Does distraction osteogenesis improve the airway volume and quality of life of obstructive sleep apnoea patients secondary to temporomandibular joint ankylosis?

Temporomandibular joint (TMJ) ankylosis leads to mandibular micrognathia that severely collapses the upper airway causing obstructive sleep apnoea (OSA), resulting in deterioration and compromise in the quality of life (QoL) of patients. In this study, we aimed to calculate airway volume changes, apnoea-hypopnoea index (AHI), and improvement in quality of life before and after distraction osteogenesis (DO). Fourteen Patients with OSA secondary to TMJ ankylosis at a mean (SD) age of 17.5 (5.43) years were enrolled in this prospective study. Multivector mandibular distractors were used in all patients following the standard Ilizarov distraction protocol with a mean (SD) anteroposterior distraction of 16.21 (4.37) mm and a consolidation period of 116.92 (14.35) days. The patients were followed up for six months. A polysomnography test (PSG) was done to quantify AHI and a low-dose computed tomographic scan was done to calculate airway volume using Dolphin medical imaging software pre and post-DO. The QoL of the patients was calculated using the OSA-18 questionnaire. Results analysis depicted that the mean (SD) preoperative AHI was 51.44 (37.99)/h which was improved to 9.57 (9.74)/h (p = 0.001) after DO. Airway volume was calculated on Dolphin software before and after DO showed a significant improvement in airway volume by 121.12% (98.30)%. Similarly, the OSA-18 questionnaire showed significant improvement in QoL from severe to normal. This study suggested that DO increases the corpus length of the mandible, leading to an increment in airway volume, which improves the QoL.

Cross-Sectional Study of Serum Metal Ions in Patients With Metal Implants in the Maxillofacial Region.

Purpose: The purpose of the present study was to measure the serum metal ion levels (titanium, cobalt, chromium) in patients who have metal implants in the maxillofacial region. Methods: The investigators implemented a cross sectional study on patients treated with procedures requiring metal implants for management of maxillofacial trauma, fixation for orthognathic surgery, and total temporomandibular joint replacement (TJR). Inductively coupled plasma mass spectrometry was used as an analytical method to detect metal ions in serum samples. Results: The study comprised of 50 patients who were divided into 4 groups- group I- total TJR (n = 18), group II- orthognathic (n = 8), group III- trauma (n = 8), and group IV- control (n = 16). The mean values of metal ions level were raised than the control group. Conclusion: The present study's results suggest a rise in serum metal ion levels after the metal implantation in maxillofacial region. None of the patients had any abnormal signs and symptoms due to raised metal levels. Further studies are warranted to correlate the serum metal ion levels and their clinical relevance.

Telangiectatic osteosarcoma of maxilla in a young child.

Telangiectatic osteosarcoma (TO) is an uncommon variant of osteosarcoma that primarily afflicts young adults. In this case report, we describe a unique instance of TO occurring in a young child's maxilla. Under microscopic examination, it reveals abundant blood-filled spaces, extensive hemorrhagic regions, alongside atypical pleomorphic tumor cells and osteoid. It is crucial to conduct a meticulous histopathological examination to distinguish TO from other lesions, such as aneurysmal bone cysts and Ewing sarcoma.

Role of iodoform in jaw lesions: a systematic review.

Iodoform formulations are used as packing material following the surgical removal of jaw lesions. The purpose of this review was to explore the evidence and efficacy of iodoform-based dressings. We have systematically reviewed published articles according to the PRISMA statement. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and the Cochrane Library database for articles mentioning the use of iodoform as dressing material for jaw lesions from January 2000 to March 2022. Finally, 92 studies were included. A total of 386 patients whose ages ranged from five months to 86 years (male n = 180, female n = 117). Different formulations of iodoform used were BIPP (n = 67), Whitehead's varnish (n = 17), iodoform (n = 7) and, iodine (n = 1) for its antiseptic properties. An iodoform impregnated gauze pack was changed once a week, most commonly, for a stipulated duration, until complete healing of the cavity. In the present review, iodoform was used, most commonly, in pathological cavities following surgical treatment of ameloblastoma and odontogenic keratocyst. Toxicity was reported in two studies. Based on the current review, iodoform is relatively safe and can be used in the management of extensive jaw lesions in which secondary healing is expected. Prospective and randomised control trials are recommended to assess the efficacy of various formulations and to delineate the timeframe for patient compliance.

Longitudinal surveillance of serum titanium ion levels in patients with indigenous 3D printed total temporomandibular joint replacement.

