Assessment of Difficulty in Mandibular Third Molar Surgery by Lambade-Dawane-Mali's Index.

PURPOSE: The evaluation of mandibular third molar (M3) difficulty is extremely important. This study aims to measure the association between preoperative Lambade-Dawane-Mali's (LDM) M3 difficulty index and postoperative assessment of difficulty score. MATERIAL AND METHODS: This prospective cohort study included patients with impacted M3 reported to the Department of OMS, RRK Dental College, Akola, from 2017 to 2022. The preoperative surgical difficulty was estimated using the predictor, LDM index with scores, easy (15-25), moderate (25-30), and difficult (>30). The postoperative surgical difficulty was analyzed with the primary outcome variable, total time intervention measured from the beginning of incision to the final suturing, wherein extraction was classified as easy if time (<15 minutes), moderate (15-30 minutes), and difficult (>30 minutes). The secondary outcome variable, Modified Parant's Scale (MPS), defines four levels of difficulty required for extraction of M3: Easy I (forceps extraction), Easy II (requiring osteotomy), Difficult III (coronal sectioning), and Difficult IV (complex extraction). Data were analyzed using agreement between LDM difficulty with three established criteria (time, MPS, Pederson index) and were assessed with Cohen's Kappa statistics. McNemar's test for paired data was used to assess concordance between two criteria of evaluation with a P-value <.05 was considered statistically significant. RESULTS: The study sample included 1000 patients with a mean age of 26.7 ± 7.6 years and 456 (45.6%) females. Those assessed preoperatively with LDM to be difficult and easy outcomes were found upon postoperative assessment with MPS to be 99% and 99% correct, respectively. Inter-criteria agreement and Kappa statistics suggested a positive Kappa value (κ) and statistically significant agreement between the LDM index with perioperative time (κ = 0.8930), MPS (κ = 0.6488), and Pederson index (κ = 0.4920) at P-value 0.0001. Pair-wise comparisons of LDM criteria with perioperative time, MPS, and Pederson scale were assessed by McNemar's test, which evaluated concordance between the two criteria. CONCLUSION: Postoperative evaluation of surgical difficulty in M3 extraction was strongly correlated with preoperative variables in the LDM difficulty-scoring index. Preoperative evaluation helps in anticipating the difficulty, planning surgical management, and scheduling time more optimally.

Titanium Lag Screw Versus Miniplate Fixation in the Treatment of Anterior Mandibular Fractures.

PURPOSE: The use of plates for open reduction and internal fixation of mandibular fractures has become a widely accepted method in the past 3 decades. However, the anterior mandible is well suited to lag screw fixation owing to the thickness of its bony cortices. Hence, the purpose of the present study was to comparatively evaluate clinical outcomes of fixation using lag screws and miniplates in anterior mandibular fractures. PATIENTS AND METHODS: Fifty patients reporting to the department of oral and maxillofacial surgery with noncomminuted anterior mandibular fractures were randomly divided into 2 groups of 25 patients each. Patients in group A were treated with 2.5-mm lag screws 22 to 26 mm in length and those in group B were treated with 2.0-mm 4-hole miniplates with a gap using monocortical screws. Subsequent follow-up was performed at 3, 6, 12, and 24 weeks postoperatively. The primary determinants included radiographic analysis of the fracture gap and biting efficiency of the patients in groups A and B. The secondary determinants included evaluation of duration of surgery, occlusion before and after injury, and postoperative complications. Results were evaluated using χ2 and unpaired t tests. RESULTS: The mean age of the patients in this study was 29.1 ± 8.32 years (range, 18 to 67 yr). The mean postoperative fracture gap was considerably larger in group B. The mean duration of surgery (minutes) was 37.60 ± 9.30 for group A and 47 ± 6.55 for group B. The difference was statistically significant (P = .001). The lag screw group showed faster improvement in biting efficiency compared with the miniplate group. CONCLUSIONS: Lag screw fixation was found to have good stability and rigidity, was inexpensive, and was less time consuming in treating anterior mandibular fractures compared with miniplates.

Two-Point versus Three-Point Fixation in the Management of Zygomaticomaxillary Complex Fractures: A Comparative Study.

