Palatal Mucoperiosteum-A Redeemable Barrier in Surgical Management of Rhinocerebral Mucormycosis.

Ever since the commencement of the COVID-19 pandemic, post-recovery complications have been in the highlights, out of which rhinocerebral mucormycosis tops the chart. The surgical management of this disease was always aggressive debridement, resection, and antifungal treatment. Oronasal communication after aggressive surgical management always leads to breathing, feeding, and cosmetic impairments. In this study, cases were managed by leaving the palatal mucosa intact after the removal of all the affected hard and soft tissues including the periosteum attached to the mucosa, to preserve the palatal mucoperiosteum and to improve the postoperative complications in patients by maintaining the oronasal separation. Prospective review of the operated case of rhinocerebral mucormycosis in 20 patients was presented. An intraoral approach for hard and soft tissue resection was employed. The palatal mucoperiosteum was salvaged in all patients. Postoperative complications like oronasal communication, ill-fitting prosthesis, and healing were evaluated. A total of 20 patients underwent maxillectomy for mucormycosis involving the maxilla and palate along with other facial bones. The palatal mucosa was preserved and used for oronasal separation. The expected complications of nasal regurgitation, crustation of the maxillary cavity, ill-fitting prosthesis, etc. were evaded due to this. The administration of Inj. liposomal amphotericin B (LiAB) postsurgically has been the backbone of this procedure.

Is Chitosan Dental Dressing Better Than Cotton Gauze in Achieving Hemostasis in Patients on Antithrombotics?

PURPOSE: Tooth extraction leads to bleeding which may be longer in patients on antithrombotics. This study was aimed to evaluate the hemostatic and wound healing efficacy of chitosan-based dressing in comparison to the cotton pressure pack after tooth extraction in patients receiving single or dual antithrombotics. MATERIALS AND METHODS: This is a prospective, randomized split mouth study. Patients undergoing tooth extractions taking either single or dual antithrombotics, with an international normalized ratio (INR) value ≤ 3 were enrolled at JSS Dental College & Hospital, Mysuru, India during February 2020 to January 2022. The study compared the efficiency of chitosan dressing in achieving quicker hemostasis in comparison to cotton pressure pack. The primary outcome was time to achieve hemostasis and the secondary outcomes were alveolar clinical healing index and alveolar osteitis. The covariates were gender, age, reason for extraction, INR, type of antithrombotic therapy, and the disease condition. RESULTS: Of the 54 enrolled subjects, 39 were males and 15 were females, aged between 33 and 86 years. Thirty six patients were on single antithrombotics, whereas 18 patients were on dual antithrombotics. The reason for extraction was periodontitis in 37 patients and dental caries in 17 patients. The time to achieve hemostasis was lesser with chitosan dental dressing when compared to cotton pressure packs (96 ± 4 and 797 ± 23 seconds; P < .001). In the chitosan group, the time to hemostasis was similar irrespective of single or dual antithrombotic therapy (90 ± 6 and 109 ± 8 seconds, respectively). On the contrary, in the cotton pressure pack group, patients on dual antithrombotics had longer time to achieve hemostasis compared to those on single antithrombotics (940 ± 20 and 726 ± 26 seconds; P < .001). The time to achieve hemostasis was dependent on INR only in cotton pressure pack group (r2 = 0.7756). The alveolar clinical healing index was better in 88.9% with chitosan and only 3.7% with cotton pressure packs. None of the patients treated with chitosan presented with alveolar osteitis, as opposed to 3.7% of patients with cotton pressure packs. CONCLUSION: When compared to cotton pressure packs, chitosan-based dressing was more effective in controlling postoperative bleeding in patients treated with single and dual antithrombotic therapy.

Isolated Pure Orbital Blowout Fracture - A Rare Case Report.

Rationale: An orbital fracture is said to be a pure blowout when it affects only one internal orbital wall and does not compromise the orbital rim. Pure blowout fracture of the orbital floor without any other associated facial bone fracture is uncommon. Patient Concerns: The patient with a history of assault presented with complaints of blurring of vision and diplopia. Diagnosis: Computed tomography of paranasal sinus scans and ophthalmologic examination confirmed the right orbital floor fracture. Treatment: Herniated orbital contents were retrieved and the orbital floor was reconstructed with titanium mesh under general anaesthesia. Outcomes: The patient was followed up regularly for six months and showed no signs of any visual disturbances. Take-away Lessons: Although orbital floor fractures are commonly associated with zygomaticomaxillary complex and midface fractures, it is uncommon as an isolated finding in facial trauma. It can be easily misdiagnosed and left untreated, which can give rise to future complications.

