Management Modalities of Aggressive Brown Tumor of the Jaws-a Case Series.

Primary hyperparathyroidism is an endocrine disorder occurring due to increased secretion of parathormone resulting in clinical, anatomical, and biochemical alterations. On the other hand, excision of a parathyroid adenoma can normalize the metabolic status. Brown tumors represent the terminal stage of the remodeling processes during primary or secondary hyperparathyroidism. They are erosive bony lesions caused by rapid osteolysis and peritrabecular fibrosis, resulting in a local destructive phenomenon. Facial skeleton is involved in about 2% of all cases of which the mandible is frequently affected. We report a case series of four patients who presented with brown tumor of both maxilla and mandible. A complete assessment of the medical history, blood investigations and radiological findings combined with biopsy results is necessary for a correct diagnosis. The standard treatment of the Brown tumors is not a surgical resection, but the treatment of the cause of the tumor, which in this case is hyperparathyroidism. However in our case, the extent of the lesion and the non resolution after the parathyroidectomy necessitated a surgical approach in two of our patients however two responded well to medical management alone.

Clear Cell Odontogenic Carcinoma: A Rare JAW Tumor-A Case Report and Literature Review.

Clear cell odontogenic carcinoma (CCOC) is a rare epithelial malignant odontogenic tumor of the jaw with a distinct histology and deceptive behavior. As the clinical presentation is often misleading, the contribution of biopsy, molecular biology, immunohistochemistry and cytogenetics are essential in the diagnostic process. This article describes the presentation of an aymptomatic, painless swelling in the lower jaw of a 63 yrs old female, who was initially diagnosed as an ameloblastoma, taken up for segmental resection, subsequently histopathologically diagnosed as a case of clear cell odontogenic carcinoma and later managed with chemotherapy. Current management protocols and presentation of CCOC have also been reviewed.

Post-Covid Orofacial Mucormycosis: A Clinico-Radiological Classification System and Management Protocol.

Background: In the wake of the second wave of the COVID-19 pandemic, a substantial number of individuals were afflicted by orofacial mucormycosis post-COVID. The immunocompromised state rendered by the SARS-COV2 (Severe Acute Respiratory Syndrome Corona Virus 2) infection provides a breeding ground for the opportunistic mucor invasion. Corticosteroid and COVID-induced hyperglycemia contribute to the unhindered progress of the mucor infection in these patients. The sino-nasal region serves as the entry point and rapid progress of the disease to the oral cavity, mid-face, orbits, and ultimately the brain proves fatal. Aim and Objectives: The aim of this study was to present a definitive clinico-radiological staging/classification system for patients of post-covid mid-face mucormycosis based on combined radiographic and clinical features for subsequent convenient staging of maxillofacial mucormycosis. The objectives are being to lay down a comprehensive management protocol for these patients. Methods: This retrospective study consisted of a cohort of 31 patients presenting to a tertiary care center over a 12-month period and diagnosed as post-covid mucormycosis. Their clinical features at the time of presentation along with radiographic presentation/extent of anatomical destruction were combined to create a clinico-radiological staging system. Further, a comprehensive management protocol including cultures, surgery and chemotherapy has been laid down. Results: This included 18 males and 13 females. Average age of the patients was 53.5 years. As per the clinico-radiological system formulated by the authors, 2 patients (1 males and 1 females) displayed features of Stage 0, 12 patients (7 males and 5 females) of Stage 1-A, 8 patients (5 males and 3 females) of Stage 1-B, 6 patients (4 males and 2 females) and 3 patients (1 male and 2 females) of Stage 3. Conclusion: The lacuna of a comprehensive staging/classification system for patients of maxillofacial mucormycosis was felt by the authors while treating those affected by post-covid mucormycosis along with a detailed algorithm for management of the study population. It is to this effect that this clinic-radiological classification system has been suggested by the authors along with a management protocol.

Effectiveness of Titratable Oral Appliance in Management of Moderate to Severe Obstructive Sleep Apnea-A Prospective Clinical Study with Acoustic Pharyngometry.

