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   Table of Contents - Current issue
January-June 2019
Volume 9 | Issue 1
Page Nos. 1-222

Online since Thursday, June 13, 2019

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The neglected aspect of applied biomaterials in medicine! Highly accessed article p. 1
Mahdi Ebrahimi
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Evidence-based maxillofacial surgery p. 3
SM Balaji
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Orthopantomography and cone-beam computed tomography for the relation of inferior alveolar nerve to the impacted mandibular third molars p. 4
Nirmalendu Saha, NS Kedarnath, Madhumati Singh
Context: Relation of inferior alveolar nerve to the impacted mandibular third molars (IMTMs). Aims: The aim of this study was to assess the reliability of seven specific radiographic signs of mandibular third molar root that are observed on orthopantomography (OPG) and to predict the proximity and the absence of corticalization between the mandibular canal and IMTM root on cone-beam computed tomography (CBCT) images. Settings and Design: The present study was conducted in the Department of Oral and Maxillofacial Surgery, Raja Rajeswari Dental College and Hospital. Subjects and Methods: Data set of 30 panoramic images was retrieved between the year of 2015 and 2016 indicated for extraction of lower third molars. The sample consisted of 30 individuals, who underwent preoperative radiographic evaluation before the extraction of impacted mandibular third molars (IMTM). Patients aged above 18 years with any of the seven specific signs observed on the panoramic radiograph which includes darkening, deflection, narrowing of roots, bifid root apex, diversion, narrowing of canal and interruption in the white line of the canal were included in the study. If any of the above mentioned seven specific sign were present, the patient was subjected to CBCT. On the CBCT images, the canal was traced in three planes. The acquired images were assessed for the presence or absence of corticalization. Statistical Analysis Used: Descriptive and inferential statistical analyses were used. Proportions were compared using the Chi-square test and Student's t-test. Results: Among the 4 subjects, diagnosed with an absence of corticalization, patients with isolated darkening of root P = 0.001 and patients with isolated interruption in white line P = 0.69. Patients with darkening of root in association with interruption in white lines on OPG showed the absence of corticalization on CBCT findings P = 0.001, respectively. Conclusions: This study showed the poor reliability of radiographic signs seen on OPG on predicting the proximity of third mandibular root with mandibular canal related to CBCT finding. Four were diagnosed with the absence of corticalization in CBCT findings.
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High-density polyethylene material versus autogenous grafts in craniofacial augmentation procedures p. 10
Kshitij Agarwal, Rajesh B Dhirawani, Sauvik Singha, Anshalika Agrawal
Aim: The objective was to do a comparative study and to evaluate the outcome in overall acceptance for correction of residual facial deformity with autogenous graft versus porous polyethylene implants. Materials and Methods: A total of 16 patients in the age group of ≥15 years irrespective of sex, caste, religion, and socioeconomic status presenting with signs and symptoms of residual facial deformities and who were declared fit for surgery were included in the study. The study patients were further divided into two groups, of eight each. Deformity correction using autogenous grafts was performed in Group A and using high-density polyethylene (HDPE) alloplastic implants was performed in Group B. During the follow-up period, patients' and doctor rating of overall acceptance between autogenous and alloplastic (HDPE) bone grafts was recorded on 100-mm visual analog scale (VAS) on the 2nd day and 7th day and at 3, 6, and 12 weeks. Results: The unpaired t-test is used for evaluation. VAS score at all the follow-up periods above stated was significantly higher in alloplastic group than in the autogenous group for both in patients and doctor evaluation. Conclusion: From the present study, it can be concluded that porous HDPE implants are an effective alternative to autogenous grafts in accordance of overall acceptance for correction of residual facial deformity when proper case selection, exclusion of negative prognostic factors, and meticulous surgical procedure are followed.
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Condylar fractures: Surgical versus conservative management p. 15
Abhishek Karan, NS Kedarnath, G Santhosh Reddy, T V. S. Harish Kumar, C Neelima, M Bhavani, Abhishek Singh Nayyar
Background and Objectives: Condylar fractures can be treated with one of the two methods, including the conservative (closed reduction and immobilization) and/or surgical (open reduction and internal fixation) methods. Both these modalities of treatment have their indications and contraindications and merits and demerits. The present study was designed with the purpose of comparing the outcomes of surgical versus conservative management of moderately displaced subcondylar and condylar neck fractures. Materials and Methods: The present study included a total of 20 patients with moderately displaced condylar fractures in patients > 18 years of age who were randomly divided into nonsurgical and surgical group and were managed accordingly. In the present study, the outcomes of conservative versus surgical management of subcondylar and condylar neck fractures were discussed in terms of seven parameters, including the maximal interincisal mouth opening, protrusive and lateral excursive movements of the mandible, status of occlusion, deviation of mandible during mouth opening, pain (in terms of visual analog scale) and the height of ascending ramus (radiographically) which were measured and evaluated pre- and post-operatively at different intervals of time. The follow-up was done for a period of up to 6 weeks postoperatively. Statistical Analysis Used: Descriptive and analytical statistics were calculated using the Statistical Package for Social Sciences version 19. The Mann–Whitney U-test was used to assess the significance of the difference between the groups, whereas the Wilcoxon signed-rank test was used to assess the significance of the difference between the paired observations in each group. Results: Patients treated surgically showed better improvement in maximal interincisal mouth opening, lateral excursions with minimal deviation, early relief from pain, and restoration of height of the ramus with symmetry in comparison with the patients managed conservatively where prolonged periods of pain apart from obvious deviation and minimal restoration of height of the ramus was observed over a follow-up period of 6 weeks postoperatively. The results were also found to be statistically significant with the value of P < 0.05. Interpretation and Conclusion: Surgery is inarguably preferred over conservative management of moderately displaced condylar fractures as per the results of the present study. The present study provided valuable information and mandated further studies with larger sample sizes to come to definitive conclusions.
