Rehabilitation of Dentofacial Asymmetry Secondary to Unilateral Temporomandibular Joint Ankylosis with Dual Distraction and Fixed Orthodontics - Stability at Three-year Follow-up.

Optimal rehabilitation of asymmetric dentofacial deformity secondary to unilateral temporomandibular joint (TMJ) ankylosis is often a challenge. The purpose of this case series is to present an insight into esthetic, occlusal and functional rehabilitation of two patients with varying degree of asymmetric Class II dentofacial deformities secondary to long-standing unilateral TMJ ankylosis. The patients were treated with one-stage surgical protocol employing simultaneous dual distraction technique along with interpositional arthroplasty. Dual distraction technique entailed the simultaneous use of two distractors which allowed for proper control of proximal condylar segment during the course of distraction and lowering the risk of ankylosis recurrence. Thereafter, comprehensive fixed orthodontic mechanotherapy involving the use of temporary anchorage devices was instituted to align and level the compensated dentition. Post-treatment records showed significant improvements in skeletal disharmony and functional stability with good functional occlusion. At the three-year follow-up, the morphological and functionally acceptable results were reasonably well-maintained, with no signs of relapse. Through the two cases reported here, we would like to highlight that one-stage concurrent arthroplasty and dual distraction technique is a safe, stable, and reliable approach for surgical and functional rehabilitation of an adult asymmetric dentofacial deformity secondary to unilateral TMJ ankylosis. Meticulously executed comprehensive orthodontic manipulations involving use of acrylic bite-blocks, elastic traction, and temporary skeletal anchorage device play a crucial role in enhancing the final occlusal outcomes.

The SGLT2 inhibitor dapagliflozin in heart failure with preserved ejection fraction: a multicenter randomized trial.

Patients with heart failure and preserved ejection fraction (HFpEF) have a high burden of symptoms and functional limitations, and have a poor quality of life. By targeting cardiometabolic abmormalities, sodium glucose cotransporter 2 (SGLT2) inhibitors may improve these impairments. In this multicenter, randomized trial of patients with HFpEF (NCT03030235), we evaluated whether the SGLT2 inhibitor dapagliflozin improves the primary endpoint of Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CS), a measure of heart failure-related health status, at 12 weeks after treatment initiation. Secondary endpoints included the 6-minute walk test (6MWT), KCCQ Overall Summary Score (KCCQ-OS), clinically meaningful changes in KCCQ-CS and -OS, and changes in weight, natriuretic peptides, glycated hemoglobin and systolic blood pressure. In total, 324 patients were randomized to dapagliflozin or placebo. Dapagliflozin improved KCCQ-CS (effect size, 5.8 points (95% confidence interval (CI) 2.3-9.2, P = 0.001), meeting the predefined primary endpoint, due to improvements in both KCCQ total symptom score (KCCQ-TS) (5.8 points (95% CI 2.0-9.6, P = 0.003)) and physical limitations scores (5.3 points (95% CI 0.7-10.0, P = 0.026)). Dapagliflozin also improved 6MWT (mean effect size of 20.1 m (95% CI 5.6-34.7, P = 0.007)), KCCQ-OS (4.5 points (95% CI 1.1-7.8, P = 0.009)), proportion of participants with 5-point or greater improvements in KCCQ-OS (odds ratio (OR) = 1.73 (95% CI 1.05-2.85, P = 0.03)) and reduced weight (mean effect size, 0.72 kg (95% CI 0.01-1.42, P = 0.046)). There were no significant differences in other secondary endpoints. Adverse events were similar between dapagliflozin and placebo (44 (27.2%) versus 38 (23.5%) patients, respectively). These results indicate that 12 weeks of dapagliflozin treatment significantly improved patient-reported symptoms, physical limitations and exercise function and was well tolerated in chronic HFpEF.

Minimally invasive intraarticular platelet rich plasma injection for refractory temporomandibular joint dysfunction syndrome in comparison to arthrocentesis.

