[Secondary treatment of cleft lip and palate]. / Traitement secondaire des fentes labio-palatines.

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

[Primary treatment of cleft lip and palate. Its fundamental principles]. / Traitement primaire des fentes labio-palatines. Ses grands principes.

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

[Bifid mandibular condyle: position of the supernumerary condyle]. / Bifidité du condyle mandibulaire: position du condyle surnuméraire.

INTRODUCTION: Bifid condyles are uncommon and include post-traumatic aberrant reorganization of the temporomandibular joint (TMJ) and congenital forms. CASE REPORT: We report two cases of unilateral bifid condyles, responsible for functional dysfunction of the TMJ. The first case, probably of congenital origin, was oriented frontally. The second case, oriented in the sagittal plane, was probably post-traumatic. Functional treatment was used for both patients. DISCUSSION: Bifid condyles is asymptomatic in most cases. Their most frequent clinical consequence is TMJ pain. Surgical treatment is rarely indicated. Determining the congenital or post-traumatic origin of bifid condyles is often difficult. The orientation of the supernumerary condyle head could help for the etiological diagnosis.

[Nasal sequels of unilateral clefts: analysis and management]. / Les séquelles nasales des fentes unilatérales: analyse et prise en charge.

Usually, the nasal sequels of unilateral cleft patient are just considered as an esthetic problem to be addressed after the growth spurt of adolescence. This very narrow vision has led the cleft lip and palate treatment to a deadend. Actually, nasal sequels are the worst in terms of consequence on facial growth. 75% of complete unilateral cleft children are more oral than nasal breathers. Today, we know about the bad consequences of oral breathing on facial growth. It is not surprising to observe a high rate of small maxilla with cleft maxilla scars. In the fetus, the unilateral cleft nose deformities are well explained by the rupture of the facial envelope and the ventilatory dynamics of the amniotic fluid. Every step of the primary treatment threatens the nasal air way patency, whether when repairing lip and nose, suturing the hard palate that is the floor of the nose, or closing the alveolar cleft which controls the width of the piriform aperture. The functional and esthetic nasal sequels reflect the initial deformity, but are also the surgeon's skill and protocol choice. Before undertaking treatment, we must analyze the deformity at every level. Usually, the best option is to reopen the cleft completely to perform a combined revision of the lip, nose, and alveolar cleft after an adequate anterior maxillary expansion. If nasal breathing is necessary for an adequate facial growth, 25 years of experience showed us that it was very difficult to erase the cortical imprint of an early oral breathing pattern. So it is essential to establish a normal nasal breathing mode at the initial surgery. When the initial surgery is efficient and/or the secondary repair is successful, the final esthetic rhinoplasty, when indicated, is just performed for the sake of harmonization, with a classic internal approach and a few refinements.

[A functional approach in the primary treatment of labial-alveolar-velopalatine clefts for a minimum of sequels]. / Une approche fonctionnelle lors du traitement primaire des fentes labioalvéolopalatovélaires pour le minimum de séquelles.

Is the poor potential of growth an ineluctable consequence of mesodermal deficiency? Should we agree with the idea that all protocols are equivalent? Actually, these opinions reflect the empiricism of previous generations. We must now become rational and develop a project without compromise to achieve good functions at primary surgery. 'The normal structures are present on either side of the cleft, only modified by the fact of the cleft...' Victor Veau's hypothesis is the conclusion of rigorous anatomical and embryological research. Our current knowledge of the pathological anatomy allows for a better restoration of the normal anatomy. Anatomy is nothing if it is not functional. Every thing should be done to control the healing process to allow the best expression and interaction of the various functions, especially for those concerning nasal ventilation and masticatory efficiency. To correct the deformity, the cleft surgeon must perform a wide subperiosteal and subperichondrial elevation and must learn the skills of this accurate work to preserve the integrity of very fragile structures. The primary treatment must take into account a rational and uncompromising selection of the age of the first operation, of the successive procedures, and their chronology to benefit from the growth spurt of the maxilla, and to avoid the worse scars resulting from secondary epithelialization. Finally, if nasal breathing is the most important function concerning facial growth, it is essential to restore this normal function at the time of the first operation. The oral breathing pattern set at the time of the first operation leaves a cortical imprint that is very difficult to erase, even after clearing the nasal airways. The results of the functional approach we have used in the last decade are particularly consistent and very convincing. In this ambitious and demanding program, the patient comes first; we decrease the burden for him and his family, and give them the benefit of a good social life before school age.

[Therapeutic approach to cleft lip-maxilla-palate: for normal facial growth. A protocol and various technics to restore nasal respiration]. / Approches thérapeutiques des fentes labio-maxillo-palatines: pour une croissance faciale normale. Un protocole et des techniques au service de la ventilation nasale.