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Efficacy of spirulina along with different physiotherapeutic modalities in the management of oral submucous fibrosis p. 23
Varsha Kanjani, Rajeshwari G Annigeri, Manjunath M Revanappa, Abha Rani
Context: Oral submucous fibrosis (OSMF) is an insidious, chronic, disabling disease that mainly affects the oral mucosa. Spirulina is a freshwater microalga which is considered as superfood by the WHO. Due to its antioxidant, anti-inflammatory, and immunomodulating properties, spirulina has shown promising results in the management of OSMF. A wide range of treatment modalities have been tried ranging from medical, physical, or surgical interventions, but combinations of these have shown better results. Aims: The study aimed to evaluate the efficacy of spirulina along with different physiotherapeutic modalities in the management of OSMF. Setting and Design: The present comparative study was conducted in the Department of Oral medicine and radiology, College of Dental Sciences, Davangere, Karnataka, India. The block randomization technique was used in the present study to enroll patients into three different groups. Methods: The study consisted of 45 OSMF patients who were divided randomly into three groups. All patients were given spirulina 500 mg twice a day for 3 months. Group A patients were instructed to perform isometric mouth exercises for 20 min, twice daily. Group B patients and Group C patients perform exercises using threaded tapered screw and mouth stretching device (MSD), respectively, ten times bilaterally twice a day. Clinical parameters such as burning sensation, mouth opening, tongue protrusion, and cheek flexibility were assessed every 15 days. Statistical Analysis Used: Descriptive data that included mean, numbers, and percentages were calculated for each group and were used for analysis. For intra- and inter-group comparison, paired t- and unpaired t-test was used, respectively. For all the tests, P = 0.05 or less was considered for statistical significance. Results and Conclusion: All the groups have shown statistically significant improvement in burning sensation, mouth opening, tongue protrusion, and cheek flexibility (P < 0.05). Group C patients have shown better results followed by Group B and Group A patients. In the present study, spirulina along with different physiotherapeutic modalities was well tolerated by the patients, and significant improvement was seen in the MSD group.
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Sleepiness score-specific outcomes of a novel tongue repositioning procedure for the treatment of continuous positive airway pressure-resistant obstructive sleep apnea p. 28
Rushdi Hendricks, Malika Davids, Hoosain Khalfey, Hilda J Landman, Anne E Theron, Eugene Engela, Keertan Dheda
Background: The gold standard of treatment for obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP). However, more than a third of patients have such difficulty with its chronic use such that they seek other options or choose to remain untreated. We evaluated sleepiness score-specific outcomes and the use of CPAP after tongue repositioning surgery for the treatment of OSA. Patients and Methods: A self-administered questionnaire was completed pre- and postoperatively by 10 patients who underwent tongue repositioning surgery for the treatment of OSA from October 2010 to December 2012. The questionnaire included the Epworth Sleepiness Scale (ESS) for the assessment of daytime somnolence and questions regarding CPAP use and overall satisfaction. Results: Preoperatively, 6 patients were “very sleepy” (ESS ≥16), 4 patients were “sleepy” (ESS = 10–16), and 0 patients were “not sleepy” (ESS ≤10). 30 days postoperatively, sleepiness scores decreased (10 patients were “not sleepy” (ESS ≤10) with 0 patients “very sleepy” or “sleepy;” P = 0.002). Thus, the median ESS score for the “very sleepy” and “sleepy,” decreased from 20 to 4 and 13 to 5, respectively, and the “nonsleepy” group increased from 0 to 4. After a 180-day review, the improved ESS scores remained unchanged (the median for “very sleepy” decreased to 3.5 that for “sleepy” remained at 5, and the median for “not sleepy” decreased to 3.5). Surgery decreased CPAP use by 100%. The surgery was judged to be worthwhile by all 10 of patients using a questionnaire, and all 10 patients said that they would recommend the treatment to other patients with OSA. Conclusions: These preliminary data indicate that tongue-repositioning surgery for the treatment of OSA may be effective in improving excessive daytime sleepiness. These proof-of-concept data require confirmation in an appropriately powered controlled study.
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Management of central giant cell granulomas of the jaws: An unusual case report with critical appraisal of existing literature p. 37
Priya Jeyaraj
Central giant cell granuloma (CGCG) is an uncommon, benign but aggressive osteolytic neoplasm of the craniomaxillofacial region, histologically characterized by an abundance of evenly distributed multinucleated giant cells within a sea of spindle-shaped mesenchymal stromal cells, scattered throughout the fibrovascular connective tissue stroma containing areas of hemorrhage. A rapid diagnostic assessment, together with an adequate histopathologic verification, is essential to improve the management and the prognosis of this locally destructive lesion. A rare case of a large destructive CGCG involving the entire right angle of mandible, causing extensive bony resorption, and buccal, medial as well as inferior border cortical expansion with multiple perforations, in a young child is presented. It was treated successfully by enucleation and aggressive curettage followed by peripheral ostectomy preserving the continuity of the mandible. Two adjunctive measures were employed; first, chemical cauterization of the residual bony walls to prevent possible recurrence, for which this tumor is notorious, and second, placement of fresh autologous platelet-rich fibrin within the bony defect to hasten bone fill and reossification, thus obviating the need for a bone graft.
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Radiographic evaluation of low-level laser therapy-enhanced maxillary sinus augmentation with simultaneous dental implant placement p. 48
Ilham Mehdiyev, Ugur Gülsen, Mehmet Fatih Sentürk, Nejat Bora Sayan
Background: To evaluate the effect of low-level laser therapy (LLLT) on bone healing in patients undergoing bilateral sinus lifting and simultaneous dental implant application. Methods: Twelve patients with total/partial posterior maxillary edentulism who needed bilateral sinus bone augmentation were included in the study. Dental implants were inserted in the same session. LLLT (λ = 630–660 nm, 25 mW/cm2, 6 min) was used for one operation side on the 1st, 3rd, 5th, and 7th days, whereas contralateral side served as control side. Preoperative and postoperative 1st, 3rd, and 6th month orthopantomograms were obtained using the aluminum step-wedge technique. Optic density analyses were performed using a Cardinal Health Digital Densitometer (Fluke Biomedical 07-443) with 1 mm diameter. Digital densitometry results were obtained as the equivalent aluminum thickness for each radiograph. These data were used to evaluate the changes in optical bone density and to compare the treatment side with the control side for each patient. Results: The LLLT side showed better results than the control side according to the densitometry results. Increase in the bone density at all the postoperative intervals was statistically significant (P < 0.05). Conclusions: LLLT enhances bone regeneration in sinus augmentation with simultaneous dental implant placement.
