Characterization of tumors of jaw: Additive value of contrast enhancement and dual-energy computed tomography.

BACKGROUND: Currently, the differentiation of jaw tumors is mainly based on the lesion's morphology rather than the enhancement characteristics, which are important in the differentiation of neoplasms across the body. There is a paucity of literature on the enhancement characteristics of jaw tumors. This is mainly because, even though computed tomography (CT) is used to evaluate these lesions, they are often imaged without intravenous contrast. This study hypothesised that the enhancement characteristics of the solid component of jaw tumors can aid in the differentiation of these lesions in addition to their morphology by dual-energy CT, therefore improving the ability to differentiate between various pathologies. AIM: To evaluate the role of contrast enhancement and dual-energy quantitative parameters in CT in the differentiation of jaw tumors. METHODS: Fifty-seven patients with jaw tumors underwent contrast-enhanced dual-energy CT. Morphological analysis of the tumor, including the enhancing solid component, was done, followed by quantitative analysis of iodine concentration (IC), water concentration (WC), HU, and normalized IC. The study population was divided into four subgroups based on histopathological analysis-central giant cell granuloma (CGCG), ameloblastoma, odontogenic keratocyst (OKC), and other jaw tumors. A one-way ANOVA test for parametric variables and the Kruskal-Wallis test for non-parametric variables were used. If significant differences were found, a series of independent t-tests or Mann-Whitney U tests were used. RESULTS: Ameloblastoma was the most common pathology (n = 20), followed by CGCG (n = 11) and OKC. CGCG showed a higher mean concentration of all quantitative parameters than ameloblastomas (P < 0.05). An IC threshold of 31.35 × 100 µg/cm3 had the maximum sensitivity (81.8%) and specificity (65%). Between ameloblastomas and OKC, the former showed a higher mean concentration of all quantitative parameters (P < 0.001), however when comparing unilocular ameloblastomas with OKCs, the latter showed significantly higher WC. Also, ameloblastoma had a higher IC and lower WC compared to "other jaw tumors" group. CONCLUSION: Enhancement characteristics of solid components combined with dual-energy parameters offer a more precise way to differentiate between jaw tumors.

Assessment of MUC5AC and MUC2 Immunoexpression in Glandular Odontogenic Cysts, Dentigerous Cysts, and Mucoepidermoid Carcinomas.

Glandular odontogenic cysts (GOCs) and dentigerous cysts may show mucous metaplasia. Central mucoepidermoid carcinoma is very rare and mostly associated with dental cysts. It is hypothesized that odontogenic cysts showing mucus differentiation in their lining, have a propensity to transform into MEC. The present study is the first attempt to explore the relationship between odontogenic cysts [GOCs and dentigerous cysts with mucus metaplasia (DCMM)] and MEC by evaluating immunoexpression of MUC5AC and MUC2. Immunoexpression of MUC5AC and MUC2 was evaluated semiquantitatively in GOCs (20 cases), DCMMs (20 cases), and MECs (20 cases). The percentage of positive cells, intensity, and localization of immunoexpression were assessed for each marker in all cases. Of GOCs, DCMMs, and MECs cases, 85%, 70%, and 80%, respectively, were immunopositive for MUC5AC. Strong cytoplasmic immunoreactivity for MUC5AC was noted, particularly in mucous cells present diffusely within MECs. However, the immunoreactivity was limited to the epithelial lining of GOCs and DCMMs. Most of the MECs (60%) showed more than 25% positivity for MUC5AC, followed by GOCs, and the least in DMMCs. Mild cytoplasmic and nuclear positivity of MUC2 was noted only in epithelial lining cells of 70% GOCs and 45% DCMMs. Whereas, 55% of MECs displayed moderate to strong cytoplasmic and membranous immunopositivity for MUC2 exclusively within mucous cells. As MECs showed strong MUC5AC immunoreactivity in mucous cells, immunoexpression of MUC5AC in odontogenic cysts with mucus cells can possibly explain the pathogenesis of MEC from cysts. However, the variable expression of MUC2 did not give any strong evidence regarding its role as a marker.

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.

Role of immunohistochemistry in diagnosing round-cell tumours affecting the oral and maxillofacial regions.

