Is Zygomatic Osteotomy a Viable Option to Achieve Symmetry and Stability in Post-traumatic Residual Deformity of the Zygomaticomaxillary Complex?

PURPOSE: In residual deformity cases, it is difficult to reposition the zygomaticomaxillary-complex (ZMC) intraoperatively, due to resorbed fracture edges, and lack of zygoma analysis to 3-dimensionally quantify the deformity. Instability after zygomatic osteotomy and miniplate fixation (ZOMF) due to the gap between osteotomized segments, scar tissue, muscle pull, and other factors is also unknown. The study aims to evaluate symmetry and stability after ZOMF. MATERIALS AND METHODS: In this prospective study, a ZMC analysis was designed and patients with unilateral post-traumatic residual deformity (>10 weeks) of ZMC were treated with ZOMF. Measurements were evaluated on affected and unaffected sides at preoperatively, immediately, and 6 months postoperatively using MIMICS software. The primary outcome variable was the symmetry and stability of ZMC. Secondary parameters were changes in orbital volume, diplopia, ocular motility, mouth opening, and patient satisfaction. P < .05 was considered statistically significant. The continuous variables were compared by paired t-test. The change within the continuous variable with time was assessed by repeated measure ANOVA, followed by multiple comparisons using the Bonferroni test. The changes within the categorical variable were assessed by the McNemar test. RESULTS: Ten patients were enrolled (mean age = 29.2 ± 9.97 years; male:female = 9:1; right:left = 4:6). The mean duration from trauma to surgery was 34.84 ± 31.35 weeks. There was an improvement in the symmetry in anteroposteriorly (P = .005), mediolaterally (P = .001), and at the arch (P = .011) postoperatively. All parameters remained stable at 6 months postoperatively (difference not significant, P > .05); with the median satisfaction score of 4 of 5. Significant improvement in mouth opening (P = .014) and orbital volume (P = .001) was noted. CONCLUSIONS: Virtual measurements as per the proposed protocol helped in communication and quantifying ZMC. Four-point fixation with miniplates provided enough stability over the 6-month follow-up period.

Does Repositioning of Temporomandibular Joint Disc With Bone Anchors Provide Better Clinical Outcomes Than Conventional Disc Plication Procedures for Anterior Disc Displacements Without Reduction in Patients Refractory to Nonsurgical Treatments?

PURPOSE: Although open temporomandibular joint arthroplasty with discopexy is a common treatment for patients with anterior disc displacements without reduction (ADDWo) unresponsive to medical management, there are no studies comparing disc repositioning with bone anchors and conventional discopexy procedure. The purpose of the study was to compare the efficacy between disc repositioning with bone anchors and the conventional discopexy procedure for ADDWo of temporomandibular joint refractory to medical management. PATIENTS AND METHODS: A randomized controlled trial was conducted in patients with ADDWo. The primary objective was to compare the improvement in mouth opening (primary outcome variable) between the 2 treatment (primary predictor variable) groups-disc repositioning with bone anchors versus conventional disc plication. Secondary outcome variables were pain measured by visual analog scale, lateral excursions, and position of the disc evaluated by magnetic resonance imaging (MRI). Other variables of interest were age, gender, and duration of symptoms. The parameters were evaluated at preoperative, postoperative day 1, and 1-, 6-, and 12-month postoperative period. Categorical variables were compared with χ2 test and continuous variables with analysis of variance and adjusted for multiple comparisons with Bonferroni test. RESULTS: The study sample comprised 14 patients (7 in each group) with MRI-proven ADDWo. Statistically significant differences were found in the improvement of mouth opening between the 2 groups, showing better improvement with bone anchors (14.42 ± 5.96 vs 7.57 ± 7.25 mm; P < .05). The reduction in visual analog scale also showed statistically significant difference with better pain reduction achieved with bone anchor (4.57 ± 1.61 vs 3.28 ± 0.75; P < .05). There was no statistically significant difference in lateral excursions and postoperative position of the disc evaluated by MRI between the groups at the 12-month follow-up period. CONCLUSIONS: Disc repositioning with bone anchors provides better clinical outcomes in terms of maximal mouth opening and pain scores compared with conventional disc plication.

Functional outcomes of gap and interposition arthroplasty in the treatment of temporomandibular joint ankylosis.

