TFM classification and staging of oral submucous fibrosis: A new proposal.

BACKGROUND: We have evaluated the rationale of existing grading and staging schemes of oral submucous fibrosis (OSMF) based on how they are categorized. A novel classification and staging scheme is proposed. METHODS: A total of 300 OSMF patients were evaluated for agreement between functional, clinical, and histopathological staging. Bilateral biopsies were assessed in 25 patients to evaluate for any differences in histopathological staging of OSMF in the same mouth. Extent of clinician agreement for categorized staging data was evaluated using Cohen's weighted kappa analysis. Cross-tabulation was performed on categorical grading data to understand the intercorrelation, and the unweighted kappa analysis was used to assess the bilateral grade agreement. Probabilities of less than 0.05 were considered significant. Data were analyzed using SPSS Statistics (version 25.0, IBM, USA). RESULTS: A low agreement was found between all the stages depicting the independent nature of trismus, clinical features, and histopathological components (K = 0.312, 0.167, 0.152) in OSMF. Following analysis, a three-component classification scheme (TFM classification) was developed that describes the severity of each independently, grouping them using a novel three-tier staging scheme as a guide to the treatment plan. CONCLUSION: The proposed classification and staging could be useful for effective communication, categorization, and for recording data and prognosis, and for guiding treatment plans. Furthermore, the classification considers OSMF malignant transformation in detail.

Oral submucous fibrosis: An update on current theories of pathogenesis.

Over the last 40 years, many theories linking oral submucous fibrosis (OSMF) to various risk factors have been proposed. Spicy, pungent foods and irritants such as supari (areca nut), paan (betel leaves), tobacco (through chewing or smoking)-the common Asian habits of chewing the aforementioned agents-have all been incriminated as causative agents. Systemic factors such as nutritional deficiency, genetic predisposition and autoimmunity have also been proposed in the pathogenesis of OSMF. However, the precise aetiology of OSMF is still unknown, and no conclusive evidence has been found despite many extensive investigations on implicated factors. Most of the ideas proposed have been derived from the existing clinical and epidemiological data. We present a comprehensive review of the various theories regarding the pathogenesis of the condition, but have not concentrated on malignant transformation in this article.

Current protocols in the management of oral submucous fibrosis: An update.

Oral submucous fibrosis (OSMF) is a debilitating condition of oral cavity which has significant potential for malignant transformation. In spite of over 20 years of research, the pathogenesis of the condition is still obscure and no single management modality is effective. Many OSMF treatment protocols have been proposed to alleviate the signs and symptoms of the disorder and there is overwhelming evidence that as areca nut is primary cause, stopping its use may have a considerable effect on symptoms rather than reversing pre-existing fibrosis. We present a review of the current protocols for managing OSMF.

Evaluation of Spontaneous Bone Regeneration after Enucleation of Large Cysts of the Jaws using Radiographic Computed Software.

INTRODUCTION: Spontaneous regeneration of bone is commonly seen in the small surgical defects caused by enucleation of cysts. However, in case of large surgical defects caused by the enucleation, spontaneous regeneration of bone is a rare phenomenon and it depends on factors, such as age of the patient, intact periosteum, and proper stabilization. MATERIALS AND METHODS: The study included 16 patients, who reported to the department of oral and maxillofacial surgery with the complaint of pain and swelling in the jaws diagnosed as cyst. The sample included equal numbers of male and female subjects aged between 15 and 40 years. Panoramic radiographs were taken pre- and postoperatively on day 2 of the enucleation. The dimensions of the cyst were evaluated on the radiograph according to the proforma. Subsequent radiographs were taken at regular intervals of 1.5, 3, and 6 months using standard parameters and were analyzed using MCID™ analysis software of imaging research. RESULTS: Mean reduction was seen in up to 39 and 60% in the cystic cavity size and increase in the mean density up to 59 and 90.2% at 3 and 6 months intervals respectively. CONCLUSION: Spontaneous bone regeneration was seen even after primary closure of the large cystic defect without the need for placement of foreign substances or grafts and it also eliminated the complications resulting from placement of foreign substance. Further studies are required in a larger sample with longer follow-up durations to confirm the outcome of the present work for the benefit of patients. CLINICAL SIGNIFICANCE: The present study depicted that spontaneous bone regeneration can occur with accepted results after simple enucleation of jaw cyst without the aid of any graft material. Hence, simple enucleation may be considered as a first line of treatment modality for cystic lesion of the jaws. This simplifies the surgical procedure, decreases the economic and biologic costs, and reduces the risk of postoperative complications. Follow-up is necessary along with patient's compliance for the success of treatment.