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Cuddling teeth: A new terminology p. 53
Anmol Agarwal, Gaurav Mittal, Uday Kiran Uppada
Literature is replete with information on the diverse patterns exhibited by impacted teeth and a clinical scenario in which >1 impacted teeth appears in close proximity is documented very rarely. Occasionally, molars are found to be impacted in interesting patterns which were described previously as “rosette teeth” or “kissing molars”. This article intends to introduce a new term, namely, “cuddling teeth” to broadly describe the clinical presentations where 2 or >2 impacted teeth are found in close approximation.
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Rationale, relevance, and efficacy of “surgery first, orthodontics later” approach in the management of cases of severe malocclusion with skeletal discrepancy p. 57
Priya Jeyaraj, Ashish Chakranarayan
A good esthetic outcome and optimal functional occlusion is the goal of management of any dentofacial anomaly. Conventional orthognathic surgery, as commonly practiced, entails a rather long-drawn management protocol comprising a triphasic treatment approach, with the surgical procedure being both preceded and followed by pre- and post-surgical orthodontics, respectively. This has numerous well-known drawbacks such as an uncertain and unpredictable patient compliance and poor motivation due to the inevitably long duration of orthodontic therapy; a transient and temporary worsening of the facial appearance brought about by presurgical orthodontic decompensation of occlusal relationships; and the inevitably prolonged time frame involved in ultimately achieving the desired esthetic and functional results. Further, unforeseen interruptions along the course of the long treatment period can result in unfavorable and even disastrous outcomes. The newer concept and technique of “Surgery First Orthodontics After” (SFOA) approach or “surgery- first approach” (SFA) entails first performing orthognathic surgery, thereafter following it up and finishing the case with postsurgical orthodontic settling and correction of the occlusion. It has two very distinct advantages over the erstwhile approach, first, an immediate and early correction of the facial deformity resulting in a remarkable improvement in facial appearance, which in most cases was what had prompted the patient to seek treatment for, in the first place. The patient, encouraged and motivated by the obvious and appreciable esthetic results, complies willingly and well with the subsequent postsurgical orthodontic treatment, even if it is lengthy or inconvenient, thus ensuring an optimal ultimate occlusion with complete functional rehabilitation as well. The second advantage of SFA is a markedly reduced overall treatment time, which is greatly appreciated by the patients. This article presents three cases of severe malocclusion with associated skeletal discrepancies, treated expeditiously and effectively using the SFA protocol. The overviews of SFA, including its rationale and relevance, indications, general and specific guidelines, different protocol variations, clinical outcome and success rate, as well as possible complications and potential problems encountered with this novel treatment protocol are also discussed.
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Prevalence of Haller's cells: A panoramic study p. 72
Rohan Shrinivas Chaudhari, Kumbhar Sagar, Nagare Sagar, Onkar Sanjeev, Kulkarni Abhay, Parkarwar Pratik
Context: Haller's cells or infraorbital ethmoid cells refer to the ethmoidal pneumatization of the superior aspect of the maxillary sinus, and floor of the orbit can be seen on panoramic radiographs. They appear as well-defined, round-, oval-, or teardrop-shaped radiolucencies with smooth corticated or noncorticated borders. Aims and Objective: To determine the prevalence and scrutinize the characteristics of Haller's cells on panoramic radiographs. Settings and Design: The present study is a cross-sectional study carried out in institutional setting. Subjects and Methods: The study group comprised 300 individuals with an age range of 08–80 years selected by convenient sampling method. Three hundred panoramic radiographs were examined for the presence of Haller's cells under ideal viewing conditions by two radiologists. Statistical Analysis Used: The data collected were tabulated and subjected to statistical analysis using SPSS version 20 for Windows (SPSS Inc., Chicago, IL, USA) to obtain the results. Chi-square test was performed, and significance was set at 0.05 levels. Results: Haller's cells were identified in 30/300 individuals giving a prevalence of 10% with 18 Haller's cells in males and 12 in females. Among the 30 Haller's cells, 14 were unilateral and 16 were bilateral. Most of the Haller's cells were oval followed by round shape. Conclusion: The overall prevalence of Haller's cells is relatively low and is in harmony with other studies conducted in various geographic populations. Knowledge of Haller's cells while interpreting panoramic radiographs is essential to forewarn surgeons before endonasal procedures, thus preventing any untoward intraoperative complications.
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Immediate functional loading: Results for the concept of the strategic implant® Highly accessed article p. 78
Aleksandar Lazarov
Background: Immediate functional loading of one-piece dental implants has become an accepted treatment modality for fixed restorations in fully edentulous mandibles and maxillae. Nevertheless, studies regarding immediate loading procedures in extraction sites in both the jaws, as well as in segment reconstructions and single-tooth replacements, are limited. Purpose: The purpose of this study was to evaluate the presently used protocol for immediate functional loading (within maximum 3 days) of one-piece implants which are placed according to the following methods as published by the IF. Materials and Methods: This prospective cohort study included totally 87 consecutively treated patients who receive 1169 immediately loaded one-piece Strategic Implant®, supporting fixed complete-arch maxillary or mandibular metal-ceramic bridges or segment reconstructions in both the jaws. All implants were placed by one treatment provider, who delivered also the prosthetics and controlled all cases himself over the years. Data were extracted by an experienced dentist from the patient records and from panoramic X-rays. A number of patients were interviewed at the end of the observation period. Although a total of 5100 implants were placed and observed for 12 – 57 months totally (with 105 implants out of these, having failed), this article reports the detailed results only for 1169 implants which have been followed for at least 48 months. Results: Immediate functional loading of using multiple, cortically anchored basal screw implants as a support for fixed full-arch and segment prosthesis in the upper and lower jaw demonstrated a high cumulative implant survival rate after an observation period of up to 57 months. Neither hypertension nor diabetes and neither smoking nor bending of the implant's neck had an influence on the success of the implants observed in this study. Within the limits of this study (5100 Strategic Implants were observed over a period of up to 57 months), “peri-implantitis” was not observed at all. Conclusion: The treatment concept developed for the technology of the Strategic Implant® is safe and effective and it avoids bone augmentations and “peri-implantitis”.
