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   Table of Contents - Current issue
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January-June 2017
Volume 7 | Issue 1
Page Nos. 1-159

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GUEST EDITORIAL  

Global surgery and the sustainable goals 2030: Implications for craniomaxillofacial surgery p. 1
AF Markus
DOI:10.4103/ams.ams_72_17  
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EDITORIAL Top

Identifying complications in distraction osteogenesis p. 3
SM Balaji
DOI:10.4103/ams.ams_90_17  
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ORIGINAL ARTICLES - COMPARATIVE STUDY Top

Piezosurgery versus rotatory osteotomy in mandibular impacted third molar extraction p. 5
Bharat Bhati, Pankaj Kukreja, Sanjeev Kumar, Vidhi C Rathi, Kanika Singh, Shipra Bansal
DOI:10.4103/ams.ams_38_16  
Aim: The aim of this study is to compare piezoelectric surgery versus rotatory osteotomy technique in removal of mandibular impacted third molar. Materials and Methods: Sample size of 30 patients 18 males, 12 females with a mean age of 27.43 ± 5.27. Bilateral extractions were required in all patients. All the patients were randomly allocated to two groups in one group, namely control group, surgical extraction of mandibular third molar was done using conventional rotatory osteotomy and in the other group, namely test group, extraction of lower third molar was done using Piezotome. Results: Parameters assessed in this study were – mouth opening (interincisal opening), pain (visual analog scale VAS score), swelling, incidence of dry socket, paresthesia and duration of surgery in both groups at baseline, 1st, 3rd, and 7th postoperative day. Comparing both groups pain scores with (P < 0.05) a statistically significant difference was found between two groups. Mean surgical time was longer for piezosurgery group (51.40 ± 17.9) minutes compared to the conventional rotatory group with a mean of (37.33 ± 15.5) minutes showing a statistically significant difference (P = 0.002). Conclusion: The main advantages of piezosurgery include soft tissue protection, optimal visibility in the surgical field, decreased blood loss, less vibration and noise, increased comfort for the patient, and protection of tooth structures. Therefore, the piezoelectric device was efficient in decreasing the short-term outcomes of pain and swelling although taking longer duration than conventional rotatory technique it significantly reduces the associated postoperative sequelae of third molar surgery.
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Application of orthodontic immediate force on dental implants: Histomorphologic and histomorphometric assessment p. 11
Mansour Rismanchian, Sayed Hamid Raji, Sayed Mohammad Razavi, Danesh Teimouri Rick, Amin Davoudi
DOI:10.4103/ams.ams_35_15  
Aims: Application of force to implants is helpful, especially in orthodontic-implant therapies. The aim of this study was a histomorphologic and histomorphometric evaluation of peri-implant bone after immediate orthodontic and orthopedic forces comparing them with a control group. Materials and Methods: Eighteen dental titanium implants were inserted in the premolar region of three dogs. Implants were divided into three groups: (1) group with immediate orthodontic force of 300 NC, (2) group with immediate orthopedic force of 600 NC, and (3) control group. Implants were explanted with adequate amount of surrounding bone after 3 months and bone-implant contact (BIC), amount of lamellar bone (LB), amount of woven bone (WB), amount of inflammatory connective tissue, and the rate of the movement were investigated. ANOVA, t-test, paired t–test, and Pearson's test were used to analyze the data using SPSS software version 16 at a significant level of 0.05. Results: Based on BIC, amount of lamellar and WB and the amount of inflammatory connective tissue, there was no significant difference between the three groups (300 centinewton (CN), 600–CN, and control group) (P > 0.05). In the 300-CN and 600-CN groups, the rate of movement was reported 0.41 and 0.94 with no significant differences (P = 0.38). Conclusion: 300-CN and 600-CN immediate static loads do not interfere with osseointegration phenomenon and it does not decrease the amount of BIC and LB. Implants can be moved by preserving osseointegration, and this movement is in direct relation with the amount of applied force.
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Magnetic field effects on bone repair after calcium phosphate cement implants: Histometric and biochemistry evaluation p. 18
Thiago Calcagnotto, Marcos Miguel Bechstedt Schwengber, Carlos Cesar De Antoni, Danilo Louzada de Oliveira, Théssio Mina Vago, Jessica Guilinelli
DOI:10.4103/ams.ams_2_17  
Objective: This work evaluated histologic and biochemically the effect of magnetic field buried in bone repair after autogenous bone graft and calcium phosphate cement implants. Methodology: Bone defects with 5,0 mm of diameter in the cranium of Wistar mice were used to analyse. These mice were submitted to different interventions: autogenous bone graft and calcium phosphate cement implants, both with and without magnetic stimulation. Longitudinal and transversal histometric and biochemistry analysis were made in times of 15, 30 and 60 post-operative days. Results: The histometric transversal analysis did not show significant differences in the bone repair between groups. Longitudinally, significant difference were found in the quantity of neoformed bone between the times 15 and 60 post-operative days in the autogenous bone graft group under magnetic stimulation. The alkaline phosphatase enzyme presented a higher activity in 30 post-operative days and the groups under magnetic stimulation presented reduced enzymatic activity in comparison to the other groups. Conclusion: The permanent and static magnetic field promoted significant differences in the neoformed bone in the groups autogenous bone graft.