PURPOSE: Recurrence is a major concern in management of temporomandibular joint ankylosis. In this study functional outcomes of gap arthroplasty (group I) and temporalis myofascial interposition arthroplasty (group II) are compared. MATERIALS AND METHODS: Preoperative, intraoperative, and follow-up data were noted from our departmental database. Outcome variables were postoperative mouth opening, open bite, recurrence, and facial nerve dysfunction. The χ2 test, Fisher test, t test, 2-sample Wilcoxon rank sum test, and logistic regression analysis were used. RESULTS: Group I comprised 207 patients, and group II comprised 55 patients. The mean age was 12.9 years (SD, 7.0 years). There were 220 nonrecurrent and 42 recurrent cases. The mean follow-up period was 3.78 years (SD, 3.0 years). In first time-operated cases, the recurrence rate was 14.7% in group I and 4.8% in group II. In recurrent cases, the recurrence rate was 34.5% and 30.8%, respectively. The differences were statistically insignificant. CONCLUSIONS: In first-time operated temporomandibular joint ankylosis cases, both treatments are satisfactory in preventing recurrence, but the recurrence rate increases with previous recurrences.

Effect of adjuvant autologous platelet concentrates on secondary repair of alveolar clefts: A systematic review and meta-analysis.

OBJECTIVE: To review the existing evidence on the adjuvant use of autologous platelet concentrates (APCs) with iliac crest bone graft (ICBG) in the reconstruction of the secondary alveolar cleft. METHODS: Electronic databases were searched systematically until November 2022. Clinical trials comparing the three-dimensional radiological outcomes of patients who underwent secondary alveolar bone grafting (SABG) with ICBG and APCs to those with ICBG alone and the radiological outcomes assessed 6 months after surgery were included. Two authors performed the study selection and the assessment of the risk of bias. Meta-analysis was performed using the random-effects model to determine the risk ratio (RR) for developing wound dehiscence and the mean difference (MD) with a 95% confidence interval (CI) for the percentage of newly formed bone. RESULTS: Nine studies (seven RCT and two CCT) were included with a low to high risk of bias. At the 6-month follow-up, the study group revealed insignificant results regarding the percentage of newly formed bone (MD = 6.49; 95% CI: -0.97, 13.94; p = .09; χ2  = 0.01; I2  = 71%). In addition, the overall risk of developing wound dehiscence was lower in the study group (RR = 0.34; 95% CI: 0.15, 0.78; p = .01; χ2  = 0.67; I2  = 0%). CONCLUSION: Currently, there is insufficient evidence to support the adjuvant use of APCs with ICBG on enhanced bone regeneration following secondary alveolar bone grafting. However, combining ICBG and APCs might be beneficial in reducing the risk of developing wound dehiscence.

Binder's syndrome: A narrative review.

AIM: The classical features of Binder's syndrome (BS) have been widely reported, yet there is a lack of information on diagnostic and treatment challenges. Therefore, we aimed to review the literature on various aspects, including the role of a multidisciplinary approach in the management of BS. METHODS: A thorough literature search was performed on PubMed, Scopus, Embase, Ovid, Web of Science, EBSCOhost, and Google Scholar using the keywords"Maxillonasal dysplasia", "Maxillonasal dysostosis", "nasomaxillary hypoplasia", "Binder type", "Binder syndrome", "Binder phenotype", and "OMIM 155050". In addition, the articles published in the English language from the inception of the database until June 2021 were considered. RESULTS: The search of different databases yielded 958 publications, out of which 145 relevant articles were reviewed. The studies were categorised by year of publication, study design, and theme. Most of the studies were case reports (42%) followed by case series (19%). The most reported topic was based on different surgical techniques (42%). Finally, the results were synthesised into a narrative review. CONCLUSIONS: The need for a multidisciplinary approach involving clinicians from different specialities is highlighted. Future research is warranted to develop concrete clinical guidelines for the management of this syndrome.

Review of osteochondroma of mandibular condyle and report of a case series.

