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Background: Negative positron emission tomography/computed tomography (FDG-PET/CT) predicts the absence of viable seminoma cells in residual disease after chemotherapy in men with metastatic seminoma. In this study, we assessed whether men with good-prognosis metastatic seminoma could be treated with 2 cycles of etoposide-cisplatin (EP) followed by only one cycle of carboplatin (CARBO) based on a negative interim FDG-PET/CT, thereby limiting the burden of treatment and toxicity. Methods: In this non-randomised, multicentre, phase 2 trial (NCT01887340), we enrolled patients with good-prognosis metastatic seminoma (stage IIB, IIC and III with a good prognosis according to the Medical Research Council classification). All patients with baseline-positive FDG-PET/CT received EP for two cycles. After completing the first two cycles, the patients underwent a second FDG-PET/CT scan to assess the response between days 17 and 20. Patients with persistent positive FDG-PET/CT (based on local review) proceeded directly to two additional EP cycles (for a total of 4 cycles); those who achieved FDG-PET/CT negativity received only one cycle of CARBO AUC=7. The primary outcome was the proportion of patients with a negative FDG-PET/CT on interim assessment who received de-escalating chemotherapy. Secondary endpoints included progression-free survival (PFS) and overall survival (OS). Findings: Between June 2013 and July 2017, 102 patients were enrolled in the study. Three patients were deemed ineligible or not evaluable; thus, 99 patients received treatment. After the first 2 EP cycles, FDG-PET/CT was available in 98 pts. Overall, 67 patients (68.4%; 95% CI: 58.2-77.4) had a negative FDG-PET/CT and proceeded to a single CARBO cycle. Twenty-seven patients (27.6%; 95% CI: 19.0-37.5) still had a positive FDG-PET/CT after 2 EP cycles; overall, 31 patients received two additional cycles of EP. After a median follow-up of 39.4 months, only 9 patients relapsed (3/31 in the EP group and 6/67 in the CARBO group). The 3-year PFS rate was 90.0% (95% CI: 74.4-96.5) in the EP group and 90.2% (95% CI: 80.2-95.5) in the CARBO group. One patient died from sepsis during the first two cycles. Interpretation: De-escalating treatment based on a negative FDG-PET/CT after 2 cycles of chemotherapy appears to be safe and feasible in most men with good-prognosis metastatic seminoma. Trial Registration: The trial was registered at ClinicalTrials.gov (NCT01887340). Funding Statement: Programme Hospitalier de Recherche Clinique (PHRC) from the Institut National du Cancer (INCA), France. Declaration of Interests: Yohann Loriot: Dr Loriot reports grants from CELSIUS, grants from SANOFI, grants and personal fees from JANSSEN, personal fees from ASTELLAS, grants and personal fees from MSD, personal fees from ASTRA ZENECA, personal fees from BMS, personal fees from SEATTLE GENETICS, personal fees from PFIZER, personal fees from ROCHE, personal fees from IMMUNOMEDICS outside the submitted work; Matthieu Texier: Dr Texier has nothing to disclose; Stephane Culine: Dr Culine has nothing to disclose; Aude Flechon: Dr Flechon has nothing to disclose; Antoine Thierry-Vuillemin: Dr Thierry-Vuillemin reports personal fees from Pfizer, Astra Zeneca, Sanofi, Janssen, Novartis, Ipsen, Roche, Bristol-Myers Squibb, MSD, Astellas; Gwenaelle Gravis: Dr Gravis has nothing to disclose; Lionel Geoffrois: Dr Geoffrois reports personal fees from BMS, personal fees from NOVARTIS, personal fees and other from IPSEN, personal fees from PFIZER, personal fees from A-Z, personal fees from MSD, outside the submitted work; Christine Chevreau: Dr Chevreau has nothing to disclose; Marine Gross-Goupil: Dr Gross-Goupil has nothing to disclose; Philippe Barthelemy: Dr Barthelemy reports advisory board and travels from BMS, advisory board from MSD, advisory board and travels from IPSEN, advisory board from EUSAPHARMA, advisory board from NOVARTIS, advisory board and travels from ROCHE, advisory board and travels from PFIZER, advisory board and travels from JANSSEN, advisory board from ASTELLAS, outside the submitted work; Emmanuelle Bompas: Dr Bompas has nothing to disclose; Hakim Mahammedi : Dr Mahammedi reports personal fees from Bayer, personal fees from BMS , personal fees from Roche , personal fees from MSD , personal fees from Astra Zeneca , personal fees from Sanofi , personal fees and other from Janssen , personal fees and other from Astellas , outside the submitted work; Brigitte Laguerre: Dr Laguerre has nothing to disclose; Sophie Abadie Lacourtoisie : Dr Abadie Lacourtoisie has nothing to disclose; Carole Helissey: Dr Helissey reports personal fees from Sanofi, Janssen, Astellas and Roche; Sylvain Ladoire : Dr Ladoire reports grants from Pfizer, grants from Astellas, grants from Roche , grants from Novartis , grants from BMS, grants from Ipsen, grants from Janssen, grants from Sanofi, outside the submitted work; Christine Abraham: Dr Abraham has nothing to disclose; Christophe Massard: Dr Massard reports Consultant/Advisory fees from Amgen, Astellas, Astra Zeneca, Bayer, BeiGene, BMS, Celgene, Debiopharm, Genentech, Ipsen, Janssen, Lilly, MedImmune, MSD, Novartis, Pfizer, Roche, Sanofi, Orion; Serena Grimaldi: Dr Grimaldi has nothing to disclose; Karim Fizazi: Dr Fizazi reports Consultant/Advisory fees from Amgen, Astellas, Bayer, Jansen, Takeda, Sanofi, Orion, Essa, Genentech, Astra Zeneca, Clovis. Ethics Approval Statement: Written informed consent was obtained from all the patients. The study was approved by the ethics committee of Ile de France II (N°2013-02-12 MS1) and the French Healthcare Agency (N°130253B-12).