The purpose of this longitudinal study was to surveil the serum titanium ion levels at various time intervals in patients with indigenous 3D-printed total temporomandibular joint replacement (TMJ TJR). The study was conducted on 11 patients (male: 8; female: 3) who had undergone unilateral or bilateral TMJ TJR. Blood samples were drawn preoperatively (T0), 3 months (T1), 6 months (T2), and 1 year (T3) postoperatively. Data were analyzed and a p value of < 0.05 was considered statistically significant. The mean serum titanium ion levels at T0, T1, T2, and T3 was 9.34 ± 8.70 µg/L (mcg/L), 35.97 ± 20.27 mcg/L, 31.68 ± 17.03 mcg/L, and 47.91 ± 15.47 mcg/L respectively. The mean serum titanium ion levels increased significantly at T1 (p = 0.009), T2 (p = 0.032), and T3 (p = 0.00) interval. There was no significant difference between unilateral and bilateral groups. Serum titanium ion continued to show increased levels till the last follow-up of 1 year. These initial serum titanium ion levels increase is due to the initial wear phase of the prosthesis which manifests over 1 year. Further studies with large sample sizes and long-term follow-ups are required to see the deleterious effect if any on the TMJ TJR.

Epithelioid inflammatory myofibroblastic sarcoma arising in the maxilla: first reported case in the jaws.

Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is a rare variant of inflammatory myofibroblastic tumors located mostly in the intra-abdominal region. Herein, we present a case of a 32-year-old male with a lobulated growth in the right maxilla. Radiology revealed a solitary osteolytic lesion with an irregular margin, causing buccal and palatal cortex erosion. Histopathology revealed a tumor composed of spindle-shaped fascicles that blend into sheets of round to ovoid-shaped epithelioid cells, areas of myxoid changes, and necrosis. Tumor cells showed a moderate amount of eosinophilic cytoplasm, large vesicular nuclei with coarse chromatin, nuclear pleomorphism, and increased mitoses. Tumor cells were immunopositive for ALK-1, focal positivity for smooth muscle actin, panCK, epithelial membrane antigen, and immunonegativity for CD 30, desmin, CD34, and STAT6. P53 showed a wild-type staining pattern, and INI-1 expression was retained. The Ki-67 proliferative index was 22%. To the best of our knowledge, this is the first case of EIMS occurring in the maxilla.

Long term follow-up results of enucleation as the definitive treatment for melanocytic neuroectodermal tumour of infancy and a review on its treatment.

Introduction: Melanotic Neuroectodermal tumour of Infancy (MNTI) is a rare entity of pigmented neoplasms of head and neck region. It predominantly occurs within the first year of life. The authors present enucleation as the definitive surgical treatment, with reference to the five departmental cases of MNTI with no recurrence at 5years and 1year of follow-up of other 4 cases. Case presentation: Five cases of MNTI (age group of 2.5months-7 months) presented to our department as a large bluish-brown non tender swelling protruding into the oral cavity. Radiologic imaging revealed a well-circumscribed solid-cystic enhancing lesion causing elevation of orbit and nasal obliteration in maxillary region and causing buccolingual expansion in mandible. The tumor was enucleated without any bony margin. Histopathological and immunohistochemical evaluation (EMA, Pan Cytokeratin, HMB45, S100, p53, ki67) were done. Patients were followed up at regular intervals and had no recurrence at mean 3years follow-up. A detailed mention of surgical pearls, differential diagnosis and a brief literature review are also done. Conclusion: MNTI is a pigmented neoplasm that occurs in infants and in head and neck region mostly involves the upper alveolus and maxilla, followed by skull and mandible. Incisional biopsy is needed to confirm the tumour and rule out other malignant round cell tumours. Enucleation of the lesion is necessary without the need for any extra bony margin removal. Close long term follow up is necessary. Conservative surgical approach is usually the best first choice for MNTI treatment.

Nonendoscopic intraoral approach for condylar fracture management-a systematic review.