CONTEXT: Internal derangements of temporomandibular joint (TMJ) with associated symptoms which do not respond to conservative therapies are refractory cases of temporomandibular joint dysfunction syndrome (TMD). Minimally invasive techniques like arthrocentesis and platelet rich plasma (PRP) injections are usually employed to improve TMJ symptoms and function in these cases. AIMS: To compare PRP with arthrocentesis for evaluating the effectiveness of PRP in relieving symptoms of refractory TMJ pain dysfunction syndrome. SETTING AND DESIGN: A clinical study was carried out on 52 patients of refractory Temporomandibular joint dysfunction syndrome. The patients were divided in two groups that is Group A - test group and Group B -control Group. METHODS AND MATERIAL: Group A consisted of 26 patients who underwent intraarticular PRP injection in TMJ and Arthrocentesis of TMJ was done in 26 patients of Group B. TMJ pain, Maximium Interincisal opening and TMJ clicking were assessed among the group as well as between the groups over a period of 6 months. STATISTICAL ANALYSIS USED: Repeated Measure ANOVA was used to compare the parameters within the groups and T test was used for group comparison at 0.05 level of significance. RESULT: There was statistically significant difference in pain intensity improvement 1 ± 0.75 versus 3.17 ± 2.13, maximum interincisal opening 39.86 ± 2.86 versus 37.59 ± 4.03 and clicking 6 versus 16 between the PRP group and arthrocentesis group at P < 0.05. CONCLUSIONS: Intraarticular PRP injection for the management of refractory TMD is more effective than arthrocentesis in reducing symptoms and functional improvement.

AgNOR as an effective diagnostic tool for determining the proliferative nature of different types of odontogenic cysts.

OBJECTIVE: To determine the proliferative nature of different types of odontogenic cysts using silver-stained nucleolar organizer region (AgNOR) staining. MATERIALS AND METHODS: Forty histopathological sections of each of odontogenic keratocyst, dentigerous, and radicular growth were taken into study. Two sections were produced using the paraffin block of separate cases, one was stained with hematoxylin and eosin and another segment was stained with silver nitrate method. RESULTS: AgNOR staining shows black dots and other parts of nuclei show yellow-brown dots. CONCLUSION: AgNOR, which stain for NOR-related proteins, corresponds to cell multiplication. Their amount regarding the number of AgNORs per cyst can be a good marker of the proliferative action of the cell in aggressive cystic lesion having malignant potential.

Technique of Dual Distraction for Correction of Unilateral Temporomandibular Joint Ankylosis With Facial Asymmetry: A Case Series.

PURPOSE: Temporomandibular joint (TMJ) ankylosis, not only results in joint hypomobility, but also causes considerable facial deformity. Its unilateral variant can cause facial asymmetry, leading to major psychosocial effects on the individual. PATIENTS AND METHODS: We present the cases of 7 patients with unilateral TMJ ankylosis and facial asymmetry of various grades who have been treated using gap arthroplasty and simultaneous dual distraction. Considerable debate has surrounded the sequencing of TMJ release and distraction osteogenesis; however, the simultaneous approach has recently become popular. The use of a single distractor simultaneously with TMJ release has been widely reported. However, one disadvantage with this technique is that the proximal condylar segment remains unstable. Dual distraction is a newer technique which we have proposed as a single-stage approach for the correction of TMJ ankylosis and facial asymmetry and to address the problems resulting from the use of a single distractor. RESULTS: After treatment, all the patients showed a mouth opening ranging from 35 to 50 mm and satisfactory facial symmetry. CONCLUSIONS: Dual distraction is a promising technique in the correction of facial asymmetry. However, further studies with adequate statistical analysis and larger sample size are required.

Study of pattern and prevalence of mandibular impacted third molar among Delhi-National Capital Region population with newer proposed classification of mandibular impacted third molar: A retrospective study.

AIM/OBJECTIVE: The mandibular third molar is the most frequently impacted tooth with incidence varies from 9.5% to 68% in different populations. Hence, the aim was to study the prevalence and pattern of mandibular impacted third molar among Delhi-National Capital Region (NCR) population. MATERIALS AND METHODS: The study was conducted with data collected from registered hospitals and dental clinics of Delhi NCR region. The study represents a retrospective analysis of panoramic radiographs and intraoral periapical radiograph of patients at these centers from June 2014 to June 2016. RESULTS: Out of 960 patients with the third molar investigated, a total of 250 patients having impacted mandibular third molar (152 [60.8%] males and 98 [39.2%]) females between June 2014 and June 2016 were included in the study. The age ranged from 20 to 55 years, with a mean age of 27.6 years and the standard deviation was 5.8 years. The prevalence of impacted mandibular third molars for this study was 26.04%. CONCLUSION: This study demonstrated that males (60.8%) were more likely to present with impacted mandibular third molars than females (39.2%). The prevalence of third molar impactions was almost the same on both the left (45.8%) and right (54.2%) sides. This study also noted that mesioangular impactions (49.2%) were the most common type of impaction. The least common form of impactions was the transverse types (2%). The prevalence of impacted mandibular third molars for this study was 26.04%.

Staged therapeutic approach for rehabilitation of severe asymmetric Class II dentofacial deformity secondary to long standing unilateral temporomandibular joint ankylosis.