Introduction: The zygoma plays an important role in the facial contour for both cosmetic and functional reasons; therefore, zygomatic bone injuries should be properly diagnosed and adequately treated. Comparison of various surgical approaches and their complications can only be done objectively using outcome measurements that require a protocol for management and long-term follow-up. The objectives of this study were to compare the efficacy of zygomatic bone after treatment with open reduction internal fixation (ORIF) using two-point fixation and ORIF using three-point fixation and compare the outcome of two procedures. Materials and Methods: Twenty patients were randomly divided equally into two groups. In Group A, ten patients were treated by ORIF using two-point fixation by miniplates and in Group B, ten patients were treated by ORIF using three-point fixation by miniplates. They were evaluated with their advantages and disadvantages and the difference between the two groups was observed. Results: We found that postoperative facial and neurological complications are minimum in two-point fixation group. Based on this study, open reduction and internal fixation using two-point fixation by miniplates is sufficient and the best available treatment of choice for the management of zygomaticomaxillary complex fractures. Discussion: Alignment of the fracture at three points and fixation at two stable points provide the most accurate and satisfactory postoperative results. Two-point interosseous fixation at the "buttress" fracture and the frontozygomatic (FZ) fracture is suitable for routine surgery. The results of these studies confirm with the present study that two-point fixation provided better stability in patients with clinical and radiological evidence of fracture in FZ and zygomaticomaxillary buttress area.

Efficacy of Murva (Sansevieria roxburghiana Schult. and Schult.f.) as a suture material in closure of incisions in third molar surgeries: A prospective study.

INTRODUCTION: Adequate closure of the surgical wound is one of the most important aspects of surgery; improper suturing techniques or improper suturing materials sometimes compromise the success of surgery. Many synthetic materials have replaced the natural materials, which were once used for suturing in the ancient era, and Murva is one of them. There are references of Murva (Sansevieria roxburghiana Schult. and Schult.f.) at various contexts of "Sushruta Samhita" where it has been used as a suture material. It is a xerophytic herbaceous plant occurring abundantly in the eastern coastal region of India. The aim of this study is to evaluate the efficacy of Murva fibers as a suturing material in closure of intraoral incision in third molar surgeries. MATERIALS AND METHODS: Fifty incisions (Wards incision) placed for the surgical removal of mandibular third molar were sutured with Murva, and follow-up was carried out postoperatively on 1st, 2nd, 3rd, and 7th day. Patients were evaluated for pain, swelling, bleeding, infection, wound dehiscence, local tissue irritation, and bacterial colonization. RESULTS: On various follow-ups, progressively significant and predictable healing was observed without any uneventful evidence. CONCLUSION: The use of Murva as a suture material proved to be effective in closure of intraoral incisions.

Efficacy of buccal fat pad in the surgical management of oral submucous fibrosis: a prospective study.

PURPOSE: Various surgical treatment modalities have been advocated in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of buccal fat pad in the surgical treatment of oral submucous fibrosis. PATIENTS AND METHOD: In the present study, 20 patients were treated for oral submucous fibrosis with interincisal mouth opening less than 16 mm. Surgical procedure included fibrotomy, all third molar extractions, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with buccal pad of fat. Postoperatively, patients were prescribed nutritional and antioxidant supplements along with vigorous mouth opening exercise for 6 months. Regular follow-up was carried out for 2 years. RESULTS: Excellent increase in the interincisal mouth opening was noticed relieving trismus. Patient's ability of masticate and tolerance to regular food was increased significantly. Buccal fat pad underwent rapid epithelization within a period of 5-7 weeks. CONCLUSION: Buccal fat pad can be used effectively in the surgical management of oral submucous fibrosis with good functional and esthetic outcome, with only drawback of supple lobulated fat, which requires delicate handling and its limitation to reach anteriorly beyond the canine region.

Efficacy of nasolabial flap in reconstruction of fibrotomy defect in surgical management of oral submucous fibrosis: a prospective study.