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To evaluate the efficiency of dexmedetomidine in atomized intranasal form for sedation in minor oral surgical procedures p. 89
Sadaf Syed, Tajamul Hakim, Mohd Rameez Riyaz, Ravinder Singh Bedi
Aim: This study aims to evaluate the efficiency of dexmedetomidine in atomized intranasal form for sedation in minor oral surgical procedures. Materials and Methods: A total 25 patients fitting the inclusion and exclusion criteria were selected from the outpatient Department of Oral and Maxillofacial Surgery, Saraswati Dental College and Hospital, Lucknow. The drug was administered intranasally half an hour before the surgical procedure. The volume of drug used was recorded. The readings of all the parameters of sedation began 30 min after the drug had been administered. Intranasal sedation status was assessed by Ramsay sedation score and observer's assessment of alertness/sedation scales, every 15 min throughout the procedure. Results: The primary outcome variable in this study is depth of sedation produced by intranasally administered dexmedetomidine. Secondary variables included respiratory rate, blood pressure (BP), heart rate (HR), and oxygen saturation (SpO2). The statistical software used was SPSS 20.0 for Windows (SPSS, Chicago, IL, USA). Data were expressed as mean and standard deviation or number (percentages). Sedation and behavior scores were analyzed by proportions. Hemodynamic variables including HR, SpO2, and BP and respiratory rate were analyzed by repeated measures ANOVA. When a significant result was obtained, the Tukey test was applied for post hoc pairwise comparisons. P < 0.05 was considered as statistically significant. All the parameters were recorded at a set interval of time. Conclusion: In conclusion, intranasal administration of 1.5 mg/kg atomized dexmedetomidine was clinically effective, convenient, and safe for the sedation of patients undergoing minor oral surgical procedures.
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Indirect sinus floor elevation technique with simultaneous implant placement without using bone grafts p. 96
Aditi Rawat, Himanshu Thukral, Anson Jose
Context: Maxillary posterior region is a problem area for the placement of implants. The advanced resorption of alveolar bone is combined with an increase in pneumatization of maxillary sinus because of higher intra-antral pressure, giving rise to severely atrophied alveolar ridges with reduced bone height. Materials and Methods: A total of 26 implants were placed in 21 patients using indirect sinus lift with simultaneous implant placement without using bone grafts. Intra-oral periapical radiographs were taken to determine residual bone height, endosinus bone (ESB), and crestal bone level. Results: All the implants were clinically and radiographically stable at the end of 6 months follow-up. All the implants showed ESB gain, with mean being 1.97 mm and 1.99 mm on mesial and distal sides, respectively. Conclusion: The findings of this study indicate that successful osseointegration is predictable using osteotome sinus floor elevation without bone graft. Spontaneous new bone formation seemed to be expected with implants placed using indirect sinus lift.
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Parotid gland tumors: 2-year prospective clinicopathological study p. 103
S Venkatesh, Teerthanath Srinivas, S Hariprasad
Context: Parotid gland tumors account for 80% of all salivary gland neoplasms. Most parotid masses are operated on before obtaining the final histological diagnosis, which complicates the management of the facial nerve damage during parotid surgery. Aims: The aim of this study is to analyze the age- and gender-wise incidence of parotid gland tumors, the incidence of various types of tumors, to assess their clinical modes of presentation, the efficacy of treatment, and to evaluate the complications ensuing therein, because of intervention. Settings and Design: The present study was conducted in the Department of Oral and Maxillofacial Surgery, A. B. Shetty Memorial Institute of Dental Sciences and Justice K. S. Hegde Charitable Hospital, Nitte University, Mangalore. Subjects and Methods: A clinicopathological study of parotid gland tumors was undertaken in a tertiary care hospital. Patients with parotid swelling were clinically evaluated, followed by fine-needle aspiration cytology (FNAC). Surgery was planned and performed based on the tumor location and FNAC report. Patients were followed up for postoperative complications. Results: The study comprised 59 patients with parotid gland tumors. The age range of the patient affected was between 18 and 75 years. Benign tumors are more common than malignant tumor in the ratio of 3.5:1. Slow progressively parotid swelling was the common presenting complaint. Superficial parotidectomy was the most common surgery (69.49%) performed. The most common postoperative complication encountered was transient facial palsy (22.03%). Benign tumors were more common (77.97%). The most common benign tumor was pleomorphic adenoma, and malignant tumor was mucoepidermoid carcinoma. Conclusions: The incidence of parotid salivary gland tumors is increasing in recent years. Parotidectomy is safe procedure for treating parotid tumors. Transient facial palsy is the most common postoperative complication, which is reduced in superficial parotidectomy.
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Role of virtual reality in pain perception of patients following the administration of local anesthesia p. 110
VR Sweta, RP Abhinav, Asha Ramesh
Background: Dental anxiety and anxiety-related avoidance of dental care creates significant problems for the patients and dental practitioners. Administration of local anesthesia is one of the procedures which results in increased anxiety level among patients. Aim: The aim of this study was to study the effectiveness of virtual reality (VR) as a distraction tool during the administration of local anesthesia in patients undergoing a dental procedure. Materials and Methods: Fifty patients were randomized into two groups, namely, control group (n = 25) and study group (n = 25). Preoperative, intra-operative, and postoperative pulse rate and oxygen saturation were measured using pulse oximeter for all the patients. Local anesthesia was administered without the use of VR for the control group and with the VR for the study group. Statistical Analysis: The data were evaluated using the Statistical Package for the Social Sciences 20. Student's t-test was used to compare the variables. Results: Statistically significant results were obtained for preoperative and postoperative oxygen saturation, intraoperative pulse rate, and postoperative visual analog scale pain scale. Conclusion: The findings of the current study indicate that immersive VR is an effective distraction tool to alleviate the anxiety of the patient.
