The ideal patient specific implant. Part II: An eight step checklist for maxillary class I, II Brown defects.

Patient specific implants (PSI) though considered the next frontier in Maxillofacial Reconstruction, the gold standard for Brown I, II maxillary defects still remains autogenous reconstruction. The authors in their previous papers have standardised the design of Patient Specific Implants for Brown I, II mandibular defects. In this paper they attempt to standardise the design of PSI for Brown I,II maxillary defects using a scientifically optimised design which has passed through a stringent set of parameters. They aim to address the complications like wound dehiscence, poor dimensional accuracy and unoptimised biomechanics due to lack of standardisation thus impeding it's widespread acceptance among the scientific community. This study presents an eight step checklist to be followed for designing of an ideal standardised patient specific implant and can serve as a go-to guide for the operating and designing team.

The Application of Pre-operative Three-Dimensional Models in the Management of Mandibular Pathology: Is it Really Useful? An Institutional Study.

AIM: To assess the usefulness of 3D models for the surgical management of mandibular pathology requiring resection with continuity defects reconstructed using reconstruction plates. PATIENTS AND METHOD: A bidirectional study was conducted in 40 patients, 20 each in group 1 and 2. Group 1 included those patients taken up for resection with continuity defects and reconstruction using reconstruction plates without using 3D models and Group 2 included those patients managed similarly with 3D models. Pre-operative pathological model and mirrored model was fabricated for accurate placement and pre-bending of plates and determining the position and length of the screws. The level of understanding of the patients with regards to the diagnosis and extent of the disease (VAS 0-10), treatment planning (VAS 0-10), accuracy of fixation by a blinded surgeon (VAS 0-5), operative time, change in the mouth Opening, occlusal disturbance, implant-related complications was assessed as outcome measures and tested statistically. RESULTS: The level of understanding of the patients with regards to the diagnosis and extent of the disease, treatment planning, operative time and accuracy of fixation was found to be statistically significant with superior performance in Group 2. No statistical significance was elicited in the change in mouth opening. No limitation in the mandibular range of movements and occlusal disturbance was found in any patient. No implant-related complications were found during the follow-up. CONCLUSION: 3D model fabrication can serve as a valuable adjunct in improving clinical outcomes with minimal operating time, increased patient compliance and radiological accuracy of fixation.

Novel hypotheses related to Temporomandibular joint derived from Ankylosing spondylitis.

Ankylosing spondylitis (AS) is a seronegative arthropathy that affects fibrocartilaginous joints leading to arthritis and eventually ankylosis. Temporomandibular joint (TMJ), a fibrocartilaginous joint is affected to a lesser extent than the other joints, very rarely precipitating TMJ ankylosis. No explanation exists for the same in the present literature. Several hypothesis have been presented to explain this phenomenon of rarity of TMJ ankylosis in AS. The presence of an intraarticular disc acts as a physical barrier to the ankylotic process. However, in cases with AS, that present with TMJ ankylosis, this hypothesis needs several clarifications since the intraarticular disc is a constant phenomenon in TMJ. The cause of TMJ ankylosis in these cases might be explained by two hypotheses. Firstly, Pathological condylar loading in some cases; secondly, an application of the orthopaedic concept of functional enthesis to the TMJ disc and thirdly, an application of the concept of enthesis organ to TMJ. Using these hypotheses, important concepts on the anatomy and evolution of TMJ can be derived with evidence from literature. The intraarticular disc may be considered as an involuted tendon of the lateral pterygoid muscle which not only attaches to the mandibular condyle but also to the temporal bone via a elastic fiber mediated enthesis extending to the malleus through the discomalleolar ligament. The fibrocartilaginous changes that occur on the undersurface of the disc may support the concept of functional enthesis and provide a reverse evidence for the disc being a tendon. The evidence presented from extant monotremes may also throw light on the embryological development of the articular disc. These evidences are more of an anecdote than being focussed. Several scientific experiments, studies and data collection needs to be carried out to validate them. The proof of these hypotheses will be of use in establishing the development and role of the articular disc in TMJ function and TMJ disorders, including AS. The understanding of the role of the articular disc is important since many firstly, TMJ disorders are being treated by discectomy with good results, apparently rendering the disc vestigial and secondly, in the era of tissue engineering where efforts are being made to artificially produce articular disc and its analogues.

Pharyngeal airway evaluation following isolated surgical mandibular advancement: A 1-year follow-up.

