loci allowed the construction of an improved Trypanosoma cruzi expression vector

TcP2beta ribosomal protein genes in Trypanosoma cruzi are encoded by four different loci, H6.4, H1.8, H1.5 and H1.3. All loci have a similar organization, except for H1.8 that harbors two TcP2beta genes arranged in tandem and separated by a short repetitive sequence, named SIRE (short interspersed repetitive element), which is also found upstream of the first gene of the tandem and downstream of the second. In this locus the trans-splicing signal of TcP2beta is located within the SIRE element, while in the other loci it is positioned within the first 50bases upstream of the AUG with an AG acceptor site at position -12 respective to the initiation codon. Transient transfection experiments were used to evaluate the efficiency of these two different trans-splicing regions to drive CAT activity. The region named HX1 located upstream the TcP2beta H1. 8 gene was clearly more efficient than the SIRE sequence contained in the region named HX2. Therefore, we decided to use the HX1 region to ameliorate the performance of the cryptic trans-splicing signal present in the T. cruzi expression vector pRIBOTEX (Martinez-Calvillo, S., López, I., Hernandez, H., 1997. pRIBOTEX expression vector: a pTEX derivative for a rapid selection of Trypanosoma cruzi transfectants. Gene 199, 71-76). By insertion of the region HX1 downstream of the ribosomal promoter of pRIBOTEX, we constructed pRHX1CAT40 that, in stable transfected cells, was able to drive CAT activity 2760 times more efficiently than the control plasmids. Based on this, a novel plasmid vector was conceived, named pTREX-n, which retains the neo gene of pRIBOTEX as a positive selectable marker and replaces the CAT-SV40 cassette in pRHX1CAT40 by a multiple cloning site.

Intraoral mandibular distraction: indications, technique and long-term results

This report describes the experience of the Trousseau Hospital, Paris, France, with distraction osteogenesis of the mandible using an intraoral distraction device. From 1993 to 1998, 26 paediatric patients with mandibular hypoplasia underwent distraction of the mandible using the Leibinger Intraoral Distractor. The majority of the patients had hemifacial microsomia. Distraction was performed at a rate of 1 mm a day following complete osteotomy of the mandible. A mean of 15 mm of distraction was obtained. In conjunction with combined orthodontic management, satisfactory morphologic results were achieved in the majority of patients with good facial symmetry, adequate occlusal relationships and balanced maxillary mandibular relationships. Radiographic evaluation revealed that substantial new bone formation and remodelling was induced by the intraoral distraction along the entire hemimandible on the distracted side and that this contributed significantly to the aesthetically pleasing clinical results.

Linkage analysis of 5 novel van der Woude syndrome kindreds to 1q32-q41 markers further supports locus homogeneity of the disease trait

van der Woude syndrome (vWS, MIM 119300) is a rare autosomal dominant clefting condition with cardinal features of mucous cysts (lower-lip pits) and clefts to the lip and/or palate. The vWS gene has been assigned to a locus in 1q32-q41 by linkage analysis and physical mapping. We have investigated 5 novel vWS families through probands attended for cleft lip and/or palate repair at the Department of Maxillofacial Surgery of Hôpital Trousseau, Paris, in order to tentatively refine the genetic map of the vWS region in 1q32-q41 and possibly identify unlinked pedigrees. Linkage analysis was carried out to 6 microsatellite markers (D1S249, D1S425, D1S491, D1S205, D1S414, D1S425), yielding a maximum cumulative LOD score of Z = 3.27 at theta = 0.00 for D1S245. The innermost four markers were found to be tightly linked to one another, with no evidence for recombination. Our results support linkage of vWS within a region of tightly linked markers and do not favour locus heterogeneity of the disease trait.

[Circumscribed mandibular osteitis in children due to hematogenous dissemination. Apropos of 5 clinical cases]

In children, mandibular swelling associated with an X-ray bone osteolysis may correspond to tumoral or infection diseases. Circumscribed osteitis of a child's mandibula, with no dental etiology occurs around 7-years of age, adjacent to a healthy first molar. Five cases reports were analyzed. Clinically, it is a bone swelling of the mandibula's lateral cortical associated with a soft tissue swelling. X-ray signs were not specific but all cases showed a bone lacuna with sharp outlines. Such clinical and X-ray signs strongly suggest diagnosis of osteitis which has a higher incidence than malignant tumors. The lack of dental pathology suggests bloodstream dissemination from another localized sepsis. Surgical removal of pathologic bone in addition to antibiotics (6 or 8 weeks) appears to be an effective treatment.

Arteriovenous malformations of the dental arcades. The place of endovascular therapy: results in 12 cases are presented

Twelve arteriovenous malformations of the dental arcades (AVMDAs) (seven mandibular and five maxillary) were seen in our institution between 1977 and 1997. All these lesions consisted of true arteriovenous shunts (of either nidus or fistulous type) involving the bone, with or without soft tissue extension. Haemorrhage was present in eight patients (67%); either torrential, necessitating emergency embolization, or recurrent and progressive. Teeth instability was detected in all patients and was the origin of the bleeding. All lesions were embolized. Lesions in nine patients were embolized with Polyvinyl Alcohol Particles (PVA): this helped to stabilize the situation but could not avoid recurrences in all patients, necessitating complementary embolizations and or surgery. The use of acrylic glue (N-Butyl-Cyano-Acrylate [NBCA] Histoacryl) as the embolic agent has changed the results obtained tremendously. Eight patients have been treated with NBCA (five as complementary therapy to PVA during later sessions and three at the first attempt); injection either via the transarterial route or direct transcutaneous puncture (four patients) achieved a cure in four of these lesions (34%) with stability at long-term follow-up of all the other AVMs. Embolization with glue represents the therapy of choice in these sometimes life-threatening lesions, achieving a cure if directed towards the osseous venous lakes. Surgery, often leading to facial mutilation and necessitating massive reconstruction should be avoided nowadays, at least as the initial therapy.