Relation of Mandibular Canal Discontinuity and IAN Paresthesia in Operated Cases of Mandibular Fracture.

INTRODUCTION: Mandibular fractures are common in maxillofacial trauma, often requiring surgical intervention for optimal recovery. One critical concern during such procedures is the potential for nerve damage, specifically involving the mandibular canal. This study aims to investigate whether the presence of postoperative mandibular canal discontinuity is associated with an increased risk of nerve damage. METHODOLOGY: A retrospective analysis was conducted on a cohort of 72 postoperative mandibular fracture patients. In total, 58 patients had entire mandibular canal continuity, while 14 showed discontinuity. Clinical records and follow-up data were examined to assess the occurrence of nerve injury. Statistical analysis was performed to determine the significance of any correlation. RESULTS: Of the 14 patients with mandibular canal discontinuity, 9 (64.28%) exhibited paresthesia. In patients where mandibular canal continuity was maintained, 5 (8.62%) patients reported paresthesia. These results suggest a higher incidence of paresthesia in patients with mandibular canal discontinuity, albeit with a small sample size. Notably, only 3 patients in the discontinuity group did not show any sign of improvement, while the remaining patients in both groups demonstrated complete recovery in 6 months of follow-up period. DISCUSSION: The findings suggest a potential link between mandibular canal discontinuity and an increased risk of paresthesia in postoperative mandibular fracture patients. It is hypothesized that discontinuity may lead to nerve compression, irritation, or direct damage during healing. The observed complete recovery in most patients, including those with paresthesia, highlights the potential for the nervous system to repair itself over a period of time. However, further studies with larger sample sizes are warranted to establish a more definitive correlation. CONCLUSION: This study provides preliminary evidence that mandibular canal discontinuity may contribute to a higher incidence of paresthesia in postoperative mandibular fracture patients. Clinicians should be cautious when addressing mandibular fractures to minimize the risk of nerve damage, particularly in cases involving canal discontinuity. The encouraging trend of complete recovery among the majority of patients suggests a positive prognosis for nerve healing.

Flap Design for Cranial Reconstruction: An Analysis of Craniectomy and Cranioplasty Incisions.

Background: The surgical approach for cranial reconstruction is influenced by the presence of pre-existing scar tissue. Scars that lie within the vicinity of cranial defect require modification. Purpose: The present study was conducted to analyse co-relation between craniectomy scar and cranioplasty incision. Materials and Methods: A retrospective evaluation of 70 patients who were divided into three groups based on location of cranioplasty incision line was done. In group I, incision was located parallel and outside the scar; group II, incision was located over the scar; and group III, mixed and criss-cross incision was present. The primary outcome variable of interest was to analyse co-relation between craniectomy and cranioplasty incisions. Results: There were 45 cases of group I, 15 cases of group II and 10 cases of group III. Thirty-three patients had defect on left side, 26 had on right side, and 10 had bifrontal defect. No significant association was noted between the site and cranioplasty incision (Chi2 = 9.155, p = 0.433 and likelihood ratio = 9.487, p = 0.394). Conclusion: Well-vascularized broad-based scalp flap that provides adequate exposure and located on healthy bone irrespective of pre-existing craniectomy scar forms the mainstay of successful cranial reconstruction.

Incidence and Management of Tooth Root Fracture in Mandibular Fracture Line - A Retrospective Study.