Background: One of the most challenging spectra of lesions in the oral and maxillofacial region (OMFR) are round-cell tumours (RCTs). They show a considerable degree of overlap in microscopy and immunophenotypes. The main aim of this study is to analyse the spectrum of RCTs encountered in the oral and maxillofacial regions. We emphasise the role of immunohistochemistry (IHC) which in conjunction with histological, clinical, and imaging findings is necessary for their correct characterisation. The secondary objectives are to discuss differential diagnosis, workflow, and diagnostic algorithm for round-cell lesions affecting the OMFR. Methods: Formalin-fixed, paraffin-embedded sections of RCTs were retrieved from the archives of the Department of Oral Pathology (January 2018 to March 2020). These cases were analysed by three pathologists independently by evaluating haematoxylin and eosin-stained sections, and immunohistochemical markers employed to characterise these lesions. Results: Under the spectrum of RCTs, 11 cases (0.53%) were diagnosed with a predominance of non-Hodgkin lymphoma (55%) followed by Ewing sarcoma (18%). The remaining were Langerhans cell histiocytosis (9%), neuroendocrine carcinoma (9%), and sinonasal undifferentiated carcinoma (9%). Except for one case, in all cases, the final diagnosis was established with the use of adjunctive IHC. Conclusion: RCTs can pose a diagnostic challenge for inexperienced oral pathologists. Thorough knowledge of the differentials of RCT occurring in oral and maxillofacial is helpful. An algorithm-based diagnostic approach incorporating the clinical, imaging, and histomorphological findings and immunohistochemical evaluation can help in minimizing diagnostic confusion and errors.

Does surgical treatment of mandibular condyle head (diacapitular) fractures provide better outcomes than closed treatment? - a systematic review and meta-analysis.

The choices for managing a condylar head fracture (CHF) of the mandible are either open surgical or closed functional treatments (CFT) and the decision depends on various factors. The purpose of this systematic review was to ascertain from the available literature whether the open method or CFT yields better outcomes in managing CHF. 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 comparative studies about both open and closed treatments from inception until April 2023. The outcomes of interest were mouth opening (MO), protrusion, laterotrusion, postoperative pain, and malocclusion. Eight studies met the inclusion criteria. The review comprised of 326 cases, among which 177 were managed by open methods and 149 were treated by CFT. The incidence of postoperative malocclusion and pain were significantly less in the open group. MO was better in the open treatment group although this was not statistically significant. Protrusion and laterotrusion occurred slightly more in CFT, although these were also statistically not significant. Overall, meta-analysis favoured open methods of managing CHF. Although enough evidence exists for the use of open methods for selected condylar head fractures, CFT still demonstrated favourable outcomes in undisplaced fractures. The selection of a particular treatment method should be individualised on the basis of each particular case considering the risk/benefits. Further high quality randomised trials are needed to establish a therapeutic guideline.

Endoscopic-assisted intraoral approach for mandibular condyle fracture management: A systematic review and meta-analysis.

OBJECTIVE: Surgical innovation led to an endoscopic-assisted intraoral approach for managing condyle fractures. The purpose of this systematic review is to purview the role of the endoscope and determine the range of information, summarizing the evidence for the benefit of surgeons on an endoscopic-assisted intraoral approach. STUDY DESIGN: A literature search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane Library databases for studies mentioning the endoscopic intraoral approach for managing mandibular condylar fractures. Outcomes include the role of the endoscope, challenges, adjunct armamentarium, duration, and complications associated with the transoral and transbuccal approach for screw fixation. The meta-analysis was conducted with prevalence estimates and standardized means using STATA. RESULTS: Thirty-nine studies were included. A 30° angulated, 4-mm-thick endoscope was the most commonly used endoscope. Two mini plates were most commonly used for fixation. Facial nerve weakness was higher in the transbuccal approach (1.24%) than in the transoral approach (0.8%). Pooled analysis (6 studies) showed that the duration of the surgical procedure was less in the transoral approach compared with the transbuccal approach for screw fixation. The bailout was 1.49%. CONCLUSIONS: The endoscopic-assisted intraoral approach is reliable for condylar fracture management. The transoral and transbuccal approaches can be used for screw fixation with comparable outcomes.

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.

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.

A systematic review and meta-analysis of the surgical outcomes in patients with osteochondroma of mandibular condyle.