Introduction L’e-monitoring de la qualite de vie relative a la sante (QdV) en pratique clinique courante consiste au recueil d’informations rapportees par le patient (symptomes et dimensions fonctionnelles) et a la transmission de ces informations en temps reel aux equipes soignantes. L’objectif est de fournir un outil complementaire pour la prise en charge des patients. Plusieurs etudes concernant des patients atteints de cancer montrent des effets benefiques, notamment en termes de QdV, de communication patient-medecin et de survie globale. Ces etudes sont majoritairement anglo-saxonnes. Des donnees evaluant la faisabilite de la demarche dans le contexte francais sont requises. Methodes Trois etudes sont en cours : GYNEQOL-Pilote (patientes atteintes de cancers gynecologiques pelviens), QOLIBRY (sein, poumon et colon-rectum), QUANARIE (rein metastatique). GYNEQOL et QOLIBRY sont des etudes monocentriques tandis que neuf centres ont ete ouverts pour QUANARIE. Le logiciel CHES est utilise pour le remplissage des questionnaires de QdV par les patients avant la consultation et la presentation graphique instantanee des scores de QdV aux cliniciens. Les questionnaires utilises sont le QLQ-C30 de l’EORTC, les modules specifiques des localisations et certains items extraits de l’« EORTC Item Library » specifiques des effets secondaires des traitements. Les criteres de jugement sont l’acceptabilite par les patients, l’exhaustivite, les taux de remplissage des questionnaires de QdV aux differents temps de mesure, l’attrition, la faisabilite organisationnelle et informatique, l’utilisation des resultats par les cliniciens et leur satisfaction, la maitrise de l’outil informatique par les patients. Resultats Les inclusions ont debute en septembre 2015. En novembre 2018, 360 patients ont ete inclus (GYNEQOL n = 116, QOLIBRY n = 188, QUANARIE n = 56). Les inclusions sont terminees pour GYNEQOL et QUANARIE et se poursuivent pour QOLIBRY. Des patients traites par chimiotherapie, therapie ciblee et immunotherapie ont ete inclus. Plus de 2350 temps de mesures de QdV ont ete recueillis et les suivis sont encore en cours. La mise en place informatique a ete possible grâce a une collaboration entre l’equipe de recherche clinique, le service informatique de l’hopital et la societe developpant le CHES. Des formations collectives et individuelles ont ete proposees aux medecins. Des supports de formation ont ete developpes (livrets, « pocket cards », tutorial video en ligne). Les analyses descriptives sont en cours et permettront de fournir les premiers resultats en 2019. Conclusion Les recherches sur l’e-monitoring de la QdV sont en plein essor, avec des perspectives d’application pour la detection precoce et le suivi des toxicites, l’adaptation de la strategie therapeutique en fonction du benefice clinique percu, l’orientation vers les soins de support, ou le suivi des interventions realisees. Par l’implication du patient pour le remplissage des questionnaires et l’opportunite de personnaliser la prise en charge au plus pres des besoins du patient, l’e-monitoring s’inscrit pleinement dans l’ere de la medecine des 4P. Une prochaine etude randomisee, REMOQOL-poumon, en collaboration avec des chercheurs en psychologie, permettra de comparer la qualite percue de la relation de soin avec et sans e-monitoring. L’ensemble de nos travaux apportera une vision multidimensionnelle et permettra l’optimisation de la demarche et des futures etudes visant a evaluer son efficacite.

