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   Table of Contents - Current issue
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January-June 2020
Volume 10 | Issue 1
Page Nos. 1-283

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EDITORIAL  

COVID-19 and maxillofacial surgery Highly accessed article p. 1
SM Balaji
DOI:10.4103/ams.ams_126_20  
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ORIGINAL ARTICLE - COMPARATIVE STUDY Top

Three-Dimensional diagnosis in orbital reconstructive surgery Highly accessed article p. 3
Chingiz R Rahimov, Sirajaddin G Ahmadov, Masuma Ch Rahimli, Ismayil M Farzaliyev
DOI:10.4103/ams.ams_183_19  
Introduction: Orbital floor fractures are common among mid-face fractures. The general aim of treatment is to restore orbital volume and anatomy with grafts or reconstructive materials. Malpositioning of the implants and inadequate volume restorations are common complications of these procedures. The aim of our study is to present the surgical outcomes of orbital reconstruction aided by our algorithm of patient-specific virtual planning. Materials and Methods: The current study was performed on 77 patients with orbital wall fractures who were categorized into two groups: Group A – 42 patients (virtual planning) and Group B – 35 patients (traditional approach). Criteria of analysis included the presence of diplopia postoperatively and duration of surgical procedures. Results: Diplopia was recorded right after surgery in 16 cases (38.1%) of Group A and in 12 cases (34.3%) of Group B. However, 6 months postreconstruction, residual diplopia was recorded in 4 cases (9.5%) of Group A and in 12 cases (34.3%) of Group B. Mean operation time in Group A for the patients with isolated zygoma fracture was 2.23 h; for isolated orbital wall fracture was 1.98 h; and for combined zygoma, orbital wall, and facial bone fracture was 3.07 h. In Group B, these indexes were 3.47, 2.05, and 3.31 h, respectively. Conclusions: Application of virtual planning could significantly improve postoperative outcomes in orbital reconstruction. However, application of this technology could be limited by complicated defects of the orbital walls, which would require complex shape of the implant that might be difficult to be prevent virtually.
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2 mm conventional miniplates with three-dimensional strut plate in mandibular fractures Highly accessed article p. 10
Shishir Kaushik, Iqbal Ali, Manish Dubey, Neha Bajpai
DOI:10.4103/ams.ams_73_19  
Aim: The aim of this study was to compare 2 mm conventional miniplates with three-dimensional (3D) strut plates in the treatment of mandibular fractures treated in the Department of Oral and Maxillofacial Surgery of a college in India, during 2012–2015. Materials and Methods: All 20 patients with mandible fracture requiring open reduction and internal fixation of the fracture were reported and reviewed in the Department of Oral and Maxillofacial Surgery of the same dental college in India, during 2012–2015. We classified the data according to the gender, age, etiology, fracture site, and method of treatment of the fractures. Fixation done in 10 patients with 2 mm conventional miniplates kept in Group I, while 10 patients with 3D strut miniplate system considered in Group II. Results: Assessment of patient was done under the following parameters with follow-up at regular intervals at 2nd day postoperatively and at 1st, 3rd, and 6th weeks postoperatively: pain, swelling, infection, interincisal mouth opening in millimeters, paresthesia/anesthesia, mobility between fracture fragments, overall occlusion, need for any supplemental fixation, fate of implant, and complications. Conclusions: 3D titanium miniplates showed similar results when compared to standard titanium miniplates with advantages such as reduction in operative time, ease of placement, and cost-effective over the conventional plate system.
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Six-hole versus four-hole miniplates in isolated, unilateral angle fracture of the mandible Highly accessed article p. 16
A Senthil Kumar, B Saravanan, J Balaji, T Rohini, C Prasad, J Amirtha
DOI:10.4103/ams.ams_168_19  
Aim: The aim of the study was to find the suitable situation for the fixation of “six” hole miniplates in open reduction and internal fixation of displaced and nondisplaced unilateral angle of the mandible fractures. Subjects and Methods: Displaced, nondisplaced, simple, compound (linear and noncomminuted) isolated unilateral angle fractures with or without occlusal derangement were included in this study. Statistical Analysis Used: Chi-square test was used for the statistical analysis. Results: The parameters assessed preoperatively and postoperatively were mouth opening, occlusion, neurosensory deficit such as paresthesia, intraoperative time, stability of fragments, and access to the retromolar trigone which showed that the six-hole titanium miniplate was clinically useful in special clinical situations when compared to four-hole titanium miniplate. Conclusion: To conclude, six-hole titanium miniplate was clinically useful when compared to four-hole titanium miniplate in the following special clinical situations such as bone loss following extraction of third molar, no posterior occlusion and instability of fracture moderately displaced fracture needs more stability.
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Evaluation of presurgical serum cortisol level in patients undergoing major maxillofacial surgery Highly accessed article p. 25
Sharvika Aher, Pushkar Waknis, Sonal Shah, Aditi Saha, Prathamesh Bhujbal, Deeisha Gupta
DOI:10.4103/ams.ams_20_19  
Background: Stress is an integral part of life. Anxiety levels may increase when it comes to being treated surgically due to road traffic accidents causing facial trauma, other pathologies or burns. The stress that is caused during a surgical procedure as well as during the treatment in debilitated patients or traumatic conditions is bound to cause disturbance in the metabolic and physiologic levels of cortisol. Therefore, a study was carried out to determine the cortisol levels just prior to surgery on the day of operation to quantify the stress levels and also aid in any preanesthetic medication changes for the patient undergoing maxillofacial surgery. Aim: To evaluate and compare pre-surgical serum cortisol levels in patients undergoing major maxillofacial surgery under general anaesthesia. Objective: To evaluate the serum cortisol level of patient 3 days prior to surgery, on the day of surgery and to compare and evaluate the difference seen in both the obtained values. Methods: A prospective, randomized, in- vivo study was carried out in the Department of Oral and Maxillofacial Surgery at a teaching dental hospital. A total of 32 patients were included in this study. Inclusion and Exculsion criteria was made along with pre-opertive assessment of the patient, informed consent was obtained from all patients involved in the study. Patient blood sample, at 8 am three days prior to surgery and on the day of surgery and sent for laboratory investigations. Result: Participants in this clinical study underwent treatment of various ailments like facial trauma, and miscellaneous pathologies like Dentigerous Cyst, Oral submucosa fibrosis, Osteomyelitis, Benign Tumor and Orthognathic surgery. The anxiety of the patients were assessed by serum cortisol level preoperatively and on the day of operation. A total of 32 patients, 26 male and 06 female were included in the study. There was statistically highly significant difference seen between the mean values obtained three days prior to surgery and on the day of surgery.Conclusion: We have concluded from this study that the serum cortisol level shows significant increase on the day of surgery. A future study can focus on association between increased levels of serum cortisol and postoperative wound healing where patients can be divided into two groups one receiving pre-operative stress reduction protocol and other not receiving the same.
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Efficacy of microplates versus miniplates in the management of maxillofacial fractures p. 31
Gaurav Mittal, Anmol Agarwal, Ritesh Garg, Siddharth Sharma, Abhishek Rathi, Pooja Kapse
DOI:10.4103/ams.ams_30_20  
Introduction: Increased facial trauma has led to advances in techniques of internal fixation, improvements in plating system, refinements in exposure of facial skeleton fueling the rapid use of internal fixation for the management of facial fractures. Evaluating 40 patients with confirmed midfacial (Le Fort I and II) and mandibular fractures, this study presents the efficacy of microplate in comparison with miniplate in terms of load bearing capacity, stability at the fracture site and postoperative palpability. Objectives: To evaluate the efficacy of microplates in comparison with miniplates in maxillofacial trauma. Materials and Methods: Study sample consists 40 subjects, 20 each in two groups clinically and radiographically diagnosed with Group 1 (maxillary) and Group 2 (mandibular fractures) which were subdivided into 10 each treated with miniplate and microplate respectively. Postoperatively, stability of fracture, bite force, need for postop MMF, pain, infection, wound dehiscence, mouth opening, occlusion and palpability was noted. All cases have been evaluated clinically for various parameters for minimum of 3 months to assess any postoperative complications. Results: We found microplates are stable enough and have adequate load bearing capacity. Due to close adaptability and less hardware, postoperative palpability is less but larger sample study with long term follow up is necessary to conclude its efficacy in load bearing fracture sites.