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Effect of Low-intensity pulsed ultrasound on postorthognathic surgery healing process p. 25
Azita Tehranchi, Mohamadreza Badiee, Farnaz Younessian, Mohamadreza Badiei, Sahar Haddadpour
DOI:10.4103/ams.ams_57_17  
Background: Orthognathic surgery can cause discomforts such as pain, inflammation, and edema. One of the challenges is bone regeneration at surgery area. The aim of this study is to evaluate the effect of low-intensity pulsed ultrasound (LIPUS) therapy on bone regeneration and pain relief after surgery. Materials and Methods: Following mandibular surgery of nine patients, LIPUS treatment was applied to the left or right side for 3 weeks and 20 min/day. The other side was treated with sham-LIPUS as the control group. Digital panoramic radiographies were obtained immediately after surgery and 3 weeks later. Bone density at surgery site was assessed using Digora version 2.8 software. The data were analyzed with one-sample Kolmogorov–Smirnov and t-paired test. Postoperation pain was evaluated by means of visual analog scale. Results: Increase in bone density at border and medulla was 23 and 28.33 for experimental group and 13 and 13.55 units in control group, respectively. The differences are statistically significant (P < 0.01). Variance analysis showed that decrease in experienced pain during 3 weeks after surgery was significantly different between groups (P < 0.01). Conclusion: LIPUS can be an effective way to increase bone modeling and decrease pain following orthognathic surgeries.
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ORIGINAL ARTICLES - PROSPECTIVE STUDY Top

Effectiveness of preoperative lymphoscintigraphy for the detection of cervical lymph node metastasis in patients with oral squamous cell carcinoma p. 30
Md Ahsan Habib, Quazi Billur Rahman, Shakhawat Hossain, Ashik Abdullah Imon, Gokul Chand Kundu
DOI:10.4103/ams.ams_176_16  
Background: Oral squamous cell carcinoma (OSCC) is one of the most common malignant tumor. OSCC is the malignancy of squamous epithelium of oral cavity, which is the sixth most common malignancy reported worldwide and one with highest mortality rate among all malignancies. Aims: The aims of this study is to assess the diagnostic performance of lymphoscintigraphy (LSG) for the detection of cervical lymph node metastasis in patients with OSCC. Materials and Methods: This was a prospective study done in Oral and Maxillofacial Surgery Department and National Institute of Nuclear Medicine and Allied Science, Bangabandhu Sheikh Mujib Medical University during July 2015–June 2016. Thirty-six patients with OSCC were included in this study. Radioisotope technique was used in the detection of cervical metastases in patients with histologically proven OSCC. Patients were assessed by LSG after diagnosis of OSCC, and then, it was compared with postoperative histopathology report. Results: Lymphoscintigraphically out of 36 patients, 23 had lymphatic channel obstruction where histologically 20 patients had lymph node metastasis. There were 20 true positive cases, 13 true negative cases, and 3 false positive cases but no false negative case was found. The test of validity result reveals that sensitivity 100.0%, specificity 81.25%, accuracy 96.66%, positive predictive value 86.96%, and negative predictive value 100.0%. Conclusion: LSG for the detection of cervical lymph node metastasis has an important role for the management of OSCC. It is also cost-effective and decreases the morbidity.
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Treatment of micrognathia by intraoral distraction osteogenesis: A prospective study p. 37
M Baskaran, S Gidean Arularasan, TK Divakar, Rohini Thirunavukkarasu
DOI:10.4103/ams.ams_181_16  
Purpose: Maxillofacial deformities are always psychologically and physically distressing to the patients and is also challenging to the treating surgeons. The term Micrognathia means a “small jaw”. True micrognathia, where the maxilla or the mandibular skeleton does not grow to the full size can be congenital or acquired. Distraction osteogenesis also called as callus distraction or callostasis or osteodistraction or distraction histogenesis is a biological process of regenerating newly formed bone and adjacent soft tissue by a gradual and controlled traction of surgically separated bone segments. The purpose of this prospective study was to assess the versatility of distraction osteogenesis in the treatment of micrognathia. Materials and Methods: Four patients (three males and one female) with micrognathia of mandible were included in this prospective study. The patients were between the age group of 10-20 years. Facial asymmetry was the chief complaint of all the patients. In all the patients following treatment protocol was carried out, Osteotomy and placement of intraoral distraction device under general anaesthesia, latency phase (5-7 days), activation period-rate 1.5 mm per day, consolidation period of 8 weeks, removal of distraction device under local anaesthesia. The parameters assessed were ramus height, body length, hyo mental distance, posterior pharyngeal airway space, chin projection, facial symmetry occlusion, mid line shift pre and post operatively. Results: The mean increase in ramus height achieved was 9.2 + 2.17 mm and the mandibular body length achieved was 10.4+1.67 mm.There was an average increase in hyo-mental distance of 2.75 cm +0.9 cm postoperatively showing a definitive improvement in the airway. The posterior pharyngeal space measured from the lateral cephalogram preoperatively ranged from 3-6 mm and post operatively from 6-9 mm.Intraorally there was a shift in occlusion to class I molar relation in three patients and there was posterior open bite in one patient. Marked correction of facial asymmetry was noticed in all cases both clinically and in PA cephalogram. There was a restoration of dental as well as lip midline and improved lip competence. There was a significant improvement in chin projection and occlusal cant however further chin correction was needed in one case by means of advancement genioplasty. Conclusion: A definite improvement in all parameters such as body length,ramus height,chin projection,occlusal cant was observed in all patients. Moreover the patients were subjectively satisfied with the outcome of the results. Distraction Osteogenesis is definitely a boon to the oral and maxillofacial surgeons in treating large deficiencies of mandible in terms of stability