Introduction: In cases of trauma, the most common fractures of the facial region are the nasal bone fractures followed by mandibular fractures. About 60% of mandible fractures are associated with teeth in the fracture line; however conversely, the dentulous mandible has a higher susceptibility of fracture in any impact. Whenever a tooth is involved in the fracture line, it is not unlikely that the tooth root fracture will be associated with it. The prognosis and treatment of such a tooth persistent in a fracture line depends upon the level of tooth root fracture. Materials and Methods: This retrospective study was conducted in the Department of Oral and Maxillofacial Surgery in a Meerut hospital. The eligibility criteria were based on the cases involving fracture line passing through the teeth bearing area of mandible. Total of 56 cases of mandibular fracture treated from January 2021 till December 2022 by open reduction and fixation were included in the study. Results: A total of 56 patients (66 fracture lines) with mandibular fractures were selected, out of which 18 (32%) patients had fracture of the root of the tooth in the fracture line. Third molar root fracture were present in 12 cases (66.6%), first premolars in 4 cases (22.2%), and first molars in 2 cases (11.1%). There were 14 multi rooted teeth (77.7%) and 4 single rooted teeth (22.2%) involvement. All the multi rooted teeth fracture were treated by extraction during open reduction and fracture fixation. The single rooted teeth were successfully treated by endodontic treatment postoperatively. Discussion: The fracture line passing through the dentate segment may fracture the tooth crown and/or root or propagate through the socket without any injury to the root. Root fracture at cervical and middle third is constantly exposed to oral fluids. The affected tooth may be mobile and lose vitality. Teeth in the line of fracture must be removed when they preclude the correct reduction of the segments or if they represent a risk for infection. If the tooth or root does not cause any hindrance during reduction or it is not infected, the tooth can be salvaged by endodontic therapy. The incidence of root fracture was seen in 32% of cases. Fracture of the third molar roots was the single largest group (66.6%). No root fracture was observed in the anterior segment.

Quantifying Upper Airway Changes Following Mandibular Orthognathic Surgery.

ABSTRACT: The aim of this study was to quantify upper airway changes following mandibular orthognathic surgery. Treatment records of 50 patients who underwent mandibular orthognathic surgery were divided into 2 groups, that is, Group 1: Cases treated with Mandibular Advancement Surgery and Group 2: Cases treated with Mandibular Setback Surgery with 25 patients in each group. The Lateral Cephalogram and Acoustic Pharyngometry records of both groups were studied at T0 (01 week before surgery) and T1 (01 year postsurgery) for changes in linear airway measurements (Nasopharyngeal Airway Space - NAS, Superior Airway Space - SAS, Posterior Airway Space - PAS and Hypopharyngeal Airway Space (HAS)), hyoid bone position (Mandibular Plane Hyoid distance), mean area and mean volume. The percentage change and change in these parameters per millimeter advancement or setback of mandible at T1 was calculated. A significant increase in linear airway parameters (SAS and PAS); decrease in hyoid distance; and increase in volume and area of upper airway was observed at T1 in Group 1 and reverse was observed in Group 2. The change in airway parameters (SAS, PAS, mean volume and area) was more significant in Group 1 as compared to Group 2. In the current airway centric approach, meticulous assessment and prediction of long-term airway changes post surgery should be an integral part of ortho-surgical diagnosis and treatment planning and suitable modifications in the treatment plan must be made to cater for any potential adverse effects on airway.

Single Layer and Double Layer Duraplasty for the Management of Persistent Cerebrospinal Fluid Rhinorrhea Following Frontal Sinus Trauma: A Retrospective Study.

ABSTRACT: Persistent cerebrospinal fluid (CSF) rhinorrhea is an infrequent complication of frontal sinus trauma. It often require craniotomy for dural repair and obliteration of sinus with well vascularized pericranial flap. The multilayer vascularized techniques have gained popularity over the years owing to low rate of postoperative CSF leaks. The study retrospectively analyzed 25 frontal sinus trauma patients (20 males, 5 females) of mean age 32 ±â€Š10.23 years with persistent CSF rhinorrhea from January 2011 to December 2018. All patients underwent frontal craniotomy and duraplasty was done with pericranial flap alone in 14 patients (Group I) and in combination with fascia lata graft in 11 patients (Group II). The clinical outcomes of single and double layer dural reconstruction techniques in management of CSF leak were analyzed. The size of defects ranged between 3 to 28 mm. Significant association was present between defect size and reconstruction technique with large defects underwent double layer repair. Two patients developed CSF leak following repair with pericranial flap alone. The rate of successful closure of CSF fistula was 100% with double layer reconstruction technique. However, statistically no significant association was noted between postoperative CSF leak and reconstruction technique. There was no evidence of meningitis, subdural hematoma, intracranial abscess, and mucocele formation in all patients during follow-up of 50.7 ±â€Š23.6 months. To conclude, pericranial flap is a reliable reconstruction material for management of post traumatic frontal sinus CSF leaks. Dual flap technique that combine the use of fascia lata provides comprehensive solution of CSF fistula repair.

