Primary Ewing's Sarcoma of Body of Mandible, Multimodal Treatment with Excellent Spontaneous Bone Regeneration: a Case Report.

Ewing's sarcoma is an invariable manifestation in facial bones. Primary lesions in head and neck region had come up with better prognosis compared to other primary sites; hence, management of such jaw lesions is a challenge particularly in pediatric patients during first decade of life as functional impairment and facial disfigurement may affect the quality of life. Here, we are discussing a unique case of primary lesion of horizontal region of mandible with special focus on use of radiation therapy, radiation dose-related effects and spontaneous bone regeneration.

Nine Years of Retrospective Study of Mandibular Fractures in Semi-urban Teaching Hospital, Shimla, Himachal Pradesh, India.

Study Design: Retrospective study. Objective: To evaluate current trends in maxillofacial trauma, a retrospective study of mandibular fractures at Government Dental College and Hospital Shimla H.P was carried out. Methods: In this retrospective study, records of 910 patients with mandibular fractures were reviewed between 2007 and 2015 in the Department of Oral and Maxillofacial Surgery out of total 1656 facial fractures. These mandibular fractures were assessed according to age, sex, aetiology in addition to monthly and yearly distribution. Post-operative complications such as malocclusion, neurosensory disturbances and infection were recorded. Results: It was observed that mandibular fractures were most frequent in males (67.5%) and in the age group of 21-30 years; accidental fall was the most common etiological factor (43.8%) in the present study and in stark difference to already published reports. The most common fracture site was that of condylar region 239 (26.2%). Open reduction and internal fixation (ORIF) were done in 67.3% cases whereas 32.6% were managed by maxillomandibular fixation and circummandibular wiring. Miniplate osteosynthesis was the most favoured technique. The complication with ORIF was 16%. Conclusions: To treat mandibular fractures, currently there are many techniques. However, in minimizing complications and in achieving satisfactory functional and aesthetic results experienced surgical team plays an important role.

Ramsay Hunt Syndrome: A diagnostic dilemma.

Ramsay Hunt Syndrome is not just a syndrome but rather an engrossing infectious disease that is difficult to rationalize owing to unpredictable onset. Reactivation of the varicella-zoster virus remains the etiological factor. The clinical depiction remains the cornerstone of diagnosis. Characteristic feature of the disease includes acute lower motor neuron facial palsy, otalgia, and mucosal and cutaneous rashes. A 37-year-old male reported to our department with pain and difficulty in closing the eye. At follow-up, the lesions got healed, but facial nerve deficit persisted. It is vital to establish an early diagnosis which aids in distinguishing the syndrome from other severe neurological illnesses, and early initiation of treatment is of prime importance to improve the impaired nerve function; hence, precise knowledge of the disease is crucial. Audiometric analysis must be performed since it can lead to permanent hearing loss.

Radiographic factors associated with inferior alveolar nerve exposure during mandibular third molar surgery and their influence on neurosensory deficit: A prospective study.

Introduction: The inferior alveolar nerve (IAN) can occasionally be observed in the extraction socket of the mandibular third molar (M3M) intraoperatively. Exposure of inferior alveolar neurovascular bundle during surgery primarily depends upon the absence of bony cortex between the canal and root of impacted third molar or either by existence of a very thin cortical lining between two which gets broken during luxation of tooth. Accurate anatomical relationship of inferior alveolar canal with root apex of impacted (M3M) and the location of canal can be determined by Cone beam computed tomography (CBCT). Material and methods: Initially 200 patients evaluated by Orthopantomogram (OPG) for anatomical relationship of IAN with impacted (M3M) and various radiographic risk factors for nerve injury. Among these 200, 75 showed the presence of two or more than two risk factors for IAN injury which then were further evaluated by using CBCT for presence or absence of cortex of canal and location of canal on buccal, lingual, inferior, and interradicular position. Conclusion: Cortex of canal is an important barrier between the root apex and inferior alveolar neurovascular bundle. Interruption of cortex on CBCT, the interradicularly and lingually positioned neurovascular bundle become a strong affirmation for intra operative nerve exposure during (M3M) surgery. Although its exposure is affected by various factors such as bone density, sex and age of patient, surgeon's expertise, operative tissue damage, post operative edema, surgical procedure, but neurosensory deficit do not occur simply after the exposure of neurovascular bundle.

Molecular and pathological screening of canine distemper virus in Asiatic lions, tigers, leopards, snow leopards, clouded leopards, leopard cats, jungle cats, civet cats, fishing cat, and jaguar of different states, India.

