Profile of Patients with Maxillofacial Space Infections and Associated Risk Factors.

Objective: To evaluate the profile of patients operated for maxillofacial space infections and associated risk factors for the length of hospital stay. Materials and Methods: We conducted a retrospective study among patients operated for maxillofacial infections at our center from 2010 to 2020. Information collected from the records were age, sex, type and number of spaces involved, clinical signs and symptoms (pain, swelling, toothache, sore throat, otalgia, hoarseness, headache, cough, neck swelling, rancid breath, sialorrhea, gingival swelling, muffled voice, trismus, fever, dysphagia, odynophagia, malaise, lymphadenopathy, dyspnoea, pus discharge), treatment modality, total leukocyte count, evidence of bacterial growth, comorbidities, complications if any and length of hospital stay. Results: A total of 128 medical records were examined, out of which 59 were female. The mean age was 38.59 ± 19.7 and the length of hospital stay was 7.56 ± 3.8 days. The most commonly involved space was submandibular space (46.1%) and the common symptoms reported were swelling (99.2%), pain (86.7%), and trismus (68%). Four patients had complications like necrotizing fasciitis (1.6%), pneumonia (0.8%), and death in one patient (0.8%). Logistic regression showed that patients more than 36 years of age, male sex, evidence of bacterial growth, and diabetics had higher odds of increased hospital stay (>6 days). Multiple logistic regression analysis showed that age (P = 0.015; OR: 2.98) and evidence of bacterial culture (P = 0.001; OR:6.64) were potential predictors associated with increased hospital stay. Conclusion: Our study showed that the age of the patient and evidence of bacterial culture were potential predictors of prolonged hospital stay among patients operated for maxillofacial space infections.

Simultaneous Reconstruction of Mandibular and Maxillary Defects Using the Single Free Fibular Osseocutaneous Flap: Case Series and Review of the Literature.

BACKGROUND: The facial profile requires adequate maxillary and mandibular projection. Although oral cancer tumor ablation might create ipsilateral maxillary and mandibular defect, fibular flap is popular in mandibular defect reconstruction. However, the maxillary defect results in sunken cheek or oral contracture. A single fibular flap can provide several struts to rebuild 2 jaws with adequate 3-dimensional spatial placement. MATERIALS AND METHODS: In total, 7 cases of secondary oral contracture and 2 cases of primary oncologic tumor ablation underwent single fibular flap for 2 jaws. Using multiple osteotomies, the distal fibular struts were used for the upper jaw, the second struts were discarded (3-4 cm), and proximal struts were used for mandible defect reconstruction. There were 5 accompanying free flaps for facial lining (2) and contralateral oral contracture release (3). RESULTS: All flaps survived without distal strut avascular necrosis, but 2 patients died from tumor metastasis. These patients presented adequate middle and lower facial profile. One patient underwent mandibular fibula strut distraction osteogenesis followed by integrated teeth on both jaws. CONCLUSIONS: Single fibular transfer can accomplish 2 jaw bony defects and facial profile reconstruction. It can release oral contracture functionally and correct sunken cheek aesthetically. The reconstructed fibula can allow secondary teeth implantation rehabilitation.

Relevance and actionable mutational spectrum in oral squamous cell carcinoma.

BACKGROUND: Screening for lesions in the oral cavity is critical for early diagnosis of oral squamous cell carcinoma (OSCC). Targeted next generation sequencing-based (NGS) mutation analysis of cancer driver genes becomes a reality for personalized medicine and cancer therapeutics. MATERIALS AND METHODS: In the present study, we have performed a targeted NGS-based mutation analysis of 50 known oncogenes and tumor suppressor genes in clinically diagnosed potentially malignant lesions and tissues of OSCC. NGS-based analysis of DNA obtained from biopsies of histopathologically confirmed cases of potentially malignant lesions and OSCC specimens were performed using Ion AmpliSeq™ Cancer Hotspot Panel V2 using the Ion Proton™ Sequencer System, followed by data analysis using Ion Reporter™ and Torrent Suite™ software. RESULTS: NGS analysis indicated a total of 69 mutations present in 25 genes in potentially malignant lesions and OSCC specimens. We identified recurrent mutations in known OSCC driver genes ATM (11%), TP53 (55%), HRAS (16%), SMAD4 (13%), PIK3CA (16%), and ERBB4 (11%) in potentially malignant lesions and OSCC specimens. Driver mutation analysis identified recurrent TP53 and HRAS driver mutations in our OSCC specimens. CONCLUSION: Data generated from our study may enable an application of targeted NGS analysis of driver mutations for better therapeutic choice and improved outcomes for OSCC subjects when combined with clinical diagnosis.