Many options exist in the diagnosis and management of condylar osteochondroma. The purpose of this study was to provide a congregate information concerning treatment of the osteochondroma involving the mandibular condyle. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane database until February 2022. Twenty-seven studies were included for the final review. The review included 439 patients who underwent surgical management for mandibular condylar osteochondroma. The position of osteochondroma was mentioned in 13 studies. Preauricular, retromandibular, endaural, submandibular, transzygomatic, and intraoral approaches were used for approaching the tumor. Surgical techniques included resection, conservative condylectomy, and total condylectomy. Concomitant orthognathic surgery was performed along with tumor resection in 19 studies. In the entire review, the recurrence rate was 0.22% (1/439). The results of the meta-analysis showed that 2 studies reported significant malocclusion events after surgical therapy. Total joint replacement after tumor resection has a higher improvement in maximal mouth opening (8 mm) compared with vertical ramus osteotomy and no reconstruction groups, which have similar improvements (6 mm). The mainstay of treatment of osteochondroma is surgical excision either as condylectomy or conservative condylectomy. Among the various reconstruction modalities, total joint replacement showed better improvement in mouth opening. Adjunct procedures like orthodontic and orthognathic surgery have an important role in holistic management of severe cases. The treating surgeon must choose the surgical procedures in a pragmatic way.

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.

Post-COVID steroid induced avascular necrosis of the jaw: Emerging challenge in India.

The COVID-19 pandemic continues to evolve and spread with new variants of SARS-CoV-2 across the globe, as well as bring to clinical attention several post-COVID conditions. We report a post-COVID condition observed at our tertiary care center: spontaneous de novo development of steroid induced avascular necrosis in patients who have recently recovered from COVID-19 following high dose steroid usage in a short span of time. Pre-COVID published literature indicates that these lesions were seen very rarely in the jaws and were related to long-term usage of steroids and recent tooth extraction. They were considered under the broad spectrum of medication-related osteonecrosis of the jaws. Present authors believe that the post-COVID-19 steroid-induced avascular necrosis of the jaws is a distinct new entity. It is analogous to the avascular necrosis noticed in the femoral head of individuals recuperating from COVID-19, a condition conventionally known to be strongly associated with steroid therapy. Rapid progression, associated morbidity and mortality, and its possible differential diagnosis require pathologists to be vigilant regarding the chance encounter of such cases in jaws. Further reporting of such cases is required to gain additional insight into its features.

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.

Metastatic oncocytic adrenocortical carcinoma of mandible: an extraordinarily rare occurrence.

Adrenocortical carcinoma (ACC) is an uncommon primary cancer in the adrenal gland. Its incidence of showing metastasis in the head and neck region is very rare. Herein, we present a case of a 46-year-old man who presented with complaints of pain and numbness on the left side of the lower face for 4 months. Radiographic examination revealed an osteolytic lesion with an ill-defined border in the left body region of the mandible. Histopathologic examination revealed a tumor composed of sheets of oval to polygon-shaped tumor cells predominantly displaying abundant eosinophilic granular cytoplasm. These tumor cells showed features of a high degree of anaplasia. On immunohistochemical examination, tumor cells were focally positive for synaptophysin, inhibin, vimentin, pancytokeratin (pan-CK), cytokeratin (CK)5/6, CD68, and CK8/18 and immunonegative for CK7, chromogranin, melan-A, S100, SMA, and SATB2. The Ki-67 proliferation index was approximately 20%. To the best of our knowledge, this is the first case of metastatic oncocytic ACC to the oral cavity region.

Rare case of spindle cell haemangioma of oral cavity.

Spindle cell haemangioma (SCH) is a slow growing, benign vascular lesion with a preference for the distal extremities. Its occurrence in the oral cavity is rare. Clinically, it presents as solitary or multiple subcutaneous nodules, therefore, it could be considered in the differential diagnosis of benign soft tissue tumours. Microscopically it mimics some malignant vascular tumours and it is necessary to differentiate it from other malignant vascular lesions. We report a case of SCH in anterior mandibular region of a young male in his 20s. Although it is a benign lesion, the reported case displayed extensive areas of muscle infiltration and necrosis. After studying the radiographic findings and considering the absence of cellular atypia, a final diagnosis of SCH was made. Literature survey suggests that this is the eleventh case of SCH reported in oral cavity.