Efficacy of lidocaine vs combination of lidocaine and bupivacaine in management of maxillofacial trauma: a clinical comparative study.

BACKGROUND: The COVID-19 pandemic has created an unprecedented situation which the treatment of maxillofacial trauma, especially mandibular fractures that were previously managed using general anaesthesia had to be performed under local anaesthesia. In these cases, there was a requirement for an anaesthetic agent that would have a rapid onset but also provide a prolonged effect. The aim of the study was to evaluate the onset, duration, depth, required volume of anaesthesia of lidocaine with epinephrine versus combination of lidocaine and bupivacaine with epinephrine anaesthetic agents in surgical management of isolated mandibular fracture patients. METHODS: A total of 30 patients with isolated mandibular fractures reported to our hospital included the study group. Patients were randomly distributed to two groups, Group A and Group B. Group A received local anaesthesia using 2% Lidocaine with 1:80,000 adrenaline and Group B received 0.5% Bupivacaine with 1:2,00,000 adrenaline combined with 2% Lidocaine with 1:80,000 adrenaline at a ratio of 1:1. The outcome variables were recorded and the data was tabulated and analysed using un-paired students t test. RESULTS: The combination of anaesthetic agents had longer duration of action (mean: 182.47 min, P-value: 0.001) and required lesser volume of anaesthetic solutions (mean: 5.38 mL, P-value: 0.001) as compared to usage of lidocaine alone. Although combination group showed quicker onset (mean: 4 min 8 s), the result was insignificant (p-value: 0.345). CONCLUSION: The study found that the combination of lidocaine and bupivacaine could serve as a potential anaesthetic cocktail in effective surgical management of isolated mandibular fractures. CLINICAL RELEVANCE: Maxillofacial injuries can be managed efficiently under local anaesthesia using combination of lidocaine and bupivacaine.

Covid-19-associated fungal osteomyelitis of jaws and sinuses: An experience-driven management protocol.

Invasive fungal co-infections with COVID-19 are currently being reported at an alarming rate. Our study explores the importance of early identification of the disease, probable etiopathogenesis, clinical and radiological features and a treatment protocol for COVID-19 Associated Fungal Osteomyelitis of Jaws and Sinuses (CAFOJS). A one-year prospective study from June 2020 to May 2021 was conducted among CAFOJS diagnosed patients at a tertiary care center in South India. Demographic details, COVID-19 infection and treatment history, time taken for initiation of symptoms after COVID-19 diagnosis, medical history and clinical features were recorded. All patients were managed with a standard diagnostic and intervention protocol which included pre-operative and post-operative administration of Inj. Amphotericin B 50 mg (liposomal), early aggressive surgical debridement and tab. Posaconazole GR 300 mg OD for 90 days after discharge. Thirty-nine (78%) patients were diagnosed with CAFOJS out of 50 osteomyelitis patients. 35 patients (90%) were diabetic and 21 patients (54%) were known to receive steroids during the COVID-19 treatment. Sole existence of Mucorales spp. was seen in 30 patients (77%), Aspergillus fumigatus in 2 patients (5%), Curvularia spp. in 2 patients (5%). Concomitant existence of Mucorales and Aspergillus fumigatus was reported in two patients (5%) and Candida albicans in three patients (8%). Patients underwent treatment with standard protocol and no recurrence noted. CAFOJS is a clinical entity with aggressive presentation and warrants early diagnosis and treatment. LAY SUMMARY: Invasive fungal infections of head and neck region cause necrosis of bones affected by it, especially maxilla. Early diagnosis and treatment are advocated in such infections due to its aggressive clinical presentation compared to similar infections before COVID-19 pandemic.

Unusual Gigantiform Angiomatosis of Jawbone.

