Role of Photodynamic Therapy in Osteonecrosis and Osteoradionecrosis of the Jaws: A Systematic Review.

Aim: Photodynamic therapy (PDT) is a minimally invasive treatment modality that has been used clinically for early stage and inoperable cancers. Successful use of this atraumatic therapy in osteoradionecrosis (ORN) and osteonecrosis of the jaws (ONJ) has been documented in the literature. The aim of this review was to systematically evaluate the role of photodynamic therapy in ORN and ONJ. Methods: Two independent reviewers conducted an elaborate search in PubMed, Google Scholar and Cochrane's CENTRAL database for studies published on PDT as stand-alone or adjuvant therapy in ORN/ONJ until June 2022. The present study was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Demographic data, type and stage of necrosis of the jaws, site, PDT protocol, time to heal and follow-up were evaluated. Eighteen articles were included totally based on the inclusion and exclusion criteria for final analysis. Results: A total of 94 patients were included in the present review out of which 36 were males and 58 were females. Five studies reported the use of PDT as an adjuvant therapy in ORN. Thirteen studies reported successful outcomes with PDT in ONJ. Complete epithelialization was achieved with PDT ± other adjuvants in 86/94 (91.48%) patients. The time taken for regression of the lesion ranged between 4 days and 12 months with PDT in the present study. Conclusion: The reviewed studies demonstrate the effectiveness of PDT, as an adjuvant therapy, in managing various stages of ORN and ONJ.

Can Prophylactic Tracheostomy be Avoided in Advanced Oral Cancer Surgery for Airway Management? An Experience and Guidelines from a Tertiary Care Facility.

Aim: To evaluate the surgical and postoperative management strategies that contribute to minimizing the need for prophylactic tracheostomy for airway management in advanced oral cancer surgery. Methods: A retrospective review of the patients who underwent surgery for advanced oral cancer, in our institution from February 2015 to January 2024. Results: In the present review, 66 patients (males, n = 54; females, n = 12; mean age 50.3 years) who were operated for advanced oral cancer (T3, T4 oral squamous cell carcinoma and osteosarcoma of the mandible requiring mandibular resection) in our institution were included. 60 patients (90.9%) had reconstruction after segmental resection of the mandible without the need for prophylactic tracheostomy. Out of these, eighteen patients (27.27%) required segmental resection of the mandible crossing midline. Six patients (9.1%) underwent prophylactic tracheostomy, of which two patients had unilateral tumor and four patients had tumor crossing midline. Comparison of hospital stays between patients who underwent prophylactic tracheostomy and those who did not yielded mean durations of 13.3 days and 7.6 days, respectively. Conclusion: Except a subset of patients with old age, obesity, bulky neck, and those with respiratory compromise, following the present guidelines, prophylactic tracheostomy can be avoided in patients undergoing surgery for advanced oral cancer.

Optimal Depth of Penetration to Access the Superior Joint Space in Temporomandibular Joint Arthroscopy: A Single Institutional Retrospective Study.

Aim: To identify the optimal depth of penetration required to access the superior joint space (SJS) for arthroscopic procedures of the temporomandibular joint (TMJ) among the study population. Materials and Methods: The study included all patients with internal derangement (ID) of the TMJ, managed by TMJ arthroscopy in our institution. The study was conducted with data retrieved from the hospital records over five years (January 2018-April 2022). Demographic factors and depth of penetration (mms) were the variables included in our study. For all the statistical interpretations, p < 0.05 was considered statistically significant. Results: The study included 66 patients (males, n = 25; females, n = 41) who underwent arthroscopic procedures of the TMJ (right = 29, left = 37). The mean duration between the development of symptoms and the point of intervention (TMJ arthroscopy) in our study was 3.94 months. The mean depth of penetration of the arthroscope as measured from the skin to the point of entry into the SJS was 20.60 ± 1.85 mms in males and 19.56 ± 1.38 mms in females (p value < 0.05). Variables such as age, duration of symptoms, side involved and stage of ID did not have any influence on the optimal depth of penetration required to access the joint space among our study population. Conclusion: The optimal depth of penetration (mean) required to access the SJS was less than 25 mms in our study population.