The present investigation was conducted to rule out canine distemper (CD) diseases in Indian wild felids (Asiatic lions, tigers, leopards, snow leopards, clouded leopards, leopard cats, jungle cats, civet cats, fishing cat, and jaguar). The collected samples were screened for CD virus (CDV) by histopathology (HP), immunohistochemistry (IHC) and reverse transcriptase-polymerase chain reaction (RT-PCR) targeting H gene and N gene. The HP and IHC of suspected samples portrayed that 22 [11 leopards, 6 lions, 3 tigers, 1 snow leopard and 1 civet cat] out of 129 (17.05%) wild felids were positive for CD. The major pathological consequences were observed in spleen, lung, kidney and brain. The syncytia and intranuclear as well as intracytoplasmic eosinophilic inclusion bodies were seen in CDV infected cells. Although the histopathological lesions in spleen were more specific and consistent, however, the severe demyelinated leukoencephalitis (usually expected in CD infected dog) was not observed in the brain of any Indian wild felids. Conversely, the CDV antigen has been portrayed via IHC in pancreatic islets of Langerhans of tiger species for the first time in this study. Moreover, the concurrent CD and babesiosis has also been observed in a lioness without a usual coffee-coloured urine. The N gene and H gene of CDV isolates were amplified, sequenced and subsequently constructed the phylogenetic tree. The phylogenetic analysis of H gene revealed that the CDV isolates from Indian lion formed separate clade with CDV isolates from Indian dog and Indian palm civet cat. Furthermore, two CDV isolates from Indian tigers formed clade with Onderstepoort vaccine strain and CDV isolates from dogs of Uttar Pradesh, USA and UK. Evidently, CDV is circulating in Indian wild felids and causing diseases in them.

Operator Experience and Fracture Location Affects the Rate of Facial Nerve Injury in Condylar Fractures: An Analysis of 89 Cases.

PURPOSE: The purpose of this study was to measure the frequency and identify risk factors for facial nerve injury (FNI) in the open treatment of condylar neck and subcondylar fractures. MATERIALS AND METHODS: A prospective cohort study was conducted over 5 years on patients who were treated surgically for mandibular condylar fractures using the retomandibular transparotid approach (RMTA). The primary result was FNI occurrence (yes/no). The predictor variables were demographic, fracture location, and pattern (dislocation, present or not), as well as surgeon experience. Post-treatment functional facial nerve changes were initially assessed in the operating room as the patient regained consciousness and documented thereafter within, the 1st and 3rd weeks, and 3rd and 6th months. Appropriate statistics were computed and, SPSS version 16 was used to analyze the data. χ2 test and Fisher exact test were used to assess significance (P ≤ 0.05). RESULTS: Eighty-nine patients with 102 condylar fractures (63 subcondylar and 26 condylar neck), with a mean age of 28.5±7.5 years and 91% men were evaluated. There were 15 subjects (16.8%) with FNI and among them 6 subjects had persistent facial weakness for 6-8 weeks that completely resolved within 3 months, with no permanent facial nerve paralysis. The marginal mandibular (n = 7), buccal (n = 6), and zygomatic (n = 2) were the facial nerve branches involved. Risk factors for FNI were operator' inexperience, fracture-dislocation, and condylar neck fracture to the site and location of the fracture. Multivariate logistic regression showed that the location of the fracture at neck level (0.030∗), fracture dislocation (<0.001∗), and operator's inexperience (0.003∗) were significant risk factors for postoperative facial nerve injury (P ≤ 0.05). CONCLUSIONS: If conducted properly, the RMTA is a safe method for treating condylar fractures with rare major complications; however, fracture dislocation, fractured condylar neck, and operator' in-experience were significantly associated with increased risk of developing transient postoperative FNI.

Partial replacement of dietary buffalo meat on the bone with chicken carcass improves serum antioxidant profile of zoo-housed Indian leopards (Panthera pardus fusca).

This experiment was conducted to study the effect of gradual replacement of dietary buffalo meat on the bone (BMB) with chicken carcass (CC) on nutrient utilization, serum cortisol, and total serum antioxidant profile of zoo-housed Indian leopard. Twelve adult leopards were randomly distributed into a replicated Latin square design comprising three treatments, three periods, four animals, and three sequences. Leopards in group T1 were fed normal zoo diet of BMB. On the basis of dry matter, 10% and 20% of BMB was replaced with CC in groups T2 and T3 , respectively. Each experimental period comprised 21 days. During each period, a digestion trial of 4-day collection period was conducted after an adaptation period of 17 days. On Day 21 of each experimental period, blood was collected from all the animals by puncturing the ventral coccygial vein. Intake and apparent digestibility of major nutrients were similar among the groups. Replacement of 20% BMB with addition of CC increased (p < 0.001) the calculated supply of I, niacin, and vitamin A. Carotenoid intake increased (p < 0.01) with increased level of CC in the diet. Serum concentration of cortisol decreased (p < 0.01) whereas serum concentration of total carotenoids increased (p < 0.001) with increased level of CC in the diet. Serum concentration of antioxidant enzymes increased (p < 0.001) with increased level of CC in the diet. It was concluded that replacement of 20% of BMB with CC increased antioxidant profile. This may reduce oxidative stress in zoo-housed Indian leopards without any adverse effect on nutrient utilization.