Comparative Evaluation of Drill-Free and Self-Tapping Titanium Miniscrews for Semi-Rigid Internal Fixation in Maxillofacial Trauma.

Introduction: Conventional semi-rigid fixation systems in maxillofacial trauma use self-tapping titanium miniscrews (STS) that require preliminary drilling of a pilot hole. Although drill-free miniscrews (DFS) accompany these systems, they have not dominated practice despite their allure of improved screw-bone contact and holding power. The COVID-19 pandemic has brought these DFS to light as they avoid aerosol production. The present study has compared DFS to STS in patients being treated with miniplate fixation for maxillofacial trauma to understand their feasibility for maxillofacial fracture fixation. Methodology: This prospective case-control study sampled 16 patients each with zygomaticomaxillary buttress fracture and parasymphysis fracture of the mandible and grouped alternating patients as case (DFS) and control (STS). Intraoperatively duration of fixation, incidence of screw failures and fragment stability; postoperatively occlusion, neurosensory deficits, teeth vitality and infection and removal rates were evaluated at postoperative week 1, 3, 6, 12 and 24 using Cramer's V test. A P value < 0.05 was considered significant. Results: In the 32 patients evaluated, DFS reduced internal fixation time at zygomaticomaxillary buttress (P = 0.001) but not at parasymphysis (P = 0.206). No significant difference in screw failures or fragment stability was observed. Stable occlusion was maintained in all groups with vital teeth and intact neurosensory function, but the summative incidence of infection was significant at week 24 when STS was used at parasymphysis (P = 0.019). Discussion: While DFS may facilitate ease of insertion with a single instrument pick-and-screw-in approach, avoiding thermal osteonecrosis and aerosol production, they fail to confer any other clinical advantage.

Inferior alveolar nerve dysfunction in mandibular fractures: a prospective cohort study.

OBJECTIVES: To assess the prevalence and recovery of inferior alveolar nerve dysfunction (IAND) in mandibular fractures. MATERIALS AND METHODS: : This was a prospective cohort study. Clinical neurosensory testing was done preoperatively and the IAND was categorized as mild, moderate or severe. Postoperatively, neurosensory testing was repeated at 1 day, 1 week, 1 month, 3 months and every 3 months thereafter. RESULTS: : A total of 257 patients with 420 fractures were included in the study with a mean age of 31.7 years. Body fractures (95.9%) had the highest incidence of IAND, followed by the angle fractures (90.1%) and symphysis fractures (27.6%). The condyle and coronoid fractures did not have any IAND and hence were excluded from further study. After eliminating those cases, 232 patients remained in the study with 293 fractures. The overall prevalence of IAND in fractures occurring distal to the mandibular foramen was 56.3%. The changes until 1 week were minimal. From 1 month to 6 months, there was a significant reduction in the severity of IAND. A significant number of cases (60.0%) were lost to follow-up between 6 and 9 months. At 6 months, 23.9% of cases still had some form of IAND and 95.0% of the symphysis, 59.0% of the angle and 34.8% of the body fractures with IAND had become normal. CONCLUSION: This study documents the reduction in the degree of severity of IAND in the first six months and provides the basis for future studies with longer periods of follow-up.

Efficacy of Prolotherapy in Temporomandibular Joint Disorders: An Exploratory Study.

INTRODUCTION: Temporomandibular joint (TMJ) disorders can be treated by both conservative and surgical approaches. Conservative interventions with predictable benefits can be considered as first-line treatment for such disorders. Dextrose prolotherapy is one of the most promising approaches in the management of TMDs, especially in refractory cases where other conservative management has failed. AIM: To study the efficacy of prolotherapy and to establish it as an effective procedure in patients with TMJ disorders, to provide long-term solution to chronic TMJ pain and dysfunctions. PATIENTS AND METHODS: We conducted a study on 25 patients suffering from various TMJ disorders who were treated with prolotherapy, the solution consisting of 1 part of 50% dextrose (0.75 ml); 2 parts of lidocaine (1.5 ml); and 1 part of warm saline (0.75 ml). The standard programme is to repeat the injections three times, at 2-week interval, which totals four injection appointments over 6 weeks with 3-month follow-up. RESULTS: There was appreciable reduction in tenderness in TMJ and masticatory muscles with significant improvement in mouth opening. The effect of the treatment in improving clicking and deviation of TMJ was found to be statistically significant (P < 0.05). There were no permanent complications. CONCLUSION: Our study concluded that prolotherapy is an effective therapeutic modality that reduces TMJ pain, improves joint stability and range of motion in a majority of patients. It can be a first-line treatment option as it is safe, economical and an easy procedure associated with minimal morbidity.