By contrast with the poor maxillary growth following primary surgery in infancy, unoperated adult cleft lip and palate subjects are known to have good facial growth. There is a strong consensus to consider that scarring from primary surgery is the main cause of this problem, particularly scarring from secondary epithelialization of denuded palatal bone, or of closure of the cleft in one layer. In an attempt to improve the outcome of facial growth, a lot of protocols have developed but, currently, none of them appears more valid and the differences between them are more in favor of the personal influence of each surgeon and his team. We are not in agreement with the widely spread opinion attributing the poor results to a severe hypoplasia which could explain the cleft itself. Actually, these patients have a normal potential of growth, but they need normal functions to show it. We think that oral breathing, so frequent among these patients, is enough to explain their poor growth. Over the past 22 years, we have tried to restore, with encouraging results, a nasal breathing mode, as early as 6 years of age, through precise secondary surgery of the nostril and the septum. But with experience, we have concluded that changing the first habit of oral breathing into a nasal one is particularly difficult in cleft patients, and that a nasal mode of breathing should be established once the primary surgery, in order to avoid compensation mechanisms and their consequences. For the last 6 years, our current protocol has allowed to achieve consistently this objective, with an evident influence on the outcome of the growth of the maxilla in complete unilateral and bilateral clefts. A longer follow-up is necessary to confirm it, but henceforth, all those who know the essential role of nasal breathing for a normal facial growth should endorse this process.

[Cleft lip, maxilla and palate treatment by Dr. Talmant's team in Nantes]. / Prise en charge des fentes labio-maxillo-palatines par l'équipe du docteur Talmant à Nantes.

Over the last 30 years, our private cleft lip and palate team has developed an increasing activity based on the Victor Veau's concept: "All the structures are present and only deformed". Our goal is to achieve an anatomical and fully functional repair in every fields with the first operation. A few recent refinements have improved our primary procedures: intravelar veloplasty; simultaneous lengthening of the columella and primary lip repair in bilateral clefts; nasal retainer for the 3 or 4 first postoperative months allowing the establishment of a nasal breathing mode at once. Our timing has been the same over the last 21 years if we except that we currently perform the gingivoperiosteoplasty between 4 and 5 years of age so that the width and the relationships of the maxillary arch are normal at the time of the mixed dentition. The timing is the same in uni and bilateral clefts. No preoperative orthopedics. At 6 months of age, nasolabial repair and closure of the soft palate with intravelar veloplasty. At 18 months of age, anatomical closure of the residual cleft of the bony palate in two planes without vomer flap or denuded bone. Between 4 and 5 years of age, after a short orthopedic treatment, closure of the alveolar cleft by a gingivoperiosteoplasty with iliac bone graft. From 6 years of age we start the orthodontic treatment. The current evolution allows to think that only few late corrections will be necessary.

[Calculation of optimized and individualized hip prosthesis. A study of feasibility]. / Calcul d'une prothèse de hanche optimisée et individualisée. Etude de faisabilité.

As logical consequence of a series of basic research studies on human femoral bones with unipodal support and under static stress, performed with physicomathematic modelling methods (finite-elements method) then confirmed by direct visualization of deformations resulting from such stress using holographic interferometry, the authors have worked on the definition of an optimized and individualized hip prosthesis. Thick CT sections digitized with a table and entered into a specially programmed computer allowed three-dimensional modelling of the femur as a volume, i.e. with its external contour and its medullary canal, and therefore of the implantable space. The prosthesis was then defined taking a number of hypotheses into account: necessity to regularize cortical bone spicules inside spongious bone, which are so often present opposite the rough line, partial machining at the level of the calcar, reduced tail length, presence or absence of collar. Thus an optimized and individualized prosthesis was defined. A prototype corresponding to a given femoral bone could then have been produced. However, the authors found it preferable to use simulation with computer synthetic images to check easy insertion and removal.

[Cranial osteopathy, delusion or reality?]. / L'ostéopathie crânienne, leurre ou realité?

After having outlined the theories of cranial osteopathy (SUTHERLAND, KARNI, UPLEDGER, and, more recently, CLAUZADE and DARRAILLANS), the authors refute the latter point by point. "Primary respiration" is in fact a way of thinking, and the various bones making up the calvaria and base of the skull, which are solidly synostosed in the adult, are clearly incapable of the pretended rhythmic displacements "described" by the osteopaths. Moreover, the C.R.L., like any liquid, is incompressible and mildly pulsatile. Conversely, although the brain clearly shows rhythmic pulsations, which every neuro-surgeon notes every day, the latter are exclusively connected to the vascular system.

A physico-mathematical model for the human femur, with and without a prosthesis, under the static constraints of one-legged stance.