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An assessment of factors influencing the difficulty in third molar surgery p. 45
Pavan Tenglikar, Ashwini Munnangi, Anand Mangalgi, Syed Furqhan Uddin, Santosh Mathpathi, Kundan Shah
DOI:10.4103/ams.ams_194_15  
Background and Objectives: Surgical removal of a mandibular impacted third molar is one among the most common oral surgical procedures. The objective of this study was to assess and identify risk indicators influencing extended operation time in relation to the surgical removal of mesioangular impacted mandibular third molar, position A, Class I and to evaluate the incidence of postoperative swelling, trismus, and pain. Materials and Methods: A prospective cohort was implemented and the patients who presented for mandibular third molar removal which were impacted in position A, Class I were enlisted for the study. During 1 year between July 2014 and June 2015, a total of 40 patients were enrolled in the study. The evaluation of patient variables and radiographic variables was done preoperatively. Depending on the duration of time taken for an operation, patients were divided into three groups: Group I, Group II, and Group III. Postoperative complications such as swelling, trismus, and pain were assessed in each of the patients. Statistical Analysis: The statistical analysis was done among the groups using Chi-square test, and ANOVA. Results: Among the six variables studied in this study including patient variables and radiographic variables, maximum interincisal opening, external oblique ridge, and root morphology were found to be dependent factors which influence the operating time. Moreover, other variables such as the crown root width ratio and the number of roots were independent factors. Swelling, trismus, and pain were statistically significant among groups and were directly related to operating time. Conclusion: We consider that the outcome of surgical removal of mandibular impacted third molar, position A, Class I depends significantly on relevant patients characteristics and radiographic variables which should be evaluated preoperatively as they are predetermined factors to avoid postoperative morbidity.
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Using carnoy's solution in treatment of keratocystic odontogenic tumor p. 51
Najwa Jameel Alchalabi, Ahmed Maki Merza, Sabah Abdulaziz Issa
DOI:10.4103/ams.ams_127_16  
Aim: The aim of this study was to assess the treatment of keratocystic odontogenic tumor using enucleation and Carnoy's solution with peripheral ostectomy. Materials and Methods: Twenty-nine patients (14 females and 15 males) with age range from 12 to 62 years were included in this study and followed up for 7 years; all the patients were treated in the Department of Oral and Maxillofacial Surgery of the Specialized Surgeries Teaching Hospital (Al-Shaheed Ghazi Al-Hariri Hospital-Medical City, Baghdad, Iraq). Enucleation followed by peripheral ostectomy and the application of Carnoy's solution is the standardized method of treatment. Results: This study showed (32.7%) unilocular radiolucency for the lesions (19.9%) as multilocular radiolucency. Furthermore, it showed that the recurrence rate by this method was 0% with a minimum neurosensory disturbance. Conclusion: The complications and morbidity originating from the application of Carnoy's solution occurred less frequently and were less serious than those associated with resection while the recurrence rate is 0% which is equal to the recurrence rate of resection.
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Maxillary distraction osteogenesis in unilateral cleft lip and palate patients with rigid external distraction system p. 57
Shadi Alkhouri, Peter D Waite, Matthew B Davis, Ejvis Lamani, Chung How Kau
DOI:10.4103/ams.ams_174_16  
Aim: Distraction osteogenesis (DO) is a treatment option for patients with maxillary hypoplasia secondary to cleft lip and palate (CLP). Purpose: The aim of this study is to present a technique for maxillary DO using Le Fort I osteotomy with rigid external distraction (RED) system. Subjects and Methods: The patient presented in this paper was an Asian female with CLP aged 13 years and 6 months. She presented with severe midfacial deficiency with a Class III dental malocclusion with a negative overjet and concave facial profile. Cone-beam computed tomography images were recorded preoperatively and the operation performed involved a high Le Fort I osteotomy. The appliance fabricated was banded to upper first molars used for anchorage of the RED system. Distraction of the maxilla was initiated after 7-day latency period. Results: Postoperative cephalometric analysis showed maxillary advancement anteriorly and superiorly, the total distraction treatment period was 10 days. The maxillary advancement was 10.5 mm and the SNA angle increased from 67.5° to 77.9°. Furthermore, the ANB angle changed from −9.8° to 1.6° and the occlusion changed from Class III to Class I. The profile of the face changed from concave to convex and a much better esthetic result was achieved. Conclusion: The study suggests RED system to be a reliable alternative procedure for the treatment of midfacial hypoplasia with or without cleft. Furthermore, it minimizes the risk of the surgical procedure and shortens the operating time.