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Efficacy of transdermal diclofenac patch as an analgesic following premolar extractions in orthodontic patients p. 37
Sanjay Talnia, Ramesh Ram Fry, Atul Sharma, Dinesh Chand Patidar, Samta Goyal, Geetanjali Gandhi
DOI:10.4103/ams.ams_220_18  
Aim: The aim of the study was to evaluate the efficacy of transdermal diclofenac patch versus oral diclofenac tablet as analgesic following premolar extractions in orthodontic patients. Materials and Methods: Thirty-three symmetrical pairs of indicated premolars (either first or second) were included for the present study. Each patient was given either transdermal diclofenac sodium patch 100 mg once a day or oral diclofenac tablet 50 mg twice a day for 3 days after the extraction. Pain was assessed by a 10-point visual analog scale and 4-point verbal rating scale given to the patient for each day for 3 days after the extraction. All observational findings were recorded, tabulated, and analyzed statistically. Results: This study consisted of 33 patients with a mean age of 18.73 ± 3.677 years. Out of 33 patients included in this study, 5 were male and 28 were female. The result of the study showed that consecutive postoperative days transdermal diclofenac patch was slightly more efficient in controlling the postoperative pain in the extraction done for the orthodontic purpose than diclofenac oral tablet, however statistically no significant difference was observed using Chi-square test (P > 0.05). Conclusion: Transdermal diclofenac patch showed potential analgesic modality for the management of mild-to-moderate intensity pain in premolar orthodontic extraction, with lower incidence of systemic adverse effects. However, cost and availability may limit the use of transdermal patch.
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Combination of articaine and ketamine V/S articaine alone after surgical extraction of impacted third molars p. 42
Tushar Dubey, Manpreet Singh, Ashish Sharma, Shyamalendu Laskar, Arpit Vashistha
DOI:10.4103/ams.ams_143_19  
Objective: Local anesthetics are the most effective drugs available for the management of pain while performing operative procedures. This study was performed to compare the clinical efficacy of treatment with local anesthetic articaine (4%) with ketamine and local anesthetic articaine alone (4%) for the relief or prevention of postoperative pain, swelling, and trismus after the surgical extraction of impacted mesioangular third molars. Materials and Methods: Sixty patients undergoing the extraction of impacted mesioangular mandibular third molars were included in the study. The patients were randomly divided into two groups: local anesthetic alone (LAA) and local anesthetic plus ketamine (LAK). Results: Facial swelling following surgery on postoperative days was significantly lower in the LAK group than in the LAA group on 3rd and 7th postoperative days (P < 0.05). Mouth opening on the postoperative days was significantly greater in the LAK group than in the LAA group on 3rd and 7th postoperative days (P < 0.05). The pain scores on the visual analog scale at 30 min and 1 h, 4 h, 12 h, and 24 h after the surgery were significantly higher in the LAA group than in the LAK group and there was no significant difference in heart rate, oxygen saturation, and blood pressure in both the groups. Conclusion: In this present study, the effect of articaine with ketamine in comparison with articaine alone intraoperatively and postoperatively was observed, and it revealed that the combination of articaine with ketamine produced good local anesthesia and provide good postoperative analgesia with less swelling and significantly less trismus.
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Extensive mandibular odontogenic keratocysts associated with basal cell nevus syndrome treated with carnoy's solution versus marsupialization p. 47
Irshaad Abdoola, Irene T Munzhelele, Muniera Ibrahim
DOI:10.4103/ams.ams_134_19  
The inherent proliferative capacity of the cystic lining of odontogenic keratocysts and tendency to recur with enucleation led to more aggressive management being widely recommended. Larger lesions preclude the possibility of resection. A case is reported in which extensive odontogenic keratocysts involve almost the entire mandibular medulla of a patient with basal cell nevus syndrome, illustrating the importance of customising treatment to accommodate the clinical and radiographic presentation of individual cases. The clinical outcome of using Carnoy's solution versus marsupialization is radiographically demonstrated in this case. Diagnostic criteria for basal cell nevus syndrome and treatment modalities of odontogenic keratocysts are discussed.
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ORIGINAL ARTICLE - EVALUATIVE STUDY Top

CBCT study of morphologic variations of maxillary sinus septa in relevance to sinus augmentation procedures p. 51
Shilpa S Dandekeri, Chethan Hegde, Pooja Kavassery, MK Sowmya, Bharathraj Shetty
DOI:10.4103/ams.ams_141_19  
Background: Augmentation of the maxillary sinus increases the lost height of ridge in the posterior maxilla. Bony convolutions from the floor of the sinus called septa may be encountered during the procedure and significantly impact the outcome of the procedure. Materials and Methods: For this retrospective study, 120 cone-beam computed tomography (CBCT) scans were collected from the archives of the department of oral radiology in the time period between January 2016 and August 2018. Planmeca Romexis® software version 3.2.7 was used to check for the incidence, and then among the septa, plane of orientation, location with respect to the wall of the sinus, and in terms of relation to tooth were examined. The average height and average width of all the septa were measured using a measuring tool in the software. Results: Thirty-five of the total 88 patients showed septa in 40 sinuses, in which 36 sinuses showed one septum and 4 sinuses showed 2 septa. Forty-one septa were located on the floor of the sinus in the frontal orientation and 3 septa were located on the lateral wall of the sinus in the axial orientation. The mean height and mean width of the 41 septa on the floor of the sinus were 5.72 mm and 3.47 mm, respectively. The mean height of septa found on the lateral wall of the sinus was 5.59 mm. Conclusion: Septa had a higher tendency to be in bucco-palatal direction and on the floor of the sinus and frequent occurrence in the region of molars. A thorough prediagnostic evaluation using CBCT is necessary prior to sinus augmentation procedures.
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Evaluation of nasopharyngeal airway to facilitate nasotracheal intubation p. 57
Vinay R Dhakate, Amol Prakash Singam, Harshvardhan S Bharadwaj
DOI:10.4103/ams.ams_190_19  
Background and Aims: Nasotracheal intubation is the most common method of airway management in oral and maxillofacial surgery patients. However, many times, it is associated with bleeding resulting from trauma to nasopharyngeal mucosa. We conducted this study to determine the effectiveness of nasopharyngeal airway (NPA) to easily facilitate the nasopharyngeal insertion and to reduce the trauma during nasotracheal intubation. Methods: A total of 120 patients scheduled for elective oral and maxillofacial surgery requiring nasotracheal intubation were randomly divided into two groups of 60 each, after preparation with xylometazoline drops intranasally, lubrication with lignocaine jelly, and thermosoftening of the tip of the endotracheal tube (ETT). In group NPA, dilatation of the nasal cavity was done with NPA before nasotracheal intubation and in Group C, nasotracheal intubation was done without dilatation of the nasal cavity. The smoothness of insertion of ETT was graded on a 4-point rating scale. Assessment of bleeding into nasopharynx was confirmed during laryngoscopy and was also graded with 4-point scale. Results: In the NPA group, all the 60 (100%) patients had smooth or relatively smooth (Grade 0 or 1) insertion compared to 51 (85%) patients in the control group (P < 0.0001). Eighteen (30%) patients had mild (Grade 1) bleeding and one (1.67%) patient had moderate bleeding (Grade 2) in the control group, whereas only four (6.67%) patients in the NPA group had mild (Grade 1) bleeding (P = 0.0005). Conclusion: Dilatation of nasal cavity with NPA significantly eases the insertion of ETT into the nasopharynx and also significantly decreases the incidence and severity of trauma and bleeding during nasotracheal intubation.
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Efficacy of various routes of dexamethasone administration in reducing postoperative sequelae following impacted third molar surgery p. 61
GK Vivek, N Vaibhav, Akshay Shetty, Imran Mohammad, Nida Ahmed, Hemavathi Umeshappa
DOI:10.4103/ams.ams_66_19  
Aim: To compare the efficacy of intravenous (IV), intramassetric (IM) submucosal (SM) routes & oral routes of dexamethasone administration post impacted third molar removal surgery. Type of Study: Prospective randomized comparative clinical study. Materials and Method: This prospective comparative study included 60 patients with Class II and position B type of impaction (according to Pell and Gregory's classification). Patients were randomly divided into 4 groups. Group A, B, C & D patients received 8mg dexamethasone immediately post-surgical tooth removal via the IV, SM and IM route & oral respectively. Assessment of swelling, mouth opening and pain was done at intervals of 1st, 3rd and 7th post-op days. Results: The average age of the patients was 27 years. The mean time taken was 20 mins 40 seconds. The IV group showed minimal swelling and better pain control on the 3rd post op day (statistically significant). All 4 routes showed comparable mouth opening results. Conclusion: IV administration of dexamethasone post third molar surgery has been the traditional way because of its faster onset of action and increased efficacy; IM and SM routes are also comparably effective although oral route had the best patient acceptance.