ABSTRACT: The purpose of this paper is to highlight rare highly infiltrative massive Angiomatosis and depict surgical outcome of a rare case series of gigantic lesions in the maxillofacial region. Data were recorded from the medical records of patients. Predictor variables were drawn from demographics, age, gender, site, evaluation of surgical treatment. The outcome variables were the challenges encountered and related complications. Out of 6 patients, the youngest was 10 and the oldest was 26 years old. Soft tissue and jawbone involvement were seen in 3 patients each with a single massive lesion involving both maxilla and mandible. All 6 patients had wide excision of the lesion with one patient having 2 stage procedures. No complications or recurrence was seen at 1-year follow-up. Angiomatosis is a rare and benign lesion in the head and neck region. its diffuse infiltrating nature may give a false malignant picture. it clinically mimics Hemangioma or Arteriovenous (AV) malformation thus requires thorough evaluation and its surgical intervention is challenging as described in this case series because of its magnitude and infiltrative nature.

Observing the Eruption of Canine After Secondary Alveolar Bone Grafting.

PURPOSE: Alveolar bone grafting is undertaken to provide stability to the dental arch and facilitate the eruption of permanent canine as teeth in the line of cleft usually have an altered pattern of eruption. The purpose of this study was to assess the eruption status and the change in the position and pattern of canine eruption after secondary alveolar bone grafting. METHODS: An ambispective cohort study was conducted in patients operated for alveolar bone grafting with unilateral/bilateral alveolar cleft between the age of 9 to 13 years using autogenous iliac crest bone graft. The predictor variables of interest include the preoperative eruption status of canine (completely erupted/partially erupted/unerupted), stage of root development (one-third/two-third/more than two-third/complete) and position (vertical/lateral/buccopalatal) of the canine. The primary outcome variable is the eruption status of the canine (completely erupted/partially erupted/unerupted) at 6 months postoperatively. Secondary outcome variables include the stage of root development, change in the vertical, lateral and buccopalatal position of the canine observed in the first 6 months postoperatively with follow-up at 1 and 3 months. Another secondary outcome variable was the status of bone graft at 6 months postoperatively. Statistical analysis was done using Spearman's rank correlation and ANOVA chi-square test. RESULT: The study sample consisted of 30 non-syndromic alveolar cleft patients with a mean age of 11.9 years, out of which partial and complete eruption of canine was seen in 43.33 and 36.67%, respectively. The canine was unerupted in 20% of the cases (P = .001). There was evidence of continued root development through the grafted bone. No significant change in the angulation of canine was observed in the postoperative period. CONCLUSION: Significant change in the eruption status and root development of canine with no statistically significant change in the vertical and lateral angulation during eruption was observed. Identifying these risk factors by continuous postoperative monitoring will help in identifying the malposition at an early stage.

Occlusal Analysis Using T-Scan in Patients With Condylar Fractures When Managed by Closed Method.

The aim of the study is to assess the occlusion in mandibular condyle fractures using T-Scan and analyze the data obtained. Twenty patients underwent non-surgical management for condylar fractures were treated with Erich arch bar and guiding elastics, and periodically subjected to T-Scan III evaluations. The data obtained was analyzed with the clinical evaluation conducted. There were 18 males and 2 females. Mean age of the patients was 25.4 ±â€Š7.4 years. There were statistically no significant changes in Centre of Force values, in Bite Force at First Contact (P < 0.05) during the study period. There were significant differences in Maximum Bite Force between preoperative and postoperative values, preoperative and sixth-month values, postoperative and first-month values, first-month and sixth-month values. There were significant (P < 0.05) differences in Bite Force at Maximum Intercuspation between preoperative and third month, preoperative and sixth-month values, postoperative and sixth-month values, first-month and consequent follow-ups. Subjective evaluation of occlusion revealed significant differences (P < 0.05) between preoperative and 1-month, preoperative and postoperative, postoperative and 1-month values. All patients improved by the end of 6 months with regards to their mouth opening. The center of force does not alter significantly in post trauma period. Mouth opening improves significantly at the end of 6-month period post-operative. Improvement in maximum bite force and maximum intercuspation take place simultaneously. Mouth opening improved significantly. Subjective evaluation of occlusion does not change significantly after the third month evaluation. Longer follow-ups would help us in understanding when or if the bite forces equilibrate after a condylar trauma.

Double-loop technique using titanium molybdenum alloy wire for fabrication of nasal stents in nasoalveolar molding therapy for cleft lip and palate patients.