Aggressive Ossifying Fibroma of the Maxilla.

The aggressive ossifying fibroma is an uncommon benign fibro-osseous lesion which has been described in the literature under a variety of terms. This tumor is distinguished from standard ossifying fibroma based on its more clinically aggressive biological behavior, occurrence in children and young adults, and tendency to occur in different anatomic sites. We report a case of a 45-year-old female who presented with a unilateral swelling of the right middle face for 5 months. Clinical examination showed a mass extended over the right maxilla. Orthopantomogram and computed tomography scan were performed. Biopsy suggests a fibro-osseous lesion. The complete surgical excision of tumor was performed under local anesthesia. The histopathological examination revealed the diagnosis of an aggressive ossifying fibroma-trabeculae type. No recurrence was noted. Because of its aggressive and compressive nature, aggressive ossifying fibroma requires an early complete surgical excision. A long-term clinical and radiological surveillance is necessary to prevent recurrence.

Assessment of the Need for Routine Distolingual Local Anesthetic Infiltration in Addition to Traditional Inferior Alveolar, Lingual and Long Buccal Nerve Blocks in Mandibular Third Molar Extractions.

BACKGROUND AND OBJECTIVES: Persistent pain during the removal of mandibular third molars is often due to accessory nerve supply causing inadequate local anesthesia. This study aims to assess the requirement of routine distolingual infiltration anesthesia in addition to traditional inferior alveolar, lingual, and long buccal nerve block in mandibular third molar extractions. METHODOLOGY: Sixty patients requiring mandibular third molar extraction were randomly divided into two equal groups; Group A (Classic inferior alveolar, lingual, and buccal nerve block) and Group B (with an additional 0.2 ml distolingual infiltration). During various steps of the procedure, any complaint of pain was recorded and graded on a subjective Visual Analog Scale (VAS). RESULTS: There was no significant difference between the two groups in regard to age (P = 0.666) and sex (P = 0.432). And also, no difference was found in angulation (P = 0.757), class (P = 0.417) and position (P = 1.000) of third molars. Mean VAS scores in Group B (0.153) were significantly lower (P = 0.004) than that of Group A (0.600). VAS scores during procedural steps were significantly lower in Group B during mucoperiosteal elevation (P = 0.050), bone guttering (P = 0.037), and tooth splitting (P = 0.052). CONCLUSION: Routine distolingual infiltration anesthesia, in addition to classic inferior alveolar, lingual, and long buccal nerve block, is recommended for the extraction of mandibular third molars.

The Versatility of Nasolabial Flaps in Maxillofacial Surgery.

INTRODUCTION: The nasolabial flap can be used for reconstruction of the orofacial region. The procedure is of a short duration and treats orofacial soft tissue defects of small to moderate size, especially when microsurgical free flaps are less feasible due to lack of infrastructure, expertise or financial constraints. AIMS AND OBJECTIVES: To study the effectiveness of the nasolabial flaps in reconstruction of orofacial defects of various origins. MATERIALS AND METHODS: In this prospective study, 10 patients (18 nasolabial flaps) were selected randomly regardless of age, sex and need for reconstruction-whether it being requirement of tissue coverage following traumatic loss of soft tissue, soft tissue coverage after resection of a benign or malignant tumor, or resection of soft tissue defects after excision of submucous fibrosis bands. Patients were treated under general anesthesia following routine investigations, using either inferiorly or superiorly based, unilateral or bilateral nasolabial flaps for local extraoral and intraoral reconstruction. Patients were evaluated for postoperative complications, flap uptake, donor site morbidity and postoperative extraoral scarring. RESULTS: In all cases, postoperative complications were relatively minor except in one flap where total flap loss was encountered. The average time taken for preparation of recipient site, flap elevation and closure was 72 min. The nasolabial flap proved itself to be extremely vascular and thus safe and suitable with satisfactory cosmetic outcomes. CONCLUSION: The nasolabial flap proves to be a versatile flap with a proven blood supply from the facial, transverse facial and infraorbital vessels. It establishes itself as a simple procedure to execute to reconstruct the various defects of the anterior orofacial region. It is considered to be a safe flap with a low complication rate, and most importantly it offers a cosmetically pleasing and functionally satisfactory solution.