Simplified practice for ophthalmologist consultation in malar fractures: A retrospective study.

Zygomatic bone contributes to the orbital walls, and therefore associated injuries carry a high risk of severe dysfunction of the visual apparatus. The aim of our study was to retrospectively assess the spectrum and frequency of ophthalmic involvement in patients presenting with malar fracture, and the need for referral to an ophthalmologist for evaluation. In total, 102 patients presenting with malar fracture between January 2008 and August 2017 at Bapuji Dental College and Hospital, Davangere, Karnataka were enrolled in this study. Patients with confirmed malar fracture were categorized according to Henderson's classification, and associated ocular injuries were recorded. Assessment of the spectrum and frequency of ophthalmic involvement in patients presenting with different types of malar fracture was then carried out, followed by categorization of the need for referral to the ophthalmologist with regard to the associated ocular injury, as per the Al-Qurainy et al. (1991) scoring system, allocating the patients to early, routine, and non-referral categories. Statistically significant differences in proportions of various types of ophthalmic involvement were found between categories of malar fracture, and in degrees of ophthalmic involvement within each category of malar fracture, except in the Type II group of patients. The most severe ocular injuries were noted in Type VII followed by Type V, with the least severe injuries noted in Type II patients. According to the Al-Qurainy et al. (1991) scoring system, eight patients required early referral, 10 patients needed routine referral, and 84 patients were in the non-referral category. Categorization of referral of patients to an ophthalmologist in hospitals lacking ophthalmology departments can be based on the Al-Qurainy et al. classification of referral for Henderson's Type III, IV, and VI. Henderson's Type I and II patients need to be referred only in medicolegal cases. Henderson's Type VII and V patients require mandatory referral.

An Analysis of the Viability of Nonvascular Iliac and Fibula Grafts in Mandibular Reconstruction in Patients with Circulatory Diseases: A Prospective Randomized Study.

Vascularized bone grafts are considered as the gold standard for mandibular reconstruction. However, there are certain limitations of them, such as they are contraindicated in patients with circulatory disturbances. Therefore, Non-vascular bone grafts become the viable option for reconstruction. Our study aims to prospectively compare the long-term viability of avascular iliac and fibula bone grafts in the reconstruction of mandibular defects. Objectives were to evaluate the difficulty in swallowing, mastication, speech problems, infection, wound dehiscence, restricted limb movement, and altered gait among the iliac and fibula group. A total of 14 patients, planned for the reconstruction of mandibular defects from 2016 to 2018 were randomly allocated into two groups; nonvascular iliac and fibula graft groups. Clinical assessment for improvement in function, esthetics, wound healing, pain, and donor site morbidity was done and was followed up for one year. Digital orthopantomogram was taken for radiographic evaluation for up to one year. Difficulty in swallowing, mastication, speech, infection, restricted limb movement, and altered gait was statistically significant and was seen more in the fibula group. Wound dehiscence with graft exposure was found in one subject. The overall success rate was 100% in the iliac group and 85.7% in the fibula group. Considering the long-term complications and success rate, the nonvascular iliac graft was found to be superior and can be used as an alternative to a nonvascular fibula graft for a defect length up to 7 cm.