The Great Imitator: Cervicofacial Actinomycosis Masquerading as Cancer Recurrence.

Cervicofacial actinomycosis being one of the unusual infections is of high relevance to a head and neck onco-surgeon. As the diagnosis may be made difficult by its nature to mimic malignancy and egregiously low culture sensitivity, the differential diagnosis for a lesion appearing to be malignant after irradiation does not usually include actinomycotic infection. Treatment usually requires a long-term antibiotic course after confirmation with histopathology, albeit surgical debridement is required in selective cases. Here we report two cases that were clinico-radiologically diagnosed as osteoradionecrosis and histopathological analysis done to rule out cancer recurrence. Unanticipated, they turned out to be cervicofacial actinomycosis, subsequently treated with long-term antibiotics following which the infection subsided.

Comparison of Intralesional Placentrex Versus Hyaluronidase and Dexamethasone Injection in the Symptomatic Management of Stage II Oral Submucous Fibrosis - a Prospective Study.

AIM: The present study aimed to compare the effectiveness of intralesional placentrex versus hyaluronidase + dexamethasone injection in the symptomatic management of stage II OSMF. MATERIALS AND METHODS: This was a non-randomized prospective study conducted over a period of 14 months at a tertiary referral center. Patients with clinical stage II OSMF were randomly grouped into A(n = 18) and B(n = 17). These patients were treated with weekly intralesional injection of placentrex and hyaluronidase + dexamethasone respectively, over a period of six weeks. Variables such as mouth opening, burning sensation and colour of mucosa were evaluated at baseline(T0), second week(T1), fourth week(T3), sixth week(T4) of follow up. A p-value < 0.05 was considered statistically significant. RESULTS: A total of 15 patients completed the study in each group with regular follow up. The mean improvement in mouth opening was 4.3 ± 0.57 mms in group A(p-value < 0.001) and 7.2 ± 0.76 mms in group B(p-value < 0.001) which were significant at the end of six weeks. Mean change in burning sensation at the end of six weeks in group A was 1.2 ± 0.73(p-value < 0.001), and 3.6 ± 0.63(p-value < 0.001) in group B. Mean change in colour of mucosa at the end of six weeks was 1.4 in group A(p-value > 0.05) and 2 in group B(p-value > 0.05). On comparison between both groups, patients in group B exhibited better mouth opening and reduction of burning sensation than patients in group A(p-value < 0.001). CONCLUSION: Both intralesional placentrex and hyaluronidase + dexamethasone injection are effective in alleviating the symptoms of stage II OSMF. However, hyaluronidase + dexamethasone injection showed slightly better improvement in mouth opening and burning sensation after six weeks.

Infralingular Versus Supralingular Medial Osteotomy in Sagittal Split Osteotomy of the Mandible: A Randomized Control Study.

PURPOSE: A recently proposed modification of the sagittal split osteotomy (SSO) of the mandible places the horizontal medial cut 'low and short' of the lingula. The purpose of the study was to answer the following clinical question: Among patients undergoing mandibular setback procedures (≤ 8 mm) via SSO, does the placement of the medial horizontal osteotomy below the lingula (infralingular), when compared to placement above the lingula (supralingular), results in different neurosensory, bite force, and range of motion outcomes? MATERIALS AND METHODS: This was a single-center, double-blind, parallel-group study among patients undergoing mandibular setback by SSO (≤ 8 mm), between January 2021 and September 2022. Patients were randomly allocated in a ratio of 1:1 to the supralingular (control) and the infralingular (study) group. Primary outcome variables included neurosensory disturbance of the inferior alveolar nerve based on clinical neurosensory testing and severity graded using Zuniga and Essick's protocol, bite force, and maximum mouth opening evaluated postoperatively during the first week (T1), first month (T2), and third month (T3) of follow-up. Secondary outcome measures included the incidence of a bad split and distal segment interferences intraoperatively. Association between the variables was assessed using Pearson chi-squared test or Fisher's exact test based on the expected observations. A P value of ≤.05 was considered statistically significant. RESULTS: A total of 29 patients (58 osteotomies) were included in the study. Group 1 consisted of 15 patients (9 females and 6 males) with a mean age of 26.4 years. Group 2 consisted of 14 patients (8 females and 6 males) with a mean age of 25.9 years. Patients with severe neurosensory disturbance of the inferior alveolar nerve were more common in group 2 (n = 15, 53.6%) than group 1 (n = 4, 13.3%) at T1 (P value = .0001) and insignificant between the two groups at T2 (P value = .63) and T3 (P value = .99). Comparison of maximum mouth opening between the two groups at T1 (P value = .535), T2 (P value = .934), and T3 (P value = .703) and bite force at T1 (P = .324), T2 (P = .113), and T3 (P = .811) was not significant. CONCLUSION: Both SSO techniques have similar clinical outcomes among patients having mandibular setbacks (≤ 8 mm) for the variables studied.