PURPOSE: Various surgical modalities have been used in the surgical management of oral submucous fibrosis with variable results. This prospective study evaluates the efficacy of nasolabial flap in the reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis in terms of functional and esthetic outcomes. MATERIAL AND METHOD: In this prospective study, we treated 20 patients of oral submucous fibrosis surgically. The surgical protocol was consisting of bilateral fibrotomy, temporal myotomy, and coronoidotomy or coronoidectomy followed by reconstruction of fibrotomy defect with bilateral extended nasolabial flaps. All patients were prescribed with nutritional supplements and antioxidants. Vigorous mouth opening exercise was made compulsory for every patient. Preoperative and postoperative evaluation was done for interincisal mouth opening, function of mastication, and cosmetic results. Patient's regular follow-up was done for 2 years. RESULTS: Postoperatively, we noted excellent increase in the interincisal mouth opening relieving trismus. Patient's ability to chew solid food was increased significantly. Extraoral scar was minimal and well accepted by all the patients. There was no morbidity of the donor site. There was no injury to the facial nerve in all cases. The only drawback was intraoral hair growth which went on reducing with mucosalization of the graft tissue. CONCLUSION: Random pattern nasolabial flap is a very good option for intraoral reconstruction of fibrotomy defect in surgical treatment of oral submucous fibrosis with excellent functional and cosmetic results with minimal complications.

"Oral Submucous Fibrosis Scoring Index" to Predict the Treatment Algorithm in Oral Submucous Fibrosis.

PURPOSE: The main aim of the study is to propose a treatment protocol based on scoring system. MATERIALS AND METHODS: One hundred patients were selected randomly having oral submucous fibrosis. They were classified into five groups based on clinical signs and symptoms, radiological and histopathological grading and severity of fibrosis. Patients of particular group were subjected to specific treatment for each group and followed for 2 years regularly. RESULTS: We found that almost all patients got symptomatic relief and they are able to take regular diet. Patient's interincisal mouth opening increased significantly. CONCLUSION: Based on this scoring and grouping we can give definite and prompt treatment to the patients with satisfactory results. This proposed scoring and staging can play major role in controlling and treating this widespread global disease. Thus, OSMF scoring index is very effective to decide the severity of disease and progress.

Oral submucous fibrosis--a treatment protocol based on clinical study of 100 patients in central India.

PURPOSE: Oral submucous fibrosis till date is a very poorly understood and unsatisfactorily treated disease with variable signs and symptoms. In this paper, we have classified the disease in different groups according to the clinical signs, radiological assessment, histopathological confirmation, progress, and severity of disease and proposed a treatment algorithm for effective treatment of the disease in 100 patients. MATERIAL AND METHOD: In our study, we randomly selected 100 patients of oral submucous fibrosis and classified them in to five groups based on clinical symptoms and radiological and histopathological parameters. We have given specific treatment for each group and followed them up for 2 years regularly. RESULTS: We found that almost all patients got symptomatic relief from the disease. Patient's interincisal mouth opening increased significantly. All patients can take regular diet. Progressive malignant transformation can be detected earlier to avoid future morbidity and mortality. CONCLUSION: Oral submucous fibrosis (OSMF) scoring index is very effective to decide the severity of disease and progress. Based on this scoring and grouping we can give definite prompt treatment to the patients with satisfactory results. Such a way this proposed scoring and staging can play major role in controlling and treating this widespread global disease.

Basal Cell Adenoma of Submandibular Salivary Gland: A Case Report and Literature Review.

BACKGROUND: Salivary gland tumours constitute about 3-4 % of all head and neck neoplasms. Approximately 80 % originate in the parotid gland and they are rarely present in the submandibular gland. Basal cell adenoma is a benign epithelial salivary gland tumour that appears to have unique histologic characteristics. The diagnosis of this entity must be established by histological study. CASE REPORT: The literature revealed only four reported cases of basal cell adenoma of submandibular salivary gland. This article presents a rarely occurring basal cell adenoma as a fifth reported case in submandibular salivary gland in a 23 year old female. DISCUSSION: A rare case of basal cell adenoma of submandibular salivary gland is reported with clinical features, diagnosis, histopathological features and treatment modalities. When there is involvement of submandibular gland with a tumour the histopathological confirmation is mandatory instead of relying on FNAC and it must be differentiated from pleomorphic adenoma, adenoid cystic carcinoma, adenocarcinoma due to its prognostic implications. CONCLUSION: Entities like basal cell adenoma can only be established by histopathological examination after excisional biopsy. The treatment done also affects the ultimate prognosis. As such the surgeon has to make his clinical decision based on many factors like history, clinical examination, histopathological examinations, radiological examination and immunohistochemistry study. No single criteria should be relied upon. We recommend to carry out genetic pattern study in a person with basal cell adenoma to rule out pathogenesis and establish a correct diagnosis of it for better understanding and prognosis.