The authors present a physico-mathematical model of a human femur, under "monopodal" static constraints, using the finite elements method. Three examples are considered: a normal femur, a femur implanted with a short-stem prosthesis without cement, and a femur implanted with a long-stem prosthesis without cement. The lines of isoconstraints were compared in the three examples, as well as the main constraints (direction and intensity). From the results, the authors suggest that a prosthesis made of titanium is currently best even though its YOUNG's modulus differs from that of the bone. A prosthesis of composite material is possible in the future. While the intensity of the constraints is nearly the same at the level of the epiphysis for the short-stem and long-stem prosthesis it seems that the short-stem prosthesis fitted accurately without cement is the best solution. The introduction of a hip prosthesis modifies the normal curve of the loaded femur by changing the center of this curve.

Study of the deformations of the isolated mandible under static constraints by simulation on a physicomathematical model.

The authors have studied the deformations of a mandible isolated from its muscular environment and submitted to statical constraints, with the help of a "modified model" and the finite elements method: the general deformation of the mandible and its modifications according to the direction of the application of the pressure, the rotation phenomenon or "torsion" in cross sections (identified by computer) of the mandible, the respective deformations of the internal and external corticals have successively been calculated. Particular mechanical phenomenons corresponding to the areas where the anatomo-clinical forms of the mandibular fractures take place have clearly been shown. The authors draw the conclusion that the mandible behaves mechanically in a similar way to a tridimensional composite.

Study of the mandible under static constraints by holographic interferometry. New biomechanical deductions.

In order to try to determine the nature of the mechanical structure of the mandible, the authors have compared, with the help of holographic interferometry, the behavior of the fresh mandible of a corpse, of a representative iron angle, and of a block of carbon-carbon under static constraint. There are no similarities between the behavior of the human mandible and that of a polycrystalline steel. On the contrary, the behavior of the mandible and of the carbon-carbon block are very similar. It would be hasty to state that bones are a heterogeneous composite. We can only prove, in a first approach, that they behave similarly under identical experimental conditions. The authors also demonstrated that the mandible presents a "mechanical hysteresis" phenomenon. This means that, when subjected to a small strain, its shape changes, but this change tends to neutralize itself in part in the course of time.

The mandible, an overhanging mechanically suspended structure. Considerations on the system of attachment and servo-command of the mandible.

The mandible, owing to its form, surrounding muscles and "position" in the craniofacial unit can be assimilated to an overhanging mechanically suspended structure. The hypothesis, according to which the temporomandibular joints would be submitted to pressure during mastication should be abandoned on the basis of anatomical and clinical findings. Furthermore, this hypothesis is in disagreement with the results of simulation on a physicomathematical model of the mandible. Accordingly, it is reasonable to assume that the mandible is a suspended structure and that the elevator muscles of mastication, especially the masseter and medial pterygoid (together forming the mandibular sling), and probably also the anterior belly of the temporalis muscle play a twin role in the suspension of this bone. These muscles obviously command the movement of closure. They also constitute the suspensory apparatus of the mandible and, by mechanical computation, should display a certain degree of elasticity and undergo most of the mechanical constraints developed during mastication. One can also consider the cranio-facio-mandibulo-hyoid group as a suspended structure. The comparison of this type of system to the basic principles of servo-robotics allows to understand that such a structure is capable of extremely precise movements in all spatial planes with a minimum of effort.

[Anhidrotic ectodermal dysplasia. Apropos of a case report of quadruplets]. / La dysplasie ectodermique anhidrotique. A propos d'une observation de quadruplés.

This study anhidrotic ectodermal dysplasia in quadruplets, allows the authors to recall the principal signs of this affliction, which are anhidrosis, or hypohidrosis, hypotrichosis and anodontia or hypodontia.

[Circumscribed scleroderma with naso-labio-alveolar localization. Apropos of a case]. / Sclérodermie circonscrite à localisation naso-labio-alvéolaire. A propos d'une observation.

A case of morphea linearis is reported. This rare affection carries a good prognosis, as opposed to that of generalized or systemic sclerodermas and certain forms of morphea. Treatment is essentially surgical.

[Romberg's syndrome. Progressive facial hemiatrophy]. / Syndrome de Romberg. Hémi-atrophie faciale progressive.

Romberg's syndrome or progressive facial hemiatrophy is a rare affection that may nevertheless be encountered by stomatologists during the course of their professional life. Diagnosis is simple if clinical and radiographic signs are recognized, an effective iconography being of particular value. This report is concerned mainly with the latter feature, and also includes a description of the principal characteristics of the affection and an extensive bibliography.

[Application of a 3-dimensional model using computer technology in the study of the structure of the mandible]. / Application d'un modèle tridimensionnel par informatique à l'étude de la structure de la mandibule.

Previous studies employing a plane "model" on the hemi-mandible confirmed the concept of a "bees-nest" structure of the mandible. As this plane model did not permit demonstration of maximal zones of iso-stress in the horizontal rami, the whole mandible was examined by means of a three-dimensional model. This gave more precise information, and thus produced more realistic results confirming previous findings. This new reliable type of model can be employed for any such exploratory procedure, and in studies totally different from those for which it was developed.