To assess effectiveness of titratable Oral Appliance (OA) in management of moderate to severe cases of Obstructive Sleep Apnea (OSA). Thirty Polysomnography (PSG) diagnosed cases of moderate to severe OSA were subjected to a thorough cranio-facial-dental evaluation, a detailed sleep history and three dimensional assessment of upper airway geometry utilising Acoustic Pharyngometry (AP) (Eccovision, sleep group solutions). A titratable OA was delivered to all patients for mandibular advancement. Apnea Hypopnea Index (AHI), Oxygen Saturation (SPO2), Epworth's Sleepiness Scale (ESS), Mean area and volume of upper airway were recorded at Baseline (T0) and after 08 weeks of appliance delivery (T1). The mean AHI & ESS scores were significantly lower and SPO2 was significantly higher at T1 compared to T0 (P-value < 0.05 for all). The mean area and volume of upper airway at T1 were significantly higher compared to values at T0 (P-value < 0.05 for both). The mean area showed 19.51% increase at T1 whereas mean volume increased by 18.55%. OA therapy is highly efficacious in cases with moderate to severe OSA, especially, in those with retrognathic mandible. This modality should be considered as an effective alternate to Continuous Positive Airway Pressure (CPAP) therapy in non-compliant patients rather than no treatment. AP is an effective modality to predict airway changes after advancement with OA, to ascertain follow up changes and is highly recommended in routine clinical practice. Large scale, multicenter studies are recommended to elaborate the findings of the present study and to add better quality evidence in this regard.

Comparative Evaluation of Success in Cases of Synovial Chondromatosis of Temporomandibular Joint Treated with Temporomandibular Joint Arthroscopy: A Case Series.

Introduction: Synovial chondromatosis of the temporomandibular joint (TMJ) is characterized by the formation of multiple nodules of cartilage with varying sizes due to metaplastic development of the synovial membrane. Aetiology revolves with primary lesion, and pathogenesis is still unknown with multiple factors, which includes low-grade trauma or internal derangement. This condition remains undiagnosed and leads to therapeutic challenges from clinical manifestations which are non-specific and needs various tools to diagnose with combination of radiologic and histopathological examination. Materials and Method: We report a case series of five cases which were diagnosed as cases of TMD of the temporomandibular joint. Diagnostic arthroscopy including lysis and lavage with Ringers lactate, hyaluronic acid was carried out. Intra-operative findings were suggestive of synovial chondromatosis. Sample taken for histopathological examination confirmed the diagnosis of synovial chondromatosis of TMJ. Postoperative status of mouth opening and pain was assessed at 15 days, one month, 3 months, 6 months and one year during the review to evaluate the success of arthroscopy of TMJ. Results: All patients reported success with the modality of arthroscopy lysis and lavage at 12 months of follow-up with improvement at every follow-up visit in terms of range of motion and reduction of pain score on VAS. Hence, arthroscopy with lysis and lavage came out to be a promising alternative for open joint surgery in cases of synovial chondromatosis of the TMJ with same outcomes in relieving patients who complain of reduced maximum inter-incisal opening and pain. Conclusion: Thus, arthroscopic procedures can be considered an alternative and effective modality for successful management of cases of synovial chondromatosis of temporomandibular joint.

Rehabilitation of Auricular Defect with Implant-Retained Auricular Prosthesis - A Case Report.

RATIONALE: Maxillofacial defect is of great concern physically, emotionally, and psychologically for a patient. However, it is an even bigger challenge for a team attempting rehabilitation, as a crucial decision has to be made between surgical approach and/or prosthetic rehabilitation. However, if both are combined, it will result in best of esthetics and function with ease of maintainance, resulting in a sucessful rehabilitation. This case report represents a case of auricular defect rehabilitated with a combination of implants and bar-retained silicone prosthesis. PATIENT CONCERN: A 38-year-old male patient with right auricular defect reported with the main concern of esthetic rehabilitation of a lost part of the external ear. DIAGNOSIS: With through evaluation and examination, a diagnosis of acquired partial auricular defect of the right side secondary to trauma was established. TREATMENT: An implant-retained auricular prosthesis was planned for this case. Surgically, three intraoral implants were placed in the mastoid bone, and after healing, bar framework was fabricated and attached. Finally, silicone prosthesis was fabricated and delivered to the patient. OUTCOME: A successful rehabilitation was carried out in this case using implants and bar attachment for retention of the silicone prosthesis. This prosthesis provided excellent retention and restored the appearance and confidence of the patient. TAKE-AWAY LESSONS: Rehabilitation of the auricular defect can be carried out with surgical approach, which involves multiple surgeries, and still, the results may not be esthetically favorable. Prosthetic rehabilitation is an option, but retention is generally a hindrance. However, implant-retained prosthesis has really paved a way for rehabilitation of the maxillofacial defect esthetically and more reliably. Cone-beam computerized tomography (CT) can be used for planning and evaluation instead of CT, which will save the patient from a lot of radiation exposure. Hence, in the maxillofacial defect, attempts should be made to explore the option of implant-retained prosthesis.

