Morphometric and Volumetric Measurements of Orbit With Cone-Beam Computed Tomography.

PURPOSE: The purpose of this study was to determine cone-beam computed tomography (CBCT) as a tool for measuring morphometric and volumetric measurements of the orbit. Also, to assess gender and age variations and compare traditional methods of measurements in dry-skull, cadaveric, and other imaging modalities. PATIENTS AND METHODS: Morphometric and volumetric values of 98 orbits (49 subjects, 21 men/28 women) were measured using CBCT. Their mean and standard deviation were measured and analyzed. The gender and age variability older and younger than 40 years were evaluated. They were compared with other dry-skull and imaging studies done among different populations. RESULTS: CBCT could accurately measure the various morphometric and volumetric parameters of the orbit. From the reference point infraorbital foramen (I) to lacrimal fossa (F1), inferior orbital fissure (F2), inferior orbital rim (F3), and the optic canal (F4) were (in mm) (mean ± SD) 22.88 ± 1.08, 32.53 ± 0.88, 7.44 ± 0.71, and 51.45 ± 1.28, respectively. From the reference point, superior orbital notch/foramen (S) to superior orbital fissure (S1), lacrimal fossa (S2), and the optic canal (S3) were 49.29 ± 2.1, 26.39 ± 1.58, and 46.82 ± 0.88, respectively. From the reference point frontozygomatic suture (L) to lacrimal fossa (L1), superior orbital fissure (L2), the optic canal (L3), and inferior orbital fissure (L4) were 18.19 ± 0.88, 39.91 ± 1.44, 47.63 ± 1.11, and 35.19 ± 1.02, respectively. Orbital volume was found to show a significant difference between older and younger than 40 years of age, though not significant compared between men and women. CONCLUSION: CBCT is a viable tool for morphometric and volumetric measurements of the orbit and other orocraniofacial structures. It can also assess age and gender variability. The low cost, high accuracy, low radiation, and ease of use can help in reproducibility among the different living populations.

Surgical Management of Complex Odontoma Associated with Agenesis of a Molar.

Odontomas are mixed odontogenic tumors composed of mineralized tissue of ectomesenchymal origin. These are usually detected in routine radiographs and may have a variable etiology such as local trauma, genetic mutation, or infection. They are classified into two main types: complex and compound. Complex odontomas are rare and they rarely erupt into the oral cavity as they lack periodontal ligament. This is the report of one such case of complex odontoma where an 11-year-old girl reported with an asymptomatic swelling, in relation to the left angle of the mandible. The case report highlights the clinical and radiographic findings, investigations done to arrive at the diagnosis and the treatment rendered. This report is of clinical importance because of its rare association with the agenesis of a molar tooth.

Multidisciplinary Approach for Management of a Patient with Oral Mucosal Malignant Melanoma.

Oral mucosal melanoma is rare and more aggressive than cutaneous melanoma. Hard palate and maxillary alveolar crest are most commonly involved. Multidisciplinary team approach is necessary for successful management of this tumor. The main treatment modality is surgical resection, which usually results in impaired mastication, deglutition, speech, oral competence and significant cosmetic deformity. Here, a rare case of oral mucosal melanoma of mandibular gingiva in a 44-year man is reported, who was treated by en-block mandibular resection followed by adjuvant therapy with high dose interferons (IFN) - 2b. Following two weeks of healing period, prosthetic rehabilitation of the patient was done with an interim removable denture prosthesis, which effectively limited the unfavourable effects of surgery and helped him in resocialisation.