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ORIGINAL ARTICLES - RETROSPECTIVE STUDY Top

Three-dimensional planning and reconstruction of the mandible in children with craniofacial microsomia type iii using costo chondral grafts p. 64
Omri Emodi, Yair Israel, Michal Even Almos, Dror Aizenbud, John A Van Aalst, Adi Rachmiel
DOI:10.4103/ams.ams_157_16  
Background: In craniofacial microsomia (CFM) Type III patients, autogenous costochondral grafts (CCG) are conventionally used for the reconstruction of the ramus and condyle. The aim of this study was to describe the use of CCG in children with CFM in terms of outcomes, growth patterns, and complications. Materials and Methods: This is a retrospective study of nine, aged 4–12 years, patients with CFM Type III, who underwent reconstruction of the mandibular ramus condyle unit by CCG. Seven patients had right-sided CFM and two had left-sided CFM. The rationale for this choice was to utilize the potential growth of the CCG, providing length to the ramus, and the joint by acting as a growth center; to control the repositioning of the chin center; and to improve child compliance by undergoing only one operation. The surgical treatment plan was determined preoperatively, based on measurements of mandibular vertical and horizontal deficiency and analysis of the mandibular posterior and anterior angulation. The mandibular planes and axis were defined by a three-dimensional simulation software program to perform a “mock surgery”, by creating a prototype model. Clinical follow-up included measurements of the maximal opening, observation of the facial symmetry, and recording of complications, such as reankylosis. Results: There were no serious postoperative complications, infections, or graft rejections. Successful postoperative occlusal cants were noted and measured in five patients and acceptable results were obtained in three patients. In one case, the CCG underwent distraction osteogenesis to improve the facial symmetry. In one patient, the graft continued to grow and the chin started to deviate into the opposite side. Measuring and calculating the ratio of the ramus height on the panoramic X-ray revealed a good relation between the healthy contralateral and the reconstructed ipsilateral ramus. Postoperative mean mouth opening was 34.3 mm, with minimal midline deviation of 2.6 mm in occlusion. Mean follow-up was 51.7 months. The mean postoperative occlusal cant analysis for eight patients was 3.66°. Conclusion: CCG is useful in treating CFM Type III. The growth potential of the CCG makes it the ideal choice for children. The advantages of this graft are its biological compatibility, workability, functional adaptability, and minimal additional detriment to the patient. The use of a stereolithographic model preoperatively improved intraoperative precision by clearly displaying detailed anatomy of the patient undergoing craniofacial surgery. The surgeon can plan the length of the CCG before surgery and use the printed template while harvesting without waiting for the exact measurements to be provided by the facial surgical team.
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A retrospective analysis of dentofacial deformities and orthognathic surgeries p. 73
Faezeh Eslamipour, Ali Borzabadi-Farahani, Bach T Le, Majid Shahmoradi
DOI:10.4103/ams.ams_104_16  
Background: Information regarding the prevalence of surgical osteotomies used for the correction of dentofacial deformities in Iran is lacking. Materials and Methods: This retrospective cross-sectional study assessed the distribution of orthognathic surgeries performed (2011–2015) at major University hospital in Iran. Records of 103 orthognathic surgery patients were assessed (58 female, 45 males, aged = 23.47 [6.44] years). Results: Class III malocclusion (incisor classification, 45.6%) and Class II skeletal pattern (based on ANB angle, 51.5%) were the most prevalent type. Overall, 4.8%, 51.5%, and 43.7% of subjects had Class I, II, and III sagittal skeletal patterns, respectively. The most prevalent (66%) osteotomy was the bimaxillary osteotomy. The frequencies of reported and corrected asymmetries in the lower third of the face (35%) were similar among patients with different malocclusions (χ2 = 4.134, P = 0.127) or sagittal skeletal patterns (χ2 = 2.133, P = 0.344), as well as between Class II and III malocclusions (P = 0.125) or sagittal skeletal patterns (P = 0.149). Conclusion: Compared to Class II subjects, Class III (malocclusions or sagittal skeletal patterns) subjects had more bimaxillary osteotomies, indicating the higher prevalence of skeletal discrepancies affecting both jaws in Class III subjects.
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ORIGINAL ARTICLES - EVALUATIVE STUDY Top

The effects of platelet-rich fibrin membrane on secondary healing after pleomorphic adenoma excision in the hard palate: A preliminary study p. 78
Ozer Erdem Gur, Nuray Ensari, Nevreste Didem Sonbay Yılmaz
DOI:10.4103/ams.ams_182_16  
Aim: This study aims to evaluate the effects of platelet-rich fibrin (PRF) membrane on secondary healing after pleomorphic adenoma (PA) excision in the hard palate. Materials and Methods: PRF membranes were laid over mucosal defects which occurred following PA excision in the hard palate. The secondary healing process was monitored in the patients by follow-up examinations on postoperative days 5, 10, 15, 20, 25, 30, 35, and 40. Results: In this preliminary study, epithelialization was observed to have completed on the 30th day of follow-up in the first patient and on the 35th day in the second and third patients. No bleeding or infection was seen in any of the three patients. Conclusions: PRF membrane as a new method in the secondary healing after PA excision in the hard palate provided rapid healing and reduced complications such as bleeding and infection.