INTRODUCTION: The aim of this study was to evaluate the stability of pharyngeal airway space changes with the use of acoustic pharyngometry 1 year after bilateral sagittal split ramus osteotomy for mandibular advancement in patients with skeletal Class II malocclusion. METHODS: The sample comprised 16 patients (mean age 21.26 ± 1.86 years). Acoustic pharyngometry measurements were recorded 1 week before surgery (T0), 2 months after surgery (T1), and 1 year after surgery (T2). Parameters were compared by means of repeated-measures analysis of variance (ANOVA). RESULTS: Significant increase was seen in minimum cross-sectional area 2 months after surgery (P < 0.001). Relapse of 12.6% was observed within 1 year after surgery (P < 0.001). Statistically significant increase, ie, 31.5%, was seen in mean cross-sectional area 2 months after surgery (P < 0.001), which relapsed by 7.9% 1 year after surgery (P < 0. 0.001). Significant increase in mean volume from 30.32 ± 2.2 cm3 before surgery to 38.91 ± 2.73 cm3 2 months after surgery (P < 0.001) was observed. Mean volume relapsed 3.9% 1 year after surgery (P < 0.001). CONCLUSION: Changes in pharyngeal airway space dimensions in patients subjected to isolated surgical mandibular advancement on 1 year follow up showed encouraging results.

Is splint therapy required after arthrocentesis to improve outcome in the management of temporomandibular joint disorders? A systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review was to assess the efficacy of splint therapy in improving outcomes after arthrocentesis for the management of temporomandibular joint disorders. STUDY DESIGN: A comprehensive electronic search was conducted to search for randomized control trials, controlled clinical trials, and retrospective studies comparing arthrocentesis and splint therapy with arthrocentesis alone. RESULTS: Six studies were included in this review. There was no statistical significant difference in pain reduction with or without the use of splint after arthrocentesis at 1 month (fixed: weighted mean difference [WMD] = -0.01; 95% confidence interval [CI] -0.46 to 0.44; P = .96; I2 = 0%) and 6 months (fixed: WMD = -0.08; 95% CI -0.27 to 0.42; P = .66; I2 = 0%). Similarly, no difference was seen in improvement in maximal mouth opening at 1 month (fixed: WMD = -0.16; 95% CI -1.75 to 1.42; P = .84; I2 = 44%), and 6 months (fixed: WMD = -0.83; 95% CI -0.52 to 2.18; P = .23; I2 = 0%). CONCLUSIONS: Within the limitation of this review, there is some evidence that splint therapy may not improve outcomes after arthrocentesis. There is a need for well-designed RCTs evaluating the additional benefit of splint therapy after arthrocentesis for managing temporomandibular joint disorders.

Surgical management of oral submucous fibrosis using buccal fat pad: a retrospective study of 30 cases.

The aim of our study was to evaluate the effectiveness of buccal fat pad (BFP) in the management of oral submucous fibrosis (OSMF). Retrospective records of 30 patients of OSMF treated with BFP with atleast a year of follow-up were analyzed. Patients were divided into groups based on the stages of OSMF. Surgical management consisted of resection of fibrous bands, bilateral temporalis myotomy, and coronoidectomy followed by grafting with BFP. There were 17 patients of stage III (mouth opening 16-25 mm) and 13 patients of stage IV OSMF (mouth opening less than 16 mm). The mean mouth opening of stage III group pre-operatively was 19.94 ± 2.19 mm which increased to a mean of 35.12 ± 5.69 mm (p < 0.0001). For patients with stage IV OSMF, the mouth opening increased from a pre-operative of 10.23 ± 4.07 mm to a post-operative of 31.46 ± 6.78 mm (p < 0.0001). No intra-operative complications were noted in any patient. Relapse was seen in 1 patient (5.8%) of stage III while 3 patients (23.07%) had relapse in stage IV group. Our results indicate that BFP is a good flap owing to its benefits which are easy to harvest and entails minimal morbidity for management of OSMF.

The use of intra-articular analgesics to improve outcomes after temporomandibular joint arthrocentesis: a review.

PURPOSE: The aim of this review was to assess the efficacy of intra-articular analgesics in improving outcomes after temporomandibular joint (TMJ) arthrocentesis. MATERIAL AND METHODS: An electronic search of PubMed, Scopus, and Google scholar databases was performed for papers in English published up to December 2017 reporting the use of intra-articular analgesics after TMJ arthrocentesis. Randomized controlled trials (RCTs), controlled clinical trials (CCTs), comparative studies, retrospective studies, and case series were included while case reports, technical reports, animal studies, cadaveric studies, and review papers were excluded. RESULTS: Of the six studies included in the review, three were RCTs, two were randomized comparative studies, and one was a retrospective study. Both opioids and non-steroidal anti-inflammatory drugs have been used after TMJ arthrocentesis. Morphine, tramadol, fentanyl, buprenorphine, tenoxicam, and COX-2 inhibitors are the drugs used till date. Placebo-controlled studies reported improved outcomes after TMJ arthrocentesis with morphine and fentanyl but no such results with buprenorphine and tenoxicam. Tramadol was found to be better than COX-2 inhibitor. The quality of literature was not high. CONCLUSIONS: There is inconclusive evidence in literature on the benefits of using intra-articular analgesics after TMJ arthrocentesis. Well-designed high-quality RCTs with standard protocol studying the effects of intra-articular opioids and NSAIDS after TMJ arthrocentesis would provide stronger evidence on its use.