Chondroid Tenosynovial Giant Cell Tumor of Temporomandibular Joint.

Tenosynovial giant cell tumor (TGCT), a benign proliferative lesion arising from the synovial membrane of the joints, is rarely seen in the temporomandibular joint. It frequently presents as a painful, preauricular swelling and affects the jaw functions. Two types of TGCT seen are diffuse TGCT (TGCT-D) and localized TGCT. A case of TGCT-D is described here, the highlight of the case being extensive areas of chondroid metaplasia which mimicked chondroid lesions, but was ruled out based on negative immunohistochemical findings within the tumor cells.

Efficacy of Intranasal Dexmedetomidine for Conscious Sedation in Patients Undergoing Surgical Removal of Impacted Third Molar: A Double-Blind Split Mouth Study.

BACKGROUND: This study was conducted to evaluate the utility and effectiveness of Intranasal Dexmedetomidine on Sedation status and pain experience of the patients undergoing surgical extraction of impacted third molar. MATERIALS AND METHODS: In this double-blind, split mouth study, in 15 patients, evaluations pertaining to classes of third molar impaction was done. Each patient was randomly assigned to receive either intranasal normal saline (placebo group) or intranasal 1.5 µg/kg atomized Dexmedetomidine during the first session. The other regimen was used during the second session. Study was conducted for over a period of 120 min and data for sedation and pain was collected at an interval of 30 min. The collected data was then compared between the two groups within the same patient. Sedation status was assessed by a blinded observer with a modified Observer's Assessment of Alertness/Sedation (OAA/S) 13 scale (Annexure- B). Pain experience was evaluated by Visual Analog Scale (VAS) (Annexure-B). Clinical evaluation for sedation and pain was done by a blinded observer at 30, 60, 90, and 120 min after administration of the intranasal solution. The values were then tabulated, and compared between two visits. RESULTS: The mean values of OAA score of Dexmedetomidine group were significantly higher as compared to Placebo group with a 'p' value of 0.000. And the mean values of Pain score of Dexmedetomidine group were significantly lower as compared to Placebo group with a 'p' value 0.009. CONCLUSION: The results of this study clearly indicated that: Intranasally administered Dexmedetomidine was significantly useful and effective to achieve optimal sedation and analgesia during third molar surgery.

Pseudolymphoma versus lymphoma: An important diagnostic decision.

Small innocuous growths on the face usually do not pose difficulty in diagnosis on histopathology. However, some benign inflammatory lesions might mimic malignancy and hence need further investigations for final diagnosis. The distinction between a benign/inflammatory/malignant lesion needs no emphasis as the treatment plan, prognosis and the patient's well-being depends on it. Lymphocytoma cutis, or Spiegler-Fendt Sarcoid, is classed as one of the pseudolymphomas, referring to inflammatory disorders in which the accumulation of lymphocytes on the skin resembles, clinically and histopathologically, cutaneous lymphomas. To obtain an accurate diagnosis, careful clinical evaluation, as well as histopathological and immunohistochemical examination is needed. One such case of an otherwise unassuming growth mimicking malignancy is being presented.

Recurrence of a giant peripheral osteoma of mandible.

Osteomas are rare benign tumours in the bone. We describe a case of giant osteoma involving the lingual side of the ramus and body of mandible that recurred 8 years after its surgical treatment at another hospital. Surgical resection with reconstruction is the treatment of choice for this lesion. The clinicopathological features of osteoma are discussed and Gardner's syndrome was excluded.

Evaluation of neurosensory disturbance following orthognathic surgery: a prospective study.