Efficacy of collagen-silicone bilayer membrane in the management of oral submucous fibrosis: a prospective case series.

BACKGROUND AND OBJECTIVE: Oral submucous fibrosis is a scourge of Southeastern Asia since a long time resulting in significant health and social problems. Mainstay of the treatment is concentrated on attempts to improve mouth opening and relieve the symptoms by medicinal or surgical means. In moderate to severe cases, release of fibrous bands is advocated followed by placement of graft. The present study was conducted to evaluate the use of collagen-silicone bilayer membrane as a mucosal substitute in its management. METHODOLOGY: Study consisted of 12 clinically and histologically proven cases of OSMF. After the incision and release of fibrous bands, a collagen membrane was placed and secured over the raw area by placement of a silicone sheet of adequate thickness. Parameters were assessed pre-operatively, intra-operatively, and post-operatively at 1 week, 1 month, and 3 months. The data was recorded and statistical analysis was done. RESULTS: Pre-operatively, the mean values of inter-incisal opening, cheek flexibility, and width of oral commissure were 16.92, 24.58, and 53.17 mm respectively whereas at 3 months post-operatively, it was 27.67, 26.58, and 55.00 mm, which was statistically significant. No incidence of infection was noted. CONCLUSION: The study concludes that the use of collagen membrane along with silicone sheet can be an alternative to other graft materials in context of reduced donor site morbidity as well as significant increase in inter-incisal opening. However, study with more sample size is needed to assess the long-term efficiency and surgical outcome of this material.

Cervico-stylo-mandibular complex fracture: a critical review of literature along with a protocol to recognize and proposal of a new classification.

Fractures of the styloid process of the temporal bone may occur with or without an obvious relation to trauma. The incidence of either isolated styloid process fracture or in combination with mandibular fractures is rare, and such occurrences are often misdiagnosed or neglected. A fractured styloid when displaced may impinge on adjacent vital structures, leading to neurological or vascular symptoms that vary according to the anatomical structure compressed. Styloid process fractures associated with atlas/C1 fractures have also been rarely reported in the literature. In this review of literature, the majority of patients was treated conservatively, as few demonstrated the necessity of surgical intervention. There is a definitive need for a protocol to recognize and classify styloid fractures to plan for further treatment. The aim of this review was to achieve a comprehensive understanding of all types of styloid fractures, determine the clinical severity of symptoms, and to consider management and prognosis. In addition, a new classification of cervico-stylo-mandibular fractures is proposed based on important evidence in the literature regarding clinical and radiographic factors that might influence the treatment and prognosis of such fractures.

Trismus in oral cancer patients undergoing surgery and radiotherapy.

OBJECTIVE: The aim of this study was to determine the incidence of trismus before and after surgery and subsequent radiotherapy for patients of oral cancer and to determine the risk factors for the same. METHODS: 30 patients diagnosed with oral cancer were included. Maximum mouth opening was measured for each patient as the inter incisal distance and was measured on 4 occasions - preoperatively at the time of diagnosis, post-operatively at discharge from the hospital, post-radiotherapy and at 6 months follow-up. The site of cancer, staging and grading of the malignancy, the surgical treatment performed, method of reconstruction, details of radiotherapy and compliance to physiotherapy were recorded, to evaluate the risk factors for developing trismus. RESULTS: Trismus was observed in 53.3% patients at the time of diagnosis which increased significantly post-surgery (86.7%) and post-radiotherapy (85.7%) and gradually decreased (65.4%) at 6 months. The use of flaps for reconstruction, delay in radiotherapy post-surgery and non-compliance of patients to physiotherapy were the risk factors for developing trismus, showing statistical significance (p < 0.05). CONCLUSION: Trismus is a significant complication of oral malignancies or its surgical and radiotherapy treatment, or both. Consideration must be given to its early diagnosis, to help in timely intervention and planning of preventive strategies.

Submasseteric tuberculous lesion of mandible: report of a case and review of the literature.

