Intra-articular injection of hyaluronic acid versus platelet-rich plasma following single puncture arthrocentesis for the management of internal derangement of TMJ: A double-blinded randomised controlled trial.

The present study aimed to compare the efficacies of intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) following single needle arthrocentesis in patients with TMJ internal derangement. This double-blinded randomised controlled trial involved the enrolment of patients diagnosed with unilateral TMD, falling into either Wilkes' stages II or III. In Group A, single needle arthrocentesis was performed using Ringer's lactate serving as a control group; in Group B, intra-articular injection of 1 ml hyaluronic acid injection was given following arthrocentesis; and in Group C, autologous intraarticular injections of 1 ml of PRP was given after arthrocentesis, twice in two weeks' interval. The primary outcome variables were maximum mouth opening and pain, while TMJ clicking sounds formed the secondary outcome variable. All the outcome variables were assessed preoperatively (T0) and postoperatively after the second dose of injection at one month (T1), three months (T2), and six months (T3). The alpha level was set to p < 0.05. Ninety patients (N = 90) comprised the final sample size of the study with thirty patients(n = 30) in each treatment group. A statistically significant decrease in the management in mean pain scores was noted between T0 [mean scores were 7.30 ± 1.05 (Group A), 7.63 ± 1.12 (Group B), and 7.56 ± 1.04(Group C)] and T3 [mean scores were 2.66 ± 0.88 (Group A), 2.4 ± 0.72 (Group B), and 1.66 ± 0.66 (Group C)] time intervals between Group A and C(p < 0.001). Significant improvement was noted in preoperative maximum mouth opening (MMO) of Group A, B, and C which was 22.83 ± 3.58, 22.17 ± 4.07, and 21.37 ± 3.69, respectively to 28.90 ± 2.72, 32.17 ± 3.97, and 34.10 ± 3.80 mm, respectively at six months postoperatively (p < 0.001). A significant decrease in joint sounds was evident for all three groups(p = 0.003 for Group A, p < 0.001 for Group B, and p < 0.001 for Group C) across the time intervals. Moreover, Group C showed a significant decrease in the prevalence of joint sound compared to the other two groups at all-time intervals postoperatively when equated to baseline (p = 0.02 at T1, p = 0.009 at T2, and p = 0.002 at T3). Within the limitations of the present study, it can be concluded that intra-articular PRP may be preferable over HA whenever appropriate, following single needle arthrocentesis in the treatment of TMJ internal derangement.

Management of Covid Associated Mucormycosis of Mandible: A Mountain Beneath a Molehill-A Lesson Learnt.

The opportunistic infection of post-Covid associated mucormycosis has been reported globally; however, it has reached alarming proportions in India. Mucormycosis of the mandibular region is rare, and only a few cases have been reported to date. Covid associated mucormycosis has not been reported in the literature before, and we are the first to report them. We report two patients who presented with tooth loosening with pus discharge a few weeks following recovery from Covid infection. After tooth extraction adjacent necrotic bony specimen was sent for calcofluor potassium hydroxide mount, which was found positive for broad pauciseptate hyphae. Although CT scan imaging demonstrated the involvement of a mandible segment, we found a much more extensive involvement in both cases during resection. There was intramedullary spread of the mucormycosis throughout the inferior alveolar canal, with pus discharge and foul odor. The management of covid associated mandibular mucormycosis consists of surgical debridement with antifungal therapy and control of the underlying disease. It became challenging because the radiological extent of the disease was different from the definite clinical extension of the lesion found during surgery. The authors recommend surgeons adopt a flexible approach during surgery to plan resection depending on the clinical judgment and not rely entirely on CT scans. And the reconstruction of the mandible will follow as per the extent of excision.

Functional outcome of two different grafting techniques in the surgical management of oral submucous fibrosis: a comparative evaluation.

OBJECTIVE: To evaluate the functional efficacy of two different grafting techniques following the fibrotomy among subjects with oral submucous fibrosis (OSMF). DESIGN: Forty consecutively treated OSMF subjects between 20 and 40 years who had grades 3 and 4a OSMF and mouth opening < 15 mm were included in the present study. All the subjects were randomly divided into two groups. In Group I, all the subjects received a buccal pad of fat sandwiched with a nasolabial flap following fibrotomy. In contrast, Group II subjects received a buccal pad of fat combined with a collagen graft. The effect of two different surgical protocols on mouth opening was evaluated clinically before the surgery (T0) and 1 month (T1), 6 months (T2), and 12 months (T3) after the surgery. RESULTS: In Group I subjects, the mouth opening increased significantly (P < 0.001) from 10.90 ± 1.971 mm at T0 to 34.25 ± 3.127 mm at T1, but reduced marginally to 32.15 ± 3.422 mm at T2, and 31.30 ± 3.358 mm at T3. In Group II, the mouth opening increased significantly (P < 0.001) from 10.85 ± 1.725 mm at T0 to 28.90 ± 3.059 mm, 29.10 ± 2.808 mm, and 28.20 ± 2.285 mm at T1, T2, and T3, respectively. At the end of 12 months of follow-up, the mean value improvement in the mouth opening (T0-T3) was 20.4 ± 3.5 mm and 17.3 ± 2.9 mm in Groups I and II, respectively, and the difference was statistically significant (P = 0.006). CONCLUSION: The buccal pad of fat sandwiched with a nasolabial flap for the reconstruction following fibrotomy had a slightly better beneficial effect on the postoperative mouth opening among OSMF subjects.