Expression of Laminin in Oral Squamous Cell Carcinomas

Background and objectives: Laminin is a significant basement membrane (BM) glycoprotein, the expression of which reflects BM integrity more precisely than do other ECM proteins. The present study aimed to evaluate laminin expression in oral squamous cell carcinomas OSCC and to determine any associations with clinico-pathological parameters (surgical margin status, lymph node involvement, survival and recurrence). Methods: Laminin expression was evaluated in 31 cases of biopsy-proven OSCC by immunohistochemical staining and its association with prognosticators and the Brynes grading system was determined by appropriate statistical analysis. Results: We observed a significant increase in linear staining pattern (p<0.001) at the tumour-host interface in well-differentiated OSCC cases, in contrast to poorly differentiated lesions which exhibited intense cytoplasmic expression within tumour cells. Higher cytoplasmic laminin expression was seen in 33.3% of cases with involved surgical margins and 69.2% of cases with lymph node metastasis (along with weak/absent staining of laminin around the tumour-host interface ­ Basement membrane around tumour islands). Similarly, in 60% of the cases who died and in 81.8% of cases with tumour recurrence, moderately intense cytoplasmic laminin expression was seen within tumour cells. On comparing variables of the Brynes grading system, significant cytoplasmic expression of laminin was linked with mild inflammation (p<0.0016) and increased mitotic activity (p<0.008). Conclusion: Based on these observations, immunohistochemical expression of laminin might be useful to evaluate histological differentiation and aggressiveness of OSCCs.

Dysgenetic Polycystic Disease of Minor Salivary Gland: A Rare Case Report and Review of the Literature.

Polycystic (dysgenetic) disease of the salivary glands is a rare entity that has only recently been described in the literature. The disease is more commonly seen in females and majority of the cases have presented as bilateral parotid gland swellings. This case presenting in a 21-year-old male is the first of this unusual entity involving solely the minor salivary gland on the lower lip. This case report highlights the importance for the clinician to be aware of this differential diagnosis, when treating an innocuous lesion like a mucocele.

Dautrey's Procedure Revisited in Management of Recurrent Mandibular Dislocation.

INTRODUCTION: Mandibular dislocation occurs when the condylar head glides out of the glenoid fossa with the condyle positioned in such a way that its posterior articulating surface lying ahead of the articular eminence. Recurrent mandibular dislocation is relatively uncommon. Patient is extremely distressed and goes through a lot of discomfort. Varied etiologies have been cited in the literature, such as keeping the mouth wide open for long periods of time during dental procedures, yawning, laughing, traumatic injuries to the mandible, psychiatric disturbances, and certain drugs. Acute dislocations are best managed immediately by reduction and intermaxillary fixation. However, dislocations that have remained over a period of a month are considered to be chronic and these cannot be reduced successfully by manual manipulation of the mandible. Such chronic recurrent dislocations are surgically managed with eminectomy, meniscectomy, and condylotomies. A downward and forward osteotomy of the zygomatic arch in front of the articular eminence so as to produce a mechanical obstruction was recommended by Dautrey and Gosserez. This article will highlight the surgical experience of managing six patients with chronic recurrent dislocations of the temporomandibular joints (TMJs) bilaterally employing Dautrey's procedure.

Tumour-Associated Tissue Eosinophilia in Oral Squamous Cell Carcinoma- A Boon or a Bane?

INTRODUCTION: The infiltration of tumour stroma by eosinophils, Tumour-Associated Tissue Eosinophilia (TATE) is known to modulate the evolution of Oral Squamous Cell Carcinoma (OSCC). Identification of eosinophils in the inflammatory stroma has been proven to be an important factor in prognostication of malignant tumours including cancers of mouth, oesophagus, larynx, pharynx, breast, lung, intestine and genitourinary tract. AIM: Our study aimed to assess the role of TATE as a prognosticator in OSCC as visualized by Haematoxylin and Eosin (H&E) and congo red staining. MATERIALS AND METHODS: Thirty histologically-proven cases of OSCC were retrieved from the archives of Department of Oral Pathology, Manipal College of Dental Sciences, Mangalore, Manipal University, Karnataka, India. Two serial sections of 4µm thickness were made and subjected to routine staining with H&E and modified congo red staining, where eosinophil granules stained red and nuclei stained blue. In 40x magnification, 10 HPF at invasive tumour front were assessed for counting eosinophils by placing a 49 square grid (measuring 0.0289 sq mm). STATISTICAL ANALYSIS: The TATE was compared with the prognosticators using Mann-Whitney U-test. The grades of carcinoma were correlated with TATE using Kruskal-Wallis test followed by Post-hoc Bonferronis correction. Agreement of the number of eosinophils counted in the two staining techniques (H&E and Congo red) in OSCC was achieved using interclass correlation coefficient, and Friedman's test. A value of p< 0.05 was considered statistically significant. RESULTS: Our results showed that tissue eosinophil counts were higher in well-differentiated cases of OSCC, cases with lymph node involvement, decreased survival, without margin involvement and in cases that did not recur. H&E stain showed significantly better visualization of eosinophils resulting in higher eosinophil counts than when seen with Congo red (p=0.008). CONCLUSION: Thus, TATE can be used as a surrogate marker in prediction of survival and recurrence in OSCC. H&E proved to be a better stain for evaluation of eosinophils.