Chimeric temporopareital osteofascial and temporalis muscle flap; a novel method for the reconstruction of composite orbito-maxillary defects.

Reconstruction of midface defects are extremely challenging owing to the lack of suitable vascularized local flaps. The temporoparietal fascia and temporalis muscle flaps make excellent choices for midface and orbito-maxillary reconstruction. The muscle provides adequate thickness while the fascia yields pliable soft tissues for lining the midface. The temporalis muscle can be divided antero-posteriorly in three parts and medio-laterally in two parts without losing its vascularity due to its segmental vascular supply. These versatile flaps can be used independently, combined or as chimeric flap based on its axial blood supply for the reconstruction of midface. When designed as a chimeric flap it makes an excellent choice for the reconstruction of composite midface defects. With the advent of micro vascular reconstruction these regional flaps are rarely used in maxillofacial reconstruction. We hereby present a case of composite orbito-maxillary defect reconstruction using a novel chimeric reverse temporalis muscle and temperopareital fascia flap with pedicled split calvarial bone.

Does methylprednisolone improve postoperative outcomes after mandibular third molar surgery? A systematic review and meta-analysis.

This systematic review and meta-analysis was performed to investigate whether methylprednisolone (MP) administered via any route improves postoperative outcomes (pain, trismus, and oedema) following mandibular third molar surgery. An electronic search of the PubMed, Scopus, Cochrane CENTRAL, and Google Scholar databases was performed to identify studies published in English up until January 2018. A total of 28 studies were included in the review: 25 randomized clinical trials (RCTs) and three controlled clinical trials. Studies were grouped according to the route of administration of MP for qualitative and quantitative analysis. Three studies were of 'high' quality and 22 were of 'medium' quality; three studies had a high risk of bias. Within the purview of the limitations of this review, the results showed that MP administered via any route significantly improves oedema in the early postoperative period, but has no effect on late postoperative oedema. Oral and intra-masseteric MP also seems to reduce pain and trismus in the early postoperative period. The results also indicate that oral MP may reduce late postoperative pain, while intra-masseteric MP may improve the late trismus outcome. More high quality RCTs are required to provide stronger evidence on the use of MP in third molar surgery.

Early Postoperative Malignant Subcutaneous Emphysema: Report and Review.

BACKGROUND: Subcutaneous emphysema is defined as presence of air or gas in subcutaneous tissue layer. It may be localized or generalized due to various aetiological factors. Although SE and pneumomediastinum are self-limiting conditions, life-threatening complications may develop. Escape of air into both pleural cavity causing bilateral pneumothorax and tension pneumothorax can be termed as malignant emphysema. PURPOSE: To report a case of malignant generalized subcutaneous emphysema in early postoperative phase following palatoplasty. CASE REPORT: A 25 year old female patient was operated for closure of residual oronasal communication using an anteriorly based tongue flap. The patient was reversed from general anesthesia and shifted to the post-operative room with the endotracheal tube in situ. Sudden swelling of the face and periorbital area was noticed which spread all over the body. A diagnosis of malignant post-operative subcutaneous emphysema was made and the patient was shifted back to the operation theatre. She was managed successfully by bilateral tube thoracotomy and tracheostomy. CONCLUSION: Close observation of the patient in early postoperative stage having endotracheal tube in situ is crucial to avoid such complication. Regardless of aetiology, early recognition of the clinical features of tension pneumothorax and timely intervention are necessary for the survival of the patient.

Mandibular fracture in a neonate.