Despite being one of the most pervasive debilitating skeletal problems in the craniofacial region, surgical-orthodontic management of long-standing asymmetric Class II dentofacial deformities is often a unique challenge posed to the clinicians. This case report describes the encouraging results of systematically sequenced and staged therapeutic approach adopted for successful rehabilitation of an adult patient with asymmetric Class II dentofacial deformity with mandibular micrognathia secondary to unilateral TMJ ankylosis. Concurrent gap arthroplasty and bilateral distraction of mandibular body were performed during the first operation for functional restoration of mandibular movements and correction of mandibular micrognathia and associated asymmetry. After 13 months of post-distraction orthodontic treatment, Le Fort I osteotomy for inferior repositioning and sagittal advancement of maxilla was performed during the second operation, in conjunction with adjunctive alloplastic reconstruction of inferior border of mandible for optimization of facial aesthetics. Postsurgical orthodontic detailing facilitated achievement of stable, balanced interdigitation. The total active treatment period was 29 months. After treatment, both the skeletal disharmony and the functional stability were significantly improved with establishment of functional occlusion. The morphological and functionally acceptable results were reasonably well-maintained during three-year follow-up. The merits of mandibular osteodistraction vs. conventional mandibular orthognathic surgery and the potential advantages of staged surgical approach are discussed.

A retrospective cross-sectional study of maxillofacial trauma in Delhi-NCR Region.

AIM AND OBJECTIVES: To evaluate the pattern, prevalence, etiology, site of fractures, and their management in patients with maxillofacial injury in Delhi-NCR region. MATERIALS AND METHODS: A total of 1278 maxillofacial trauma patients visiting different registered hospitals from Delhi-NCR region from January 2012 to December 2017, treated by open reduction and internal fixation under general anesthesia (GA)/local anesthesia (LA) or closed reduction/conservatively, were taken into the study. The parameters considered in the study were age and sex distribution, etiological factors and incidence of maxillofacial trauma, pattern and site distribution of maxillofacial fractures, and management. RESULTS: From a total of 2250 trauma patients, 1278 patients (1053 males and 225 females) had maxillofacial injury. The average prevalence rate was 56.8%. Yearly incidence rate was 20.4%. Road traffic accident (RTA) was the most common cause of trauma in 1029 (80.5%) patients, followed by physical assault [158 (12.3%)] with significant male predominance in different age groups. Isolated mandibular fractures were the most common [48.6% (parasymphysis 31.6%, condyle 28.2%)], followed by midface with maxilla fracture [27.6% (zygomatic bone and arch 50.2% and Lefort II fractures 18%)]. Treatment modalities were conservative management, closed reduction, and open reduction with internal fixation under GA/LA. CONCLUSION: RTA followed by physical assault is still the leading cause of maxillofacial trauma in young males in Delhi-NCR region. Mini plate osteosynthesis is the main treatment procedure for maxillofacial trauma. We need to enforce strict traffic rules, road safety law, and preventive measures along with improvement in education and socioeconomic status in the population to avoid maxillofacial injuries.

Mucormycotic osteomyelitis of maxilla following maxillofacial trauma: The disease of the diseased.

Mucormycosis is a rare opportunistic fungal infection with acute, aggressive, and invasive nature, seen in immunocompromised/debilitated patients, especially with diabetes mellitus. The key to successful therapy is the early diagnosis of signs and symptoms of the disease, correction of the underlying medical disorder(s), and aggressive medical and surgical intervention. The case presented here is mucormycotic osteomyelitis of the nasomaxillary-zygomatic complex following trauma in a middle-aged man. Preoperative amphotericin B therapy along with surgical resection of necrotic tissue was done followed by prosthetic rehabilitation with an obturator. There was no sign of recurrence of the diseases for the follow-up period of 1 year.

Management of myofascial pain dysfunction syndrome with meditation and yoga: Healing through natural therapy.

AIMS AND OBJECTIVES: Aims and objectives of the study were to study the effectiveness of Raj-yoga meditation and pranayama in patients with myofascial pain dysfunction syndrome (MPDS) and compared the effects with ongoing conventional noninvasive treatment modalities. MATERIALS AND METHODS: The study comprised 30 patients divided equally (10 each) into 3 group, i.e., control group (conventional, noninvasive treatment), Experimental A group (conventional, noninvasive treatment with raj-yoga meditation therapy and pranayama), and Experimental B group (Raj-yoga meditation therapy and pranayama only). Parameters such as pain, mouth opening, mandibular deviation, inflammation, swelling, clicking, occlusion, and psychologic evaluation such as anxiety, stress, and depression were assessed before the start of the study and at weekly intervals for 3 months. RESULTS: Posttreatment pain and inflammation improved both in the control group and Experimental A group, but statistically it is highly significant in the Experimental A group. Furthermore, it is effective immediately as well as for a long period in Experimental A group. Improvement in mouth opening was statistically highly significant in control group but not in the experimental groups. Posttreatment anxiety and stress status was improved with statistically highly significant result in the Experimental A and B. The posttreatment depression status along with mandibular deviation, swelling, clicking, and occlusion has not improved significantly in any of the groups. INTERPRETATION AND CONCLUSION: Raj-yoga meditation and pranayama in combination with conventional, noninvasive, treatment modalities showed promising results in MPDS patients as compared to either modalities alone.