Chronic recurrent osteomyelitis: A surgeon's enigma.

BACKGROUND: Chronic recurrent forms of osteomyelitis of the mandible with their morbid clinical course have long been considered a challenge to maxillofacial surgeons in terms of both diagnosis and treatment. Various classifications and treatments have been established through the ages to define and manage the inflammatory symptoms occurring in adults and children. This paper discusses two such entities occurring in an adult and a child, highlighting the diagnostic and treatment challenges of recurrent osteomyelitis. METHODS: A thorough workup which included clinical, radiographic, blood investigations was done, followed by administration of antibiotics and anti-inflammatory with or without surgical debridement/adjuvant therapies. Correlation of our findings and treatment plan was done with evidence-based literature and practice. RESULTS: Complete resolution of symptoms with radiographic evidence was achieved in both the cases. In the recurrence period, long-term steroids, NSAIDs, antibiotics resulted in better outcomes. CONCLUSION: The evidence-based protocol for osteomyelitis stresses on short inpatient stays predicated on efficient literature. Thorough clinical and radiographic evaluation with aggressive medical management and surgical intervention when necessary can result in longer symptom-free periods. Thus understanding the disease, recurrence pattern and response to therapy is essential.

A Modified Peri-Angular Approach for Exposure of Condylar Fractures.

PURPOSE: To describe a modified peri-angular approach to address subcondylar and condylar neck fractures. MATERIALS AND METHODS: A modified peri-angular incision is used to approach a fractured condyle through the anteroparotid transmasseteric approach. RESULTS: In the authors' experience, this method provides quick and clean exposure to the fractured condylar base and neck fractures for open reduction and internal fixation. CONCLUSION: Although the peri-angular approach has been discussed in the literature, the authors' modification lessens the chance of complications, such as marginal nerve injury and parotid fistula formation, because the nerve is visualized and kept isolated throughout.

Platelet-rich fibrin combined with synthetic nanocrystalline hydroxy apatite granules in the management of radicular cyst.

Radicular cysts are inflammatory jaw cysts confined to the apices of teeth with infected and necrotic pulp. They arise from the epithelial residues in the periodontal ligament as a result of inflammation, following the death of pulp. The treatment of such lesions vary with regard to their sizes; the small cystic lesions heal after an endodontic therapy, but larger lesions, may require additional treatment. Apical surgery for radicular cysts generally involves apical root resection and sealing with endodontic material. This case report, describes the treatment of a cyst related to the maxillary central and lateral incisors using platelet rich fibrin along with synthetic nanocrystalline hydroxyapatite granules for the regeneration of lost tissues. A follow-up evaluation at 6 months and 1-year revealed a significant radiographic bone fill with satisfactory healing at the surgical site.

Subcranial Approach for Management of Secondary Frontal Bone Deformity.

Abstract: Secondary correction for aesthetic purposes can be more challenging as the fractured segments may be united in abnormal positions and would require osteotomy procedures before mobilizing the segments for reconstruction. Such maneuvers require adequate exposure and visibility. The subcranial approach is an effective alternate to classical approaches, which required frontal lobe retraction. Conclusion: Subcranial approach is a viable alternative to posttraumatic deformity of frontal bone.

Re-Examination of the Maxillary Vestibular Approach with Emphasis on Facial Mimetic Muscle Preservation.

Introduction: The standard Keen's or the maxillary vestibular incision allows direct access to the zygomatico-maxillary complex with inadvertent transection of the facial muscles and more laborious visualisation of the zygoma. Materials and Methods: We describe modifications to the vestibular and Keen's technique, based on identification and re-orientation of the facial muscles as well as utilisation of anatomical gaps between the facial mimetic muscles. Conclusion: Our modifications are based on the principle of facial mimetic muscle identification, preservation and re-orientation to near normal anatomy.

Metastatic Intestinal Adenocarcinoma: A Rare Case Involving the Mandible.