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Square face correction by gonial angle and masseter reduction p. 66
SM Balaji, Preetha Balaji
DOI:10.4103/ams.ams_22_20  
Introduction: The association of mandibular gonial angle, facial height, and jaw relationship in masseteric hypertrophy (MH) has not been adequately described for the typical Indian population. The aim of this study was to report the gonial angle relationship with facial height parameters in cases diagnosed with bilateral MH and its possible influence on the treatment plan. Materials and Methods: This is a retrospective study based on archival records of bilateral MH cases surgically treated over a 10-year period at the author's center. Patients' records fulfilling inclusion and exclusion criteria were considered for the study. Age, gender, upper anterior facial height (UAFH), lower anterior facial height (LAFH), upper posterior facial height (UPFH), ramus height (also a reflection of the lower posterior facial height), and gonial angle were collected along with the type of bite (open/normal/deep), surgical procedure (debulking with/without bone removal), and concomitant jaw bone corrections (yes/no). These were subjected to statistical analysis using SPSS, and P ≤ 0.05 was taken as statistically significant. Results: Overall, 21 patients formed the study group comprising 9 females and 12 males. Gender influenced the UAFH, LAFH, UPFH, ramus height, and gonial angle significantly. Males had higher values than females. Normal bite had an obtuse gonial angle than the deep bite, and the difference was statistically significant (P = 0.036). When the gonial angle was acute or square faced, the need for other surgical procedures was high and the difference was statistically significant (P = 00.048). Discussion and Conclusion: The results are discussed in the light of Indian skeletal anthropometry. The relationship of the gonial angle with facial height parameters in bilateral MH cases in this part of the world is presented.
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Extended total temporomandibular joint replacement with occlusal adjustments: Pitfalls, patient-reported outcomes, subclassification, and a new paradigm p. 73
Maurice Yves Mommaerts, Ion Nicolescu, Mihai Dorobantu, Nikolas De Meurechy
DOI:10.4103/ams.ams_245_19  
Context: Alloplastic temporomandibular joint (TMJ) replacement is a treatment strategy for segmental mandibular defects with occlusal abnormalities. Aims: To describe our experience with extended total TMJ replacement (eTMJR) by reporting operative obstacles, complications, and patient-reported outcomes, as well as to suggest a subclassification system and paradigm shift. Setting and Design: University hospital and private clinic; case series with retrospective follow-up. Methods and Materials: Five patients (6 eTMJRs) were followed for more than 1 year after surgery. Patient-reported outcomes were assessed using FACE-Q™ “Satisfaction with Outcome” questionnaires (sum and corresponding transformed Rasch scores). Statistical Analysis: Descriptive analyses were performed. Results: Problems were related to contralateral mandibular osteotomy healing (if performed), keying the prosthetic condyle into the fossa component, intra- and postoperative prosthetic lag, and intraoperative proper establishment of the occlusion when unilateral replacement was performed. Patients reported high satisfaction with the outcome, with a mean Rasch score of 89.2/100. Conclusions: Unilateral eTMJR obstacles related to three-dimensional rotational repositioning of the remaining mandible. We suggest a paradigm shift, considering primary alloplastic replacement instead of microvascular osseous transplantation for reconstruction when radiotherapy is not required. This can avoid donor site morbidity and long reconstructive surgery. An autologous osseous transplant is still available in case of implant failure. A subclassification system is proposed for eTMJR, which accounts for contour corrections, occlusal adjustments, and simultaneous contralateral mandibular osteotomy.
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Incidence of neurosensory disturbance and success rates of solid-screw implants placed in conjunction with inferior alveolar nerve transposition p. 80
Saad Al-Almaie, Abdul Majeed Kavarodi, Abdullah Al Faidhi, Ali Alorf, Saeed A Alzahrani
DOI:10.4103/ams.ams_160_19  
Background: Implant-supported prosthetic rehabilitation of a severely atrophic posterior mandibular alveolar ridge is a real challenge. Implant placement in such situations is very difficult and implies the risk of inferior alveolar nerve (IAN) damage. Purpose: The purpose of this study is to evaluate the incidence of neurosensory disturbance and the cumulative survival of dental implants placed after the IAN transposition (IANT) procedures followed by dental implants placement. Materials and Methods: Twenty International Team for Implantology implants were placed in eight patients following unilateral IANT. In two patients, nerve transposition was performed bilaterally, and hence, a total of 10 IAN transposition surgeries were performed. Neurosensory dysfunction was objectively evaluated by using light touch test (LT), pain test (PT), and 2-point discrimination test (2-DT). In addition, patients were asked to answer a short questionnaire to investigate the individual feeling of discomfort and advantages related to this surgical technique. The mean follow-up periods were 47.1 months (range 12–78 months). Results: Neurosensory disturbance (i.e., disturbance registered by the LT, PT, and 2-DT tests) was experienced in 2 of 10 cases. The cumulative implant survival was 100%. However, at the time of data analysis (12–79 months after surgery), all patients indicated that they would go through the surgery again. Conclusion: IANT can permit the placement of implants with adequate length and good initial stabilization as used in routine sites, with the same favorable prognosis. All patients felt that they had received benefits from their new prostheses in terms of improved comfort, chewing efficiency, and esthetics.
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Do Patients have the same experience of pain following tooth extraction and dental implants? p. 88
Reza Tabrizi, Hassan Mohajerani, Atieh Nabtieh, Shervin Shafiei
DOI:10.4103/ams.ams_281_19  
Introduction: Postoperative pain is an important concern for patients who need dental implants. This study aims to compare the experience of pain in patients who undergo tooth removal and dental implant surgery. Materials and Methods: This is a crossover study. Patients who underwent a simple tooth extraction and dental implant surgery were studied. The pain severity was assessed using a visual analog scale at 12, 24, 48, and 72 h after procedures. The repeated measure test was used to compare pain severity between two treatment sessions. Results: Forty patients were studied. Patients reported higher pain levels in a tooth extraction at study times than implant surgery (P = 0.001). Conclusion: It seems patients who had experience of tooth extraction and a dental implant placement reported significantly lower pain in implant surgery.
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Clinical study on the minimally invasive-guided genioplasty using piezosurgery and 3d printed surgical guide p. 91
Olivier Oth, Pierre Mestrallet, Régine Glineur
DOI:10.4103/ams.ams_79_19  
Introduction: A retrospective clinical study was performed regarding the minimally invasive-guided genioplasty technique (MIGG technique) described in a previous clinical note. The aims of this clinical study were to study the incidence of immediate complications with this technique compared with a control group using a nonminimally genioplasty technique, to validate the accuracy of the three-dimensional (3D) printed cutting guide, and to evaluate the duration of the surgery and the satisfaction of the surgeons with this technique. Materials and Methods: One controlled group, including 56 patients, operated with a classical genioplasty and one group, including 24 patients operated with the MIGG technique. The inclusion criteria were patients from 18 years old benefiting from orthognathic surgery for dysmorphic maxillofacial disorders, sleep apneas, or posttraumatic malocclusion; operated by the three same surgeons. A database was retrospectively made, including the demographics parameters, the indication, the type and the duration of surgery, the incidence of complication, and the type of complication. The accuracy of the cutting guide was also studied by the comparison of two distances in the MIGG group on the preoperative surgical simulation and on the postoperative cephalometric radiography. A satisfaction survey for the surgeons of the department regarding the MIGG technique was also analyzed. Conclusion: No statistical difference was found in the incidence of complications between the MIGG group and the control group. Using a guide does not cause more surgical infection. The protection of the inferior alveolar nerve is obvious. The absence of statistical difference is due to the fact that the majority of patients also benefited from the bilateral sagittal split osteotomy during surgery. The 3D-cutting guide used is very accurate: There is indeed no significative difference in the measurements A and B before and after the genioplasty. The MIGG technique is thus a predictable, safe, and easy-to-use technique that should be used routinely by maxillofacial surgeons. It combines the latest technologies in piezosurgery and in 3D-guided surgery by the creation of a validated-accurate 3D-printed cutting guide. This technique is affordable by the use of open-source program and a desktop fused deposit Modeling 3D-printer. Finally, the comfort of the surgeon is improved, and the operating time is decreased.
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Feasibility and reliability of microvascular reconstruction in the vessel-depleted previously operated neck p. 96
Thyagraj Jayaram Reddy, Ehtaih Sham, Mandakulutur S Ganesh, P Suresh Menon, Karthik Vishwas Gowda, Rayan Malick
DOI:10.4103/ams.ams_201_19  
Background: Microvascular reconstruction of defects in the head and neck has always been a challenge in patients who have undergone previous neck dissection, owing to the prior resection of potential recipient blood vessels used for free flap perfusion. Objective: The objective of the study is to evaluate the reliability and safety of free flap reconstruction in patients who have had previous neck dissection. Materials and Methods: Twenty-four free flaps were performed in 22 patients with a previous history of neck dissection for head-and-neck squamous cell carcinoma. These included patients who underwent salvage surgery for recurrent cancer as well as patients undergoing secondary reconstruction following previous oncological resections. Flap includes 12 radial forearm free flaps, 5 fibula flaps, 1 rectus abdominis flap, and 6 anterolateral thigh flaps. Results: In cases with the previous history of selective neck dissection, recipient vessels on the ipsilateral/same side of the previously operated neck were used, while contralateral vessels were used in patients with a history of modified radical or radical neck dissection. Vein grafts were not necessary, except for one case. In our series, we did not have any flap loss or considerable increase in operative time. Conclusions: Free flap reconstruction of head-and-neck defects is highly successful in patients with a history of previous neck dissection, despite a relative scarcity of recipient blood vessels. Careful planning and relying on flaps with a long vascular pedicle obviates the need to perform a suitable vein graft. In our present series, careful planning and the right choice of a free flap with a long vascular pedicle contributes to the absence of free flap failure. In our experience, previous neck dissection should not be considered as a contraindication to microvascular reconstruction of previously operated oncologic defects.