Half of patients with KRAS wild-type colorectal cancer do not benefit from adding anti‐epithelial growth factor receptor (EGFR) to standard chemotherapy regimens. This retrospective study was performed in 94 patients with metastatic colorectal cancer (mCRC) treated in the second line with cetuximab and chemotherapy. Signal transducer and activator of transcription 3 (STAT3) phosphorylation in tumor cells was correlated with decreased median progression-free survival and overall survival (OS). These results highlight the potential role of STAT3 as a molecular target to optimize anti-EGFR therapies. Background: Signal transducer and activator of transcription 3 (STAT3) is involved in epithelial growth factor receptor (EGFR) signaling in a KRAS-independent manner. Phosphorylated STAT3 (pSTAT3) expression in patients with metastatic colorectal cancer (mCRC) treated with anti-EGFR– containing salvage chemotherapy has never been investigated. Patients and Methods: The first endpoint of this retrospective study was to evaluate the impact of pSTAT3 on the time to progression (TTP) in 94 patients with mCRC treated with anti-EGFR– based therapies in the second- or third-line setting between July 2004 and November 2009. The influence of pSTAT3 on objective response rate and overall survival (OS) was also reported. Nuclear expression of pSTAT3 status was evaluated by immunohistochemical tests on formalin-fixed and paraffin-embedded tumor samples obtained before therapy. Results: Positive expression of pSTAT3 was observed in 24.5% of the tumor samples. The probability of achieving an objective response was 13% among patients with positive nuclear expression of pSTAT3 compared with 41% for patients displaying pSTAT3-negative tumors (P .02). In a multivariate logistic regression model, high-grade skin rash, wild-type KRAS status, and negative pSTAT3 status significantly improved TTP and OS. Conclusion: These results underscore an impact of pSTAT3 on the clinical efficacy of anti-EGFR– containing chemotherapy regimens and support the prospective assessment of this biomarker.

This Phase II trial investigated the combination paclitaxel (P) and uracil–tegafur (UFT) in patients with metastatic breast cancer (MBC). Methods Main eligibility criteria included HER-2 negative MBC, ECOG performance status of 0–2, exposure to 1–2 prior chemotherapy regimen in the metastatic setting, previous exposure to an anthracycline containing regimen either at metastatic or adjuvant setting. Each 35-day cycle consisted of P at 80 mg/m 2 by intravenous infusion on days 1, 8, 15, 22 and 29 and oral UFT at 300 mg/m 2 TID (three time a day) from days 1–28 and oral folinic acid at 90 mg QD (one a day). Results Between March 2003 and December 2007, 31 patients were enrolled. Median age was 66 years (range 44–78). All tumours were HER-2 negative and 7% were triple negative (ER, PgR, HER-2). The majority of patients had visceral disease (81%). All patients had received an anthracycline containing regimen and 74% had a previous docetaxel containing treatment. Median of 4 and 3 cycles of P and UFT were administered with a relative dose intensity of 85.3% and 94.3%, respectively. Twelve (40%)(95% CI: 22.5–57.5) confirmed ORR were observed. Stable and progression disease were reported in 43% and 17% of cases. Median Response duration was 8.4 month (95% CI: 4.9–11.7), median Time to progression was 9.5 months (95% CI: 6.6–13.8) and median Overall Survival was 23.5 months (95% CI: 16.8–37.2). Thirteen pts (43%) experienced a grade 3 or 4 adverse events (AEs): One death occurred related to the study drugs (febrile neutropenia). Chemotherapy was discontinued due to toxicity in 30% of pts Conclusions Accrual was closed in January 2008 due to concerns regarding the degree and accumulative nature of AEs. Nonetheless, the ORR is encouraging and warranted further studies with adapted doses and schedules.