BACKGROUND: Metastatic intestinal adenocarcinoma involving the mandible is rare, posing diagnostic challenges because of its unusual presentation. CASE PRESENTATION: A 55-year-old male presented with a rapidly growing mass in the right mandible, accompanied by facial asymmetry and vestibular obliteration. Histopathological examinations revealed features consistent with adenocarcinoma. Immunohistochemical analysis supported the diagnosis of intestinal adenocarcinoma, with subsequent metastasis confirmed by PET scan findings. DIAGNOSIS: The lesion was conclusively diagnosed as intestinal adenocarcinoma metastasizing to the mandible. MANAGEMENT: The patient pursued treatment at a government facility, leading to a loss of follow-up.

Use of the Smith's Spreader as a Self-Retaining Retractor in the Direct Approach to Clival Tumours - A Technical Note.

The traditional Le Fort level 1 osteotomy has proven to be an effective in approaching central skull base lesions. The challenge being - stabilization of the down-fractured maxilla in an amenable position for tumour resection. The authors describe a simple technique to overcome the task of stabilizing the down-fractured maxilla.

Synchronous Aberration of the Jugular and Carotid-a Case Report.

Vascular aberrations in the head and neck region pose a grave diagnostic and a surgical challenge. Numerous reports in the literature have highlighted the incidence and the lethality associated with carotid or jugular anomalies signifying the need for awareness and preparedness by the clinicians while treating patients. Our paper reports a peculiar case showing asymptomatic double vessel aberration in relation to the internal jugular vein as an ectasia and carotid kinking in the same patient diagnosed with oral carcinoma. In addition, carotid kissing was also noted at the pharyngeal level.

Nintedanib-induced osteomyelitis of the jaw against the background of COVID-19 infection.

PURPOSE: Various medications are administered to treat Coronavirus Disease 2019 (COVID-19) infection and prevent its complications. Some medicines have complications and long-term effects, which may mimic other conditions, making precise diagnosis difficult. This report aims to bring to light one such complication, medication-related osteonecrosis of the jaw (MRONJ), secondary to a commonly prescribed medication for preventing lung fibrosis post-COVID-19 infection. METHOD: A 33-year-old male reported to our department with the typical clinical and radiological features of Mucormycosis of the upper jaw post-COVID-19 infection. However, on detailed evaluation of his history (controlled diabetic and short duration of steroid therapy) and review of the mycology staining, bacteriology, culture, and histopathological reports, we came to a negative diagnosis for Mucormycosis. The patient was, however, on treatment for the prevention of lung fibrosis with Nintedanib (tyrosine kinase inhibitor) 150 mg twice a day for one month. RESULT: In the absence of predisposing factors and negative laboratory findings for mucormycosis, we arrived at a diagnosis of MRONJ, attributable to Nintedanib therapy given to prevent lung fibrosis post-COVID-19 infection. CONCLUSION: The use of Nintedanib has recently increased due to the high incidence of lung fibrosis post-COVID-19 infection. However, Nintedanib should be considered a causative agent for osteonecrosis of the jaw in the absence of other obvious predisposing factors. Therefore, Nintedanib must be administered after a thorough consideration of risk factors.

Reconstruction of Maxillary Defects Using Virtual Surgical Planning and Additive Manufacturing Technology: A Tertiary Care Centre Experience.

Introduction: Maxillary reconstruction is often a challenging task for the surgeons because of the complex anatomy. However, with the advances in virtual surgical planning (VSP) and 3D printing technology there is a new avenue for the surgeons which offers a suitable alternative to conventional flap-based reconstructions. Patients and Methods: In this article, we have described 4 case scenarios which were managed with the help of VSP and additive manufacturing technology for complex maxillary reconstruction procedures. Use of the technologies aided the clinician in achieving optimal outcomes with regards to form, function and esthetics. Discussion: Virtual surgical planning (VSP) has gained a lot of impetus in past 1 decade. These aides the surgeon in determining the extent of disease and also carry out the treatment planning. In addition to VSP, the concept of additive manufacturing provides a viable alternative to the conventional reconstruction modalities for maxillary defect rehabilitation. Increased accuracy, rehabilitation of normal anatomical configuration, appropriate dental rehabilitation, decreased intra-operative time and post-operative complications are some of the advantages. In addition, patient-specific implants eliminate the need for a separate donor site. Apart from the treatment of pathologies, they also can be used for reconstruction of post-traumatic defect, where endosteal implant placement is not possible. Conclusion: These modalities show promising results for reconstruction of complex maxillary defects.