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ORIGINAL ARTICLE - PROSPECTIVE STUDY Top

Platelet-rich fibrin for hard- and soft-tissue healing in mandibular third molar extraction socket p. 102
Deborah Sybil, Madhuri Sawai, Mohammad Faisal, Sanjay Singh, Vanshika Jain
DOI:10.4103/ams.ams_228_19  
Background: Successful management of patients reporting with extreme sensitivity in second molar after surgical extraction of deeply impacted mandibular third molar poses a big challenge to oral surgeons and periodontists worldwide. A variety of grafts, barrier membranes, and guided tissue regeneration techniques have been used postsurgically for soft- and hard-tissue formation. In the current study, platelet-rich fibrin (PRF), a second-generation platelet aggregate, was assessed for its effectiveness in promoting hard- and soft-tissue healing. Objective: The aim of the study was to evaluate the efficacy of PRF in hard- and soft-tissue healing after extraction of mandibular third molar. Materials and Methods: Bilateral surgical disimpaction of mandibular third molar was done on 25 patients. In every patient, randomly allocated test side received PRF and the other side acted as control. Pain, edema, tenderness, sensitivity, Sulcus Bleeding Index (SBI), Plaque Index, clinical attachment level (CAL), probing depth, and bone height were measured at different intervals for a maximum period of 6 months. Results: There was a statistically significant improvement in patients' signs and symptoms of pain, tenderness, edema, and sensitivity with the use of PRF. A statistically significant improvement was seen in SBI, Plaque Index, and probing depths, while CALs and bone height were not influenced by PRF use. Conclusion: PRF is a very viable and useful biomaterial for soft-tissue healing and relieving patient symptoms, however, it does not help in hard-tissue healing with respect to cortical bone.
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Role of serratiopeptidase and dexamethasone in the control of postoperative swelling p. 108
B Pramod Krishna, B Praveen Reddy, DS Yashavanth Kumar, M Ummar, Vijay Shekhar, Rahul Vinay Chandra Tiwari
DOI:10.4103/ams.ams_249_19  
Aim: The present study is designed to evaluate and compare the ability of serratiopeptidase and dexamethasone to control edema following the surgical removal of mandibular third molar. Materials and Methods: Two drugs, dexamethasone and serratiopeptidase, were compared for its efficacy in reducing the postoperative swelling. A total of 100 patients requiring the surgical removal of impacted mandibular third molar were randomly divided into two groups, consisting of 50 patients each. One group was administered 1 mg dexamethasone, one-half h preoperatively and every 8th hourly for 3 days postoperatively. The other group was given 10 mg serratiopeptidase every 8th hourly for 3 days postoperatively. The swelling was measured on 1st, 2nd, 5th, and 7th postoperative days. The results of this study showed that serratiopeptidase was effective in reducing swelling from 2nd to 5th postoperative day, and dexamethasone was effective in reducing swelling from 1st to 2nd postoperative day, further, it also reduced the swelling from 2nd to 5th postoperative day. Results: There was highly significant difference in the facial measurement between serratiopeptidase and dexamethasone group on postoperative day 2 (the mean difference was 62.5 with P < 0.001) and statistically significant difference on postoperative day 1, day 5, and day 7 (P < 0.01). Conclusion: It can be concluded that serratiopeptidase, a proteolytic enzyme and dexamethasone, a long-acting corticosteroid was effective in reducing the swelling, but dexamethasone was more effective than serratiopeptidase in reducing the swelling.
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Effects of corticobasal implant protrusion inside the nasal and maxillary sinus Highly accessed article p. 114
Fadia Awadalkreem, Abdelnasir Gafar Ahmad, Stefan Ihde, Motaz Osman
DOI:10.4103/ams.ams_42_20  
Background: Implant protrusion into the nasal and maxillary sinuses presents a challenge in cases of severely resorbed maxillae. Aim: The aim of this study was to evaluate the clinical and radiographic effects of BECES® implant penetration depth into the nasal and maxillary sinuses. Setting and Design: This was an observational study conducted in a tertiary institution. Materials and Methods: Forty-nine BECES® implants were inserted into the maxilla of patients who presented with severely resorbed ridges but no history of sinusitis. Forty-five implants protruded into the sinus cavities. Patients were examined clinically and radiographically at 1 week and 3, 6, 12, and 18 months after insertion. Maxillary sinus health, survival and success rates, and peri-implant health were assessed using the plaque index (PI), calculus index, modified gingival index (MGI), and probing pocket depth (PPD). Statistical Analysis: Wilcoxon signed-rank test and Mann–Whitney test were used in this study. Results: Four (8.16%) of the 45 implants that penetrated the cavities reached the sinus floor without disrupting the membrane; the penetration depth was ≥4 mm in 20 implants (44.44%) and <4 mm in 25 (55.56%). No patient showed clinical or radiographic signs of sinusitis during the observation period. There were significant differences in the PI, MGI, and PPD values between baseline and the 18-month follow-up with no association with the penetration depth. All implants showed radiographically direct bone-to-implant contact. Where the implant tip barely reached the sinus floor, the membrane healed uneventfully while when deeply penetrating the sinus, the membrane healed around the implant but did not cover the tip. All prostheses and implants survived during the observation period. Conclusion: Penetration depth of polished implants with cortical engagement into the maxillary sinus or the floor of the nose does not negatively affect implant survival, the success rate of the treatment, nor peri-implant soft-tissue health. It also does not provoke the development of sinusitis.
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ORIGINAL ARTICLE - RETROSPECTIVE STUDY Top

Conservative management of odontogenic keratocyst in a tertiary hospital p. 122
Priyangana Nath, Col Suresh Menon, ME Sham, Veerendra Kumar, S Archana
DOI:10.4103/ams.ams_260_18  
Introduction: Odontogenic keratocysts (OKCs) are benign intraosseous odontogenic lesions that have a locally aggressive behavior and exhibit a high recurrence rate after the treatment. The most appropriate surgical approaches for the successful treatment of OKCs remain controversial. Aim: The aim of this study was to evaluate the conservative management of OKCs by enucleation along with peripheral ostectomy and chemical cauterization in terms of recurrence rates after the surgical procedure. Materials and Methods: A retrospective study on 36 cases of OKCs treated at the Oral and Maxillofacial Surgery Department of a tertiary hospital from 2010 to 2017 was done. The demographic, clinical, radiographic, and histologic data were collected for each patient. All cases were surgically treated by enucleation followed by peripheral ostectomy and chemical cauterization using Carnoy's solution. The teeth that were involved in the lesion were extracted. The diagnosis was confirmed with excisional biopsy and histopathology reports. Results: Most of the OKCs were found in the mandible, except three which were present in the maxilla. A significantly higher incidence was seen in males in the age group of 21–30 years. Most of the cases (30 out of 36 cases) were accessed intraorally. Patients were followed up for up to 5 years. Recurrence of the operated OKCs was observed in five cases which were managed by enucleation with peripheral ostectomy and chemical cauterization again with good results. Conclusion: The results suggest that proper enucleation followed by peripheral ostectomy and chemical cauterization using Carnoy's solution may be the best and optimal approach for the management of OKC.
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Extramaxillary zygomatic implants: An alternative approach for the reconstruction of the atrophic maxilla p. 127
Ori Blanc, Dekel Shilo, Efi Weitman, Tal Capucha, Adi Rachmiel
DOI:10.4103/ams.ams_157_19  
Background: Limited bone quality in the posterior maxilla results in low success rates for dental implants. Various bone augmentation methods have been described, yet most require two-step surgical procedures with relatively high rates of resorption and failure. An alternative for these patients is zygomatic implants. Zygomatic implants utilize the basal craniofacial bone. Materials and Methods: A retrospective study was conducted on 25 patients exhibiting ridges classified as V–VI according to the Cawood and Howell classification. Seventy-six extramaxillary zygomatic implants were placed. Immediate rehabilitation was performed with a mean follow-up of 18.6 months. Results: Three implants failed, and two were replaced successfully. No significant bone loss was observed in the rest of the implants. Soft tissue around the implant heads healed properly. All implants were prosthetically rehabilitated successfully. Conclusions: Zygomatic implants allow for immediate loading of an atrophic maxilla. The emergence of the implant is prosthetically correct compared to the intrasinus approach, leading to better dental hygiene and decreased mechanical resistance. 96.1% of the implants survived, with good anchorage and proper soft tissue healing and rehabilitation. We suggest using extramaxillary zygomatic fixture as the first line of treatment in severe atrophic maxilla.