PURPOSE: To present a retrospective analysis of 10 cases of osteochondroma of the mandibular condyle (operated between 1993 and 2009) with respect to age, gender, site of the pathology, treatment modality and recurrence, with review of literature. MATERIALS AND METHODS: Medical records with x-rays, computed tomography scans, and bone scans of all histologically proven osteochondroma of mandibular condyle cases operated between 1993 and 2009 were retrieved and examined. The data were tabulated and analyzed. RESULTS: There were 8 males and 2 females, with a right:left ratio of 2.3:1. Age range was 18 to 45 years with a mean of 29.4 years. Seven of 10 were superomedial in location. Six patients were treated by conservative condylectomy, whereas 4 required total condylectomy. In all cases, a preauricular with extended temporal approach was used. In the follow-up period ranging from 1 year to 13 years, there was no recurrence. CONCLUSION: Mandibular condylar osteochondroma is thought to be a relatively rare lesion with only 90 cases documented in the English language literature to date. Gradual facial asymmetry over the years is the most striking feature. Two types are identified: those causing growth potential in mandible causing bowing of ipsilateral body and requiring gnathic correction after excision of tumor, and others growing as tumors superior or superomedial to condyle without causing much growth in the mandible, requiring only excision and automatic swing back to correct asymmetry. Both the procedures---conservative condylectomy and the total condylectomy---are curative. The decision, however, depends on how much swing of mandible is required postsurgery for correction of asymmetry and occlusion.

Equivalence randomized controlled trial of bioresorbable versus titanium miniplates in treatment of mandibular fracture: a pilot study.

PURPOSE: The present study was undertaken to test bioresorbable fixation versus titanium for equivalence in terms of clinical union and complications using the American Association of Oral and Maxillofacial Surgeons parameters of care. The study design was a randomized, controlled, equivalence trial. MATERIALS AND METHODS: A total of 40 patients were enrolled and allocated to the titanium group and bioresorbable group using a computerized randomization table. All were plated using standard plating principles. In the bioresorbable group, 2 weeks of maxillomandibular fixation was also used. Evaluation of the study endpoint was done at 8 weeks postoperatively. For statistical analysis, the upper limit of the 95% confidence interval was calculated for failure to achieve the primary outcome variable and compared with the maximal clinically acceptable difference between the standard and test modalities in the failure to achieve clinical union (delta). Delta was predetermined as 2%. The other complications were tested for significance using Fisher's exact test. RESULTS: Of the 40 patients, 21 were in the titanium group and 19 were in the bioresorbable group, with 20 men and 1 woman in the titanium group and 18 men and 1 woman in the bioresorbable group. The mean age was 28.7 years in the titanium group and 26.6 years in the bioresorbable group. In the titanium group, the complications noted were nonunion in 0%, malocclusion in 7.7%, continued postoperative swelling in 0%, chronic pain in 2%, infection in 5.2%, an inability to chew hard food after 8 weeks in 7.7%, the need for alternative treatment in 0%, and the need for reoperation in 31%. In the bioresorbable group, the complications were nonunion in 4.17%, malocclusion in 11.1%, swelling in 8.3%, chronic pain in 37.5%, infection in 0%, an inability to chew hard food in 11.1%, the need for alternative treatment in 11.1%, and need for reoperation for plate removal in 0%. CONCLUSIONS: The small sample size did not allow any meaningful conclusion to be drawn from the present study in terms of the primary question of achieving union. Both groups matched in outcomes when evaluated only on a clinical basis. The avoidance of repeat surgery for plate removal is a definite advantage of using resorbable plates. However, the results are inconclusive in favor of any particular plating system.

Efficacy of bioresorbable plates in the osteosynthesis of linear mandibular fractures.

BACKGROUND AND OBJECTIVES: There are limited evidences available about the performance of biodegradable system in the treatment of linear mandibular fractures without the aid of postoperative maxillomandibular fixation (MMF). Hence, the present study was planned to evaluate the treatment outcomes in mandibular fractures, using 2.5 mm bioresorbable plates and screws without postoperative MMF. METHODOLOGY: This cohort study compares both prospective and retrospective data. The prospective study treated 20 adult patients with linear mandibular fracture using bioresorbable plates and screws, without using postoperative MMF (Group 1). Retrospective data were collected from a previous published study in which patients were treated with bioresorbable plates and screws with 2 weeks postoperative MMF (Group 2) and those treated with metal plates and screws without postoperative MMF (Group 3). Group 1 patients were followed up at 2 and 4 months to evaluate the functional outcomes in terms of fracture mobility, malocclusion, pain, and soft-tissue deformity and compared with its preoperative findings. Further, the treatment outcomes of Group 1, Group 2, and Group 3 were compared among themselves at 2-month follow-up. RESULTS: Group 1 patients showed a significant improvement in the treatment outcomes at 2 and 4-month follow-up. In addition, when 2 months postoperative outcomes were compared among the three groups, no statistically significant difference was observed in the treatment outcomes. CONCLUSION: Endpoint osteosynthesis can be achieved with the bioresorbable fixation system when used in the treatment of un-displaced linear mandibular fractures, without postoperative MMF. A minor modification of using a lower size osteotomy drill can prevent screw loosening.