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Reconstruction of drug-induced cleft palate using bone marrow mesenchymal stem cell in rodents p. 82
Julie Christy Amalraj, Manasa Gangothri, Hari Babu
DOI:10.4103/ams.ams_140_16  
Background: Triamcinolone acetonide (TAC) (Kenacort*) is a commonly used synthetic glucocorticoid in today's medical practice. The drug is also a potential agent in inducing cleft palates in rats. This drug has been used to induce cleft palate in the fetus of the pregnant rats to bring out a suitable animal model for human cleft lip and palate. The drug was given intraperitoneally to induce congenital cleft palate in pregnant mother rats. Aim: The aim of this study is to induce congenital cleft palate in pregnant Wister albino rats and reconstruct the defect with bone marrow mesenchymal stem cells (BMSCs) isolated from the same species along with PLGA (poly lactic co glycolic acid) scaffold. Methods: Twenty female animals were divided into two groups. Each group contains 10 animals. The animals were allowed to mate with male rat during the esterase period and the day, in hich vaginal plug was noticed was taken to be day 0. The pregnant rats were given triamcinolone acetonide (Kenacort* 10 mg/1 ml intramuscularly/intravenous [IM/IV] injections) injection intraperitoneally at two different dosages as the existing literature. The injection was given on the 10, 12, and 14th day of gestation. The clinical changes observed were recorded, and the change in the body weight was noted carefully. Group 1 which received 0.5 mg/kg body weight of TAC had many drug toxic effects. Group 2 which received 0.05 mg/kg body weight produced cleft palate in rat pups. The pups were divided into three groups. Group A control group without cell transplant, the cleft was allowed to close by itself. Group B containing palate reconstructed with plain PLGA scaffold (Bioscaffold, Singapore) without BMSC, Group C containing BMSC and PLGA scaffold (Bioscaffold, Singapore), Group C operated for the cleft palate reconstruction using BMSCs and PLGA scaffold. There was faster and efficient reconstruction of bone in the cleft defect in Group C while there was no defect closure in Group A and B. Results: There was complete reconstruction of the cleft palate in the group of rat pups which received BMSCs along with PLGA scaffold. Bone growth in the cleft defect was faster; complete fusion of the defect was achieved. Conclusion: The dosage of drug used for inducing cleft palate was standardized in rodents for a definitive congenital cleft palate model. The cleft palate induced was reconstructed using BMSCs and PLGA scaffold. This was compared with a control group and the other group with plain PLGA used for reconstruction of the palate. This study will invite future research in the effect of the drug on human beings, especially on pregnant mothers.
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Conservative surgical approach to restore necrotic columella in patients undergoing neonatal usage of nasogastric tube p. 89
Francesco Inchingolo, Fabio Massimo Abenavoli, Francesca De Angelis, Alessandro Orefici, Luigi Santacroce, Gianna Dipalma
DOI:10.4103/ams.ams_130_16  
Context: A common complication, related to the use of nasogastric tube during the 1st day of life, is the necrosis of the columella. Esthetic damage in the early age typically leads to a healing request with very high result expectations. Aims: We aimed to develop and use an innovative surgical technique.Settings and Design: We used our technique in four cases. Subjects and Methods: Our technique requires two flaps designed with two paramedian release incisions. The two flaps will be sutured to what remains of the fibrous septum; finally, the two flaps will be sutured together in the medial region. Results: Postoperative course was devoid of any complication. All patients gained esthetic improvements and an increase in the volume of the columella on the sagittal and frontal planes. Conclusions: This technique allows a conservative approach with low donor site morbidity and rapid postoperative course.
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Bone ring augmentation around immediate implants: A clinical and radiographic study p. 92
Girish B Giraddi, Aamir Malick Saifi
DOI:10.4103/ams.ams_58_17  
Purpose: The purpose of this study was to evaluate the efficacy of bone ring augmentation technique for three-dimensional augmentation of severely defective sockets along with placement of immediate dental implants. Materials and Methods: A clinical study was conducted on 14 patients with 15 defective sockets requiring extractions and immediate implant placement. Following extraction, bone ring with an implant osteotomy, harvested from chin, was sculptured and fitted into the extraction socket. The bone apical to the socket was prepared for implant through the central osteotomy of the ring. Implant was then placed through the ring into the apical bone. After 6 months, prosthesis was placed. Clinical and radiographic examination was done to evaluate the soft tissue and crestal bone level around implants immediate postoperatively and at 1st, 3rd, 6th, and 9th month postoperatively. Results: Out of 15 grafted sockets, 14 showed an evidence of bone healing with no significant crestal bone resorption. One ring showed soft tissue dehiscence which underwent severe resorption at 6th month postoperative visit. Conclusion: The bone ring augmentation technique is an effective method for three-dimensional augmentation of severely defective sockets. This technique helps in reducing the overall treatment time by allowing grafting and placement of implant simultaneously in a single visit. However, longer observation periods are needed to draw more definite conclusions on the success of bone ring augmentation technique.