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Donor site morbidity in submental flap: Emphasizing on facial hairs direction p. 133
Amin Rahpeyma, Saeedeh Khajehahmadi
DOI:10.4103/ams.ams_215_19  
Introduction: Donor site morbidity is an important factor for selecting a flap for reconstruction. Submental flap using submentum skin for reconstruction has low donor site morbidity. Up to now, donor site morbidity of submental flap in Caucasians has not been evaluated. Materials and Methods: In a retrospective study, donor site morbidity of the submental flap including changes in hair direction, hypertrophic scars, and suture marks was evaluated. Results: Forty patients with at least 2 years of follow-up were evaluated. Female patients indicated better esthetic results. Abrupt beard hair direction change occurred in five male patients. Two hypertrophic scars and one suture mark were recorded. Conclusion: The direction of beard hairs in submentum may be changed after submental flap harvest. Accordingly, this is important in some ethnic and religious groups.
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Surgically assisted rapid palatal expansion to correct maxillary transverse deficiency p. 136
Adi Rachmiel, Shahar Turgeman, Dekel Shilo, Omri Emodi, Dror Aizenbud
DOI:10.4103/ams.ams_163_19  
Background: Transverse maxillomandibular discrepancies are widespread. Treatment is comprised of orthodontic expansion in patients younger than 15 years or by surgically assisted rapid palatal expansion (SARPE) in skeletally mature patients where the possibility of successful orthodontic maxillary expansion decreases as sutures close and resistance to mechanical forces increases. Aim: To present our experience of treating transverse maxillary deficiency using a unique L-shaped osteotomy and to demonstrate stable results. Patients and Methods: 32 patients aged between 19 and 54 years exhibiting transverse maxillary deficiency. L-shaped osteotomy was performed laterally from the pterygoid plate posteriorly to above the roots of the second incisive anteriorly continuing with a vertical osteotomy between the lateral incisive and canine teeth toward the horizontal osteotomy. In 18 patients with dysgnathia, bimaxillary surgery was performed one year following the SARPE procedure. Results: Mean transverse maxillary expansion of 6.2mm at the canine incisal and 6.4mm at the first molar occlusal regions were obtained. One year postoperatively results were relatively stable, 5.8mm and 6.2mm respectively. The SARPE procedure resulted in overcoming the maxillary buttress resistance, expansion of the anterior dental arch and bilateral distraction creating bone on both sides of the premaxilla contributing to better alignment of the anterior teeth and superior stability. Conclusions: We conclude that SARPE is an effective and stable method for addressing severe maxillary transverse discrepancy in adults while the unique osteotomy performed allowed for maintaining proper position of the premaxilla and maxillary midline and allowing for division of the newly created bone bilaterally thus resulting in a more stable outcome.
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Superioralization of the inferior alveolar nerve and roofing for extreme atrophic posterior mandibular ridges with dental implants p. 142
Fares Kablan
DOI:10.4103/ams.ams_236_19  
Introduction: Posterior mandibular ridges with extreme atrophy are usually combined with superficial location of the mental nerve and inferior alveolar nerves (IAN) and with a short residual mandibular ridge. As a result, dental implants cannot be placed in conjunction with IAN transposition alone. The aim of this paper is to introduce a new treatment approach to treat those patients. Patients and Methods: Eleven patients with 18 extreme atrophic posterior mandibular ridges characterized by superficial location of the IAN and short residual ridge had been treated during a 4-year period. The treatment approach included superior transposition of the IAN (IAN superioralization), 18 onlay bone block grafts harvested from the calvarial bone, implants placement through the block, and repositioning of the nerve under the onlay graft (IAN roofing). Patients were examined every 2–3 weeks; they received panoramic radiograph immediately after the surgery, at 4 months, at 6 months, and then once a year. Fixed prosthesis was performed after 4–5 months. Results: The donor sites of the bone blocks healed very well. The increase of bone height ranged between 4 and 6 mm at the recipient sites, and 63 long implants were placed (10–13 mm). All the patients were hospitalized 1–3 days. The healing process was uneventful, and the nerve recovery lasted a maximal period of 6 months. The implant success and survival rates were 100%. All patients received fixed prosthesis. The functional outcomes were satisfactory with marked improvement in the quality of life of the patients. The follow-up period was 12–58 months. Conclusions: Superioralization of the IAN and roofing is a fast and predictable option to treat extremely atrophic posterior mandibular ridges with fixed prosthesis supported by dental implants.
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CBCT Evaluation of the Vital Mandibular Interforaminal Anatomical Structures p. 149
Ankush Puri, Pradhuman Verma, Princy Mahajan, Amit Bansal, Shivani Kohli, Samar Ali Faraz
DOI:10.4103/ams.ams_144_19  
Background: Oral implants are considered safe in the mandibular anterior region, but complications often occur if vital structures such as inferior alveolar nerve, mandibular incisive canal (MIC), anterior mental loop (AL), or mental foramen (MF) are not properly identified. Aim: The aim was to evaluate vital anatomical structures in the mandibular interforaminal region and to investigate sexual dimorphism and differences with respect to left and right side regions using cone-beam computed tomography (CBCT). Materials and Methods: Eighty CBCT scans (forty male and forty female) were analyzed for MF position and shape, presence and measurement of AL and MIC (both in mm), emergence patterns of mandibular canal, and symmetry of MF and AL. A pilot study was conducted on five patients to determine interobserver reliability among two oral and maxillofacial radiologists, considered for interpretation of CBCT images. All the scans were taken by CS 9300, CBCT machine adjusted at 80 kVp, 15 mA, voxel size 0.3 × 0.3 × 0.3, and field of view of 10 × 5 (mandible only). The acquired images were reconstructed into multiplanar views (axial, panoramic, and cross-sectional) for evaluation. Results: The mean age of the study population was 42.64 ± 16.22 years, with males noted with slightly higher age. Position 4 of MF (below the apex of the second premolar) was noted the most on the right side, whereas position 3 (between the first and second premolars) was noted on the left side, with 75% of symmetrical MF position. The oval-shaped MF was most common among both genders and sides. The prevalence of MIC was noted in 93.75% of patients with a mean length of 12.09 ± 5.95 mm. The prevalence of AL was 53.13%, with a mean length of 1.07 ± 1.42 mm. No statistically significant sexual dimorphism (P > 0.05) was found between genders or sides for all the evaluated interforaminal parameters. Conclusion: CBCT evaluation of vital anatomical structures needs to be elicited before planning an interforaminal placement of implants, and no sexual dimorphism was found regarding them.
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Locally advanced oral tongue cancer: Is organ preservation a safe option in resource-limited high-volume setting? p. 158
Muntazir Hussain, Muhammad Faisal, Muhammad Abu Bakar, Tahir Muhammad, Saman Qadeer, Sameen Mohtasham, Raza Hussain, Arif Jamshed
DOI:10.4103/ams.ams_166_19  
Background: Oral tongue is found to be the most common intraoral subsite with worse prognosis despite the use of multimodality treatments. Extensive resections have resulted in loss of form and function of tongue in advanced tumors. The objective of the study was to analyze the role of induction chemotherapy (IC) in intermediate to advanced staged oral tongue cancer for organ preservation and survival outcome in a developing country. Materials and Methods: The records of oral tongue cancer patients treated from 2007 to 2016 were retrospectively analyzed. Results: Eighty-one oral tongue cancer patients with advanced stage were treated using induction arm in 10 years. The median follow-up was 24 months with 3- and 5-year survival of 77% and 58%, respectively. IC has an overall response in 87% of the patients at primary site. The chemotherapy has completely resolved the nodal disease in 17% of the patients, but 23% of the patients had failed to respond. Only 21% of the patients received reconstruction using local or regional flaps. Conclusion: IC has shown encouraging results in advanced staged oral tongue cancers with function preservation and improved survival outcome in less privileged high-volume centers.