Facial asymmetry revisited: Part I- diagnosis and treatment planning.

Facial asymmetry is an individualized characteristic and is commonly observed sub clinically in overall population. However, clinically significant facial asymmetry with associated morphologic, esthetic and stomatognathic problems warrant investigation of the underlying etiology and comprehensive clinical examination in conjunction with imaging studies for diagnosis, localization of asymmetry and treatment planning. The principal aim of this article is to present an invaluable insight into etiopathogenesis, myriad classifications and various systematic diagnostic approaches indispensable for formulation of treatment plan and appropriate management of facial asymmetry.

Facial asymmetry revisited: Part II-Conceptualizing the management.

Management of facial asymmetry is one of the arduous and challenging task to accomplish in disciplines of orthodontics and maxillofacial surgery. This article aims to describe various treatment modalities adopted conjointly by the orthodontist and maxillofacial surgeon, taking into consideration the realistic concerns and expectations of the patient. This would help improve treatment outcomes while ensuring overall well-being of the patient.

The "Red Line" Conundrum: A Concept Beyond Its Expiry Date?

Introduction George Winter attempted to assess the depth and difficulty of extracting impacted mandibular wisdom molars by describing three imaginary lines drawn on an intra-oral radiograph. Of these lines, the red line is the only one which is measured and great importance is attached to its actual length. Method The authors of this short paper describe the difficulty in drawing this red line accurately through examples. Conclusion The authors believe that Winter's lines and their interpretation are only of historical value and have no place in contemporary texts on oral surgery.

A correlation of permanent anterior tooth fracture with type of occlusion and craniofacial morphology.

AIMS: To assess the relationship of anterior tooth fractures with type of occlusion and craniofacial morphology. MATERIALS AND METHODS: The study was conducted on 76 subjects of age group 9 to 13 years with at least one fractured permanent anterior teeth. Lateral cephalograms were taken and study models were prepared for each subject with prior consent of their parents. Then cephalometric tracings were done and overjet was recorded through study models. STATISTICAL ANALYSIS USED: Standard error of mean (SEM) and unpaired t-test has been applied to test the significant difference between the seven parameters under consideration. Karl Pearson correlation test has also been used to correlate all the parameters used in this study with each other. All the tests were performed at 5 and 1% levels of significance. RESULTS: Frequency of tooth fracture increases with increasing overjet. At 5% level of significance, significant difference were observed between the standard values and observed values for overjet measurement, SNA angle, SNB angle, ANB angle, upper incisor to NA (angle), upper incisor to NA (linear) and interincisal angle for overall data and also for both male and female data separately. CONCLUSION: Probability of permanent anterior tooth fracture increases with increasing overjet. A significant difference was observed between the standard value and the observed values of all parameters under consideration. How to cite this article: Chaturvedi R, Kumar A, Rana V, Aggarwal A, Chandra L. A Correlation of Permanent Anterior Tooth Fracture with Type of Occlusion and Craniofacial Morphology. Int J Clin Pediatr Dent 2013;6(2):80-84.

Efficacy of v-y closure of upper lip after le fort I osteotomy advancement and superior repositioning on facial esthetics in comparison to simple continuous closure: a statistical analysis.

This study aims to evaluate efficacy of V-Y closure of upper lip incision on facial esthetics in comparison to simple continuous closure after Le Fort I advancement and superior repositioning of maxilla. Thirty-four patients were divided in two groups i.e. V-Y closure group (group I = 17 patients) and simple continuous closure group (group II = 17 patients). The preoperative and 1 year post-operative linear and angular changes of hard and soft tissue points of groups I and II were statistically compared. Labial changes were more favourable in V-Y closure group in comparison to simple continuous closure group in both the Le Fort I maxillary movements. The upturning and forward movement of the nose were seen in both the maxillary movements but these nasal changes did not differ significantly between the groups. It was observed that the technique of V-Y closure of upper lip delivers adequate results contributing to better facial esthetics when compared to simple continuous closure.