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REVIEW ARTICLE Top

Access osteotomy in the maxillofacial skeleton p. 98
K Kamalpathey, NK Sahoo, PK Chattopadhyay, Yuvraj Issar
DOI:10.4103/ams.ams_88_12  
Surgical accesses for the facial skeleton are based on the concept of modular osteotomies. Various techniques and combination of osteotomies facilitate access to the most inaccessible tumors of craniomaxillofacial region. Most appropriate surgical access is determined by considering size, location, extension of the tumor, and experience of the surgical team. These are primarily used for tumors in the nasopharynx or the skull base. The aim of this paper is to review surgical accesses that aid in removal of inaccessible tumors of craniomaxillofacial region with series of cases operated in the Department of Oral and Maxillofacial Surgery, Armed Forces Medical College, Pune, India, between July 2008 and June 2010. The surgical approaches constituted of transfacial, transoral, lip-split mandibulotomy and modified osteotomy of the orbital rim in cases of juvenile nasoangiofibroma, squamous cell carcinoma of the base of the tongue, orbital floor tumour respectively. Only 3 cases (33.33%) reported with postoperative paresthesia of the infraorbital region and mandibular symphysis region which resolved in 6 months. None of the patients presented with occlusal discrepancy, neuromotor deficit or sign of recurrence in the follow up period of one year.
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CASE REPORTS - DEVELOPMENTAL DEFORMITIES Top

Recovering breathing and feeding of a newborn with pierre robin sequence p. 104
Francisnele Maria de Aquino Fraporti Tomaz, Alvaro Henrique Borges, Alexandre Meireles Borba, Luiz Evaristo Ricci Volpato
DOI:10.4103/ams.ams_20_16  
Pierre Robin sequence (PRS) is characterized by the triad micrognathia, glossoptosis, and airway obstruction, commonly associated with cleft palate. This study reports the case of a patient with characteristics consistent with the diagnosis of PRS in the 1st week of life. To stabilize the airway, oro-tracheal intubation was performed without success, followed by tracheostomy and glossopexy and after a small improvement in symptoms, it was decided to perform the mandibular distraction osteogenesis (MDO). At the age of 6, her maxillofacial development was within expectations, with patent airway, the presence of deciduous teeth, and without neurological impairment. The MDO described in this case allowed patient's respiratory and feeding improvement, thus avoiding episodes of cyanosis, allowing timely removal of the tracheostomy and glossopexy, and execution of palatoplasty at the right time. While it is uncertain whether MDO will replace the possible need for future orthognathic surgery, treatment greatly improved the quality of life of the patient.
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Unicoronal craniosynostosis and plagiocephaly correction with fronto-orbital bone remodeling and advancement p. 108
SM Balaji
DOI:10.4103/ams.ams_80_17  
The standard surgical treatment for unilateral coronal synostosis is fronoto-orbital advancement. The technique is known for its high recurrence rate and established plagiocephaly remains a challenge. In this case report, the management of a 5-year-old with unicoronal plagiocephaly correction with fronto-orbital bone remodeling and advancement is presented. The previous surgery done at 6 months of age resulted in failure with establishment of hypertelorism and sudden progressive diminishing vision. Furthermore, temporal hallowing was evident in the imaging technique. As the child is in the active growing phase, only one end of the bandeau was secured with plates and screws while the other end was welded with ultrasonic waves. This ensured that the plate was held in position while bone remodeling will ensure normal healing and establish regular sutural growth. The child recovered well with regaining of vision. The report also discusses the possible reason for failures and the effectiveness of modification of the standard technique for growing child.
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The surgical management of skeletal disproportion with lingual orthodontics and three-dimensional planning p. 112
Krutiben Patel, Chung How Kau, Peter D Waite, Ahmet Arif Celebi
DOI:10.4103/ams.ams_55_17  
This case report describes the successful treatment of a 26-year-old Caucasian male with skeletal and dental Class III malocclusion associated with mild maxillary and mandibular crowding. The patient had anteroposterior and transverse discrepancies with a reverse overjet and bilateral posterior crossbites. The nonextraction treatment plan included aligning and leveling of the teeth in both arches, Le Fort I and bilateral sagittal split osteotomies, and postsurgical correction of the malocclusion. Orthodontic treatment was initiated with custom lingual appliances followed by orthognathic surgery planned with virtual surgical planning. Treatment was concluded with detailed orthodontic finishing, achieving optimum esthetics and function.
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Closure of oroantral communication using platelet-rich fibrin: A report of two cases p. 117
Mounzer Assad, Waseem Bitar, Mohammed Nasser Alhajj
DOI:10.4103/ams.ams_77_17  
Oroantral communication (OAC) is an abnormal connection between the maxillary sinus and oral cavity. It is mostly formed after the extraction of the first and second upper molars. Platelet-rich fibrin (PRF) created by Choukroun's protocol concentrates most platelets and leukocytes from a blood harvest to a single autologous fibrin biomaterial. It has been used widely in oral and maxillofacial surgery. However, no data are available concerning the use of PRF alone as a clot and a membrane for the closure of OACs. Two clinical cases presented with OAC, created after extraction of tooth #16 in two patients, were closed with PRF as a clot and a membrane and monitored until the epithelization of the sockets was ended successfully. Two months postclosure, the sockets were evaluated clinically and on waters' view radiography. The results of these case reports showed that PRF can be successfully applied for the closure of OACs.