Pandemic proofing dental education.

Imparting dental education in times of the current pandemic of COVID-19 has transformed it to a Gordian knot. Dental education must focus on educating dental students for a lifetime of clinical practice. It must inspire them to pursue professional development during this era of rapid advancements and transformation, while being ethical and empathic. This pandemic has denied or limited access to clinical learning avenues for students. Hence, there is a need to adapt to the 'new normal' during and after this pandemic by finding a viable solution. This adverse situation must stimulate the dental educators to prepare a COVID-proof curriculum to tackle any (including the current) pandemic situation and prepare academicians to be ready to face such untoward occurrences in future. This would entail redefining learning outcomes, improvising teaching protocols, and adapting current assessment practices.

Histopathological Evaluation of Inferior Alveolar Neurovascular Bundle in Cases of Trigeminal Neuralgia.

BACKGROUND: Trigeminal neuralgia is a painful disease that has been afflicting mankind since time immemorial. The etiology and pathophysiology have been widely studied but poorly understood. There are well-documented researches analyzing ultrastructural changes in trigeminal root specimens obtained following microvascular decompression surgery. However, there are no studies evaluating microscopic changes following peripheral neurectomy. PURPOSE: The present study examined microscopic changes in inferior alveolar neurovascular bundle in trigeminal neuralgia patients of mandibular division with no underlying cause. MATERIALS AND METHODS: The biopsy specimens were obtained from peripheral neurectomy of 11 trigeminal neuralgia patients' refractory to anti-neuralgic medications. The autopsy specimens from 10 cadavers were used as control. The specimens were subjected to histopathological examination by hematoxylin and eosin, Masson trichrome and Luxol fast blue stains. RESULTS: All biopsy specimens reported luminal occlusion of small vessels, medial degeneration and intense mononuclear inflammatory infiltrate. Focal myelin digestion chambers were observed in large and small axons. No pathological alterations of either blood vessel or nerve fibers were reported in autopsy specimens. CONCLUSION: The demyelination of inferior alveolar nerve due to pathologic vascular changes in peripheral vasculature may have a role in initiation and precipitation of trigeminal neuralgia, and hence, peripheral neurectomy has a significant role in alleviating pain.

Cranioplasty With Autogenous Frozen and Autoclaved Bone: Management and Treatment Outcomes.

Cranioplasty is a widely employed procedure for restoration of calvarial form and shape. The use of autogenous bone flap offers biological reconstruction with minimal donor site morbidity. One of the options to re-use bone autograft is low temperature preservation followed by autoclaving during cranioplasty. A retrospective evaluation of 12 patients with a mean age of 32.58 ±â€Š10.04 years who underwent frozen autogenous autoclaved bone cranioplasty was done. Cranial bone flaps were removed during the initial craniectomy and stored at 4°C for 20 minutes followed by preservation at -40°C in the deep freezer of the blood bank. Cranioplasty subsequently was performed at a mean time period of 172.17 ±â€Š26.20 days by thawing the bone at room temperature followed by autoclaving at 121°C under 15 psi for 40 minutes. Data regarding patients' characteristics and complications were recorded. Clinical outcomes based on skull shape and symmetry, cosmesis and scars were analyzed by a panel of 4 raters, including 3 doctors and 1 patient. Radiological outcomes were analyzed based on remaining bone thickness and bone gap widening. The present study revealed functionally, structurally, and cosmetically satisfying results. All the cases had satisfactory healing and no incidence of bone graft infection. The skull shape and symmetry, cosmesis and scars revealed excellent to moderate improvement in three-fourth of the patients. Radiological outcomes revealed none of the patients had severe resorption requiring surgical revision with excellent to good implant alignment in 92% of cases. It was concluded that frozen autogenous cranial bone flaps sterilized by autoclaving is safe and effective material for cranioplasty.

Mandibular Distraction Osteogenesis.