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The patterns and etiology of maxillofacial trauma in South India p. 114
Rajendra Prabhu Abhinav, Kathiravan Selvarasu, G Uma Maheswari, A Ankita Taltia
Background: Maxillofacial trauma is any physical trauma to the facial region, commonly encountered by maxillofacial surgeons, and is often associated with high morbidity. Maxillofacial injuries can occur as an isolated injury or may be associated with multiple injuries in other parts of the body. Aim: This study aims to assess the patterns, etiology, and management outcomes of maxillofacial trauma in a teaching hospital in Chennai, South India, over an 8-year period. Methods: Patients with maxillofacial injury were identified using the department database and clinical records. Nine hundred and forty-four patients were identified with maxillofacial trauma in the Department of Oral and Maxillofacial Surgery between January 2009 and December 2017. Results: The mean age of the patients was 30 ± 12 years. Of the 944 patients with maxillofacial injuries, 64% had isolated lower face (mandibular) fractures, followed by isolated midface fractures (19%). Road traffic accidents were the most common form of etiology for trauma. Conclusion: The etiology and pattern of maxillofacial injuries reflect the trauma patterns within the community and can thus provide a guide to help design programs toward prevention and treatment.
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Acute fascial space infections of the neck: 1034 cases in 17 years follow up p. 118
Supreet Ratnakar Prabhu, Enosh Steward Nirmalkumar
Aim: The aim of this study was to provide insight about all the common fascial space infections of the neck, their presentation, their etiology, complaints, length of stay, and the treatment given. Patients and Methods: It was conducted in a tertiary center in Nadiad, Gujarat, India. A total of 1034 patients were treated for fascial space infections of the neck in the hospital from 2001 to 2017. There were 63.24% male and 36.75% female with age ranging from 21 days to 96 years having the mean age of 31.4 years. Results: Odontogenic infection with poor oral hygiene as a cause was found in most (78.43%) of the abscesses. Diabetes was the most common comorbid condition found in 98 (9.47%) patients along with HIV found in ten (0.96%) patients. Pain (99.41%), fever (86.07%), swelling (86.94%), and dysphagia/odynophagia (67.21%) were the most common presenting symptoms. Ludwig's angina and submandibular abscess were found to be the most common deep head-and-neck space infection making up for 52% cases. The most common group of microorganisms isolated were Streptococcus sp. (19.82%) and Staphylococcus aureus (18.66%). Conclusion: Treatment was given in the form of incision and drainage of the abscesses (83.69%) and systemic antibiotics (100%). The most common space infection among the deep neck infections is the submandibular space infection (52%). If the etiological factor was not removed which mostly was carious teeth, high chances of recurrence were found (27.27%). Four patients required tracheostomy, and there was one mortality in the entire series.
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Retrospective analysis of 162 mandibular fractures: An institutional experience p. 124
Bhuvaneshwari Srinivasan, Ramdas Balakrishna, H Sudarshan, GC Veena, Suhas Prabhakar
Objectives: The objective was to evaluate the age, gender distribution, side and site distribution, etiology, and common patterns of the mandibular fractures. Materials and Methods: This was a systematic retrospective review of records of 94 patients with 162 mandibular fractures treated in a single institution. Results: Of 94 patients, 72 male and 22 female patients belong to the age group of 4–62 years (average 31.57 years). Among the various etiologies, i.e., assault, road traffic accident (RTA), self-fall, workplace injury, and sports-related injury, RTA accounts for 62.76% and self-fall for 18.08% of cases. Of the 100 fractures analyzed, 46% are unilateral fractures and 54% are bilateral. Sides affected among these are left (58%), right (39%), and symphysis or midline (3%). The site distribution is as follows: symphysis – 5; parasymphysis – 64; body – 13; angle – 43; and subcondylar – 37. The most common fracture pattern is the ipsilateral parasymphysis with contralateral angle (21 cases). Open reduction and internal fixation was the predominant modality of treatment. Complications were observed in 27.65% of patients. Conclusion: Surveys play a vital role in better understanding the biomechanics of the mandible fractures. Furthermore, analysis of the treatment modalities used and their respective outcomes are of paramount importance in guiding surgeons to evaluate their efficacy.
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Surgical correction of diplopia in orbital fracture: Influence of material and design p. 129
SM Balaji, Preetha Balaji
Purpose: The purpose of this study is to compare the association of diplopia after orbital fracture repair using titanium mesh and high-density polyethylene-coated titanium mesh. Materials and Methods: Retrospective review of records of consecutive patients who presented for primary/secondary correction of orbital fracture attending author's institute was done. Patients attending the institution between January 2013 and December 2017 (5 years' period) fulfilling the inclusion and exclusion criteria were included for this study. Results: In all, 44 patients, who fulfilled the inclusion and exclusion criteria, were included in the study. The mean age was 31.86 ± 9.1 years and the mean period of follow-up was 9.37 ± 2.1 months postoperatively, with a range of 6.5–24 months. There were 65.91% males, and the most common etiology was road traffic accident (50%). In all, 11 (25%) cases had postoperative diplopia. Of the 11 cases that had diplopia, 6 had Class 1 and 5 had Class 2 diplopia. Of these 11 cases, 8 cases had completion or partial resolution of diplopia by the end of 8 weeks' period, and in 3 cases, it persisted even after 3 months of care. The occurrence of diplopia was compared by demographic factor using Chi-square test, and the mesh type was only statistically significant (P = 0.026). Discussion: The present study indicates that both types of mesh provide reliable, clinically better results. However, with passage of time, it was clinically observed that removing uncoated mesh poses extreme difficulty by the adherences and growth penetrating the meshes. In certain instances, clinically, it was observed that such adhesions may be a cause of compromise of eyeball movement. Conclusion: Noncoated titanium orbital implants may lead to the adherence of orbital and periorbital structures, resulting in restrictive diplopia. High-density polyethylene-coated titanium mesh shows better performance as compared to noncoated mesh in preventing adherence situations.