The aim of the present study was to compare the tumour grade, Estrogen Receptor (ER), Progesteron Receptor (PgR) and Human Epidermal Receptor-2 (HER-2) status in the core needle biopsy (CNB) with those observed in the subsequent excisional primary tumour (EPT). All patients diagnosed with an early breast cancer in our University Hospital Center between January 1, 2005 and December 31, 2006 were included but exclusion criteria of patients with large tumour requiring neoadjuvant chemotherapy and cases with more than one tumour (multicentricity/multifocality tumours). Histological tumour grade assessed according to Nottingham Grading System (SBRm), ER, Pgr and HER-2 tumoural status were assessed twice in CNB and in EPT. A total of 175 patients were assessed. The concordance between CNB and EPT for Grade, ER, PgR and HER2 status were 75.4% ( p > 0.00001), 84% ( p > 0.00002), 78.3% ( p = 0.002) and 98.3% ( p = 0.486) respectively. In conclusion CNB can be used with confidence for HER2 determination. For grade, PgR and ER due to substantial discordance results from CNB should be used with caution.

International audience; A main criterion to identify activity in phase II studies is the response rates achieved in a well-defined subset of patients. The response could be defined as a measure of tumor shrinkage. For 30 years, metric methods have been used to assess this response. The World Health Organization was the first organization to propose a unified definition for response status. Over time, the latter evolved and 10 years ago an international consensus panel proposed the Response Evaluation Criteria in Solid Tumors criteria. Although these guidelines for response assessment have limitations and biases, they have nevertheless been proven useful and advantageous. This article reviews those criteria and describes their use.

Construction of different kinds of prostheses on irradiated bone tissues after tumour surgery is a complicated part of modern implantology. In irradiated regions of the jaws where the bone layers are thin and the blood supply also is minimal, knowledge of the impact of each dose of radiation is very important. The aim of this study was to compare the bone response around titanium implants loaded with fixed bridges in dog mandibles irradiated with total doses of 40, 50 or 60 Gy. The results suggest that after irradiation with 40-50 Gy, when the dose is fractioned in order to achieve higher tolerance of the tissues compared with single dose irradiation, titanium implants may become osseointegrated in the mandibles. For high success rates, however, careful planning of radiotherapy and selection of implantation site with an adequate blood supply are essential.

Reconstruction of craniomaxillofacial defects caused by injury, tumor ablation, or congenital deformities can be accomplished by a variety of methods. Nonvascularized (free), vascularized (pedicled), and revascularized (microvascular) bone grafts have been employed for osseous restoration of the upper, mid, and lower facial skeleton. In comprised recipient tissue beds or when rapid functional restoration is desired, revascularized flaps hold certain advantages over their nonrevascularized counterparts. The revascularized flaps used most commonly for craniofacial reconstruction are discussed with regard to anatomy, clinical applications, and aesthetic and functional limitations.

The treatment of zygomatic fractures varies among surgeons, and the cosmetic and functional results are frequently less than optimal. A treatment guideline based on a simple classification of zygomatic fractures is presented. The emphasis is placed on the indications for closed and open reduction, consistent methods of three-dimensional alignment and fixation, and the management of concomitant infraorbital rim and orbital floor fractures. Postoperative results with regard to infraorbital nerve and maxillary sinus dysfunction, malar asymmetry, and orbital complications in the treatment of 1,025 consecutive zygomatic fractures are presented.