A rare spindle-cell variant of non-Hodgkin's lymphoma of the mandible.

A 64-year-old male farmer presented with a rapidly progressive swelling of the left mandible since 6 months. The swelling was firm to hard, diffuse, nontender, obliterating the vestibule with paresthesia of lower lip. The cone beam computed tomography imaging revealed an ill-defined, moth-eaten radiolucency with destruction of the buccal and lingual cortical plates. The rapid growth and aggressive behavior of the lesion coupled with guidance from the patient's previous reports from the incisional biopsy and fine needle aspiration cytology warranted a mandibular resection. Microscopic examination showed an encapsulated lesion situated in the connective tissue containing a mixture of proliferating spindle-shaped cells arranged in fascicles and round cells infiltrating into the connective tissue stroma and bone. The neoplastic cells exhibited atypical features such as pleomorphism, hyperchromatism and increased mitotic figures with noncleaved nuclei. A working diagnosis of a spindle-cell sarcoma was arrived at with various differentials provided such as fibrosarcoma, rhabdomyosarcoma, leiomyosarcoma, malignant peripheral nerve sheath tumor, Langerhans cell histiocytosis and lymphoma and stating the need for immunohistochemistry to subtype the tumor. The neoplastic cells were negative for Van Gieson's stain and Masson's trichrome. Immunohistochemical analysis performed using desmin, smooth muscle actin, S-100 and CD1a in a bid to determine the phenotype of the tumor and rule out the previously stated differentials were all negative for the lesion. Lymphoid markers such as leukocyte common antigen and CD20 (cluster differentiation marker for B-cells) showed positivity in spindle-shaped cells as well as round cells indicating the tumor to be a lymphoproliferative lesion of B-cell type. A final diagnosis of "spindle-cell variant of non-Hodgkin's lymphoma" was rendered based on the immunohistochemical profile.

Revisit of Nasolabial Flap in the Reconstruction of Defects Involving the Oral Floor.

AIM: The aim of this article is to present the usefulness of the nasolabial flap (NL flap) along with a detailed review of the factors that lead to its selection for the reconstruction of post-ablative oral floor defects. MATERIALS AND METHODS: The records of patients who underwent the procedure between June 2009 and June 2011 were retrospectively analyzed. A total of 16 reconstructive procedures were performed. NL flap was selected for reconstruction in all the cases due patient related factors mainly associated medical comorbidities, resource constraints, and the relatively small size of defects, which precluded the use of free flaps. RESULTS: None of the flaps were lost, 26% of patients had flap related complications. Most of the complications were minor and managed conservatively. CONCLUSION: Data from this study suggest that NL flap is a reliable option for reconstruction of the oral floor, in form as well as function, without esthetic compromise and has a major role even in this era of free flaps.

Bone wax to improvise a screw-holder: a makeshift emergency tool.

A missing screw-holder threatened cancellation of a case of facial trauma surgery. We present a simple makeshift tool using bone wax to improvise a temporary replacement for the screw-holder missing in our surgical instrument kit. This impromptu set-up is especially useful when operating in the field and faced with mass casualties.