Surgical Correction of Craniofacial Fibrous Dysplasia Involving Orbits: A Unique Application of Patient-Specific Implants.

ABSTRACT: Craniofacial fibrous dysplasia is a slow-growing bony disorder causing asymmetry of the face; leading to aesthetic, functional, and psychological ramifications. Surgical recontouring is the most accepted form of treatment. Reconstruction of the orbit poses a serious challenge to the surgeon; hence the present study is intended to describe and evaluate a most anatomically accurate virtual treatment planning and defect-specific implant technique, enumerating postoperative functional and esthetic outcome. The study highlights a valid application of three-dimensional models and computer-guided surgical splints. The current study included 5 patients with craniofacial fibrous dysplasia involving orbits with a mean age of 19.6 years. Detailed pre- and post-operative ophthalmologic workup were documented for one year. All the participants showed improvement in eyeball position and movement. Visual acuity and intraocular pressure have returned to near normal values, and astigmatism was reduced significantly. No recurrence was noted in any of the subjects. The current technique was found helpful in reconstructing the complex orbital anatomy; however, long-term follow-up studies with a greater number of patients are recommended.

A novel prefabricated patient-specific titanium cranioplasty: reconsideration from a traditional approach.

OBJECTIVE: Patient-specific implants (PSI) for cranioplasty are expensive, and cost remains the limiting factor in low- to middle-income countries. The authors describe a novel, reproducible and cost-effective method of designing prefabricated titanium PSI cranioplasty. METHODS: Ten patients from June 2018 to December 2020 were included in this retrospective study. A three-dimensional stereolithography model was made on a custom-built 3D printer with variable layer heights to produce efficient and accurate details. A certain amount of defect in the temporal region was left uncovered to avoid complications related to temporalis muscle dissection. The stereolithography model with a cranial defect was reconstructed with modelling wax. The wax model was scanned with a blue light visible scanner. The digital data was transferred to the milling machine (Jayon Surgical®, Kerala, India), where a 1-mm-thick sheet of titanium was milled according to the specifications. RFCC scoring system was used for assessing cosmetic outcome. RESULTS: The mean duration of the surgery was 56.50 min, SD = 14.916 min (range 45-75 min). In 9/10 patients, the RFCC score was 4 points. No other complications were found at a minimum follow-up of 18 months in all patients. The cost per patient was approximately 30,000 INR or 400 US dollars. The average time required for us to get the PSI ready for surgery was about 15 days. CONCLUSION: The authors demonstrate a novel, cost-effective and reproducible method of PSI using titanium for cranioplasty.

Modified Medial Ramus Retractor to Facilitate Horizontal Osteotomy During Sagittal Split Ramus Osteotomy Procedure.

Introducing a horizontal osteotomy is the first and a critical step in sagittal split ramus osteotomy procedure. Identification of the lingula and medial displacement of the vital structures entering the inferior alveolar foramen are of paramount importance in ensuring a risk-free placement of the medial cut with bur or a saw. Quite often, identification of lingula and retrolingular fossa can be an arduous task owing to the thickness of the internal oblique ridge. Hence, placement of horizontal osteotomy depends on the experience of the operator.Here, the authors describe a simple, low profile instrument that aids in the identification of the lingula as well as provide a posterior stop for horizontal osteotomy during the sagittal split ramus osteotomy procedure.

Virtual Surgery Planning in Orthomorphic Correction of Mandibular Dysmorphology.

Three-dimensional virtual surgery programs are widely available for orthognathic surgery. The advent of imaging software programs has proved to be useful for diagnosis, treatment planning, outcome measurement, and three-dimensional surgical simulation. Complex maxillofacial malformations continue to present challenges in analysis and correction beyond modern technology. Orthomorphic correction for mandibular dysmorphology refers to basal bone movement without any change in dental component. The purpose of this paper is to present a virtual surgery planning for surgeons to perform the orthomorphic surgery with precision and quantification. Moreover, it provides an essential educational tool for patients to foresee predicted surgical outcome.

Le Fort I Disassembly for the Management of Juvenile Ossifying Fibroma Extending To the Skull Base.

Ossifying fibroma is a rare benign osteogenic neoplasm arising from undifferentiated cells of the periodontal ligament. Ossifying fibroma have a well-defined border that differentiates it from fibrous dysplasia clinically; these tumors manifest as a round or ovoid, expansile, painless, slow-growing mass may displace the roots of adjacent teeth and also cause root resorption. A variety of approaches for resection of the maxilla have been described. Most involve the use of facial and lip-splitting incisions to gain wide access. Surgical approach specifically to the ossifying fibroma located in the midface includes the Le Fort I approach, Caldwell-Luc access, lateral rhinotomy with medial or total maxillectomy, external ethmoidectomy, and endoscopic surgery. The access through Le Fort I disassembly is a versatile approach not only because of the aesthetic potential in using intraoral incision but also due to its minimal invasiveness, lesser complications and gives the possibility of reconstruction in a single operation. Le Fort I disassembly followed by an excision appears to be a versatile, secure, and satisfactory option.