This article presents a technique for fabricating a modified nasoalveolar molding appliance using 0.032-inch titanium-molybdenum alloy wire for nasal stents incorporating a double loop. The nasal stents are included in the acrylic molding plate at the time the appliance is inserted. The acrylic retention button used in a conventional appliance is replaced by a simple retention hook fabricated using titanium-molybdenum alloy wire. This technique is an effective alternative to a conventional appliance, and it simplifies the appliance-modification process during follow-up visits.

Rehabilitation of a patient with gunshot injury through the iliac graft and implant-retained restorations with a 3-year follow-up: a brief clinical study.

Trauma is one of the most common causes of teeth loss. Assault with a gunshot and bullet shot is life threatening, and for patients who survive the injury, it results in hard and soft tissue loss in the tissues and organs crossed by the bullet. The tissue loss results in the loss of structure and function. Rehabilitation of these patients to function and aesthetics requires surgical and prosthodontic procedures over time. This report is of a 24-year-old male patient who had a bullet injury resulting in hard and soft tissue deficiency. The ridge deficiency was augmented with iliac bone graft, and 3 months later, implants were placed. Five months later, hybrid prosthesis was delivered. At 3-year follow-up visit, the hybrid prosthesis was replaced with porcelain fused to a metal bridge. The bone levels on all the implants were stable.

Comparative Evaluation of Relapse After LeFort 1 Osteotomy in Cleft Palate and Non-cleft Individuals: A Longitudinal Study.

PURPOSE: The aim of this study was to assess and compare the likelihood of relapse one year after LeFort I advancement surgery in patients with and without cleft lip and palate. METHODS: A retrospective observational study which included two groups of participants who underwent LeFort I maxillary advancement was performed. Group 1 included 10 non-cleft subjects and Group 2 included 21 subjects with cleft palate. These maxillary deficient patients were chosen and operated using a technique where only a sagittal displacement was intended. Patients who underwent additional mandibular surgery, significant vertical or transverse alterations, or both were excluded. Pre-operative (T1), immediately post-operative (T2), and minimum one-year follow-up (T3) lateral cephalograms were studied for each group. Skeletal stability and dental stability after LeFort I surgery at a minimum of one-year follow-up in cleft palate and non-cleft patients were evaluated. RESULTS: For the given sample size, relapse tendencies showed statistically significant differences between cleft palate patients and non-cleft palate patients after maxillary advancement. The sella nasion angle and horizontal overlap of the maxillary and mandibular incisors (overjet) decreased by 2 degrees and 0.9 mm respectively in the cleft palate group while decreasing by 1.10 degrees and 0.40 mm in the non-cleft group. CONCLUSIONS: After maxillary advancement with LeFort I osteotomy and miniplate fixation in patients with cleft palate and non-cleft patients, some degree of relapse was detected in both groups for the given sample size after one year post-operatively. The cleft palate group displayed additional relapse tendencies when compared to the non-cleft group.

Evaluation of Long-term Stability of Secondary Alveolar Bone Grafts in Cleft Palate Patients Using Multislice Computed Tomography and Three-Dimensional Printed Models: A Prospective Study.

AIM: Three-dimensional (3D) printed models are contemporary volumetric bone graft assessment technique for secondary alveolar bone grafting (SABG) in cleft lip and palate (CLP) patients. The study aimed at evaluation of long-term stability of iliac autograft in SABG using multislice computed tomography (CT) and 3D-printed model-based volumetric analysis. MATERIALS AND METHODS: Twenty-eight patients were included in this prospective clinical study. CT image (T1) was taken after orthodontic maxillary expansion, correlating with the presurgical image. Furthermore, 3D-printed model was prepared, and volumetric assessment of graft needed was ascertained with water displacement technique. SABG was carried on with the anterior iliac crest autografting procedure. After 1-year follow-up, postoperative CT analysis (T2) was followed upon. RESULTS: The stability of bone graft at the 1-year postoperative was found to be 43.74% with mean bone loss of 56.26% (95% confidence interval; P < 0.005). The moderate scale of CLP cases has shown statistically significant bone stability compared to that of severe and mild cases. Furthermore, the 3D-printed model has shown a significant difference to that of T1 CT imaging (P < 0.005). CONCLUSION: Within the limitations of the study, it seems appropriate to conclude that 3D-printed models serves as better reference than CT imaging in the context of planning and execution of precise bone grafting in SABG.