A systematic review and meta-analysis of the surgical outcomes in patients with osteochondroma of mandibular condyle.

Many options exist in the diagnosis and management of condylar osteochondroma. The purpose of this study was to provide a congregate information concerning treatment of the osteochondroma involving the mandibular condyle. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane database until February 2022. Twenty-seven studies were included for the final review. The review included 439 patients who underwent surgical management for mandibular condylar osteochondroma. The position of osteochondroma was mentioned in 13 studies. Preauricular, retromandibular, endaural, submandibular, transzygomatic, and intraoral approaches were used for approaching the tumor. Surgical techniques included resection, conservative condylectomy, and total condylectomy. Concomitant orthognathic surgery was performed along with tumor resection in 19 studies. In the entire review, the recurrence rate was 0.22% (1/439). The results of the meta-analysis showed that 2 studies reported significant malocclusion events after surgical therapy. Total joint replacement after tumor resection has a higher improvement in maximal mouth opening (8 mm) compared with vertical ramus osteotomy and no reconstruction groups, which have similar improvements (6 mm). The mainstay of treatment of osteochondroma is surgical excision either as condylectomy or conservative condylectomy. Among the various reconstruction modalities, total joint replacement showed better improvement in mouth opening. Adjunct procedures like orthodontic and orthognathic surgery have an important role in holistic management of severe cases. The treating surgeon must choose the surgical procedures in a pragmatic way.

Extracranial schwannoma of the maxillary nerve misdiagnosed as trigeminal neuralgia in an elderly patient with schizophrenia - A diagnostic dilemma.

The present paper discusses the diagnostic challenges we faced in a 60-year-old woman with a history of schizophrenia, presenting with left unilateral facial pain for the past three months. Based on the elaborate clinical examination and diagnostic nerve blocks, the patient was diagnosed with trigeminal neuralgia (TN) and non-surgical therapy commenced. Further investigations with magnetic resonance imaging (MRI) and ultrasound-guided fine needle aspiration cytology (FNAC) revealed the presence of an extracranial schwannoma involving a branch of the maxillary nerve. The patient was symptomatically relieved after surgical excision of the benign tumor under general anesthesia. Hence, we emphasize the need for special care and attention in psychiatric patients presenting with orofacial pain.

Comparison of the effectiveness of soft and hard splints in the symptomatic management of temporomandibular joint disorders: A randomized control study.