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Intraoperative blood loss in maxillofacial trauma surgery p. 164
Ehsan Aliabadi, Behrooz Malekpour, Saeid Tavanafar, Hamideh Karimpour, Mehdi Parvan
DOI:10.4103/ams.ams_165_19  
Background and Objectives: This study is aimed to assess the intraoperative blood loss of patients with maxillofacial bone fracture surgical intervention and to assess their need for blood transfusion. Materials and Methods: In this retrospective study, intraoperative blood loss of 206 patients with facial bone fractures, who underwent surgery between 2017 and 2018, was retrieved. The patient's demographic information, the amount of blood loss, the type of facial bone fracture, and the patient's requirement for blood products were evaluated. Results: The average amount of intraoperative blood loss was 77.6 ml, and none of the patients required a blood transfusion during the operation in this group of patients. maxillofacial bone fracture was most common in young males. The leading cause of fractures was motor vehicle accident. There was a reverse correlation between the patient's age and surgical blood loss, but there was no statistically significant relationship between the patient's gender and intraoperative surgical blood loss. Conclusion: The results of the present study show that preparation for blood transfusion in patients with maxillofacial traumatic bone fracture requiring surgery is uncommon if patients have no systemic disease or specific blood dyscrasias preoperatively.
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The retromandibular transparotid approach for reduction and internal fixation of mandibular condylar fractures p. 168
Kishore Felix, Madhumati Singh
DOI:10.4103/ams.ams_193_19  
Introduction: The retromandibular transparotid approach is most useful for condylar and subcondylar fractures and provides the best access to the joint and ascending ramus. The study aims at evaluating the ease of access and outcomes encountered on using the retromandibular transparotid approach to access the fracture site for the open reduction and internal fixation (ORIF) of condylar and sub-condylar fractures. Materials and Methods: An observational clinical study was carried out among 10 patients with unilateral and bilateral condylar fracture requiring ORIF. Maximal interincisal mouth opening, facial swelling, occlusal discrepancy, facial nerve injury, scar formation, and acceptability and complications including wound dehiscence, infection, and sialocele/salivary fistula were assessed and measured preoperatively and postoperatively. Results: There was a notable improvement in mouth opening and facial nerve weakness. Postoperative intermaxillary fixation was done with selective patients who had a discrepancy in their occlusion. Preoperatively, swelling was present in four patients (40%) out of 10 patients studied. There was no incidence of sialocele/salivary fistula in any of the cases studied. Conclusion: Retromandibular transparotid incision is technique sensitive and thorough knowledge about the retromandibular area is must for good results and minimal morbidity. The cosmetic results are good in this approach, as well as the facial nerve injury were less in this without any permanent damages.
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TECHNICAL NOTE Top

The minimally invasive-guided genioplasty technique using piezosurgery and 3d printed surgical guide: An innovative technique p. 178
Olivier Oth, Maria Fernanda Orellana, Régine Glineur
DOI:10.4103/ams.ams_78_19  
Introduction: Mental nerve injuries with neurosensory deficits, asymmetries, and intra-operative bleeding are the main immediate complications of genioplasty. Following a recent systematic review, three-dimensional (3D)-printed cutting guide could improve the predictability and accuracy of this surgical technique avoiding postoperative asymmetries. Furthermore, anatomical structures in the surgical area (mental nerve and teeth roots) are better protected, reducing the morbidity and providing safer results. Ultrasonic piezoelectric osteotomy allows by its intrinsic characteristics, a selective cut of mineralized structure with a lower risk of vascular and nervous damage (microvibrations), intra-operative precision (thin cutting scalpel and no macro-vibrations), and blood-free site (cavitation effect). The aim of this article is to present a new minimally invasive technique: the minimally invasive-guided genioplasty technique (aka MIGG technique). This technique combines the advantages of piezosurgery and of a space-saving 3D-printed cutting guide, requiring open-source programs and an affordable 3D printing technology. Materials and Methods: All the steps of this technique are described: preoperative surgical planning (CT scanner, segmentation with 3D slicer®, and design of the cutting guide with Blender®) and 3D printing of the guide and sterilization of it. The surgical procedure is presented in detail as well as the postoperative care. Conclusion: The MIGG technique offers, according to the authors, a better postoperative recuperation, a reduction in operating time, less complications, and protection of the anatomical structures (mental nerve, teeth, lingual soft tissue and vessels). This minimally invasive technique for genioplasty is a promising approach to perform a chin osteotomy.
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Forehead flap ballooning for scar revision p. 182
Anshuman Dwivedi, Manmeet Kour, Deepti Awasthi
DOI:10.4103/ams.ams_266_19  
Nowadays, cutaneous expansion is used progressively in reconstructive surgery for treating the variety of problems such as burns alopecia scar revision in children and adults. With the use of tissue expansion technique, the reconstruction of many acquired and congenital defects has been made possible. Tissue expanders are principally based on the mechanical and the biological creep in which mechanical creep is the morphological changes occurring in cellular level in response to applied stress and biological creep is the resultant expansion of skin surface. There is an excellent closure of extensive soft tissue defects without additional scars in donor area with tissue expanders as compared with other methods of plastic surgery the case report highlights the excellent results of tissue expander in an esthetically compromised patient due to hypotrophic scar on the forehead. This is a novel technique as it was performed under local anesthesia without the use of any sedation in a regular clinical setup.
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Surgical strategy of endoscopically assisted periradicular surgery using novel head-mounted display system p. 186
Shintaro Sukegawa, Takahiro Kanno, Akira Matsuo, Yoshihiko Furuki
DOI:10.4103/ams.ams_83_19  
A novel head-mounted display offers high quality of endoscopic imagery in front of the eyes, irrespective of the head position. We present an application of the head-mounted display system as a personal integrated multi-image monitoring system in endoscopically assisted periradicular surgery. Our head-mounted display system displayed multiple forms of information as integrated, sharp, high-definition endoscope, biological monitor, and X-ray image (such as panoramic and computed tomography images) synchronously using a picture in picture. In addition, this system can cope with both the endoscopic field of view and the direct field of view. While monitoring the patient's general condition with a head-mounted display, the surgery was performed with endoscopic animation. We could also switch to the direct surgical field and endoscopic field of view smoothly without moving the head and without surgical interference. The availability of a head-mounted display system during endoscopically assisted periradicular surgery enabled the provision of a comfortable and appropriate surgical environment for the surgeon.
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SYSTEMATIC REVIEWS Top

Magnitude of gonial angle influence on the commonness of mandibular angle fractures p. 190
Preeti Tiwari, Rathindra Nath Bera, Nishtha Chauhan
DOI:10.4103/ams.ams_23_20  
Background: The aim of the study was to review the literature on the influence of gonial angle on mandibular angle fracture. The present systematic review addresses the following focus question: Does the magnitude of gonial angle influence the incidence of mandibular angle fractures? Materials and Methods: Electronic and manual literature searches were conducted on databases: PubMed/MEDLINE, Embase, Science direct, the Cochrane Library, and clinicaltrials.gov for studies published up to August 2019 to collect information about the effect of gonial angle, a skeletal morphological parameter with an incidence of fracture of the angle of the mandibular arch. Systematic literature review was performed to identify studies evaluating the effect of gonial angle in patients suffering from mandible fractures. Large retrospective studies were included and case reports were excluded. Results: Fifteen hundred articles published before August 2019 were identified. One hundred and sixteen articles met the inclusion criteria. Two articles remained when exclusion criteria were applied. As measured in the two included studies containing 280 panoramic radiographs of mandibular fractures, the mean gonial angle of patients in the angle fracture group ranged from 126.8° ± 7.9° to 128.5° ± 5.4°. The mean gonial angle of patients in the nonangle fracture group ranged from 118.5° ± 4.4° to 122.3° ± 4.9°. The mean gonial angle of patients in the angle fracture group displayed a range from 118.9° to 134.7° (confidence interval [CI] 95% 5.89–8.05), whereas the mean gonial angle of patients in nonangle fracture group displayed a range from 114.1° to 127.2° (CI 95% 3.89–4.95). Conclusion: A high gonial angle is an important factor influencing the occurrence of mandibular angle fractures owing to the poorer quality of bone and reduced height at the ramus angle region, all of which necessitate a modification of osteosynthesis techniques.
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Ligaplants: A revolutionary concept in implant dentistry p. 195
Mehvish Saleem, Mayur Kaushik, Apeksha Ghai, Nitin Tomar, Soundarya Singh
DOI:10.4103/ams.ams_58_19  
Replacement of the missing tooth with an implant has gained popularity among patients. The advent of periodontal tissue engineering has brought about a revolution not only in the field of periodontology but also in the field of implant dentistry at large. Currently, the development of a periodontal ligament (PDL) attachment around dental implants has now become an important new therapeutic tool to replace lost teeth. PDL houses various vital cells that are important in the dynamic relationship between the tooth and the bone. Thus, ligaplants are now an available option to improve the biological performance and to prolong the life of the prosthesis.
