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.

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.

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.

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.

Unusually elongated styloid process: A report of two cases with literature review.

Eagle's syndrome is most often associated with an elongated styloid process or ossified stylohyoid ligament, which may result in cervicofacial pain. Since the symptoms are vague and nonspecific, patients with the Eagle's syndrome are difficult to diagnose. We here report two cases of Eagle's syndrome, one case with unusually elongated styloid process of size 6.97 cm, in whom imaging with computed tomography established the diagnosis and managed by local infiltration of lidocaine and steroid; in another case the length of styloid processes were 3.47 cm and 3 cm respectively and was managed surgically.

Self-exfoliation of large submandibular stone-report of two cases.

Sialoliths are the most common diseases of the salivary glands. They may occur in any of the salivary gland ducts but are most common in Wharton's duct and the submandibular gland. This report presents clinical and radio graphical signs of two unusually large sialoliths which exfoliated by itself. There were painless swellings on the floor of the mouth in both cases. Radiographical examination revealed large irregular radioopaque mass superimposed right canine and premolar areas. Sialoliths were yellow in color and approximately 1.8 cm and 2.1 cm in size.

Cemento-ossifying fibroma.

The cemento-ossifying fibroma is classified as a fibro-osseous lesion of the jaws. It commonly presents as a progressively growing lesion that can attain an enormous size with resultant deformity if left untreated. A case of cemento-ossifying fibroma involving the left mandible is described in a 35 year old female patient. The clinical, radiographic and histological features as well as surgical findings are presented. The cemento-ossifying fibroma is a central neoplasm of bone as well as the periodontium which has caused considerable controversy because of the confusion regarding terminology and the criteria for its diagnosis.

Maxillofacial Injuries due to Bear Mauling.

Bear bite injuries have become a common occurrence as the forest covers and natural habitats are diminishing. Patients injured in bear attack present with different patterns of injuries. A common protocol may not be suitable for the management of injuries inflicted by these large wild animals. These animals usually attack in remote areas where composite trauma centres do not exist and urgent referrals of these patients will have significant effect on the final outcome. Limited literature is available describing bear bite management in maxillofacial practice. The goal of the present case reports is to document the injuries suffered in bear mauling and to add to the literature on the conservative management with minimal complications.

Ameloblastoma relapse after 16 years of resection in symphysis of mandible sparing the bone graft.

Ameloblastoma is a tumor derived from epithelium involved in odontogenesis. Although it is considered a benign tumor, its clinical behavior may be regarded as lying between benign and malignant. It is characterized by slow but persistent growth, local infiltration into adjacent tissues and recurrences; however, metastases are rare. Diagnosis mainly from tissue biopsy and characteristic finding on plain X-rays does assist in differentiating between types of ameloblastoma. The challenges in the management of this tumor are to provide complete excision as recurrence may occur in incomplete removal and also to reconstruct the bony defect in order to give reasonable cosmetic and functional outcome to the patient.