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Facial trauma: A retrospective study of 1262 patients p. 135
Gabriele Bocchialini, Andrea Castellani
Introduction: Traumatic injuries are the leading cause of death among <40 year olds, a good part of the working age population. Traumatic injuries are also the leading cause of lost productivity, causing more lost working days than cancer or vascular cardiomyopathy. Materials and Methods: We retrospectively and statistically analyzed the characteristics of facial fractures treated between June 2010 and December 2016 at the Maxillofacial Adult Surgery Unit, Spedali Civili Brescia, Italy. Discussion: Facial fractures are common in polytrauma patients, due to exposure of the cephalic end. The incidence of concomitant facial injuries with major trauma is 15%–24% in England (between Liverpool and London) and up to 34% in Washington, based on a large database of 87,174 patients. High-energy trauma frequently involving multiple traumatic injuries often leads to complex facial fractures, affecting different portions of the splanchnocranium. Conclusions: Treatment of facial fractures often focuses on functional or esthetic outcomes, and the outcomes are often substantially worse than those of other trauma treatments. Given the esthetic value of the face, facial trauma often leads to heightened emotional distress.
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Holoprosencephaly with clefts: Data of 85 patients, treatment and outcome: Part 1: History, subdivisions, and data on 85 holoprosencephalic cleft patients p. 140
Engela M Honey, Kurt W Bütow, Roger Arthur Zwahlen
Context: Cleft patients with Holoprosencephaly (HPE) constitute a controversy due to a variable facial appearance. HPE appearance varies from only a columella to a prolabium-premaxilla complex agenesis up to a common unilateral or bilateral cleft lip and palate with a single central incisor, various brain deformities, and/or even normal brain development. It is challenging to designate such various appearances, to understand their etiopathogenesis, and to choose the most appropriate management. Literature was reviewed for diagnostic criteria, pregnancy history, clinical findings, brain development, survival rate, initial perioperative management, and postsurgical midfacial growth in cleft patients with HPE. The findings were compared with a clinical database of 85 cleft patients with HPE at the Department of Maxillofacial and Oral Surgery, University of Pretoria. Aims of Part 1: The aim of the study is to overcome disparities widely existing among clinicians regarding definitive diagnostic criteria, especially in cases with a common appearance of a uni- or bilateral cleft lip alveolus or cleft lip, alveolus and palate deformity, and cases presenting facial structural agenesis. Materials and Methods: A literature search related to diagnostic criteria was compared to results of a cleft HPE database from a single tertiary institution. Results: HPE cleft cases can be allocated to one of the following subdivisions: (1) columella complex agenesis (Ag-Colum), (2) prolabium-premaxilla-columella complex agenesis in cleft lip-alveolus deformities (Ag-CLA), (3) prolabium-premaxilla-columella agenesis in cases with complete cleft lip alveolus palate (Ag-CLAP), and (4) standard type (holoprosencephaly in patients with a standard cleft) with uni- or bilateral CLA or CLAP, hard and soft palate cleft (hPsP), and atrophic premaxillae, with or without single central incisor. Further, incidence, variation in brain development, and appearances in HPE cleft patients of different races and gender, epilepsy, and early death are discussed. Conclusion: This paper adds new data and facts to the existing literature related to cleft lip and palate patients suffering from HPE.
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Holoprosencephaly with clefts: Data of 85 patients, treatment, and outcome: Part 2: Management, surgical treatment, and unexpected aspects of holoprosencephaly cleft patients p. 146
Kurt W Butow, Roger Arthur Zwahlen
Context: Cleft patients with holoprosencephaly (HPE) provide a wide clinical spectrum. Besides accessory agenesis of facial tissue structures, spanning from a single central incisor to the columella, up to the entire prolabium-premaxilla complex, brain deformities with various functional deficits may prevail, just like normal brain development. Making a precise diagnosis, just like choosing the most appropriate treatment plan often is challenging. A literature and chart review comprising 85 HPE cleft cases at the Cleft Clinic of the University of Pretoria, South Africa, was performed. It yielded pertinent diagnostic criteria and collected information about pregnancy history, brain development and survival rate as well as the initial perioperative management and the course of postsurgical midfacial growth. Aims of Part 2: The aim is to highlight how the here presented classification system of HPE cleft patients according to their clinical picture may facilitate the most appropriate treatment protocol. Materials and Methods: The classification system elaborated in Part I due to diagnostic criteria facilitated establishing classification related treatment protocol for 85 cleft cases with HPE. Results: According to diagnostic criteria, HPE cleft cases can be subdivided into (1) columella complex agenesis (Ag-Colum), (2) prolabium-premaxilla-columella complex agenesis in cleft lip-alveolus deformities (Ag-CLA), (3) prolabium-premaxilla-columella complex agenesis in complete hard and soft palate clefts (Ag-CLAP), and (4) “standard” uni-or bilateral CLA or CLAP (HPE-Std-cleft), including cases with an atrophic premaxilla with or without single central incisors. Relevant treatment protocols according to the particular classification are highlighted with figures and intra-operative pictures. Conclusion: This paper addresses the following aspects in cleft patients with HPE: A subdivision into four groups, the 3-in-1 surgical approach, the anteriorly directed midfacial growth and maternal HIV infection.
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Odontogenic keratocyst: Developing a protocol for surgical intervention p. 152
Rajesh Ashok Kshirsagar, Rajat Chandrashekhar Bhende, Pratik Hemantkumar Raut, Vrushika Mahajan, Vishal Jugalkishor Tapadiya, Vikram Singh
The aim of this study was to report the outcome of a conservative treatment protocol – “enucleation and packing open” for odontogenic keratocyst (OKC). Ten patients with OKC were treated at our institute by peripheral ostectomy, enucleation followed by open packing. This conservative treatment protocol was selected because of relatively young age of the patients and relatively large size of the lesions. All the cases were monitored at regular predetermined intervals using clinical evaluation and panoramic radiographs. There was no evidence of recurrence during follow-up. The conservative treatment protocol for OKC, based on enucleation followed by open packing would be a possible choice in view of the simplicity of surgical procedure and low morbidity. This treatment modality has a low recurrence rate and may be particularly useful in young patients and patients with advanced systemic disease not amenable to major surgical intervention.