The subcranial approach for the osteotomy of the skull base and orbital roof in cases with hypertelorism is described. Advancement of the fronto-orbital segments is performed, avoiding the transfrontal procedure, thus making frontal lobe retraction unnecessary. The advantages of this method are pointed out.

International audience; The pemetrexed disodium (Alimta), LY231514) is the first antifolate able to inhibit at the same time the synthesis of purins and pyrimidins. Many therapeutic tests were carried out in clinical situations where the methotrexate and the fluorouracil had been the proof of their effectiveness. It then showed an interesting activity in a great number of tumours but with very different profiles of tolerance according to the studies and pathologies. The explanation will come in 2001 by the description from the relation between the vitamin deficiencies among treated patients and occurred from toxicities. The two randomized studies carried out in the malignant pleural mesothelioma and the non small cell lung cancer made it possible to establish its utility and to record the pemetrexed in these clinical situations. Others axes of development remain possible, but the results are stanby or to confirm as in squamous-cell cancer in the head and neck and breast, digestive or urinary tracts cancer. In all the cases, the optimization of the pemetrexed in terms of amount/methods of administration and associations possible because of its profile of tolerance makes of it a molecule of chemotherapy with a future.

Introduction L’efficacite et la tolerance des inhibiteurs de mTOR (mTORi) sont desormais bien connues en cancerologie et en transplantation. Si la survenue de certains effets secondaires peut etre anticipee et controlee, d’autres restent encore peu connus. Nous rapportons le cas d’un patient traite par inhibiteur de l’enzyme de conversion (IEC) depuis de nombreuses annees, qui a developpe un angiœdeme bradykinique (AOB) apres l’introduction d’everolimus. Materiel et methodes Un homme de 83 ans etait traite par IEC depuis 15 ans pour une HTA. Un adenocarcinome renal etait diagnostique en 2010 et une deuxieme ligne de chimiotherapie par everolimus est decidee en decembre 2013, devant l’apparition d’une insuffisance renale. A j30 apparaissait un premier episode d’AO de l’hemilangue gauche, cedant spontanement en 15 heures. L’everolimus etait stoppe puis, devant l’absence de recidive, reintroduit a demi-dose puis a dose pleine. A j4 et j18 de la reintroduction apparaissaient deux recidives d’AO de topographie similaire, durant 72 et 16 h. Dans l’hypothese d’un AO histaminique (AOH), une perfusion de Solumedrol® administree per-critique a 1 mg/kg etait inefficace, posant le diagnostic d’AOB. Biologiquement, les dosages de tryptase, C4, dosages ponderal et fonctionnel de C1 inhibiteur etaient normaux, sans argument pour un AOB hereditaire ou acquis. Nous avons retenu le diagnostic d’AOB lie aux IEC et revele par l’everolimus. Apres discussion en RCP d’AOB, l’IEC etait arrete et l’everolimus poursuivi, sans recidive d’AO avec plusieurs mois de suivi. Discussion La bradykinine(B) est un puissant vasodilatateur via l’activation du recepteur B2 endovasculaire. Ce recepteur est inhibee par plusieurs molecules, principalement par l’enzyme de conversion de l’angiotensinogene et a moindre echelle par la dipetidyl-peptidase-4 (DPP4). Les AOB sont ainsi un effet secondaire connu des IEC. Les mTORi ont une action inhibitrice de la DPP4. C’est pourquoi la co-administration de ces deux traitements augmente fortement le risque d’AOB. Il a ete demontre que 3,8 % des patients cotraites par IEC et mTORi declenchent un AOB versus 0,5 % des patients traites par mTORi seuls et 0,5 % des patients cotraites par ARA2 et mTORi. Le centre national de reference des AO a kinines (CREAK) recommandent donc une evaluation stricte de la balance benefice-risque avant toute co-prescription d’IEC et mTORi. Il est aussi possible d’associer d’emblee un ARA2, car le risque d’AOB est moindre. En cas d’AOB, et apres arret de l’IEC, l’mTORi peut etre poursuivi. Conclusion En raison de la co-prescription frequente d’IEC et d’mTORi chez les patients transplantes renaux ou porteurs de cancers, cet effet secondaire doit etre connu afin d’optimiser leur prise en charge.