Establishing the accuracy of a new and cheaper sample collection tool: Oral cytology versus oral histopathology.

OBJECTIVE: High cost of tools used for the collection of oral cytology sample; deters their use as mass screening tool in the developing countries. Hence, this study aims to assess the diagnostic accuracy of a new, cheaper sample collection tool in the field of oral exfoliative cytology through comparison with histopathology. MATERIALS AND METHODS: Fifty-seven patients out of 394 cases were selected for the study in whom the cytological examination was performed using the wooden end of a sterile cotton swab followed by biopsy. The cytological smear classified in accordance with the Pap classification was compared with the histopathological diagnosis. RESULTS: The study recruited 11 cases of oral potentially malignant disorders, 33 cases of oral carcinomas, and 13 cases of other lesions. The sensitivity and specificity of the cytology test using the wooden end of a sterile cotton swab was 75.0% and 61.5%, respectively. The Spearman's correlation coefficient was 0.618, with the P < 0.01. CONCLUSION: Our study proves that the use of wooden end of a sterile cotton swab stick offers a low cost and fairly effective solution which is not only easily available but can be potentially applied as a mass screening tool at primary health-care centers.

NOVEL USE OF FLUORESCEIN DYE IN DETECTION OF ORAL DYSPLASIA AND ORAL CANCER.

BACKGROUND: India is now regarded as the country with one of the highest incidence of oral cancer in the world. Considering poor survival in cases with late diagnosis, early detection can reduce morbidity and mortality of cancer patients and may impede malignant transformation in cases of oral potentially malignant disorders (OPMD). Most of the diagnostic aids are expensive and not available for mass screenings in developing countries. There is a need to develop a sensitive and affordable technique for screening of oral cancer, which can be accurate even in hands of health care workers with limited experience. Fluorescein dye has been used for tumour detection in colon, stomach, breast and brain. However, its utility in the diagnosis of oral cancer and OPMD has not yet been explored. METHODS: This is the first study to report the role of fluorescein in the detection of oral cancer and OPMD. The present cross sectional study was conducted at a tertiary care dental centre. It included 100 individuals presenting with 42 OPMDs, 40 oral squamous cell carcinoma (OSCC) and 18 controls. RESULTS: The sensitivity and specificity for the fluorescein detection method for OPMDs and OSCC was found to be 96.6% and 52.4% respectively. The positive predictive value was 73.7% and the negative predictive value was 91.7% for the fluorescein method. The likelihood ratios stood at 2.03 for a positive test and 0.066 for a negative test. CONCLUSION: We conclude that fluorescein staining along with blue light is likely to improve detection of early oral cancers and dysplasia and can play a vital role in mass screening programmes of oral cancer.

Literature review of 86 cases of mandibular ameloblastic carcinoma.

Ameloblastic carcinoma is considered to be a rare epithelial malignant neoplasm of odontogenic origin occurring mainly in the mandible. Ameloblastic carcinoma has been a topic of controversy regarding management from past many years. We reviewed 86 cases of mandibular ameloblastic carcinoma from 1981 to 2014, on the basis of the electronic search of peer-reviewed journals in MEDLINE (PubMed) database. Age, sex, tumor size, treatment delivered, recurrence, metastasis, follow-up period, and dead/alive status are tabulated, and the data are analyzed. The mean age was 43.47 years with standard deviation ± 21.09. The age range was between 15 and 91 years, and male to female ratio was 2.18:1. Knowledge gained from the present review would help in establishing the best therapeutic options for ameloblastic carcinoma, and it also encourages the further reporting of ameloblastic carcinoma.

Retrospective study of mandibular angle fractures treated with three different fixation systems.