Mandibular hypoplasia is a common dentofacial deformity requiring a combination of orthodontic and surgical treatment. Before the introduction of distraction osteogenesis various orthognathic surgical procedures were carried out to treat mandibular hypoplasia. Orthognathic procedures like corpus lengthening by bilateral sagittal split ramus osteotomy and genioplasty are commonly practised all over the world to address the high esthetic demands and functional problems. But hardly there are any established orthognathic surgical procedures to address the deficiency of the posterior part of the mandible that is ramus and condyle. Transverse mandibular deficiency is one of the most difficult problems to be addressed surgically.With the advent of distraction osteogenesis there is a change in concept of addressing mandibular deficiency. Mandibular corpus distraction was first performed by McCarthy et al using an extraoral unidirectional distraction device. The precision of bone lengthening with extraoral distracters did not accurately match the device settings. Since then due to sustained research and design and collaboration with the manufacturers, clinicians have developed various devices to improve the results of mandibular lengthening. Distractor devices of various shape and size are developed for intraoral use in specific anatomical locations of mandible.This presentation will focus on use of intraoral distraction devices on different anatomical locations of mandible. The surgical methods of corpus, ramus, ramuscondylar unit, and symphyseal distraction osteogenesis and associated complications will be discussed in detail.

Complications of Cranioplasty.

Cranioplasty is a time-honoured surgical procedure to restore the calvarial form and function that is associated with a relatively high complication rate. The present article analyzed various complications and reviewed the complications based on study of the relevant research in the craniofacial literature. Complications were broadly divided into 2 groups, intraoperative and postoperative, for ease of understanding. The etiological factors, local and systemic condition of the patient, prevention, and management of various complications were widely discussed. The article also highlighted problems and complications associated with various reconstructive materials. Insights into various complications of cranioplasty enable surgeon to understand them better, minimize the chances of occurrence, and improve surgical outcome. In spite of reported high rate of complications, serious complications like meningitis, air embolism, and death are rare.

Classification of the Residual Cranial Defects and Selection of Reconstruction Materials.

The cranial defects are complex in nature and are due to various causes. Therefore, there is a need for a common term of reference to these defects. This requirement stood as a prime reason for proposing a classification system for cranial defects. The classification is based on 2 decades of experience in cranioplasty. This efficient and simple way of representation would fill the existing lacunae for a systematic communication on cranial defects. Over the ages the evolution of reconstruction and grafting had undergone a massive progress. Therefore, it is essential to enumerate all available graft and bio-materials for restoring the cranial defects. The aetiology for these defects, age and sex of the patient, site and size of the defect, associated systemic conditions, cost factor, and operator's choice are the factors that play key role in the selection of the reconstructive material. This article discusses on these factors in cranioplasty. High success rate with excellent function and cosmetic outcome in using a variety of materials, as shared in this article. The advantages of autografts cannot be matched by any existing alloplast. However, in case of larger defects, for a better cosmetic outcome and to reduce the donor site morbidity, alloplasts are the most widely preferred material of choice.

Mucormycosis of the Frontal Sinus: A Rare Case Report and Review.

Mucormycosis of the frontal sinus are rarely seen in day to day clinical practice. Although this fungus is commonly found in the environment, the disease is usually prevented by the immune system and is hence rare. Well-recognized risk factors for the disease include diabetes mellitus, leukemia, aplastic anemia, myelodysplastic syndrome, blood dyscrasias, and immunosuppressive therapy in organ transplantation, renal disease, sepsis, and severe burns. The disease is primarily found in those who are immunocompromised, but it may also manifest in immuno competent persons. Current therapy for the invasive disease includes early surgical debridement, antifungal therapy management of underlying predisposing factors. Early recognition of the disease and treating the underlying cause of mucormycosis, such as diabetes, are key to improving outcomes. The antifungal treatment of choice for mucormycosis is amphotericin B, although very high doses are required because of the relative resistance of the fungus to the drug. Here, we present a case of rhinocerebral mucormycosis of frontal sinus in a diabetic patient, who was managed by systemic antifungals, surgical debridement, and obliteration procedures.

Oro-Nasal Communication.