• We describe 78 patients with fronto-orbital and sphenoethmoidal tumors surgically treated with the subcranial approach. This approach was developed by us in 1978 primarily for the treatment of skull-base trauma and craniofacial anomalies. Since 1980, we have extended the indications to include tumor resections. This extended anterior exposure of the anterior fossa skull base, including the sphenoidal and clival planes, enables an en bloc tumor removal obviating the transfrontal approach or lateral rhinotomy. In contrast with the conventional transcranial approach, the anterior subcranial approach provides an extended exposure of these locations, avoiding frontal lobe retraction. Reduction of complications, such as recurrent cerebrospinal fluid leaks, postoperative brain edema, damage to cranial nerves, and infection plus decreased hospitalization, are the major advantages of this procedure. ( Arch Otolaryngol Head Neck Surg. 1993;119:385-393)

The advantages of the subcranial over the transcranial approach for fronto-orbital tumor resection and subcranial exposure of the skull base are described in this paper. The primary reconstruction and fixation of the bone grafts with miniplates or wire ligatures are illustrated. The utilization of lyophilized cartilage for the reconstruction of the orbital roof, as well as the bridging of the defects with Biocement, are pointed out. The reconstruction of the articulate fossa of the temporomandibular joint in extensive resections of tumors in the temporal area is emphasized.

• A 10-year experience with surgical treatment of 813 zygomalateral orbital complex fractures is reviewed. Regardless of the type or severity of the fracture pattern, concomitant fractures of the orbital floor and rim were approached exclusively through the transconjunctival approach without a lateral canthotomy. The advantages of this approach compared with the subciliary access are the avoidance of a visible scar and markedly reduced incidence of postoperative lower eyelid complications such as ectropion and edema. Implants of lyophilized dura or cartilage and autogenous bone were used to reconstruct orbital floor defects. Malar asymmetry is a frequent complication of zygoma fractures resulting from inadequate three-dimensional reduction. Methods for accurate reduction and stabilization, indications for closed and open reduction, and management of the fractured infraorbital rim are emphasized. The indications for miniplates vs wire ligatures for the infraorbital rim are discussed. Long-term follow up and evaluation of the results with regard to the fracture pattern, complications, maxillary sinus dysfunction, and facial and orbital symmetry are presented. ( Arch Otolaryngol Head Neck Surg . 1991;117:611-622

The subject of this paper is the evaluation of the advantages pertaining to the THORP (titanium hollow screw reconstruction plate) condylar prosthesis for reconstruction after hemimandibulectomy and exarticulation. The THORP condylar prosthesis is three-dimensionally adjustable, enabling the intraoperative meticulous functional adaptation of the condyle. Various designs of the condyle make it possible to achieve optimal congruency between the articular fossa and condyle. The anchorage of the prosthesis to the stump of the mandible is achieved with perforated hollow-screws rigidly fixed to the plate, thus producing optimal functional stability. The long-term follow-up of eleven cases, reconstructed with this system, confirmed the correct guidance and functional efficiency of this type of condylar prosthesis.

The titanium hollow screw reconstruction plate (THORP) system for reconstruction of lower jaw defects provides a functional stable fixation and is used as a long-term or permanent implant in tumor surgery and in traumatology. The rigid fixation of the head of the screw to the plate, avoiding unphysiologic loads to the bone underneath the plate, and the titanium plasma-coated perforated hollow screws, enabling the development of direct bone-titanium contact as well as the ingrowth of bone into the lumen and perforations, are the major advantages of this system compared to conventional systems. The different surgical methods, such as preservation of the condylar process with only two screws, intra-operative freely adjustable condylar prosthesis, lingual application of the plate, and primary bone transplantation, are described. The evaluation of 62 patients reconstructed with the THORP system between 1981 and 1986 revealed no plate loosening, even in irradiated bone, and showed satisfactory aesthetic and functional results.