Multidisciplinary approach for management of a patient with fibrous dysplasia of maxilla.

Fibrous dysplasia is a non-neoplastic hamartomatous developmental fibro-osseous lesion of bone. Monostotic fibrous dysplasia is more common than the polyostotic form and usually involves jaw bones, ribs and femur. Maxillary lesions may extend to involve the maxillary sinus, zygoma, sphenoid bone and floor of the orbit and require surgical intervention resulting in an acquired defect of the involved site. A multidisciplinary team approach involving an oral pathologist, oral surgeon, oral medicine expert and maxillofacial prosthodontist is required for successful treatment and rehabilitation of such patients. This article describes a case of a patient with fibrous dysplasia of the left maxilla, which was successfully managed by integrating surgical intervention and postoperative rehabilitation, with a surgical obturator and an interim partial denture prosthesis that successfully limited the detrimental effects of surgery, and helped the patient in resocialisation, thereby improving her quality of life.

The Effects of Topical Hemocoagulase Solution on the Healing Process of Post-extraction Wounds: A Split Mouth Design.

OBJECTIVES: To evaluate the effects of topical hemocoagulase on intra-oral extraction sockets and impact on the healing process as well as to produce a clinico-histological healing score. STUDY DESIGN: This prospective study compared two extraction sites in each subject. One site received topical hemocoagulase while other site did not receive it. Both the sites were chosen in the same patient and extraction was done at separate intervals. The biopsy was done on a random basis with the pathologist being blinded to the study. Clinical evaluation was done on days 7, 14 and 21. Biopsy was done either on days 7 or 14 for the case as well as for the control. A clinical as well as histological score was developed and the healing was assessed. Statistical analysis was done using Wilcoxon signed rank test and p value ≤ 0.05 was considered significant and z-score was also calculated. RESULTS: The clinical score did not show any statistical significance. The histological total score on day 14 and combined overall analysis of days 7 and 14 showed statistical significance. There was an increased incidence (n = 4) of osteoid formation in the hemocoagulase group on day 14. CONCLUSION: The application of hemocoagulase may improve and accelerates the process of wound healing in extraction sockets.

Fracture of the coronoid process associated with frontosphenoidal fractures.

Coronoid process fractures are rarely encountered, commonly undiagnosed, usually asymptomatic, and most commonly treated conservatively, hence very little written about. We present two cases of coronoid process fractures with associated frontosphenoidal injuries.

Epidermoid cyst of the floor of the mouth.

Dermoid cysts are malformations that are rarely seen in the oral cavity. An intraoral dermoid cyst grows slowly, but may enlarge and interfere with deglutition and speech, or can pose a critical risk to the airway and therefore require immediate surgical intervention. Dermoid cysts may develop above or below the mylohyoid muscle, causing a submental or submandibular swelling. Surgical excision is the treatment of choice and recurrence is rare. An intraoral approach for the treatment of large lesions presenting above the mylohyoid muscle provides good cosmetic and functional results. We report a case of a 26-year-old female who developed an epidermoid cyst presenting as a large sublingual swelling causing speech and swallowing difficulties. The lesion was surgically excised using an intraoral approach. Microscopic examination revealed a dermoid cyst of the epidermoid type. This case shows that dermoid cysts may be successfully diagnosed and managed using a series of simple yet effective clinical procedure.

Necrotizing sialometaplasia: A rare lesion that mimics oral cancer clinically and histopathologically.

With screening for oral cancer being increasingly performed by physicians, ulceroproliferative lesions of the oral cavity that resemble carcinoma may present a diagnostic challenge. We present one such case wherein the lesion resolved spontaneously after incisional biopsy. A clinical diagnosis of necrotizing sialometaplasia was confirmed by histopathology. General medical practitioners and otolaryngologists should consider this rare lesion in the work up of a suspicious oral ulcer. Decisions must be based on biopsy and clinicians should resist the urge to make diagnoses unsupported by biopsy or at least toluidine blue staining.