Incidence Pattern of Bear-Inflicted Injuries to the Maxillofacial Region-Soft and Hard Tissue Injuries, Their Management, and Sequelae.

PURPOSE: The aims of the study were to elucidate the incidence pattern of bear-inflicted facial injuries and to document soft and hard tissue injuries, their management, and complications. MATERIALS AND METHODS: A prospective study was performed of 21 bear-associated injuries sustained to the facial region. Most patients were young to middle age and most were male. Most attacks occurred during the daytime, and the highest incidence occurred during the months of April to October. Wounds were assessed for soft and hard tissue injuries, including tissue loss, and corresponding management in the craniofacial region for 18 months. A standardized surgical treatment was used for patient management, which included thorough debridement of wounds and routine primary repair of soft tissue. Bony defect reconstruction was performed by open reduction and internal fixation. Regional or distant flaps were used for the reconstruction of soft tissue defects. RESULTS: Mauled patients were treated for injuries varying from lacerations and puncture wounds to fractures and avulsive tissues. On average, most patients underwent a single operation for reconstruction of bony fractures and soft tissue repair and spent 3 to 7 days in the hospital; however, some patients underwent more than 1 operation and stayed in the hospital for more than 4 to 6 weeks. Facial fractures were mainly seen in the midfacial region (71%), followed by mandibular fractures (24%). Overall, the results were satisfactory, except for a few instances of scar formation, facial nerve palsy, and ectropion. The mortality rate was 5% (1 patient) from the severe injury caused by bear mauling. CONCLUSIONS: Extensive bear-bite injuries of the facial skeleton can be treated with immediate primary wound repair after meticulous wound debridement and according to commonly used criteria of esthetic reconstructive facial surgery.

Assessment of Fixation of Mandibular Interforaminal Fractures by Using a Single Second-Generation Headless Compression Screw: A Pilot Study.

The aim of this article is to evaluate the efficacy of a single second-generation headless compression screw along with a lower arch bar in the fixation of interforaminal mandible fractures. A total of seven patients were included in the study. An open approach was used either intraorally or extraorally. A second-generation 3.0 HCS (headless compression screw), 24 to 32 mm in length, diameter at the head of 3.5 mm, smooth shaft with 2.0 mm and at the leading edge 3.0 mm (Synthes, Paoli, PA) was used for the fixation along with a lower arch bar. Postoperative clinical and radiographic follow-up was performed at 3 weeks, 3 months, 6 months, and 1 year. A single, cannulated HCS was found to be effective in fixation of interforaminal mandible fractures except in one case where a miniplate had to be applied subapically. Clinical and radiographic follow-up revealed accurate reduction and fixation in all cases and no postoperative occlusal disturbances. A single, second-generation HCS along with a lower arch bar provides good results when used for the fixation of interforaminal mandible fractures. Headless compression screw fixation of interforaminal mandible fracture is a simple, quick, economic, and efficient method of rigid fixation with minimum complications.

Post-Ankylotic Temporomandibular Joint Reconstruction Using Autogenous/Alloplastic Materials: Our Protocol and Treatment Outcomes in 22 Patients.

The purpose of this study was to evaluate the various options of autogenous and alloplastic reconstruction modalities available for posttraumatic temporomandibular joint (TMJ) ankylosis. In a retrospective study of 22 patients, various autogenous/alloplastic materials were used based on type and severity of ankylosis and age of patient. Final outcome of reconstruction was critically evaluated in terms of maximal mouth opening, occlusion, and facial symmetry. Fourteen patients (63.63%) developed TMJ ankylosis due to road traffic accidents and eight patients (36.36%) had a history of fall. The mean age was 15.61 years. The mean preoperative maximum interincisal mouth opening (MIMO) for the entire series was 3.39 mm ± 2.16 and postoperative MIMO was 43.69 mm ± 2.63. Costochondral grafts were used in seven children, whereas titanium reconstruction plate with condylar head was used in five adults and interpositional arthroplasties using temporalis muscle, temporalis fascia, and relocation of the articular disc were used in the rest of the ten patients. We conclude that all these age-specific treatment modalities yield clinically comparable results in terms of postoperative mouth opening and facial symmetry with no evidence of reankylosis in a follow-up ranging from 24 to 96 months.

Efficacy of Retromandibular Transparotid Approach for the Management of Extracapsular Subcondylar Mandibular Fractures Using 2-mm Titanium Miniplates: A Prospective Clinical Study.