Tuberculosis is still a major health hazard in the developing world, while its incidence has recently started to escalate after decreasing for many years. It is a chronic granulomatous disease that can affect any part of the body, including the oral cavity. Oral lesions of tuberculosis, though uncommon, are seen in both the primary and secondary stages of the disease. This paper presents a case of tuberculosis of the submasseteric space, manifesting as a persistent swelling at ramus and angle of mandible. The diagnosis was confirmed based on histopathology after an open incisional biopsy. Patient underwent antituberculosis therapy and his extraoral swelling completely resolved after 4 months of the therapy. The purpose of this paper is to emphasize the importance of early and definitive diagnosis of orofacial tuberculosis, to recognize it based on signs and symptoms, and to refer the patients suspected of active tuberculous infection for appropriate medical treatment.

A modified surgical approach to a case of mandibular fracture in a 5-year-old girl.

Injuries to the face are far more uncommon than other injuries in children. However, when they occur they can pose considerable management challenges to concerned specialists and the subsequent functional and esthetic impact to the growing child can be overwhelming. Here is a report of a 5-year-old girl diagnosed with fracture of the body of the mandible and an associated fracture of the parasymphysis. This paper presents a unique treatment modality considering the various anatomic and developmental factors in such young children.

A randomized clinical trial to compare the efficacy of submucosal aprotinin injection and intravenous dexamethasone in reducing pain and swelling after third molar surgery: a prospective study.

OBJECTIVE: The purpose of this study was to compare two different groups of drugs, aprotinin and dexamethasone for its efficacy in reducing post operative swelling and pain after third molar surgery. METHODS: Fifty consecutive patients requiring surgical removal of single mandibular third molar (class II position B) under local anesthesia were randomly divided into two groups, each group consisting of 25 patients. One group was administered 8 mg dexamethasone through intravenous route pre-operatively. The other group received 1 ml of Aprotinin through submucosal route in operating area after the onset of local anesthesia. Swelling was assessed by measuring facial contours at baseline and at 1st, 3rd and 7th post-operative days. Pain was measured on the 1st, 3rd and 7th post-operative days using visual analog scale. Based on statistical analysis (paired t test and Wilcoxon's signed ranking test), the results showed statistically significant difference in post operative swelling and pain on 3rd postoperative day in dexamethasone group as compared to aprotinin group. RESULTS: The results of present study showed a similar reduction in the severity of pain and swelling at the aprotinin and dexamethasone sites on 1st and 7th postoperative day. It was also noticed that the aprotinin promoted a greater reduction of swelling and pain on 3rd postoperative day. CONCLUSION: It appeared that, benefits of aprotinin against the risks of dexamethasone and its efficacy in controlling pain and swelling after third molar surgery makes aprotinin to be a valuable alternative to dexamethasone.

Osteochondroma of the mandible: a rare case report.

Osteochondroma, also known as osteocartilaginous exostosis is a benign cartilage forming tumor that usually develops in long bones and relatively uncommon in the craniofacial region. Both the condyle and coronoid tip being the most common sites of occurrence in the mandible, it rarely appears at the symphysis region. Here, we describe a case of osteochondroma arising from the left parasymphysis of mandible.

Carnoy's in Aggressive Lesions: Our Experience.

Carnoy's solution is used in the treatment of various aggressive cysts and tumors in the maxillofacial region as a chemical cauterizing agent. Its use has been extensively studied in case of odontogenic keratocysts. It is used in the management of unicystic ameloblastomas and ossifying fibromas. In our institution from 2006 to 2010 we have treated 14 cases of maxillofacial lesions using carnoy's solution. Among these cases 7 were of odontogenic keratocyst, 4 cases were of amelobalstoma and one case was of juvenile ossifying fibroma. So here we share our experience of treating these lesions with the carnoy's solution.

Comparative evaluation of pre-emptive analgesic efficacy of intramuscular ketorolac versus tramadol following third molar surgery.