OBJECTIVE: The recent trend favors the open reduction and internal fixation of condylar fractures to prevent long-term consequences. Nonendoscopic intraoral approach is an option for management without a visible scar. The purpose of this systematic review was to explore the evidence, armamentarium, methods of reduction and fixation, challenges, and complications. STUDY DESIGN: We have systematically reviewed published articles on the intraoral approach for condylar fracture management following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane library database, to find relevant articles from January 1980 to March 2022. Descriptive statistics were applied to obtain the results. RESULTS: Finally, 23 studies were included. The incision described for the intraoral approach was similar to sagittal split osteotomy in all studies. A wide array of specialized instruments, methods, and challenges has been outlined for visualization, reduction, and fixation. The incidence of complications in the entire review was 23% (72/306). CONCLUSION: The challenges encountered in the nonendoscopic intraoral approach for condylar fracture management can be negated with the use of specialized instruments and with experience. However, further research is warranted for a specialized set of miniature instruments to ease the procedure, make it time-efficient and optimize hardware selection.

A rare case of bilateral pseudoaneurysm secondary to mandibular condyle fracture-a case report with review of literature.

This paper aims to present a rare case report of bilateral pseudoaneurysm secondary to condylar fracture and its management with a brief review of literature. A patient of age 19 years with alleged history of road traffic accident presented 6 weeks lately to our department with slow growing swelling in right preauricular area. History revealed bilateral condylar fracture with right parasymphysis fracture of mandible for which patient underwent maxillomandibular fixation for 4 weeks. The diffuse swelling in preauricular region showed positive signs of pulsation and audible bruit. Ultrasonography and contrast-enhanced computed tomography suggested the bilateral presence of vascular anamoly from the terminal branches of external carotid artery. Diagnostic angiography confirmed presence of pseudoaneurysm at the bifurcation of the internal maxillary artery and superficial temporal artery (STA) on right side whereas on the left side it was at proximal STA. Bilateral endovascular coil and gel foam embolization was done and thrombosis was confirmed with high frequency ultrasound on fourth postintervention day. The swelling completely resolved in a period of 1 month with no evidence of recurrence in the following 2-year follow-up period. Routine investigation revealed presence of pseudoaneurysm on left side which was completely without any clinical signs as repoterd by many cases of condylar fracture in the literature review. Pseudoaneurysm may remain silent and are exposed intraoperatively with massive bleeding which causes significant morbidity. Hence, prompt diagnosis and management is essential to avoid unexpected complication perioperatively.

How does changing the vector of transport disc distraction affect the outcomes of surgery in patients of temporomandibular joint ankylosis with obstructive sleep apnea?

PURPOSE: Temporomandibular joint ankylosis (TMJA) in children is associated with retrognathia, reduction in pharyngeal airway volume (PAV), and obstructive sleep apnea (OSA). Distraction-osteogenesis (DO) is the proven method in the management of OSA. There is paucity in literature about the effect of distraction vector on PAV. It can be expected that an oblique vector would improve PAV and relieve OSA. Thus, the study was designed to explore the feasibility, advantages, and disadvantages of this modified technique for managing TMJA and OSA simultaneously. MATERIALS AND METHOD: The investigators designed a prospective study on patients of TMJA with retrognathia. Ethical approval was obtained (IECPG-547/14.11.2018). In all patients, simultaneous ankylosis release and mandibular distraction were performed. Primary outcome variables were improvement in 3-dimensional (3D) PAV and maximal interincisal opening (MIO). Secondary outcome variables were changed mandibular length, distraction relapse, and re-ankylosis. Paired t-test and multivariate ANOVA were used to assess all the parameters. RESULT: The study included 13 joints in 8 patients of TMJA with retrognathia (2 unilateral and 6 bilateral ankylosis) with mean age of 14.25 ± 7.37 years. Mean distraction performed was 19 ± 4.0 mm. There was a statistically significant improvement of PAV by 225% (p = 0.002), a reduction in Epworth's scale (p = 0.017), an increase in MIO (p = 0.001), and an increase in mandibular length. Three patients had re-ankylosis at the 25-month follow-up. CONCLUSION: The results of the present study conclude that modification of distraction vector improves 3D PAV and MIO in TMJA patients, with the added advantage of a reduction in overall treatment time and improved patient compliance.

Contrast-enhanced multidetector computed tomography features and histogram analysis can differentiate ameloblastomas from central giant cell granulomas.