Schwannoma of the cheek: clinical case and literature review.

INTRODUCTION: Schwannoma is a relatively uncommon benign tumor that apparently originates from Schwann cells of peripheral nerves. The most common intraoral site is the tongue followed by the palate, floor of mouth, buccal mucosa, lips and the jaws. The preoperative diagnosis is often difficult, and in the majority of cases, the diagnosis can only be made during surgery and by histological study. The immunohistochemistry reveals that the schwannoma cells test positive for S-100 protein. CASE REPORT: The authors report here a case of an intraoral schwannoma situated in the cheek, treated by complete surgical excision. In the present case the schwannoma presented as a slow growing, circumscribed swelling without any particular features to distinguish it from other benign soft-tissue lesions. The final diagnosis was established based on the clinical, histopathologic and immunohistochemical findings. CONCLUSION: The presence of schwannoma calls for the careful search for nerve tumors in other parts of the body, although in most cases none may be found. The differentiation of schwannoma from neurofibroma is essential, because an apparently solitary neurofibroma may be a manifestation of neurofibromatosis.

Reconstruction of Orbital Floor Fractures with Autogenous Bone Graft Application from Anterior Wall of Maxillary Sinus: A Retrospective Study.

INTRODUCTION: Orbital wall fracture implies a situation where disruptions of the walls or floor have occurred. It is a blowout type fracture where bone fragments with torn periosteum are pushed outside of the original bony orbit. There is no intact bone even near the defect area except the thin bone rim surrounding the blowout fracture. The purpose of this defect repair is to support orbital contents, free entrapped tissue, and, especially, restore the original orbital volume. MATERIAL AND METHODS: Ten patients (seven males and three females) who underwent repair of orbital floor factures with maxillary sinus bone grafts were included in this study. Surgical procedure for harvesting graft and its fixation was almost same in all operated cases. CONCLUSION: The collection in the maxillary sinus due to fracture of floor of orbit, blood and bony fragments collected in the maxillary sinus can be easily drained and removed after removal of anterior wall of maxillary sinus and through the same approach you can reduce the floor of orbit manually to the proper position which helps to decease the orbital floor defect.

The autologous platelet rich fibrin: A novel approach in osseous regeneration after cystic enucleation: A pilot study.

CONTEXT: The platelet rich fibrin (PRF) is second generation platelet concentrate that has been widely used and researched for stimulation and acceleration of soft tissue and osseous healing. Its continuous delivery of growth factors and proteins mimic the need of physiological wound healing and regenerative tissue processes. AIMS AND OBJECTIVES: The aim of this study was to evaluate the efficacy of PRF in osseous regeneration after enucleation of cystic lesions. The objectives of this study were: (1) To evaluate osseous regeneration radiographically with the use of PRF in intrabony defects after cystic enucleation. (2) To evaluate the degree of bone density in intrabony defects with the use of PRF postoperatively after 1 st , 3 rd , and 6 th months. SUBJECTS AND METHODS: 10 cases of cystic lesions were treated using PRF after cystic enucleation. Follow-up radiographs (orthopantomogram) were taken 1 st , 3 rd , and 6 th months postoperatively. Bone density was measured with grayscale histogram using Adobe Photoshop 7.0 software. RESULTS: The subsequent follow-up examinations revealed progressive, predictable, and significant radiographic osseous regeneration. CONCLUSION: The use of PRF in management of cystic lesions seems to be a novel therapeutic approach promoting faster osseous regeneration within 6 months postoperatively however further study is required with larger sample size and with a control group.

An Unusual Complication with Use of Lignocaine: A Case Report.

Allergic responses to lignocaine (amide local anaesthesia) used in dentistry is extremely rare. It is widely used by Oral Maxillofacial surgeons to carry out various procedures safely, comfortably and efficiently. It is important for the practitioners to be aware that allergic reactions though very rare, can occur after injection of lignocaine intradermally for allergy testing. A proper diagnosis and management of such allergic reaction is very essential to avoid undesired consequences. We report a case of a 50-year-old male who suffered itching and generalized skin reaction within 5 minutes after administration of test dose of lignocaine intradermally for allergy testing. Clinical presentation, Diagnosis & management of such allergic reaction are discussed. As local anaesthetic agents are commonly used drugs in day to day practice clinicians are encouraged to be familiar with the presentation of various allergic reactions and there management.