PURPOSE: The aim of this study was to evaluate the long-term clinical and radiologic results of the retromandibular transparotid approach to displaced extracapsular subcondylar mandibular fractures. PATIENTS AND METHODS: A prospective cohort study was conducted over a period of 5 years on patients surgically treated for displaced extracapsular subcondylar mandibular fractures by the retromandibular transparotid approach. Variables including the type of fracture, degree of mouth opening, fracture displacement, deviation, excursive movements of the mandible, and facial nerve function were monitored before and after treatment. Appropriate statistics were computed. RESULTS: Thirty-nine patients with 47 fractures were evaluated. There were 34 subcondylar fractures (located below the sigmoid notch) (87%), and 5 fractures were located in the head region in bilateral cases. Of the fractures, 31 (79%) were unilateral and 8 (21%) were bilateral. In a multivariate study, condylar coronal displacement, coronal sagittal displacement, difference in the ramal height, maximal interincisal distance, protrusive movements, and deviation of the mandible on opening showed statistically significant differences in pretreatment and post-treatment patients (P = .001). The interincisal distance was 46.8 mm (SD, 5.2 mm) postoperatively versus 24.1 mm (SD, 6.7 mm) before treatment. The average range of protrusion was significantly lower (P = .001) in patients before treatment, at 1.9 mm (SD, 1.2 mm), when compared with 6.1 mm (SD, 2.0 mm) postoperatively. During mouth opening, deviation of the mandible is often a sign of compensatory movement of the contralateral joint due to shortening of the ascending ramal height on the affected joint. The mean deviation of the mandible from the midline was 4.2 mm (SD, 1.0 mm) in patients before treatment, with a significant difference (P = .001) in patients after treatment, with a mean of 1.9 mm (SD, 0.995 mm). Temporary injuries to the facial nerve branches were observed in 3 cases (8%) 1 week after treatment, which later resolved within 3 weeks to 3 months. CONCLUSIONS: The retromandibular transparotid approach provides good exposure and facilitates accurate reduction and fixation of the subcondylar fragment with positive outcomes, good cosmetic results, and rare major complications. Most facial nerve injuries are transient in nature after this approach. A Synthes 2-mm titanium single mini-plate (West Chester, PA) provides stable results after fixation.

Pediatric Maxillofacial Trauma Outcomes Based on a Survey of 65 Patients: A Prospective Study of Etiology, Incidence and Methods of Treatment.

BACKGROUND: The purpose of this study was to assess the etiology, incidence, and various methods of treatment of maxillofacial injuries in children presenting at our centre and to compare our findings with literature. PATIENTS AND METHODS: We carried out prospective study of 65 pediatric maxillofacial trauma patients treated from January 2011 to October 2012 at our centre. Data was collected on age, gender, etiological factors, anatomic site and treatment methods. Follow-up was performed by recall survey. RESULTS: Out of 65 patients 17 (26.15 %) presented with isolated soft tissue injuries and 48 (73.84 %) patients reported with 81 craniomaxillofacial fractures. Falls were most common mode of injury with 53 fractures (81.53 %). Treatment for fractures in our series comprised of periodic observation for non-displaced fractures (46.15 %), closed reduction (maxillomandibular fixation with IMF screws, acrylic cap splints) for minimally displaced fractures (15.38 %) and open reduction and internal fixation (ORIF) for grossly displaced fractures (12.30 %). CONCLUSION: Paediatric maxillofacial trauma can be managed conservatively and surgical treatment by ORIF is required in a very small group of children with grossly displaced fractures as a result of high velocity injuries. LEVEL OF EVIDENCE: Prognostic study, Level II.

Neck dissection for oral squamous cell carcinoma: our experience and a review of the literature.

OBJECTIVES: This article describes our experience with neck dissection in 10 patients with oral squamous cell carcinoma. MATERIALS AND METHODS: Between January 2007 and October 2009, 10 patients underwent primary surgery for the treatment of squamous cell carcinoma of the oral cavity. For patients with N0 disease on clinical exam, selective neck dissection (SND [I-III]) was performed. In patients with palpable cervical metastases (N+), modified radical neck dissections were performed, except in one patient in whom SND (I-III) was performed. The histopathologic reports were reviewed to assess the surgical margins, the presence of extra-capsular spread, perineural invasion, and lymphatic invasion. RESULTS: On histopathologic examination, positive soft tissue margins were found in three patients, and regional lymph node metastases were present in five of the ten patients. Perineural invasion was noted in five patients, and extra nodal spread was found in four patients. Regional recurrence was seen in two patients and loco-regional recurrence plus distant metastasis to the tibia was observed in one patient. During the study period, three patients died. Seven patients remain free of disease to date. CONCLUSION: Histopathological evaluation provides important and reliable information for disease staging, treatment planning, and prognosis. The philosophy of neck dissection is evolving rapidly with regard to the selectivity with which at-risk lymph node groups are removed. The sample size in the present study is small, thus, caution should be employed when interpreting these results.