BACKGROUND: No qualitative or quantitative analysis of contrast-enhanced computed tomography (CT) images has been reported for the differentiation between ameloblastomas and central giant cell granulomas (CGCGs). AIM: To describe differentiating multidetector CT (MDCT) features in CGCGs and ameloblastomas and to compare differences in enhancement of these lesions qualitatively and using histogram analysis. METHODS: MDCT of CGCGs and ameloblastomas was retrospectively reviewed to evaluate qualitative imaging descriptors. Histogram analysis was used to compare the extent of enhancement of the soft tissue. Fisher's exact tests and Mann-Whitney U test were used for statistical analysis (P < 0.05). RESULTS: Twelve CGCGs and 33 ameloblastomas were reviewed. Ameloblastomas had a predilection for the posterior mandible with none of the CGCGs involving the angle. CGCGs were multilocular (58.3%), with a mixed lytic sclerotic appearance (75%). Soft tissue component was present in 91% of CGCGs, which showed hyperenhancement (compared to surrounding muscles) in 50% of cases, while the remaining showed isoenhancement. Matrix mineralization was present in 83.3% of cases. Ameloblastomas presented as a unilocular (66.7%), lytic (60.6%) masses with solid components present in 81.8% of cases. However, the solid component showed isoenhancement in 63%. No matrix mineralization was present in 69.7% of cases. Quantitatively, the enhancement of soft tissue in CGCG was significantly higher than in ameloblastoma on histogram analysis (P < 0.05), with a minimum enhancement of > 49.05 HU in the tumour providing 100% sensitivity and 85% specificity in identifying a CGCG. CONCLUSION: A multilocular, lytic sclerotic lesion with significant hyperenhancement in soft tissue, which spares the angle of the mandible and has matrix mineralization, should indicate prospective diagnosis of CGCG.

Vertical Bone Implant Contact Around Anterior Immediate Implants and Their Stability After Using Either Alloplast or L-PRF or Both in Peri-Implant Gap: A Prospective Randomized Trial.

Purpose: Various graft materials have been studied for filling peri-implant gap (PIG), but there was no similar randomized clinical trial to evaluate the effect of Platelet-rich fibrin or alloplast or their combination on vertical bone implant contact (BIC) around immediate implants and their stability over a period of 1 year. Methods: Immediate implants were placed in maxillary anterior region of 30 subjects (n = 10). Either alloplast (group I) or L-PRF (group II) or both (group III) were used to fill the PIG following randomization chart. Vertical BIC was measured on peri-apical radiographs which were taken immediately after placement, after 3, 6 and 12 months using Image J software. Periotest was used to measure the implant stability at the time of implant placement, at 3, 6 and 12 months after implantation. Results: The comparison of distance from implant shoulder to the first visible bone-to-implant contact (IS-BIC) in each group showed statistically significant bone formation on mesial and distal sides over a 1 year period (p < 0.05). There was no significant difference in IS-BIC distance among the three groups at 1 year (p > 0.05). Periotest values showed that there was significant improvement in implant stability in all groups in 1-year period. On intergroup comparison, the mean difference of periotest values was statistically non-significant among three groups (p > 0.05). Conclusions: All the graft materials were effective in promoting osseointegration when used as PIG filling materials alone or in combination around immediate implants in maxillary anterior region. CTRI No: REF/2015/06/009200.

Does suprahyoid muscle complex pull cause relapse following genial advancement by distraction osteogenesis? An electromyographic study.

Active pull of the suprahyoid muscle complex (SMC) was thought to be the main contributor of relapse in mandibular or chin advancement, but literature evidence lacks human studies that assess the role of the SMC following genial advancement (GeA). This study therefore aimed to analyse the influence of SMC pull on relapse following GeA by distraction osteogenesis based on electromyographic (EMG) changes. EMG was recorded and analysed preoperatively (T0), at four months (T1), and at one-year follow up (T2) at three submental regions during two different activities. The outcome variables were EMG changes of the SMC, and hard and soft tissue relapse. Assessment was carried out by comparison of EMG and lateral cephalograms taken at T0, T1, and T2. Ten patients (7 male and 3 female; median (SD) age 21.2 (3.99) years, range 18-28) were included. The EMG values revealed a statistically significant reduction between T0 and T1. T2 values were not higher than T0 during any activity. The results of Pearson's correlation demonstrated no significant relation between the amount of relapse and change in EMG values. This study concluded that active pull of the SMC is not the actual reason for skeletal relapse in chin or mandibular advancement. Passive biomechanics such as adnexial or muscular connective tissue, and paramandibular periosteum pull with native bone remodelling might be the prime reasons for relapse. However, further large sample studies are warranted to find the actual causes of relapse.

Longitudinal changes in electromyographic activity of masseter and anterior temporalis muscles before and after alloplastic total joint replacement in patients with temporomandibular ankylosis: a prospective study.