Malignant fibrous histiocytoma: an uncommon sarcoma with pathological fracture of mandible.

BACKGROUND: Tumors composed of cells differentiating as both fibroblasts and histiocytes have been designated fibrous histiocytomas. Only a small percentage of these lesions behave in a malignant fashion, they are called malignant fibrous histiocytoma (MFH).The occurrence of MFH in membranous bones including the mandible is quite unusual. Involvement of the mandible accounts for only 3 % of all MFH bone lesions. Recent literature revealed only a few (30) cases of MFH involving the mandible but not a single case of MFH associated with pathological fracture of the mandible, probably the first such kind of case to support antecedent trauma as an initial proliferative response for its occurence. CASE REPORT: A rare case of MFH involving the mandible and submandibular glands with pathological fracture in a 14-year-old boy is presented with special emphasis on the poor prognosis even after prompt therapy, its controversial histogenesis, high malignant potential, high recurrence rate and tendency to metastasise. The patient was regularly followed up for 11 months post-operatively, during which patient complained of pain in the operated region after 8 to 9 months. Though there was no clinically obvious abnormality seen, the young boy died after 11 months. The clinical, surgical, radiographic and pathological features of this lesion are discussed. DISCUSSION: Malignant fibrous histiocytoma, the most frequent soft tissue sarcoma of adulthood, was first described as a new malignant tumour by O'Brian and Stout in the 1960s and the details of the histopathological features of MFH were first described by Kempson and Kyriakos. Despite the frequency of diagnosis, MFH has remained an enigma as no true cell of origin has ever been identified. Treatment consists of surgical excision and in some cases chemotherapy and radiation. Early and complete surgical removal using wide or radical resection is indicated because of the aggressive nature of the tumor. The combination of infrequent occurrence, varied pathologic features, uncertain histogenesis, numerous subtypes and the many potential sites of presentation makes these tumors a challenge for the diagnostician, surgeon and oncologist. Close follow-up after treatment is important, as local recurrence is common and early metastasis to the lungs is also frequent, which are the reasons for high mortality rate in MFH.

Implant supported mandibular overdenture: a viable treatment option for edentulous mandible.

The prosthetic management of the edentulous patient has long been a major challenge. Complete maxillary and mandibular dentures have been the traditional standard of care. However, most of the patients report problems adapting to their mandibular denture due to a lack of comfort, retention, stability and inability to masticate. Implant-supported overdentures have been a common treatment for edentulous patients for the past 20 years and predictably achieve good clinical results. Implant supported overdentures offer many practical advantages over conventional complete dentures and removable partial dentures. These include decreased bone resorption, reduced prosthesis movement, better esthetics, improved tooth position, better occlusion, increased occlusal function and maintenance of the occlusal vertical dimension. This article presents a design and fabrication technique of the implant-retained overdenture that uses four freestanding mandibular implants.

Dentigerous cyst associated with ectopic canine and a supernumerary tooth: a rare occurrence.

Amongst the cysts of the jaw dentigerous cyst (DC) is one of the most prevalent types of odontogenic cysts, which is associated with the crown of an unerupted or developing tooth. DC is more commonly seen with mandibular third molar and maxillary canine and rarely other teeth are involved. These cysts seldom associate with supernumerary teeth. The purpose of this article is to describe a case of large dentigerous cyst associated with supernumerary teeth and an ectopic canine, which is a rare presentation along with its management.

Osteoradionecrosis of the mandible: a review.

BACKGROUND: Osteoradionecrosis is a serious complication of radiotherapy that often leads to severe facial deformity, pain, pathological fracture, sequestration of devitalized bone, and orocutaneous fistulas. Preventive measures for osteoradionecrosis are the best treatment plan to avoid osteoradionecrosis. Radical surgery is indicated when conservative methods fail or when severe bone and soft-tissue necrosis prevails. CASE REPORT: The purpose of this paper is to explore the recent theories about the definition, classification, incidence, and pathophysiology of osteoradionecrosis (ORN) of the jaws. The predisposing and risk factors for the development of osteoradionecrosis based on the literature review along with case report are also discussed. DISCUSSION: A better understanding on the risk factors responsible for causing ORN and the underlying pathophysiology may improve our ability to prevent this complication and help to improve the prognosis for those being treated for osteoradionecrosis.