AIM AND OBJECTIVES: The prospective study was to evaluate the incidence, type of neurosensory disturbance (NSD), grade its severity and monitor its recovery occurring in the lower lip and chin due to damage to inferior alveolar nerve following orthognathic surgery involving mandible. MATERIALS AND METHODS: The study included 10 patients who have undergone sagittal split osteotomy, genioplasty, and anterior subapical osteotomy (ASO). All the patients examined preoperatively and post operatively 1 week, 1 and 6 months according to standardized test to clarify the subjective and objective neurosensory status of the injured nerve. Pin prick test, blunt test, two-point discrimator test, brush stoke direction, light touch test, warm and cold test were used bilaterally to lower lip and chin area. RESULTS: Seven patients underwent bilateral sagittal split osteotomy (BSSO) (70 %), one patient had BSSO with genioplasty (10 %), two patients had BSSO with ASO (20 %). During the operation none of the nerves were transectioned, in 60 % of patients nerve was not visible and in 40 % of patients nerve was seen in distal segment. 70 % of patients underwent setback, 30 % of patients underwent advancement. The subjective evaluation of the patients revealed the incidence of 90 % at 1 week, 30 % at 1 month, 20 % at 6 months and 10 % at 1 year post operatively. The altered sensation reported subjectively was hypoesthesia in 50 % of the patients, anaesthesia in 40 % of the patients. There was 100 % recovery in advancement cases and 93.5 % recovery in setback cases. CONCLUSION: There is a high incidence of NSD of the lower lip and chin after BSSO related to advancement, setback, intraoperative nerve encounter and surgical skill. However, recovery of sensation occurs with increasing frequency during the follow-up period. The clinical neurosensory tests are effective guides to study the neurosensory deficit.

Detection of Bacterial Flora in Orofacial Space Infections and Their Antibiotic Sensitivity Profile.

INTRODUCTION: Most odontogenic infections arise as a sequel of pulp necrosis caused by caries, trauma, periodontitis, etc. They range from periapical abscesses to superficial and deep infections in neck. Some resolve with little consequence and some lead to severe infections of head and neck region. The purpose of this study was to identify microbial flora present in orofacial space infection of odontogenic origin and thereby provide better perspective in management of odontogenic infection. MATERIALS AND METHODS: Twenty-six patients with space infection of odontogenic origin were selected irrespective of their age and gender. Pus samples were collected and processed in the microbiology laboratory for the growth of anaerobic and aerobic bacteria and antibiotic sensitivity profile. RESULTS: Demographic profile of the patients showed that male patients were more commonly involved and most patients fell in to the third and fourth decade of age groups. Most common site of involvement was submandibular space. Alpha hemolytic streptococci were the frequent aerobic bacterial isolate and among anaerobes, anaerobic streptococci followed by bacteroids were the major pathogens. Clindamycin, Gentamycin, Linezolid, Imipenam were the most effective antibiotics. 20 % of the aerobes were resistant to penicillin. CONCLUSION: Streptococcus species are still the commonest pathogen in orofacial infections of odontogenic origin. Administration of amoxicillin clavulanic acid combination and metronidazole followed by surgical drainage of abscess and extraction of infected teeth, yielded satisfactory resolution of infection.

A comparison between 2.0-mm standard and 2.0-mm locking miniplates in the management of mandibular fractures.

PURPOSE: The purpose of this clinical study was to compare effectiveness of 2.0-mm locking miniplates and screws with 2.0-mm standard miniplates and screws in treating mandible fractures. PATIENTS AND METHODS: A randomized prospective study comprising of 40 samples, where 20 patients (group 1) were treated with locking plates and 20 patients (group 2) were treated with standard miniplates. All the cases were evaluated for the type of fracture, need for the Intermaxillary Fixation (IMF) and its duration, duration of surgery, anatomic reduction, paresthesia / neurosensory changes, occlusal discrepancies, infection at the fracture site and any need for the removal of the plates and screws. RESULTS: In our study Road Traffic Accidents (RTA) accounted for the majority of patients 30 (70%). RTA was more prevalent (52.5%) in 21-30 age group, with assault being more common (67%) in 25-35 years. There was a significant difference between group 1 and 2 in postoperative occlusal discrepancy and need for IMF (p=0.008). There was no significant difference in complication rates between group 1 and group 2 patients. CONCLUSION: Locking plate/screw system proved to be more rigid than conventional plate/ screw system, thereby reducing the need and duration of IMF. However there was no significant difference in complication rates.