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Arthrocentesis of temporomandibular joint- Bridging the gap between non-surgical and surgical treatment p. 158
Abhishek Soni
The temporomandibular joint forms one of the most fascinating and complex synovial joints in the body. Movements of the temporomandibular joint are regulated by an intricate neurological controlling mechanism, which is essential for the system to function normally and efficiently. Lack of such harmony may cause disruptive muscle behavior or structural damage to any of the components. The management of refractory pain and dysfunctions in the temporomandibular joint poses challenge both to the oral physician and maxillofacial surgeon. Arthrocentesis is a simple, minimally invasive technique that can be used instead of more invasive procedures in patients with pain that fails to respond to conventional conservative measures. This review provides a full comprehensive overview of the literature about the various technical and prognostic aspects in relation to arthrocentesis of the temporomandibular joint, and every clinician must take into account this consideration when performing this procedure in treating patients with temporomandibular disorders.
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Maxillary fungal osteomyelitis: A review of literature and report of a rare case p. 168
Ankita Srivastava, Mounabati Mohpatra, Ashoka Mahapatra
Fungal osteomyelitis is a life-threatening and seldom seen opportunistic infection. It is commonly an affectation of the nose and paranasal sinuses within the orofacial region. It is an aggressive infection that needs to be addressed promptly to prevent fatal consequences. Here, we present a case of a 62-year-old female who presented with complaints of pain and pus discharge from the extraction socket of the left maxillary 23, 24, 25, 26 teeth. She had a history of uncontrolled diabetes mellitus. On further investigation, using diagnostic and Interventional aids, a final diagnosis of maxillary fungal osteomyelitis was made. The infective fungal agents were a mixture of Mucorales and Aspergillus species. A review of all literatures on the subject in the past 13 years using different search engines showed that craniofacial fungal infections with primary maxillary involvement are a rare phenomenon. The primary aim of reporting this case, therefore, is to highlight its rarity, presentation, management and most importantly the outcome of management.
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Trauma-induced unilateral buccal nonocclusion p. 174
Amin Rahpeyma, Saeedeh Khajehahmadi
Buccal nonocclusion is a difficult situation for orthognathic surgeons. This is the severest form of crossbite with congenital or traumatic origin. Unilateral cases are more difficult and need more attention. Posttrauma-acquired buccal nonocclusion is easier for management than congenital cases that need orthodontic preparation and more complicated orthognathic surgeries. Two cases of trauma-induced unilateral buccal nonocclusion are presented with different etiologies. Preoperative model surgery and posterior segmental surgery are keys to correct trauma-induced buccal nonocclusion.
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Orthosurgical management of a case of facial asymmetry secondary to temporomandibular joint ankylosis p. 177
Payal Sharma, Sanjeev Kumar, Prashant Kapoor, Anubha Verma
This case report describes the successful treatment of a patient with facial asymmetry secondary to temporomandibular joint ankylosis with a combined orthodontic–surgical approach. Presurgical orthodontics involved surgically assisted rapid maxillary expansion followed by a bilateral sagittal split osteotomy and LeFort I osteotomy to reposition the mandible and correct the canting of the maxilla. The total active treatment period was 24 months. A significant improvement in occlusion and facial esthetics was achieved with treatment.
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KIMURA'S disease – An E[X]clusive condition p. 183
Prashanthi Gurram, Saravanan Chandran, Priyadarshini Parthasarathy, Magesh Karuppur Thiagarajan, Karthik Ramakrishnan
Kimura's disease is a rare autoimmune disease of unrecognized etiology. Due to its unspecific clinical presentation and laboratory studies, Kimura's is a diagnosis of exclusion . A systematic multidisciplinary approach is mandatory to rule out the other common causes of cervicofacial lymphadenopathy. A thorough Histopathological examination including immunohistochemical analysis along with the presence of specific biochemical markers, including raised Absolute eosinophilic count is necessary to conclude the diagnosis as Kimura's Disease. In this article we present a case of a middle aged Asian woman with cervicofacial lymphadenopathy with no associated illness. The above described protocol of clinical, radiological and histolopathological investigations was followed before establishing the final diagnosis of Kimura's. The review of literature on contemporary management and prognosis is discussed.
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Chronic diffuse sclerosing osteomyelitis of the mandible p. 188
Candice Jacinta Antao, Ajit Dattatray Dinkar, Manisha Maruti Khorate, Sapna S Raut Dessai
Chronic diffuse sclerosing osteomyelitis (CDSO) is a disease that presents a rather unusual clinicoradiographic picture creating diagnostic and therapeutic problems. Involvement of the temporomandibular joint is not frequently observed in CDSO. We report a unique case of a 37-year-old male with cyclic episodes of insidious swelling and progressive trismus for the past 4 years. Each episode was followed by spontaneous remission after 2 weeks. Radiographic examination detected unilateral coarse trabeculae with ground-glass appearance of the left hemimandible and resorption of ipsilateral condyle. Computed tomography demonstrated endosteal sclerosis, cortical thickening, and condylar resorption, while magnetic resonance imaging revealed altered marrow intensity with postcontrast enhancement of the surrounding musculature. Bone histopathology was consistent with the diagnosis of osteomyelitis. Palliative antibiotic therapy and regular follow-up were recommended. Of particular interest in the present case is ipsilateral condylar resorption not associated with any dermato-skeletal conditions, which is uncommon in CDSO of the mandible.
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Rhinocerebral mucormycosis: A prospective analysis of an effective treatment protocol Highly accessed article p. 192
Ashok Ramadorai, Poornima Ravi, Vinod Narayanan
Objective: The objective of this study was to prospectively analyze the effectiveness of a treatment protocol in patients diagnosed with rhinocerebral mucormycosis. Materials and Methods: This series included ten patients who reported with suspicious clinical signs of mucormycosis. The diagnosis was established by histopathology, and computed tomography imaging was used to assess the extent of spread. All patients were treated with immediate radical surgical debridement and antifungal chemotherapy with amphotericin B. Simultaneous correction of the underlying immunosuppressive condition was carried out. The primary outcome assessed was disease-free survival, and the patients were followed up for up to 6 months after discharge. Results: In this series, the cause of immunosuppression was uncontrolled diabetes mellitus in all patients. All the patients responded to the treatment protocol and were free of the disease up to 6 months of follow-up. Conclusion: Mucormycosis is an invasive and potentially fatal disease. Prognosis can be improved by early recognition and prompt treatment with aggressive resection, intravenous amphotericin B, and control of the patient's underlying systemic condition.