Mandibular fractures in the neonate are rare. The aetiological factors are traumatic delivery, accidental fall, road traffic accidents, and attempted infanticide. The diagnosis is difficult due to facial oedema masking the clinical features and the absence of dentition. The treatment of fractures in the newborn represents a unique problem in terms of investigations, diagnosis, selection of anaesthesia, and method of fixation. The case of a 1-day-old infant referred for the management of a mandibular fracture sustained in an accidental fall is presented herein. During oral suctioning, the neonatologist observed continuous blood-stained secretions, which raised the suspicion of a trauma to the oral cavity. The infant was diagnosed as having a fracture of the mandibular symphysis with displacement. The fracture was reduced under local anaesthesia with sedation, and was stabilized with an acrylic splint, which was secured with circum-mandibular wiring. The patient was followed up for 1.5 years and the healing was satisfactory.

Distraction Osteogenesis for Management of Severe OSA in Pierre Robin Sequence: An Approach to Elude Tracheostomy in Infants.

BACKGROUND: Severe obstructive sleep apnoea (OSA) is a life threatening condition associated with Pierre Robin sequence (PRS) due to mandibular micrognathia and glossoptosis. Often these patients require tracheostomy at an early age which has high morbidity. Distraction osteogenesis (DO) is an accepted method of treatment for patients with hypoplastic mandible to achieve mandibular lengthening without need for a bone graft. It has also been used in respiratory distressed neonates and infants to avoid tracheostomy. CASE REPORT: An eight month old baby, a diagnosed case of PRS with severe OSA and recurrent episodes of aspiration pneumonia and on nasogastric tube feeding since birth was referred to us for evaluation and possibility of therapeutic augmentation of the mandible by DO. After a thorough clinico-radiological assessment the child was operated for bilateral extraoral placement of horizontal corpus distractor. A total distraction of 12 mm was carried out and consolidation of callus was monitored by USG. Postoperatively the patient was followed up for 12 months. Presently she has normal respiratory and feeding function without any episode of aspiration pneumonia. CONCLUSION: Mandibular corpus DO is a safe and effective technique that can be applied to predictably relieve severe upper airway obstruction in selected PRS cases. In order to avoid the limitations of alternative surgical procedures and the tracheostomy-associated morbidity, DO should be considered among the routine treatment modalities.

Zurich pediatric distractor for ramal condylar unit distraction in temporomandibular joint ankylosis.

Temporomandibular joint (TMJ) Ankylosis is an extremely disabling condition characterized by difficulty or inability to open the mouth resulting in facial asymmetry, malocclusion and dental problems. Surgical excision of the ankylosed mass is the only treatment option available to gain mouth opening. The loss in vertical height of ramus following release of ankylosis is difficult to manage in both unilateral and bilateral TMJ ankylosis. Out of all the methods to restore this height Distraction Osteogenesis (DO) is gaining popularity because of predictable gain in the length without any associated morbidity. Recurrent bilateral TMJ ankylosis in a 32 year old male was treated by osteoarthrectomy and temporal fascia interpositioning arthroplasty. Bilateral reconstruction of ramal condylar unit (RCU) was carried out by Zurich paediatric distractor (KLS Martin, Tuttlingen Germany). Following a latency period of 7 days distraction was carried out at a rate of 1mm/day for 8 days. Distractors were removed after 12 weeks of consolidation period. The case was followed up for 12 months during which the mouth opening was maintained at 38 mm and there was no anterior open bite.

Collision tumor of maxilla: a diagnostic dilemma.

Most malignant tumors arise from the primary tissue except when showing extreme dedifferentiation. This can be identified by examination of tumor cells and their products. Occasionally two distinct tissues are recognized within a malignant tumor. In mixed malignant tumors both carcinomatous and sarcomatous elements are present either because of simultaneous malignant change occurring in the epithelium and its nonepithelial stroma or there is a sarcomatous transformation of stroma of a carcinoma. Willey's in 1960 stated that in these circumstances the resulting tumor must be classified as a "carcino-sarcoma". These separate tumors arise in nearby structures and may grow to infiltrate in each other resulting in a tumor mass. The present article is a report of a diagnostic dilemma in an extremely rare carcinosarcoma of maxilla in a 24 year old male which was first on biopsy reported as odontogenic myxoma. After resection (right maxillectomy under GA using Weber Fergusons approach with Diffenbach's extension) was diagnosed as Squamous Cell Carcinoma arising from lining of the maxillary antrum associated with Osteogenic Sarcoma (chondroblastic differentiation) of maxilla with negative margins. The tumor was restaged to T2NoMx and further managed as per National Comprehensive Cancer Network Guidelines. Immunohistochemistry later re-diagnosed it to be an Osteogenic Sarcoma maxilla with chondroblastic differentiation. 'T' stage remains the most reliable predictor of survival and loco-regional control. Complete surgical resection for all 'T' stages (except T4b, any N) followed by postoperative therapy remains a corner stone of treatment of maxillary sinus tumors.