Buccal fat pad in cleft palate repair- An institutional experience of 27 cases.

OBJECTIVES: The purpose of this paper is to consider the anatomical basis and surgical technique along with the utility of buccal fat pad (BFP) for the reconstruction in cleft lip and palate patients. METHODS: We reviewed 27 cases of CLAP treated with BFP over three year period in our institution which included 2 cases of primary palatoplasty & 25 cases of secondary palatoplasty. Inclusion criteria consisted of patients operated by a single surgeon with a minimum follow up of 2yrs. Exclusion criteria included all syndromic cleft lip and palate patients. Predictor variables recorded were demographic characters, follow up period, type of cleft, type of surgical procedure, site & dimension of the fistula. Outcome variables of the study were post-operative fistula formation, post-operative hemorrhage & speech assessment. RESULTS: The study included 8 female & 19 male patients with mean age group 3.75 ± 1.75yrs. Cleft of soft palate & Lt. CLAP were the most common type of cleft. The surgical technique used was: BFP with V-Y pushback palatoplasty for primary palate repair, BFP with Furlow's technique for VPI correction, and BFP in conjugation with rotation flap, straight-line closure or redohardpalatoplasty for fistula closure. All cases showed satisfactory healing with favorable speech assessment outcomes for 18 patients (67%). CONCLUSION: BFP along with other types of flap is the choice of treatment in cases of moderate defect owing to its favorable anatomic location & high vascularity. The size limitation of the BFP must be known to permit a successful outcome.

An aggressive pyogenic granuloma masquerading as a vascular neoplasm.

Pyogenic granuloma (PG) is a benign lesion, with a female predilection, commonly associated with local irritation or trauma. We report an unusual, destructive case of PG, displaying excessive loss of blood and destruction of alveolar bone leading to the loss of maxillary anterior teeth in an 18-year-old female, compromising function and esthetics. The incisional and excisional biopsy specimen of this recurrent lesion obtained during a 5-year span was studied, which revealed an increase in vascularity and extensive proliferation of endothelial cells admixed with varying degree of inflammatory cell infiltrate. The clinical, radiographic, and histopathological diagnostic tools enabled to precisely diagnose the lesion as an aggressive variant of PG, distinguishing it from other vascular neoplasms. No recurrence has been noted during a 5-year follow-up. The clinicians should be aware of the aggressive and destructive clinical behavior of PG to avoid the inadvertent treatment of this reactive lesion.

The versatility of the tongue flap in the closure of palatal fistula.

Aims Tongue flaps were introduced for intraoral reconstruction by Lexer in 1909. A retrospective study was performed in the Department of Oral and Maxillofacial Surgery, S.D.M. College of Dental Sciences (Dharwad, India), to assess the use of tongue flap in closure of palatal fistula. Material and Methods A total of 40 patients treated for palatal fistulas were included in this study from the period of January 1, 2000, to January 1, 2007; fistulas present in anterior and midpalate were considered. Patients' preoperative photographs, clinical records, and preoperative speech analysis were recorded. Following completion of fistula closure, patients were assessed over 6 months to check flap viability, fistula closure, residual tongue function, aesthetics, and speech impediment. Results A total of 40 (24 male and 16 female) patients with palatal fistulas were treated with tongue flap in our study. Six patients were 4 to 6 years old, three were 7 to 10 years old, and 22 were 11 to 20 years old, which accounts for 68% of study subjects. There were nine patients 21 to 30 years old. In the early postoperative period, we encountered bleeding in one patient and sloughing in one patient. There are three recurrences, and two flaps were detached; all remaining cases showed satisfactory healing, and donor site morbidity was minimal. No speech deficits were evident. Conclusion Tongue flaps are used in cleft palate surgery because of their excellent vascularity, and the large amount of tissue that they provide has made tongue flaps particularly appropriate for the repair of large fistulas in palates scarred by previous surgery.