Oral Metronomic Chemotherapy in Advanced and Metastatic Oral Squamous Cell Carcinoma: A Need of the Hour.

Aim: The present review article aims to compile the best available evidence-based data on oral metronomic chemotherapy (OMCT) including its mechanism of action, its utility, and future directions. Methods: A systematic search was carried out in PubMed database for available English literature from last 10 years between 2011 and 2021. Keyword combinations used were 'Oral Metronomic chemotherapy for oral cancer, mechanism of action of OMCT, Oral metronomic chemotherapy in India, OMCT in recurrent and palliative treatment of oral cancers.' Results: Multitudes of studies have been published recently stating the role of OMCT in head and neck squamous cell carcinoma (HNSCC), but the studies with the category of level of evidence required to advocate OMCT as a recognized therapy are still scarce. On careful stratification of these studies, we found that OMCT has a lot to offer in palliative settings, recurrent, and metastatic HNSCC. There is some limited evidence of its role in adjuvant therapy as maintenance and in neoadjuvant setting. Conclusion: With current evidence, there is a definite role of OMCT in treatment of oral SCC. OMCT can be an alternative in patients who are not tolerable or affordable for standard palliative chemotherapy and also an option for patient who are waiting for surgery. However, results of ongoing and future studies on exact mechanism, indications, and implications of this drug regimen would help in integration OMCT in current standard of therapy.

The interplay of EMT and stemness driving malignant transformation of Oral Submucous Fibrosis.

Background: Oral submucous fibrosis (OSF) is a persistent oral mucosal condition that carries an elevated risk of undergoing malignant transformation. Our objective was to elucidate the involvement of epithelial-to-mesenchymal transition (EMT) in OSF and its progression to malignancy by studying a panel of EMT markers, thereby understanding the molecular mechanisms. Methods: An immunohistochemical analysis was done to detect the presence of E-cadherin, N-cadherin, pan-cytokeratin (PanCK), vimentin, α-SMA (alpha-smooth muscle actin), and CD44 in a total of 100 tissue samples. These samples comprised 40 cases of OSF, 20 cases of oral squamous cell carcinoma associated with OSF (OSFSCC), and 40 cases of oral squamous cell carcinoma (OSCC). A whole transcriptomic analysis was performed on a group of seven matched samples encompassing NOM, OSF, OSFSCC, and OSCC. Results: We observed significantly decreased expression of E-cadherin and PanCK, while N-cadherin, vimentin, α-SMA, and CD44 showed significantly higher expression in OSFSCC and OSCC as compared to OSF, both at protein and RNA levels. CD44 expression was noticeably higher in OSFSCC (p < 0.001) than in OSCC. Conclusion: Downregulation of epithelial markers with concomitant upregulation of mesenchymal and stem cell markers suggests the potential role of EMT and stemness in accelerating the pathogenesis and malignant transformation of OSF. The high levels of CD44 expression seen in OSFSCC indicate a high propensity for aggressiveness and acquisition of stem-like characteristics by the cells undergoing EMT.

Oral health in cancer palliative care: cross-sectional study.

OBJECTIVES: Patients on anticancer therapy attending palliative care services often have oral health problems, but not enough is known in this regard (in India). This cross-sectional study aimed to elucidate this issue. METHODS: Participants were 98 patients with metastatic cancer (52 males, 46 females) who attended the palliative care clinic and were assessed by a multidisciplinary team consisting of dental health professionals working alongside the palliative care team, between August 2021 and October 2022. Their demographic and medical details were collected from the charts. Details about oral health were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events for dysphagia and xerostomia, Dental Caries Decayed, Missing, and Filled Teeth (DMFT) index, and the WHO Mucositis scale. Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Module for Oral Health (EORTC QLQ-OH15). RESULTS: Patients had an average age of 58 years, with 46.9% having an Eastern Cooperative Oncology Group score of 1, and 61 (64.9%) receiving anticancer treatment along with palliative care. Dental issues were prevalent, with 39.5% classified as DMFT score grade 2. Subgroup analysis showed higher mean DMFT scores in head/neck cancers, particularly in those receiving radiation therapy (2.3) versus without (1.7), and older age (p<0.05). CONCLUSION: Patients with cancer on anticancer treatment attending a palliative care clinic, especially those with head/neck cancers and older age, had poor oral health. Further prospective research with a dentist on the team is warranted to assess its impact.