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CASE REPORT - DEVELOPMENTAL DISORDERS Top

Surgical correction of congenital double lip p. 198
Hirak S Bhattacharya, Manvi Chandra Agarwal, Shiva Shankar Gummaluri, Ashutosh Agarwal
DOI:10.4103/ams.ams_271_19  
Double lip is an unusual clinical finding, considered to be a developmental anomaly, and usually involving the upper lip more frequently than the lower lip. It may be seen in isolation or in association with Ascher's syndrome. It is caused by excessive areolar tissue and noninflammatory labial mucosa gland hyperplasia of pars villosa. During smiling, the lip is retracted, and the mucosa is positioned over the maxillary teeth, resulting in “cupid's bow” appearance. The incidence of this anomaly is not known. It has been reported in cleft patients, following lip trauma, and as a consequence of lip-biting habits. It might pose esthetic or functional problems and may be a reason for psychological stress to the affected individual because of over shown hyperplastic lip tissue. Surgical treatment is indicated for the correction of this disfigurement. Various surgical techniques have been suggested to address the double upper lip anomaly. All of these involve the excision of excessive mucosa and the underlying tissue. This case series puts forward the surgical management of this rare anomaly in a relatively simple manner. Double lip is a subject of interest to the dental clinicians because they usually are the first professionals to detect, identify, and treat this uncommon condition.
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Anterior tonsillar fossa approach to elongated styloid process p. 203
Ehtaih Sham, Thyagraj Jayaram Reddy, P Suresh Menon, Veerendra Kumar, Archana Susan Nathan, Sheron Mathews, Karthik Vishwas Gowda, CV Dhanush
DOI:10.4103/ams.ams_189_19  
Aim: To demonstrate the efficacy of a new novel anterior tonsillar fossa approach in management of elongated styloid process syndrome. Material and Method: We operated upon 20 patients with confirmed, symptomatic elongated styloid process. None of these patients gave a previous positive history of trauma or any other procedure relating to tonsillar area. All these patients had undergone treatment or were under treatment for neuralgia/TMJ dysfunction syndrome. Diagnosis was confirmed by clinical examination followed by radiological findings. Results: 12 patients underwent bilateral styloidectomy (60%) and 8 patients, underwent unilateral styloidectomy (40%). The length of stolid process ranged from 34mm to 62mm (mean 44 mm). Post operative follow up period ranges from 6 months to 12 months.17 patients (85%) were asymptomatic & had complete remission of symptoms over a follow up period of 12 months. 2 patients had partial remission of symptoms & 1 patient was lost to follow-up. Conclusion: Our anterior tonsillar fossa approach to elongated styloid is safe & adequate in effective surgical management & more so with an additional advantage of not requiring tonsillectomy which is often performed in trans-pharyngeal technique.
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CASE REPORT – MINOR ORAL SURGERY Top

Removal of displaced maxillary third molar using modified gillie's temporal approach p. 210
TM Shruthi, Akshay Shetty, Mohammed Imran, KS Akash, Fazeel Ahmed, Nida Ahmed
DOI:10.4103/ams.ams_254_19  
Tooth impaction is a pathological situation where a tooth is unable to achieve its normal functional position within the expected time span. The removal may be associated with intra-operative or post-operative complications. The Le Fort I osteotomy is a procedure used by maxillofacial surgeons to correct a wide range of dentofacial deformities. Due to its versatility and simplicity, it has gained popularity for a wide range of uses. This case report describes the location and surgical removal of a right maxillary third molar which was accidentally displaced into the infratemporal fossa in a 26-year-old female while performing Le Fort I osteotomy. The patient underwent a second surgery for the retrieval of tooth using modified Gillie's temporal approach. The important role of the cone beam computed tomography in determining the localization of the displaced tooth is demonstrated.
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Esthetic indication for dental implant treatment and immediate loading (3). Case report and considerations regarding the aspect of the patient's right to self-determination in medical decision-making p. 213
Stefan Ihde, Olga Sipic
DOI:10.4103/ams.ams_153_19  
The technology of the Strategic Implant® has expanded the indications for tooth and bone removal. This case report shows what kind of results are possible and how much the appearance of a patient can be changed within a few days if both teeth and bone are removed. The treatment option explained here could be considered by patients with a gummy smile. This treatment conflicts with the traditional thinking of dentists, who are educated to keep and maintain teeth. This can be compared to other fields of esthetic surgery where the patient's right to self-determination in medical decision-making has been established for a considerable period of time and is more frequent than in dentistry.
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CASE REPORT - TRAUMA Top

White-eyed blowout fracture p. 217
Cheruvathur Prasad, M Arulmozhi, J Balaji, MP Nilopher Nisha
DOI:10.4103/ams.ams_150_19  
White-eyed blowout fracture is often found in pure orbital floor blowout fracture among pediatric patients. Unlike common orbital blowout fractures with apparent clinical signs, the diagnosis of white-eyed orbital blowout fractures is difficult because of minimal soft-tissue signs. This report describes an early missed-out diagnosis of a white-eyed blowout fracture in a 7-year-old child, due to negligible soft-tissue manifestation.
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A rare fracture pattern with extensive disruption of the zygomatico-orbito-maxillary complex p. 220
Priya Jeyaraj
DOI:10.4103/ams.ams_93_20  
A case of an unusually oriented fracture pattern and significant disruption of the right Zygomatico-orbito-maxillary complex, with severe comminution and gross displacement of its skeletal components, is described. Wide surgical access to all the fracture sites was provided by a combination of hemicoronal and intraoral surgical approaches. This enabled successful reduction, precise reapproximation, and stable fixation of the multiple displaced fracture fragments. An excellent restoration of the skeletal morphology and orbital volume to their original, preinjury status was achieved, obviating the development of any residual facial deformity, functional deficit or ocular complications.
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CASE REPORT – ORTHOGNATHIC Top

Enhancing the orthognathic surgery experience: Treatment in 10 weeks “surgery first” approach p. 227
Aylin Gallegos Salazar, Peter D Waite, Chung How Kau
DOI:10.4103/ams.ams_203_19  
This case report describes the successful treatment of a 25-year-old male with maxillary retrognathism, skeletal and dental Class III malocclusion, anterior and posterior crossbite, negative overjet and overbite, mild mandibular crowding, and lower midline deviation. The nonextraction treatment plan included: (1) maxillary and mandibular arch fixed appliance and (2) Le Fort 1 maxillary osteotomy and postsurgical orthodontic treatment. The orthodontic treatment was initiated with 0.022” preadjusted brackets bonded to all the teeth except the maxillary second molars, 2 days before the surgery without any archwires. Two weeks after the surgery, maxillary and mandibular arch alignment along with the occlusal adjustments was started with the use of 0.018” NiTi wires, in both arches. Optimum esthetic and functional results were achieved in 10 weeks after the surgery, with the cooperation of two specialties and the use of surgery first approach.
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CASE REPORT - CYST & TUMORS Top

A unique case of Gorlin–Goltz syndrome with associated Sotos syndrome p. 232
Jeevan Lata, Jaspreet Kaur
DOI:10.4103/ams.ams_91_19  
Both Gorlin–Goltz syndrome and Sotos syndrome are rare genetic conditions showing variable expressiveness. They both are inherited in an autosomal dominant pattern. Since these conditions tend to be multisystemic disorders, the familiarity of various medical specialists with its manifestations may reduce the time necessary for providing a diagnosis, better differentiation of these two conditions, or even the co-existence of two syndromes.
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Carcinoma ex pleomorphic adenoma in the floor of the mouth: An unusual diagnosis in a rare location p. 238
Shalini Krishnan, Varsha Salian, Shubha Bhat, Vikram Shetty
DOI:10.4103/ams.ams_171_18  
Carcinoma ex pleomorphic adenoma (CXPA) is a rare malignant salivary gland tumor, mostly involving the parotid and submandibular glands. Minor salivary gland involvement is even rarer, palate being the most common site. Other reported sites are upper lip, sinonasal tract, and buccal mucosa. Here, we report a case of CXPA in an unusual location, the floor of the mouth.
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Concurrent occurrence of odontogenic keratocyst and lateral periodontal cyst in the mandible p. 243
Uday Kiran Uppada, Khalid Gufran, Nandini Dayalan, Shazia Salim
DOI:10.4103/ams.ams_186_19  
Clinical presentation of odontogenic keratocyst (OKC) along with other pathologies of the jaw such as ameloblastoma, and ossifying fibroma is well documented. However, the simultaneous occurrence of OKC with lateral periodontal cyst (LPC) is very rare. We present a clinical scenario where there was concurrent presentation of OKC with LPC.