Ectopic mandibular third molar leading to osteomyelitis of condyle: a case report with literature review.

BACKGROUND: A tooth is said to be ectopic if it is malpositioned either due to congenital factors or displaced due to pathological lesions. The incidence of osteomyelitis of condyle has a rare occurrence, very few cases have been reported, either their etiology is unknown or is due to hematogenous spread or a tuberculous focus. This particular case may be a rare of its kind, as recent literature did not reveal any case where an ectopic mandibular third molar led to osteomyelitis of the condyle. CASE REPORT: This report presents a unique case where an ectopically placed mandibular third molar led to extraoral sinus and scar formation below the ear lobule with osteomyelitis of the mandibular condyle and proposes various indications for its removal along with literature review. DISCUSSION: Ectopic eruption of a tooth into the dental environment is common, whereas ectopic eruption of tooth in other sites is rare. The exact etiology of ectopic eruption of mandibular third molar in condyle is a rare occurrence and to the best of our knowledge, only 14 cases have been reported in the literature. Management of such cases should be meticulously planned after ruling out various local as well as systemic factors as an underlying cause for osteomyelitis and on the basis of the position and type of ectopic tooth and related potential trauma which could be caused by surgical intervention with less morbidity. CONCLUSION: This particular case may be the unique of its kind, as recent literature did not reveal any case where an ectopic mandibular third molar led to osteomyelitis of the condyle. Diagnosis and management in such cases deserve very special attention to rule out various local and systemic causes which can cause osteomyelitis to affect very unusual site like mandibular condyle. The aim of surgical intervention should be to cause minimum morbidity without affecting the functional efficiency of the mandibular condyle. In this report, we also have proposed the indications for surgical intervention to remove ectopically erupted teeth.

Unusual intramaxillary plexiform schwannoma.

BACKGROUND: Neoplasms of peripheral nerve in the head and neck region are of common occurrence, but origin in the oral and para-oral tissues is uncommon and they rarely occur centrally within the jaws. Schwannoma is a benign neoplasm originating from the neural sheath of peripheral soft tissues, but its occurrence within the jaw bones is most unusual. Plexiform schwannoma is a unique variant of Schwann cell tumours having plexiform pattern. Literature revealed only one case of plexiform schwannoma of the jaw bones, i.e. involving the mandible. CASE REPORT: In this report, we present the first documented case of intraosseous plexiform schwannoma of the maxilla, an extremely rare benign neurogenic tumour treated surgically. DISCUSSION: Schwannoma is a benign neoplasm originating from the neural sheath of peripheral soft tissues, but to occur within the jaw bones is exceptional. Plexiform schwannoma is a rare variant of Schwann cell tumour having plexiform pattern of intraneural growth with multinodularity. Plexiform schwannoma is a benign neoplasm with no malignant potential, but recurrences are evident if excised incompletely. Plexiform schwannoma has similar clinical and histopathological features as that of plexiform neurofibroma which has high malignant potential; hence, it is imperative to correctly diagnose and differentiate this lesion as treatment modality of these two lesions differs.

Maxillary osteonecrosis and spontaneous teeth exfoliation following herpes zoster.

BACKGROUND: Reports of osteonecrosis and spontaneous tooth loss following herpes zoster infection of the fifth cranial are extremely rare. Only 39 previously recorded cases of post-zoster osteonecrosis have been found in the literature. The unusual feature of the case of interest to the dental surgeon is a rare complication of tooth exfoliation and maxillary osteonecrosis. CASE REPORT: This article reports a case of 52-year-old man with herpes zoster infection of the trigeminal nerve and related alveolar bone necrosis and teeth loss. The etiology and management of herpes zoster infection associated with destructive sequelae are discussed. DISCUSSION: Very few cases of osteonecrosis and spontaneous teeth exfoliation secondary to herpes zoster are found in the literature. The exact mechanism by which herpes zoster induces these destructive changes in the alveolar bone and teeth cannot be proposed. As Varicella zoster virus is an aneurotropic virus, the possible provoking factors may be the infection of the nerves innervating the periosteum or the chronic inflammatory changes in the form of adverse periodontal disease and delayed healing of the extraction sockets associated with compromised host resistance.