The surgical treatment of 26 patients with ankylosis of the temporomandibular joint, as well as various methods and materials used for functional restoration are described. The significance of radical removal of the ankylotic bone, as well as the advantages of the interpositioning of the lyophilized cartilage, are emphasized.

Summary The aim of this paper is to emphasize the advantages of a one-stage, step by step repair of facial skeletal injuries as well as the dural tears and lesions of the anterior fossa, by one and the same team. The methods described permit optimal reduction of the pseudohypertelorism and major displacements in severe combined craniofacial injuries. The simultaneous subcranial exposure of the entire basal region of the anterior fossa obviates the intracranial approach or frontal lobe retraction thus making early stage surgical management feasible. The surgical treatment of these injuries as a single entity, as well as further modifications reduce complications such as recurrent CSF leakage, anosmia, mucocoele or secondary operations for inadequate fracture reduction. The significance of primary meticulous reconstruction of the combined cranial vault and midface fractures for the achievement of normal physiological function of the various systems is particularly highlighted.

Experience in the management of 916 fractures of the mandible stimulated us to develop new methods and surgical techniques for functionally-stable intraoral internal plate osteosynthesis. The development of a fixation bar which is adapted to the alveolar process of the fractured mandible enables a compression of this area prior to the plate osteosynthesis. This procedure facilitates the plate application from the intraoral approach so that in 358 cases all types of fractures of the body, angle and ascending ramus can be reduced using this access, and not only the selected favourable cases. A new plate and screws of our own design have been successfully used in cases with comminuted multifragmentary and defect fractures. The rigid fixation of the head of the screws to the plate produces an optimal functional stability compared with conventional systems. The combination of the advantages of an external fixation device and those of stable internal osteosynthesis produces a long term functional stability even in cases with extensive defects where delayed consolidation is to be expected; tilting and loosening of the screws or resorption of the compact bone underneath the plate do not occur. Thus the extraoral approach and visible skin incisions can be avoided. This procedure is time sparing and less traumatic to the soft tissues compared with the extraoral approach. The extremely low complication rate in 358 fractures managed by plate osteosynthesis using the intraoral approach confirms the efficiency of this method.

In the usual reconstruction of maxillary contour, the grafts are usually exposed to the antral or nasal cavities. This leads to postponed remodelling and a higher rate of resorption and sequestration. To avoid exposure of the grafts, the buccal fat pad is rotated into the maxillary sinus and lined to the bone grafts. The vascularized buccal fat pad not only contributes to a better integration of the bone grafts but also enables the restoration of normal physiologic function of the maxillary sinus.

One hundred three patients underwent a modified sagittal ramus split osteotomy of the mandible. Maintenance of the temporomandibular joint relationship prior to the procedure was achieved postoperatively by using a three-dimensionally adaptable fixation bar. Techniques were also developed to avoid damage to the inferior alveolar nerve during the osteotomy and application of lag screws. These procedures avoided the disadvantages of lag screw osteosynthesis, and reduced relapse.

The subject of this paper is the evaluation of the results after surgical management of 29 dislocated fractures of the condylar process. Only fractures with total dislocation of the condyle out of the articulate fossa were surgically treated. The surgical procedure, making a broad exposure necessary, is detailed. The low rate of complications as well as the satisfactory function of the joints in spite of severe dislocation seems to confirm the surgical treatment of this type of fractures.

In severe craniofacial injuries, the involvement of the skull base with concomitant major dural tears is significantly high. Our methods and treatment plan are controversial compared with the conventional procedure: primary urgent neurosurgical exploration and repair with deferral of maxillofacial reconstruction. To avoid the disadvantages of the transfrontal intracranial management of the skull base, we modified the transethmoidal approach so as to enable the subcranial exposure of all the anterior fossa planes, including the sellar-sphenoidal region. The advantages rendered by this method are the feasibility of an early one-stage craniofacial reconstruction and avoiding retraction of the frontal lobes and damage to the olfactory filaments. The reduction of pseudohypertelorism, the decompression of the optic nerve, and the meticulous reconstruction of the midface and skull base are performed in one session and are regarded as one entity. The results of the surgical management of 395 craniofacial injuries and the low rate of complications emphasize the advantages of the methods described in this article.