INTRODUCTION: Breach in the palatal vault leading to an abnormal communication between oral and nasal cavity is known as oro-nasal communication. It is an uncommon presentation in day-to-day clinical practice except in some patients of cleft lip and palate.Etiology may be congenital or acquired. Alveolar and palatal cleft defects are the most common etiological factor. The acquired causes may be trauma, periapical pathology, infections, neoplasms, postsurgical complications, and radio and chemo necrosis.Clinical features like nasal regurgitation of food, defective speech, fetid odor, bad taste, and upper respiratory tract and ear infection are associated with oro-nasal communication.Management depends upon the size and site of defect, age of patient, and associated comorbidity. The definitive management is always surgical. Two layered closure provides greater support and stability and reduces the risk of failure. Palatal rotational flaps are suitable for smaller defects. The other local flaps are buccal mucosal flap, tongue flap, and facial artery myomucosal flap. Temporoparietal galeal flap, turbinate flap, free radial forearm flap, and scapular flap have also been successfully used for closure of oronasal communication. Newer procedures like the use of bone morphogenic protein, acellular dermal matrices, human amniotic membrane, and distraction osteogenesis have been tried successfully. The rate of recurrence is high.Unsuccessful surgical attempts and larger defects associated with compromised medical conditions are better managed nonsurgically with obturator incorporating the missing teeth.

Periodontal plastic procedure for the management of the residual gingival defect after excision of an epulis.

Dentinal hypersensitivity and unesthetic appearance are common findings after excision of an epulis due to exposure of root and underlying bone. The simultaneous placement of subepithelial connective tissue grafting after excision of the lesion seems to be viable surgical option in such cases. Furthermore, this will avoid second surgical procedure for the management of the residual gingival defect.

Skeletal relapse following sagittal split ramus osteotomy advancement.

BACKGROUND: Sagittal split ramus osteotomy (SSRO) is an accepted and standard procedure to address mandibular corpus deficiency. The relapse following the mandibular advancement has a negative impact both on clinician and patient. PURPOSE: To analyse the hard tissue changes and to investigate relapse following SSRO advancement procedure. MATERIALS AND METHODS: A retrospective review of 21 patients treated by bilateral SSRO advancement at our institute was conducted. Lateral cephalograms obtained at pre-treatment (T1), pre-surgery (T2), 2 months (T3) and 2 years post-surgery (T4) were evaluated by an independent investigator. The data T2-T3 revealed immediate postoperative changes, and T3-T4 revealed skeletal relapse following surgery after 2 years. RESULTS: Twelve females and nine males with age ranging from 16 to 24 years underwent mandibular advancement. The mean follow-up period was 2 years 7 months ± 4 months. The mean mandibular advancement at pogonion was 5.1 ± 1.25 mm with significant improvement in SNB, ANB, CoGn, maxillo-mandibular differential and SN:GoPg ratio following surgery. Comparison of the outcomes following surgery revealed that the mean relapse at pogonion was 0.2 ± 0.44 mm. B point, mandibular corpus length, anterior and posterior facial height remained stable with no significant relapse following mandibular advancement. CONCLUSION: Sagittal split ramus osteotomy within the range of mandibular advancement is a stable procedure.

Pleomorphic adenoma palate: Major tumor in a minor gland.

Pleomorphic adenoma (PA) is the most common benign mixed salivary gland neoplasm that accounts for 60% of all benign salivary gland tumors. It has diverse histological presentation and occurs in both major and minor salivary glands. PA of minor salivary gland in the palate is a common entity. We report the case of a 45-year-old female who presented with a painless slow growing swelling of palate over the last 20 years. The mass was extending to oropharynx causing mechanical obstruction of airway. Magnetic resonance imaging (MRI) depicted an oval-shaped mass occupying oropharynx and displacing the tongue inferiorly. Fine needle aspiration cytology (FNAC) was suggestive of PA. The entire tumor mass was excised along with overlying mucosa. Histopathological examination confirmed diagnosis of PA of minor salivary gland. There has been no recurrence of the lesion since 1 year.

Mandibular symphyseal distraction osteogenesis--simplified.