AIM: To evaluate the outcomes of mandibular angle fractures treated with metal 2.0 mm locking, metal 2.0 mm nonlocking, and 2.5 mm resorbable systems. STUDY DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Trauma records were screened for linear angle fractures treated with open-reduction and internal semi-rigid fixation with single metal/bioresorbable plates, and baseline variables were tabulated. The outcome variable was the presence or absence of any complication. STATISTICAL ANALYSIS USED: The Fisher's exact test and analysis of covariance (ANCOVA) using STATA 11. RESULTS: A total of 60 case records of over four years were included. The mean age of the patients was 27.4 (SD 9.7) years. Fifty-five were male and five female. There were 20 nonlocking and 16 locking metal miniplates and 24 bioresorbable plates. In 55 (91.6%) cases there was a third molar in the fracture line. In 51/55 (92.7%) cases the third molar was retained. In seven patients postoperative complications were seen. There was no difference between the complication rates of the three treatment groups. Infection was the most common complication followed by delayed union and hardware failure. CONCLUSIONS: This retrospective study found no difference in the complication rate when fractures of the mandibular angle were treated with locking or nonlocking miniplates or bioresorbable plates.

Use of indomethacin as an adjuvant to surgery for recurrent temporomandibular joint ankylosis in adults.

Two cases with multiple recurrences of temporomandibular joint ankylosis and multiple failed interposition/gap arthroplasty procedures are presented here. Heterotopic bone formation was thought to be the reason. Indomethacin prophylaxis for prevention of heterotopic new bone formation at the osteoarthrectomy site was used as an adjuvant to surgery, in dosages of 75 mg/day for six weeks. Indomethacin is used frequently in hip and elbow arthroplasties to prevent heterotopic ossification, but its use in temporomandibular joint is not routine. The presented cases did not develop further recurrence and attained stable mouth opening over two-year follow-up after osteoarthrectomy and oral indomethacin.

Traumatic bone cyst of the mandible in Langer-Giedion syndrome: a case report.

INTRODUCTION: Langer-Giedion syndrome (trichorhinophalangeal syndrome type II) is an extremely rare disorder characterized by dysmorphic facial features, multiple exostoses, mental retardation and digit deformities. We report the first case of any maxillofacial pathology in such a syndromic patient. CASE PRESENTATION: A 22-year-old Indian woman with mild intellectual disability presented with malaligned teeth. Routine radiographic screening demonstrated a large multilocular lesion in her right mandible. She had peculiar features such as short stature, short limbs, brachydactyly, and dysmorphic facial characters, which prompted us to evaluate her further. After findings of multiple bony exostoses she was diagnosed with Langer-Giedion syndrome. On surgical exploration of her right mandibular lesion an empty cavity was found suggestive of traumatic bone cyst. The lesion healed completely after 1 year without loss of vitality of any teeth. CONCLUSIONS: Although diagnosis and management of any maxillofacial pathology can be challenging in syndromic patients, our report suggests a possible correlation between traumatic bone cyst and Langer-Giedion syndrome. Clinicians should routinely screen these patients for any undetected maxillofacial pathology. In future cases of this syndrome, one should consider the possibility of traumatic bone cyst which may not require aggressive surgical management.

Piezoelectric osteoarthrectomy for management of ankylosis of the temporomandibular joint.

We describe the use of a piezoelectric osteotome for removal of bone in patients with ankylosis of the temporomandibular joint (TMJ) and its advantages over conventional techniques. We studied 35 patients with ankylosis of 62 TMJ (27 bilateral and 8 unilateral, 2 recurrent) who were treated by gap arthroplasty between 1 January 2011 and 31 December 2012. We used a preauricular, with extended temporal, incision in all cases. The ankylosis was released with a piezoelectric scalpel. There were 23 men and 12 women, mean (SD) age 16 (9) years. We noticed a substantial reduction in bleeding with the piezoelectric bone cutter compared with the dental drill, though the operating time was longer. We noticed no bleeding from the maxillary artery or pterygoid plexus. Mean (SD) bleeding/side was 43 (5) ml, and mean (SD) operating time was 77 (8) minutes for a single joint. At 6 months' follow-up mean (SD) passive mouth opening was 35 (3) mm. Piezoelectric bone removal for the release of ankylosis of the TMJ is associated with minimal bleeding, few postoperative complications, and satisfactory mouth opening at 6 months' follow up.