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CASE REPORT - INFECTION Top

Mucormycosis of the frontal sinus: A rare case report and review p. 120
Nanda Kishore Sahoo, Vishal Kulkarni, Amit K Bhandari, Arun Kumar
DOI:10.4103/ams.ams_23_16  
Mucormycosis of the frontal sinus are rarely seen in day to day clinical practice. Although this fungus is commonly found in the environment, the disease is usually prevented by the immune system and is hence rare. Well-recognized risk factors for the disease include diabetes mellitus, leukemia, aplastic anemia, myelodysplastic syndrome, blood dyscrasias, and immunosuppressive therapy in organ transplantation, renal disease, sepsis, and severe burns. The disease is primarily found in those who are immunocompromised, but it may also manifest in immuno competent persons. Current therapy for the invasive disease includes early surgical debridement, antifungal therapy management of underlying predisposing factors. Early recognition of the disease and treating the underlying cause of mucormycosis, such as diabetes, are key to improving outcomes. The antifungal treatment of choice for mucormycosis is amphotericin B, although very high doses are required because of the relative resistance of the fungus to the drug. Here, we present a case of rhinocerebral mucormycosis of frontal sinus in a diabetic patient, who was managed by systemic antifungals, surgical debridement, and obliteration procedures.
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CASE REPORT - TRAUMA Top

Comminuted laryngeal fracture following blunt trauma: A need for strict legislation on roads! p. 124
Shraddha Jain, Pragya Singh, Minal Gupta, Bhavna Kamble, Suresh S Phatak
DOI:10.4103/ams.ams_60_15  
Laryngeal fracture is a rare condition with potential life-long implications related to airway patency, voice quality, and swallowing. Rarity of the condition leads to lack of consensus on the most suitable way to manage this injury. The mode of injury can be prevented by strict legislation on the roads. We report a case of a 28-year-old Indian male who sustained a comminuted displaced fracture of the thyroid cartilage with disruption of anterior commissure due to blunt trauma caused by the metallic side rod of a ladder projecting from the rear of a vehicle in front of the bike on which he was riding. He presented with breathing difficulty, change in voice, surgical emphysema, and pneumomediastinum, but without any skin changes over the neck. His airway could be restored due to early tracheostomy and open reduction with internal fixation with sutures along with laryngeal stenting. He has no significant swallowing or breathing problem and reasonably good voice 6 months after surgery. This case highlights the need for strict legislation on roads in India and the importance of high level of suspicion for laryngeal fracture in acute trauma patient. Early identification and timely internal fixation not only restore the airway but also improve long-term voice and airway outcomes.
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Parotid duct repair with intubation tube: Technical note p. 129
Muhammed Besir Ozturk, Seda Asrufoğlu Barutca, Elif Seda Keskin, Bekir Atik
DOI:10.4103/ams.ams_166_16  
The parotid duct can be damaged in traumatic injuries and surgical interventions. Early diagnosis and treatment of a duct injury is of great importance because complications such as sialocele and salivary gland fistula may develop if the duct is not surgically repaired. We think the cuff of an intubation tube is an ideal material in parotid duct repair, because of its technical characteristics, easiness of availability, and low-cost. In this paper, we described the use of the cuff cannula of an intubation tube for the diagnosis and treatment of parotid duct laceration, as a low-cost and easy to access material readily available in every operating room.
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CASE REPORTS - CYST AND TUMORS Top

Largest De Novo parapharyngeal pleomorphic adenoma: A rare case removed via minimal access approach p. 132
Vikas Malhotra, Nikhil Arora, Varun Rai
DOI:10.4103/2231-0746.208640  
Parapharyngeal tumors are relatively rare tumors of head and neck. In general, pleomorphic adenoma is one of the most common benign tumor of the parapharyngeal region. Various approaches have been described in the literature for removal of parapharyngeal tumor with mandibulotomy generally carried out for large tumors. Here, we describe removal of a large parapharyngeal pleomorphic adenoma transcervically without mandibulotomy which subsequently turned out to be one of the largest ever reported in the literature and describe how large tumors of parapharyngeal can be removed with minimal invasive approach with mandibulotomy kept as a backup thereby avoiding complications associated with mandibulotomy.
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Removal of multiple keratocystic odontogenic tumors in a nonsyndromic patient p. 136
Artur Cunha Vasconcelos, Paulo Henrique de Souza Castro, Alvaro Henrique Borges, Luiz Evaristo Ricci Volpato
DOI:10.4103/2231-0746.208663  
Multiple keratocystic odontogenic tumors are one of the key features of Gorlin–Goltz syndrome. A 15-year-old nonsyndromic female child presented with multiple keratocystic odontogenic tumors. The presence of the tumors was observed in immunological examinations. The images led to the suspicion of Gorlin–Goltz syndrome which was discarded after analyzing the patient's medical history and complementary examinations. Le Fort I osteotomy was opted to access the maxillary tumors favoring visibility and allowing simultaneous bilateral accesses. A sagittal vestibular incision in the lower rim was performed to access the mandibular lesions. After 3 months, the patient underwent a bilateral myotomy to reduce the volume of the masseter muscles. The occurrence of nonsyndromic multiple keratocystic odontogenic tumors is rare. Clinicians facing this situation shall seek for other known features of the Gorlin–Goltz syndrome and follow up closely these patients for the possibility of occurrence of basal cell carcinoma.