The limb lengthening technique of distraction osteogenesis (DO) used in orthopedic surgery is a well established procedure. DO has been adapted to the facial skeleton to change the anterior-posterior position of the jaws. Historically, the mandibular arch transverse dimension has been considered immutable. Mandibular arch expansion is done with a variety of methods including Schwarz plates, lingual arches, functional appliances and arch wires; these methods produce limited dimensional change with questionable long-term stability. Adapting the Ilizarov treatment protocol to the mandibular symphysis can produce a regenerate bone thereby adding dimension to the innate basal bone. This can then be used to produce a potentially greater effect than the conventional modes of mandibular expansion. The modified mandibular symphyseal distraction device used by the authors is a tooth borne device fabricated with a Schwartz screw and self cured acrylic resin coverage over all the erupted mandibular teeth. The appliance used by the authors has been found to be very economical, easy to fabricate and clinically efficient. The surgical approach used, requiring surgery under local anesthesia in the outpatient department obviates need of hospital admission and the cost and time factors associated with in-patient therapy Mandibular Symphyseal Distraction Osteogenesis (MSDO) with this innovative low cost approach may be compared in a multi centric study with other established methods of MSDO.

Radiographic assessment of changes in articular tubercle after Dautrey's procedure.

PURPOSE: The aim of this retrospective study was to evaluate the increase in height and change in position of neo-articular tubercle in cases treated by Dautrey's procedure. METHOD: 10 cases of Tempromandibular joint (TMJ) disorders satisfying the inclusion criteria were included in this study, out of which 8 had bilateral chronic recurrent dislocations (CRD) and remaining 2 were suffering from bilateral symptomatic TMJ subluxations. Clinical and radiographic finding were recorded. Bilateral Dautrey's procedure was done under general anaesthesia (GA). Post operative clinical findings and radiographic parameters were compared. RESULTS: Data analysis showed mean age in this study group was 40.9 years. Out of 10 patients 7 were females and 3 males.The procedure resulted in statically significant stable decrease in mouth opening after 12 months. In radiological evaluation using orthopantomograph (OPG), average increase in articular tubercle height was 3.65 mm on right side and 3.52 mm on left side. The mean anterior shift of articular tubercle lowest point was 4.56 mm on right side and 4.51 mm on left side which were statically highly significant. CONCLUSION: Dautrey's procedure is simple, effective procedure to prevent anterior excursion of condyles. In this study it was found that down fractured zygomatic arch significantly increases the articular tubercle height and relocates the lowest point anteriorly thereby preventing excessive anterior excursion of condyles.

Evaluation of upper airway dimensional changes and hyoid position following mandibular advancement in patients with skeletal class II malocclusion.

BACKGROUND: Class II skeletal malocclusion due to mandibular deficiency is considered a risk factor for sleep disorders due to oropharyngeal airway deficiencies. In view of the above, a prospective interventional study was undertaken to evaluate upper airway dimensional changes and position of hyoid bone by comparing pretreatment and posttreatment lateral cephalograms. The objective also included the establishment of the ratio of mandibular advancement to increase in airway dimensions. PATIENTS AND METHODS: Pretreatment and posttreatment lateral cephalograms of 20 adults (13 females and 7 males) with skeletal class II malocclusion treated by combined orthodontics and bilateral sagittal split ramus osteotomy was evaluated for changes in posterior airway space (PAS), superior airway space (SAS), minimum airway space (MAS), hyoid bone position (MP-H), effective mandibular length (Co-Gn), mandibular corpus length (Go-Pg), and pogonion position (N perpendicular-Pg). The cephalograms were manually traced by a single operator and the data analyzed using MINITAB 13.2 version software. RESULTS: There was a statistically highly significant (P = 0.0001) increase in PAS, SAS, MP-H, Co-Gn, and Go-Pg. The mean ratio of mandibular advancement to increase PAS, SAS, and MAS was 1:0.35, 1:0.34, and 1:0.24, respectively. Hyoid bone moved superiorly and in an anterior direction by 2.1 ± 2.8 mm and was found to be statistically highly significant (P = 0.0001). CONCLUSIONS: The study showed an overall increase in airway dimension and improvement in hyoid position. Thus, the procedure may be considered beneficial in reducing upper airway collapsibility and preventing sleep disorders due to oropharyngeal airway deficiencies in skeletal class II malocclusion.