Evaluation of the hard and soft tissue changes after maxillary advancement with rigid external distractor in unilateral cleft lip and palate induced maxillary hypoplasia.

BACKGROUND: Midfacial growth retardation in cleft lip and palate (CLP) cases, is seen in all the three dimensions. Conventionally these cases are managed by orthographic surgery which has a high rate of relapse. The application of the distraction osteogenesis (DO) has revolutionized the management protocol. The aim of the study was to evaluate the efficacy of rigid external distractor (RED) in management of cleft induced maxillary hypoplasia. METHODS: Ten cases of unilateral CLP between 11 and 20 years of age having gross midfacial deficiency and those who have undergone presurgical orthodontic treatment were included in the study. The cases were operated for Le Fort 1 osteotomy and application of RED. DO was carried out through transnasal traction wires. Clinico-radiological evaluation of presurgical and 1, 6 and 12 months post distraction parameters were statistically analysed by application of paired 't'-test. RESULT: There were 4 males and 6 females with a mean age of 15.1 years. The mean distraction carried out was 14.95 mm. There was a significant improvement in all the hard and soft tissue parameters except SNB. Facial profile improvement and stable occlusion was achieved in all the cases. CONCLUSION: Midfacial DO using RED is a versatile procedure where the maxilla can be moved in multiple planes to achieve a functional, aesthetic and occlusal balance. Keeping in view of the significant relapse rate the clinicians are required to plan 15-20% excess amount of distraction.

Stability of Cleft maxilla in Le Fort I Maxillary advancement.

CONTEXT: Le Fort 1 maxillary osteotomy in operated patients of cleft lip and cleft palate (CLCP). AIMS: To study stability of Le Fort 1 maxillary osteotomy in operated patients of CLCP by two-dimensional evaluation using cephalometric analysis. SETTINGS AND DESIGN: Prospective study conducted at Army Dental Centre (Research and Referral) from May 2009-May 2012. MATERIALS AND METHODS: Subjects included nine consecutively operated patients of CLCP with maxillary hypoplasia. Maxillary advancement by Le Fort 1 maxillary step osteotomy was performed. There were four males and five females with an age range of 16-18 years and follow-up range was 12-36 months. Presurgical and postsurgical changes were compared using cephalometrics for orthognathic surgery (COGS) system to determine stability of maxillary movement and quantify amount of relapse at 15 days and 12 months. STATISTICAL ANALYSIS: Student's t-test. RESULTS: Mean linear horizontal advancement achieved along nasion (N) to anterior nasal spine (ANS) with reference to true vertical plane at 15 days and 12 months was 5.17 and 3.91 mm, respectively. The mean relapse in anteroposterior dimension was 21.63%. The mean vertical displacement observed along nasion and ANS with reference to true horizontal plane at 15 days and 12 months was 5.21 mm and 3.2, respectively with a resultant relapse of 41.54%. CONCLUSIONS: Based on clinical and COGS analysis, it is evident that Le Fort 1 advancement in operated cases of CLCP has inherent potential for relapse.

Implant rehabilitation of partial maxillectomy edentulous patient.

Edentulous patients with maxillectomy defects present a significant challenge for prosthetic rehabilitation and the adaptive capabilities of the patient as retention is highly compromised. Hence, the option of using endosseous implants to increase obturator retention has been used. A patient of mucormycosis of the left maxilla was treated with surgical excision. After satisfactory healing, definitive implant supported magnet retained prosthesis was fabricated for the patient. Implants with magnetic units offer a practical method of improving the retention of obturators provided acceptable prosthetic protocols are followed for the rehabilitation.