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Successful management of a gigantic ameloblastic fibroma: A 12-year follow-up p. 197
Wladimir Gushiken De Campos, Camilla Vieira Esteves, Gustavo Alkmin Paiva, Camila Eduarda Zambon, André Caroli Rocha, Celso Augusto Lemos
An ameloblastic fibroma (AF) is a benign mixed odontogenic tumor that mainly affects patients in the first and second decades of life. It is usually associated with an impacted tooth, commonly the first or second permanent molar. We present a case of an 11-year-old male patient diagnosed with AF, showing well-defined borders almost completely affecting the body and inferior alveolar nerve (IAN) branch on the right side of the mandible and displacing teeth 46 and 47 associated with the lesion. The treatment included conservative surgery, with oral rehabilitation, including IAN lateralization, implant placement without sensorial alteration, and posterior rehabilitation, performed after 10 years of follow-up. Rehabilitation with implants is a safe and effective procedure for the prosthetic rehabilitation of the posterior atrophic mandible. However, sensorial alteration of the IAN occurs in 100% of cases and tends to regress with time or may be permanent in few cases.
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Ameloblastic fibroma mimicking dentigerous cyst: A diagnostic dilemma p. 201
Kiran C Khande, Husain J Mograwala, Rajshekhar C Halli, Manjula A Hebbale
Ameloblastic fibroma is a rare, slow-growing odontogenic mixed tumor with neoplastic epithelial and ectomesenchymal tissue, which does not show inductive changes to form enamel and dentin. It is frequently found in the first two decades of life. It is often confused with ameloblastoma and dentigerous cyst due to the presence of an impacted tooth and can be distinguished histologically. Ameloblastic fibroma can be differentiated from ameloblastoma by the presence of myxoid appearance of connective tissue. A case of an 11-year-old female with a slow-growing swelling on the left side of mandible in the molar ramus region has been presented which was diagnosed as ameloblastic fibroma postenucleation.
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A rare case of mucoepidermoid carcinoma of parotid with mandibular metastasis p. 205
Jitendra Kumar Diwakar, Arjun Agarwal, Cheena Garg, KY Giri, Ramakant Dandriyal, Geetika Kumar
Mucoepidermoid carcinoma is the most common malignant tumor of salivary gland. Majority of the salivary gland tumors arise in parotid gland with maximum being of benign nature. Although Mucoepidermoid carcinoma accounts for less than 10% of all tumors of the salivary gland, it constitutes approximately 30% of all malignant tumors of the salivary gland. It is characterized by a mixed pattern of the two main cell types: epidermoid and mucus-producing cells. Metastasis from salivary gland malignancy is infrequent and predominantly found in bone, lung, liver and lymph nodes. We are presenting a rare case of metastasis of mucoepidermoid carcinoma of parotid gland to the contralateral mandible.
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Preliminary report of a true nasomaxillary infantile fibrosarcoma: Single-modality management and 2-year follow-up p. 208
Naveenkumar Jayakumar, Veerabahu Rathnaprabhu, Singaravelu Ramesh
Infantile fibrosarcoma (IFS) is a malignant tumor, commonly presenting in long bones and seldom encountered after 2 years of age. It is extremely rare in the faciomaxillary region. The condition is often mistaken for teratomas, and histopathology/immunohistochemistry is confirmatory. Treatment involves surgical resection as primary modality. Prognosis is much better compared to the adult variant with even scope for spontaneous regression following “conservative” resection. We present a case of IFS of the nasomaxillary complex in a 3-month-old female child. We managed our case with surgical resection, and the patient has remained disease free for over 2 years.
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Squamous cell carcinoma of lower lip reconstructed with bilateral fan flap p. 211
Bhatt D Supreet, Semmia Mathivanan, Mustafa I Merchant, Niranjan S Patil
The most frequent tumor related to the lips is the squamous cell carcinoma, with the lower lip more commonly involved than the upper lip. The pivotal risk factors having impact on the prognosis include size of the tumor, histopathological type and grade, perineural invasion, regional lymph node metastasis, and local recurrences. Management of lip cancer and reconstruction is a surgical challenge.
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Management of a penetrating orbital trauma from an unusual foreign body with associated eye injury p. 214
Martín Fernandez.Ferro, Marta Fernández-Fernández, Jacinto Fernández-Sanromán, Alberto Costas-López, Annahys López-Betancourt
The aim of this article is to describe the principles that should guide the management of an orbital trauma with ocular injury through an updated review of the literature and the study of a clinical case involving an 80-year-old woman who presented with a penetrating orbital wound due to a wooden foreign body with a closed ocular trauma. Satisfactory and stable results over time are determined by systematically analyzing and evaluating each aspect of the case following a surgical strategy based on the most current protocols.
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Mandibular body fracture during inferior alveolar nerve transposition: Review of literature p. 218
Amin Rahpeyma, Saeedeh Khajehahmadi
Inferior alveolar nerve transposition is a useful adjunctive surgery in implant dentistry when there is insufficient bone between the ridge crest and the inferior dental canal. However, if this surgery is done carelessly, complications such as mandibular fracture and permanent lower lip numbness can occur. This article reports the first case of bilateral mandibular body fracture occurring during inferior alveolar nerve transposition. The surgical management of a complicated bilateral displaced mandibular body fracture is explained herein. A literature review of mandibular fracture after inferior alveolar nerve transposition is also presented. Adhering to the principles of fracture, treatment is mandatory for the successful management of mandibular fracture after inferior alveolar nerve transposition.
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Ancient schwannoma of the parotid gland: A note on surgical management p. 221
Joyce P Sequeira, Jagadishchandra , MS Mithun, Sujesh Viswanathan
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