Pre-emptive analgesia aims at preventing the central nervous system from reaching a hyper-excitable state known as central sensitization, in which it responds excessively to afferent inputs. The clinical implication would be more effective pain management, thereby reducing post-operative pain and analgesic requirements. This study aimed at investigating the existence of pre-emptive analgesia and to compare the pre-emptive analgesic efficacy of im ketorolac [NSAID] versus tramadol [SYNTHETIC OPIOD] for post-operative pain management following third molar surgery. Fifty patients under the age group of 16-25 years with asymptomatic, symmetrically impacted mandibular third molars were equally divided into 2 groups and underwent third molar surgery under local anesthesia. Ketorolac 30 mg and tramadol 50 mg were used in the study group, while sodium chloride 0.9 % was used in the control group. Study parameters included pain intensity scores for 12 post-operative hours, time to 1st rescue analgesia, total number of analgesics consumed during the 5 post-operative days and patients' self assessment of efficacy of the surgery with regardsto no pain. Statistically, the data are presented as the mean values with their standard deviations and a 95 % confidence interval [p is significant, if p < 0.05] for the mean are applicable. Incidences of adverse events like pain on injection of the study drug, local reactions, nausea and vomiting were noted. Patients in the study group significantly performed better than the control group in terms of all the parameters; while among the study group, ketorolac fared better than tramadol. All the drug related complications were mild and did not require any intervention. Pre-operative ketorolac or tramadol in comparison to placebo resulted in a significantly better post-operative pain management. However as against tramadol, ketorolac is a better choice as a pre-emptive analgesic agent for the post-operative pain management following third molar surgery.

Aneurysmal bone cyst, a lesion of the mandibular condyle.

Benign and malignant tumors of the temporomandibular joint are rare. An aneurysmal bone cyst (ABC) of the condyle is even more unusual and usually presents as a slowly enlarging firm swelling which occasionally may be associated with pain and tenderness. Surgical curettage or excision is the treatment of choice, in an attempt to reduce the potential problem of recurrence; we undertook surgical resection of the affected bone. Immediate mandibular reconstruction using autologous bone was deferred though it is generally recommended in such type of cases.

A Bony Landmark 'RAI Triangle' to Prevent 'Misplaced and Misdirected' Medial Cut in SSRO.

'Rai triangle', a new anatomic landmark on the medial surface of the ramus of the mandible which when identified and taken into consideration, may have a definite advantage. This is especially in terms of performing the medial horizontal cut which is an important and integral part of the sagittal split ramus osteotomy so as to avoid a bad split. The objective of this article is to propose an easily identifiable bony land mark, which is closely related to lingula of mandible that may ease the procedure of osteotomy and avoid bad splits.

Regional odontodysplasia: An unusual case report.

Regional odontodysplasia is an uncommon developmental anomaly affecting a localized area of dentition, with distinctive clinical, radiographic, and histological findings. This article reviews a case of a 14-year-old female who reported with unerupted maxillary anterior teeth. This case was rare in that it involved maxillary dentition with unerupted maxillary anterior teeth on the right side, but the left central incisor was missing. The molars on the right side were showing some amount of abnormality. Radiographically, the affected teeth had a 'ghostly' appearance, showing a marked reduction in radiodensity. Both enamel and dentin appeared to be very thin, the pulp chamber was exceedingly large, and the roots were short with wide open apices. All the characteristics were consistent with the diagnosis of regional odontodysplasia. The care and treatment of this patient required a multidisciplinary approach. The unerupted maxillary anterior teeth were surgically removed, following which temporary prosthetic restoration was provided to improve esthetics and to restore the function.

Management of congenital bilateral temporomandibular joint ankylosis with secondary mandibular hypoplasia.

The aim of this article is to present the course of the condition in a case of congenital temporomandibular joint ankylosis that caused facial disfigurement, significant reduction of mouth opening, difficulty in feeding and breathing, and general interference with physical development.