AIM: Splint therapy is a well-established modality in the management of temporomandibular joint disorders (TMDs). We aimed to evaluate and compare the effectiveness of hard and soft splints in the symptomatic management of TMDs using the modified Helkimo index. METHODS: This study included 91 patients diagnosed with TMDs. Participants were randomly allocated into two treatment groups. All these patients were treated by hard or soft stabilization splint therapy. Group 1: hard splint group, n = 42 (mean age - 31.62 ± 8.5 years), 10 males and 32 females; group 2: soft splint group, n = 49 (mean age - 32.86 ± 9.06 years), 13 males and 36 females. The anamnestic and clinical dysfunction component of the modified Helkimo index was used to evaluate the outcomes at baseline (T0 ), first month (T1 ), and third month (T2 ). RESULTS: Symptoms such as clicking of the joints, temporomandibular joint (TMJ) pain and muscle pain showed improvement in both groups (P < .05). Restriction and deviation of mouth opening did not show significant improvement in either group. The patients who underwent hard splint therapy showed an early improvement of symptoms at T1 (P < .05). However, there was no statistical difference in the improvement of symptoms between hard and soft splints at T2 . CONCLUSION: Both hard and soft stabilization splints were effective in the symptomatic management of TMDs. However, hard splints provide an earlier reduction of symptoms.

Palatal Flap: An Optimistic Salvagable Option to Negate the Maxillectomy Defects in COVID Related Rhino-Orbito-Cerebral Mucormycosis.

We present three cases diagnosed with COVID-19 associated Rhino-orbito-cerebral mucormycosis, managed by aggressive debridement and resection of the involved maxilla, followed by primary closure with preserved palatal flap, thus trying to establish its versatility for the closure of the maxillectomy defects.

Retrieval of Migrated Embedded Sewing Machine Needle from the Tongue.

Foreign body in the oral cavity can be encountered by Head and Neck Surgeons in their clinical practice. Here, we report a rare case of an embedded sewing machine needle in the posterior tongue that migrated by tongue movements, and was retrieved successfully by surgical intervention.

Embedded Foreign Bodies in the Maxillofacial Region: Our Experience.

Impacted Foreign Bodies (FB) within the maxillofacial region are often inadequately diagnosed during the initial examination. Proper evaluation and management are mandatory to avoid untoward consequences. We depict a series of five cases with impacted FBs, managed case-specifically, along with an algorithm for dealing FBs in the maxillofacial region.

Pattern of maxillofacial fractures in a Tertiary Referral Centre in Central Kerala - A comparison between the Pre-COVID and COVID periods.

Our aim was to observe if there was any appreciable difference in the etiology and pattern of maxillofacial fractures during the pre-COVID-19 and COVID-19 periods in Central Kerala, South India. This retrospective study was conducted with data over a period of two years from the central database registry of our hospital. Age, sex, etiology, date of injury, and site of facial fractures were recorded and compared between both the time periods. Increase in facial fractures due to fall at home (p value < 0.01) and decrease in mass casualty cases (p value < 0.01) were observed during the COVID-19 period. Pedestrians involved were significantly more in the pre-COVID-19 period (p value < 0.01) and heavy vehicle accidents producing facial fractures were significantly more in the COVID-19 period (p value < 0.01). Frontal bone (p value = 0.008), nasal bone (p value < 0.001) and zygomatico-maxillary complex fractures (p value < 0.001) occurred significantly more in the COVID-19 time period whereas naso-orbito-ethmoidal (p value = 0.003), mandibular (p value = 0.011) and dentoalveolar fractures (p value < 0.001) were seen significantly more in the pre-COVID-19 period. There was decrease in the total number of maxillofacial cases during the COVID-19 period. However, this was not significant when only the number of facial fractures were compared between the two periods. This study provided an insight on the differences in etiology and pattern of maxillofacial fractures during the pre-COVID-19 and COVID-19 periods. Road traffic accidents involving two wheelers predominate during the COVID-19 period also, prompting further critical exploration of the reasons behind this finding.

Ludwig's angina in a COVID positive patient-An atypical case report.

The management of odontogenic infections is established and several guidelines have been proposed for its effective treatment. Outbreak of COVID-19 has posed serious challenge in the management of odontogenic infections, further complicated by immunocompromised status of the patient, where adequate evaluation and prompt attention is mandatory to avoid untoward consequences. Ludwig's angina being a life threatening infection by itself, association or simultaneous presentation with COVID-19 infection can add further complexity in the management for a maxillofacial surgeon. Here we present a case report of Ludwig's angina in a patient who tested positive for Coronavirus infection and how we treated her successfully.