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A rare report of two cases: Ancient schwannoma of infratemporal fossa and verocay schwannoma of buccal mucosa p. 140
Prerna Piyush, Sujata Mohanty, Sujoy Ghosh, Sunita Gupta
DOI:10.4103/ams.ams_3_17  
Schwannoma is a benign tumor that originates from Schwann cells of the peripheral nerve. Occurring as a common tumor in the head and neck region, its intraoral presentation is rare which accounts for only 1%. They are solitary, slow-growing, smooth-surfaced, usually asymptomatic, and encapsulated tumor. This paper comprises two case reports, both of which presented with an intraoral soft tissue swelling which turned out to be schwannoma of buccal mucosa and infratemporal fossa with extension into the oral cavity, respectively. The treatment was done with complete surgical excision. Soft tissue tumors of the oral cavity can present with similar clinical feature, which can make it difficult to distinguish one lesion from the other. Thus, final diagnosis for such lesions can only be rendered based on complete analysis of clinical, radiological, surgical, and histopathological findings.
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Tumor-induced osteomalacia: A sherlock holmes approach to diagnosis and management p. 143
GV Chanukya, Manoj Mengade, Jagadishwar Goud, I Satish Rao, Anuj Jain
DOI:10.4103/ams.ams_123_16  
Tumor-induced osteomalacia (TIO) is a subtype of paraneoplastic syndrome associated with hypophosphatemia due to renal phosphate wasting in adults. The humoral factor responsible for clinical picture known as fibroblast growth factor 23 (FGF23) is most often secreted by benign yet elusive mesenchymal tumors, difficult to localize, access, and excise completely; rarely, they are multiple and malignant. Paradoxical inappropriately normal or low levels of 1,25-dihydroxyvitamin D in the setting of hypophosphatemia is due to suppressive effect of FGF23. The following case report describes a 31-year-old male with symptoms of multiple fractures and severe muscle weakness, hypophosphatemia with elevated tubular maximum reabsorption of phosphate/glomerular filtration rate with low active Vitamin D, prompted assay for C-terminal FGF23, which was elevated multifold. The tumor was localized with whole body 68-Gadolinium DOTANOC positron emission tomography-computed tomography fusion scan in the left nasal cavity with ipsilateral maxillary antrum. It was excised through transnasal approach and found to be mesenchymal tumor on histopathology. At 1 week of follow-up, serum phosphate became normalized without supplementation. The patient is in follow-up for further measurement of FGF23 level and signs of recurrence. Because the occurrence of such a condition is rare and most often misdiagnosed or mismanaged for years, it is important to recognize this condition in differential diagnosis as potential curative surgical option is a reality.
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Dental invasion by adenoid cystic carcinoma of the oral cavity p. 148
Marco Guzzo, Pasquale Quattrone, Roberto Bianchi, Sarah Colombo
DOI:10.4103/ams.ams_4_17  
Cancer progression through the mandible bone is still questioned. Once the tumor has eroded the cortex, it can extend vertically and laterally. It usually spreads in the medullary spaces and finally affects the alveolar nerve. The presence of the teeth has been considered as a relative barrier to cancer infi ltration until now. Herein, we report an uncommon case of dental root invasion by adenoid cystic carcinoma of the floor of the mouth.
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Epidermoid cyst: Clinical and surgical case report p. 151
Jose Carlos Garcia de Mendonca, Ellen Cristina Gaetti Jardim, Cauê Monteiro dos Santos, Danilo Chizzolini Masocatto, Diones Calado de Quadros, Murilo Moura Oliveira, Juliana Andrade Macena, Fernando Ribeiro Teixeira
DOI:10.4103/ams.ams_68_16  
The epidermoid cyst is a development cyst, skin, filled with keratin and imprisoned by stratified squamous epithelium similar to skin. They are more frequent in males. Clinically presenting as flabby, prevalent over the face, neck and back. They are usually asymptomatic and its etiology is directly linked to trauma, as well as the imprisonment of epithelial rests during embryonic fusion. This study aims to present a case report of a patient 54 years old, with an epidermal cyst in the face, which was treated surgically.
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Two concurrent large epidermoid cysts in sublingual and submental region resembling plunging ranula: Report of a rare case p. 155
Ranjan Kumar Sahoo, Pradyumna Kumar Sahoo, Debahuti Mohapatra, Santosh Subudhi
DOI:10.4103/ams.ams_50_15  
An elderly female patient presented to surgical outpatient clinic with complaint of gradual onset of painless submental and sublingual midline swellings for 6 months of duration. The swellings were noncompressible, nontranslucent, nonpulsatile, and nontender on palpation. Clinical diagnosis was plunging ranula or dermoid cysts. Ultrasound examination of sublingual swelling showed cystic lesion with particulate content. Submental swelling showed cystic swelling with few echogenic floating lobules inside suggesting possibility of epidermoid/dermoid cyst. Magnetic resonance imaging of the face showed homogeneous fluid content within the sublingual cystic lesion and heterogeneous fluid content with few floating nodules within submental swelling. Both cystic lesions were noncommunicative and were showing diffusion restriction and no fat signal. Radiological diagnosis was sublingual and submental epidermoid cysts. She was operated under general anesthesia, and two separate cystic masses were excised with intact capsule. Histopathological diagnosis of masses confirms epidermoid cyst. Several literature have reported isolated sublingual or submandibular epidermoid cyst. However, concurrent sublingual and submental epidermoid cysts with different imaging appearance are rarely reported.
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NOTICE OF RETRACTION Top

Retraction: 6-0 nylon versus 6-0 vicrylrapide in chieloplasty p. 159

DOI:10.4103/2231-0746.208664  
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