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Concentrated growth factor – surgical management of large periapical lesion using a novel platelet concentrate in combination with bone graft p. 246
Nivedhitha Malli Sureshbabu, Aishwarya Ranganath, Benoy Jacob
DOI:10.4103/ams.ams_80_19  
Although endodontic therapy is typically successful, in approximately 10%–15% of the cases, symptoms can persist or reoccur. Periapical surgery is the preferred treatment of choice in failed root canal therapy, chronic periapical lesion, persistent apical periodontitis, etc., i.e., when conventional treatment modalities fail. Over the past few decades, although the list of indications for endodontic surgery has diminished, there exist definite cases in which the tooth cannot be retained without surgery. This case report, however, sheds light on the incorporation of a novel autologous platelet concentrate-concentrated growth factor (CGF) coupled with an osseograft in surgical endodontic procedure to ensure a swift and successful recovery of the periapical region subjected to extensive lesions. The use of an osseograft combined with CGF has numerous advantages as well due to the formation of sticky bone. There are no articles published in the literature with respect to the potent application of CGF and bone graft (sticky bone) in large periapical lesions to aid in the reparative process. In this case report, the 1-year follow-up radiographs and cone-beam computed tomography showed complete healing of the hard and soft-tissue lesions that conform to achieving repair and regeneration at a rapid rate in extensive periapical lesions.
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Angioleiomyoma of the Lower Lip p. 251
Payal Dilipkumar Mehta, Nimisha Desai, Kalpesh Makwana, Yama Patel
DOI:10.4103/ams.ams_275_19  
Leiomyoma is a benign smooth muscle tumor that occurs most frequently in the uterine myometrium, gastrointestinal tract, skin, and lower extremities. Leiomyoma rarely affects the oral cavity. Angioleiomyoma (vascular leiomyoma) is a histological subtype of the leiomyoma. The diagnosis is commonly determined by histopathological studies. This case report shows a 57-year-old male patient with a lesion of the lower lip. After laser excision, hematoxylin and eosin and smooth muscle actin staining confirmed the diagnosis of angioleiomyoma.
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Eosinophilic granuloma of the mandible p. 254
Akhilesh Prathap, Ravi Rajan Areekkal, Eapen Thomas, Nithin Pratap, Vinesh Udayakumar
DOI:10.4103/ams.ams_139_17  
Eosinophilic granuloma (EG) is a rare histiocytic disorder resulting from clonal proliferation of Langerhans cells. Eosinophilic granuloma, the most benign of the three entities of Langerhans cell histiocytosis, may be multiple or solitary. This lesion can affect any bones but commonly involves the mandible when the jaws are affected. It is difficult to make a correct diagnosis on it without proof of a pathological diagnosis, which correlates with the diverse clinical and radiographic presentations of EG in the jaws. This report describes a case of unifocal EG of the mandible occurring in a 6-year-old boy whose initial presentation led to confusion of any solitary bony lesion. A final diagnosis of EG was established after histopathological examination of the biopsy specimen.
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Swelling in the floor of the mouth: A diagnostic dilemma p. 258
Ginni Datta, Ankita Yadav
DOI:10.4103/ams.ams_263_19  
Epidermoid cysts are abnormal structures originating from abnormal ectoderm and are benign and slow growing. These are found anywhere in the body. They arise during embryonic fusion due to entrapment of epithelial remnants and sometimes due to faulty implantation of the epithelium. The cysts can be epidermoid (squamous epithelium), true dermoid (skin apppendages), and teratoid (all germ layers). They are usually diagnosed by fine-needle cytological aspiration and require imaging to plan line of treatment. Diagnostic dilemma is always an issue as cystic lesions are commonly found in the head-and-neck region. Here, we present a case of large epidermoid cyst involving sublingual and submandibular region.
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Aggressive ossifying fibroma of the maxilla p. 262
Sujeeth Kumar Shetty, Saubhik Dasukil, Geetanjali Arora
DOI:10.4103/ams.ams_121_18  
The aggressive ossifying fibroma is an uncommon benign fibro-osseous lesion which has been described in the literature under a variety of terms. This tumor is distinguished from standard ossifying fibroma based on its more clinically aggressive biological behavior, occurrence in children and young adults, and tendency to occur in different anatomic sites. We report a case of a 45-year-old female who presented with a unilateral swelling of the right middle face for 5 months. Clinical examination showed a mass extended over the right maxilla. Orthopantomogram and computed tomography scan were performed. Biopsy suggests a fibro-osseous lesion. The complete surgical excision of tumor was performed under local anesthesia. The histopathological examination revealed the diagnosis of an aggressive ossifying fibroma-trabeculae type. No recurrence was noted. Because of its aggressive and compressive nature, aggressive ossifying fibroma requires an early complete surgical excision. A long-term clinical and radiological surveillance is necessary to prevent recurrence.
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Rapidly growing facial tumor in a 5-year-old girl p. 267
Martín Fernandez-Ferro, Annahys López-Betancourt, Eloísa Santos-Armentia, Martín José Mosteiro-Cerviño, Jacinto Fernández-Sanromán, Alberto Costas-López
DOI:10.4103/ams.ams_200_19  
The aim of this study is to describe the clinical, radiological and histological characteristics that define lipoblastomas with special emphasis on differential diagnosis. The patient is a 5-year-old girl who consulted for a rapidly growing lower cheek tumor. This study analyzes, evaluates, and discusses the issues that need to be addressed throughout the process that affect treatment planning and provides an updated review of these rare head-and-neck tumors.
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Enchondroma of the mandibular body: An occult entity p. 272
Vaibhav Shukla, Anmol Agarwal, Gaurav Mittal, Uday Kiran Uppada, Abhishek Rathi
DOI:10.4103/ams.ams_226_19  
Cartilaginous tumors are commonly encountered tumors that can involve almost any bone and very rarely found in the maxillofacial region. These tumors may have varied presentations ranging from a simple enchondroma to a high-grade osteo or chondrosarcoma. Owing to their membranous development they are reported to occur usually in the cartilage bearing areas of the jaws like condylar process of the mandible. This article is intended to present a rarest of rare case of enchondroma of the mandibular body which to the best knowledge of authors', is not reported in the literature so far.
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Patient-specific implant for temporomandibular joint replacement in juvenile arthritis and facial asymmetry p. 275
Sergio Olate, Victor Bahls, Francisca Uribe, Alejandro Unibazo, Felipe Martínez
DOI:10.4103/ams.ams_82_19  
The aim of this report is to present a patient with juvenile arthritis, condylar resorption, and residual facial asymmetry treated with orthognathic surgery and unilateral joint replacement with a full three-dimensional computer-aided design and computer-aided manufacture (CAD-CAM) temporomandibular joint (TMJ) prosthesis, including an increase in the left ramus and mandibular angle to achieve facial symmetry. The patient, a 30-year-old male, came to our department for orthosurgical treatment. The patient had been receiving treatment for juvenile arthritis for 15 years; at facial level, he had a chin deviation of 12 mm from the facial midline, maxillary retrusion, and Angle Class III. The computed tomography revealed a reduced height of the left condyle and a significant difference in the morphology of the mandibular ramus and angle. Using CAD-CAM technology and additive manufacturing, a TMJ prosthesis was produced, through the use of the mirror image, orthognathic surgery was realized using the right side as “esthetic side” with suitable shape and angulation. The prosthesis was created, and this was taken to the surgery. The surgery was performed without problems, a mouth opening of 35 mm and absence of pain were noted after 12 months of follow-up. The surgery remained stable, and facial symmetry was restored. In conclusion, it is viable to develop a TMJ prosthesis by CAD-CAM that includes esthetic modifications to the face; prospective and clinical studies must be conducted to confirm protocols.
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Sublingual dermoid cyst: Review of 14 cases p. 279
Omisakin Olatunde Oluleke, Kache Stephen Akau, Ayuba Iko Godwin, Aghadi Ifeanyi Kene, Ajike Olusegun Sunday
DOI:10.4103/ams.ams_207_19  
Background: Dermoid cyst is a benign congenital lesion of ectodermal origin. They are commonly found throughout the body but rare in the oral cavity. It is a developmental lesion and usually due to retention of germinal epithelium during growth of brachial arches and lower jaw. It is commonly present in the sublingual region as a swelling in the middle of the mouth. It presents as a slow growing mass, causing elevation of the tongue and interference with speech and swallowing. Aim and Objective: To determine the epidemiology, presentation, co-morbidities and treatment of sublingual dermoid cyst in our Centre. Materials and Methods: This is a retrospective review of all patients with sublingual dermoid cyst managed over a period of eight years from January 2010 to December 2017. Information was extracted from case files of patients. Data collected included: age of patient at presentation, sex, location of cyst, co-morbidities, treatment giving, findings and histological diagnosis. Only patients with a histological diagnosis of dermoid cyst were included in the study. Results: Fourteen cases were included in this study. Eight were males (57.1%) and six (42.9%) females. Male to female ratio is 1.3:1. Age range is from Day 1 to 25years. Five were congenital sublingual dermoid cyst in newborn, one was attached to the tongue ventral surface, two were bulging from the submandibular and submental spaces in adults. The remaining six cases were limited to the floor of the mouth. Conclusion: Sublingual dermoid cyst could interfere with swallowing and speech, this affects patient nutrition and breathing. Therefore, surgical excision of the cyst should be done promptly.
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