Occurrence of Second Oral Potentially Malignant Disorder following Excision of Primary Lesion: A Prospective Study of Cases from a Tertiary Care Centre.

Background: Early diagnosis and timely management of potentially malignant oral disorders may prevent malignant transformation and prompt diagnosis of frank malignancies favours better prognosis. The aim of this study was to evaluate the outcome of surgical management of oral potentially malignant disorders of the oral cavity and observe the prevalence of recurrence at the primary site and occurrence of another potentially malignant lesion in these patients. Methods: The study participants included patients who had undergone clinical oral examination, surgical excision of biopsy-proven cases of dysplastic oral potentially malignant disorders (leukoplakia, erythroplakia, non-healing ulcerative and erosive areas, etc.) who were on routine follow-up as per the standard guidelines. These patients were followed up closely during each monthly follow-up visit for the first year. The patients were then prospectively analysed for any recurrence of lesion. On follow-up visits, detailed clinical oral examination was done to note the prevalence of a new lesion in any oral cavity sub site other than the previous site. If a new lesion was detected, then biopsy followed by surgical excision was followed as per standard guidelines. The follow-up period after the second surgical intervention was 12 months. Results: Fifty patients with potentially malignant oral disorders underwent surgical excision. The majority of the study subjects were males (39/50) and 41 of them were below 65 years of age. Of 50 patients, 13 (26%) had second oral potentially malignant lesion other than the primary site. The rate of recurrence of the lesions at the primary site was 4% (2/50). Of these patients with recurrence, all had malignant transformation (2/2). Also, patients who were initially diagnosed with moderate dysplasia had a higher chance of recurrence. A second lesion at a site different from the primary lesion was seen in 26% of the cases. Conclusion: Surgical management of such lesions with one-centimetre oncological margins in all dimensions contrary to the routine five millimetre surgical margins reduces the chance of recurrence.

Non-familial paediatric oral myofibroma - A masquerade. Case report with a brief literature review.

Myofibromas are fibrous tumours that could be of familial or non-familial origin, belonging to the fibroblastic and myofibroblastic subset with a wide spectrum of clinical behaviour. Oral myofibromas present with a broad range of differential diagnoses, including benign and malignant lesions. Histopathologically, these lesions may imitate many other soft tissue tumours of the oral cavity, such as spindle cell tumours of nerve, smooth muscle cell origin, and other myofibroblastic lesions, thus leading to misdiagnosis and mistreatment. In the present paper, we report a soft tissue lesion, which presented as a growth on the gingivobuccal sulcus in a 7-year-old child. We also emphasise the various differential diagnoses that need to be eliminated and the importance of immunohistochemistry to know the nature of tumour cells in establishing the accurate diagnosis.

"Giant cell fibroma of buccal mucosa -an unusual lesion of unusual size": A case report.

Giant cell fibroma is a benign oral fibrous tumour. The clinical appearance of majority of non-neoplastic fibrous growths is similar, but unique histopathological features of giant cell fibroma aid in its final diagnosis. It usually manifests as an asymptomatic, sessile or pedunculated mass usually less than 1 cm in diameter. In this case report, we highlight a case of giant cell fibroma in a 58-year-old male patient, which had an unusual size with associated pain. Although giant cell fibromas are benign lesions, it is important for dentists to be aware of this lesion based on its frequency of occurrence and need for its accurate diagnosis.

Difficulty of Arch Reduction with Gillies Temporal Approach in a Coronoid Hyperplasia Case.

Introduction: Bilateral coronoid hyperplasia is an abnormal elongation of the mandibular coronoid process which is rare in occurrence and causes progressive but slow reduction in mouth opening. In case of reduction in zygomatic arch fracture by Gillies temporal approach, the presence of bilateral coronoid hyperplasia can be a possible factor for hindrance and improper reduction. Material and methods: We propose a technical note to overcome this hindrance caused by the coronoid hyperplasia and propose tips and tricks to successful reduction in zygomatic arch. Results: Adequate reduction in the zygomatic arch and pretrauma mouth opening was achieved. Conclusion: Manual repositioning of the mandible during Gillies temporal approach along with ultrasound guidance leads to a satisfactory outcome.