The purpose of the study was to evaluate the longitudinal changes in electromyographic (EMG) activity of the masseter and temporalis muscles before and after temporomandibular joint (TMJ) total joint replacement (TJR) in ankylosis patients. A prospective longitudinal study was designed on patients undergoing unilateral or bilateral TMJ-TJR. EMG activity at rest and maximal voluntary contraction (MVC) was recorded for the muscles preoperatively (T0), and at one-week (T1) and six-month (T2) follow up. The study sample was composed of 10 (male: female 2.3:1) patients undergoing TMJ-TJR. The number of unilateral and bilateral cases was three and seven, respectively. In both unilateral and bilateral cases a statistically significant reduction in EMG activity of the masseter and anterior temporalis muscles was observed at T1. At T2, EMG activity of the muscles was found to be approaching the preoperative value. In unilateral cases, when the affected side at T0, T1, and T2 was compared with T0 for the unaffected side, statistically significant differences were seen for the masseter. In the case of the temporalis, similar results were seen except at T2 for the postural rest position. The results indicate that re-attachment of the masseter and temporalis muscles occurs progressively post TMJ-TJR.

A randomized controlled trial to compare functional, combined rigid and functional and rigid fixation in double mandibular fractures.

Purpose: The purpose of the study was to evaluate whether the rigid fixation at one site and functional fixation at other site is enough in double mandibular fractures (DMF). The specific aim of the study was assessment of masticatory function on the basis of bite force and other clinical parameters. Methods: A prospective, randomized controlled trial was conducted on patients having DMF. The patients were randomized into 3 groups. Group-1, managed with 2-miniplates at anterior and 1-miniplate at posterior site, group-2 patients managed with one 2.4 mm reconstruction plate at anterior and 1-miniplate at posterior site and in group-3, both fractures were managed with 1-reconstruction plate. Primary outcome variable was bite force. Secondary outcome variables were type of fracture, pain, swelling, mobility between fracture segments, occlusal discrepancy, paresthesia, implant exposure/fracture. Results: The study sample included 60 (20 in each group) patients with mean age of 29.28 ± 12.35 years. Statistically significant difference was seen in bite force from preoperative to follow-up (p = 0.0) in all the groups. Difference in bite force was statistically significant between group 1 and 2 (p = 0.0) and group 1 and 3 (p = 0.0) at follow-up but the difference was statistically insignificant between group 2 and 3. Conclusion: The present study concludes that treatment of DMF with rigid fixation at one site and functional fixation at other fracture site provides enough fixation.

Does Evoked Electromyography Detect the Injured Facial Nerve Recovery Earlier Than Clinical Assessments?

PURPOSE: The key element in managing postoperative facial nerve (FN) injuries is timely diagnosis and intervention as indicated. The purpose of this study was to measure and compare evoked electromyography (EEMG) and clinical assessment in terms of the recovery of the injured FN in operated temporomandibular joint ankylosis (TMJA) cases. METHODS: The investigators designed a prospective cohort study in the primary operated TMJA patients. The primary predictor variable was the technique used to assess FN function, House-Brackmann Facial Nerve Grading System (HBFNGS) or EEMG. The primary outcome variable was time to FN recovery. The FN recovery was assessed in different time points (1 week, 1 month, 3 months, and 6 months). Age, gender, side (unilateral/bilateral), type of ankylosis (Sawhney's classification), and operating time were kept as covariates. Categorical variables were analyzed using Fisher's exact test. Multilevel survival analysis was performed considering the subject as cluster to perform Kaplan-Meier analysis and compute the hazards ratio using the Cox-regression method with adjustment for covariates. P <0.05 was set as statistically significant. RESULTS: The study sample composed of 43 (69 sides) TMJA cases who underwent surgery developed iatrogenic FN injury in 10 cases (14 sides [9 right; 5 left]). The incidence of FN injury was 20.3% (14/69). Sawhey's type III/type IV ankylosis and the operating time for more than 2 hours showed a statistically significant (p<0.05) increase in FN injury. The mean duration to detect FN recovery by EEMG was 9 days (95% confidence interval, 5 to 12 days), but the HBFNGS took 161 days (95% confidence interval, 141 to 181 days). The chance of early detection by EEMG was 18.6 times more than the chance by the HBFNGS (Cox-hazard ratio, 18.6). CONCLUSIONS: To conclude, EEMG is a noninvasive and reliable tool that detects FN recovery much earlier than the HBFNGS in the postoperative TMJA cases.