Management of multiple and displaced mandibular fractures in a pediatric patient sans mandibular immobilization, sans open reduction and internal fixation.

Maxillofacial fractures in the pediatric population are generally managed by conservative approaches such as soft diet and medication or semi-invasive procedures namely inter-maxillary fixation or circum-mandibular wiring. These approaches are preferred over any invasive treatment to minimize injury to the growing skeleton and tooth germs. Displaced fractures that cause functional problems such as restricted mouth opening, malocclusion or impaired breathing, mandate open reduction and internal fixation. However, surgical management is associated with morbidity related to general anesthesia, risk of injury to vital structures, and potential, skeletal or dental growth disturbances. This case report describes a non-invasive method of managing displaced, multiple fractures of the mandible in a pediatric patient, with the use of low intensity pulsed ultrasound to achieve favorable clinical outcomes and nil complications. Neither immobilization of the mandible with inter-maxillary fixation nor open reduction and internal fixation was used. Low intensity pulsed ultrasound therapy is painless and patient-friendly.

Do Splints Play a Role in the Management of Condylar Postfracture Syndrome After Mandibular Angle Fractures?-A Randomized Controlled Clinical Trial.

PURPOSE: Fractures of the mandibular angle can result in condylar postfracture syndrome (CPFS) due to indirect injury to the condylar region. Studies evaluating early intervention for CPFS are lacking. In the present study, we evaluated the efficacy of interocclusal splint therapy for the prevention and early management of CPFS. PATIENTS AND METHODS: A prospective randomized controlled clinical trial was designed and included patients who required open reduction and internal fixation for a unilateral angle fracture. The patients were divided into 2 groups. The study group received interocclusal splints postoperatively and the control group did not receive such splints. The patients were followed up at 2 weeks and 1, 2, and 3 months. The primary outcome measure was the presence or absence of CPFS after 3 months. CPFS was defined as the presence of any 1 of the clinical signs of temporomandibular joint dysfunction. The secondary outcomes included the mean pain scores and degree of mouth opening, which were evaluated at each follow-up visit. RESULTS: The study included 40 patients, with 20 patients each randomized to the study and control groups. At the end of 3 months, CPFS was present in 2 patients in the study group and in all 20 patients in the control group. The mean pain scores were significantly lower in the study group than in the control group, and the mean mouth opening was significantly greater. CONCLUSIONS: The use of interocclusal splints was found to be effective in the prevention and early management of CPFS. The use of splints also resulted in decreased pain and an improved mandibular mouth opening.

Evaluation of labial versus labio-inferior lines of osteosynthesis using 3D miniplate for fractures of anterior mandible: A finite element analysis with a pilot clinical trial.

PURPOSE: The fractures of anterior mandible are subject to severe torsional forces due to muscles acting in opposite directions. 3D miniplate has been suggested as a good alternative by some researchers. However, finite element model (FEM) studies indicate that labio-inferior positioning of two miniplates perpendicular to each other offers better stability as compared to labial positioning. This study aims at combining the advantages of a single 3D miniplate and labio-inferior positioning of two conventional miniplates, which was assessed by finite element analysis along with a pilot clinical trial. METHODS: Two FEM models were created using CT data of a 24-year-old patient with Angle class I occlusion: control model with labial plating and study model with labio-inferior plating. The models were processed with MIMICS® (materialise, Leuven, Belgium), CATIA® (Dassault Systemes) and finite element analysis softwares. Parameters adopted for analysis were (1) displacement (mm) of fracture fragments during each screw fixation, (2) lingual splay and post fixation stability of fracture fragments with masticatory load, and (3) stress distribution (MPa) across fracture fragments. Moreover, a pilot clinical trial including five patients with anterior mandible fracture was conducted. The fractures were managed by intraoral open reduction and 3D miniplate fixation in labio-inferior position. Intraoperative interfragmentary gap, post fixation lingual splay and radiographic fracture union and complications were assessed clinically. RESULTS: Labio-inferior plating demonstrated less displacement (mm) of fracture fragments during screw fixation (0.059 vs. 0.079) as well as after application of masticatory load (1.805 vs. 1.860). Negligible lingual splay and less stress distribution (MPa) across fracture fragments (1.860 vs. 1.847) were appreciated in the study group as compared to control group. Clinical trial support the favorable outcome related to intraoperative and postoperative assessment parameters. CONCLUSION: FEM analysis and clinical trial reveal better results with labio-inferior positioning of 3D miniplate when compared to labial positioning.

Comparison of two incisions for open reduction and internal fixation of mandibular body fractures: A randomised controlled clinical trial evaluating the surgical outcome.

PURPOSE: The purpose of the study is to compare the surgical access and post-operative outcome of two intra-oral incisions used for approaching a mandibular body fracture. METHODS: This clinical trial involved 60 patients with mandibular body fractures who were randomly allocated to control and study groups. The fractures were approached using the routine vestibular incision in the control group and crevicular incision with vertical release in the study group. The effects of incision design on the post-surgical outcome variables like swelling, trismus, paresthesia, wound healing and gingival recession were statistically analysed with non-parametric tests by using SPSS 22.0 software. Comparison of continuous variables between the groups and time points was done using Mann Whitney test and Friedman test respectively. Chi-square test was used to compare proportions between groups. Dunn's test with Bonferroni correction was used for pair wise comparisons. RESULTS: The study group demonstrated favourable surgical outcome in the immediate postoperative phase as compared to the control group. The difference in mouth opening, swelling and neurosensory impairment between the two groups was found to be statistically significant (p < 0.05). CONCLUSION: Crevicular incision was found to be an ideal alternative to vestibular incision in achieving surgical access and fixation of mandibular body fractures with reduction in postoperative patient discomfort and better surgical outcome.

'Plain lignocaine' vs 'Lignocaine with vasoconstrictor'-Comparative evaluation of pain during administration and post-extraction wound healing by a double blinded randomized controlled clinical trial.

OBJECTIVES: The aim of this double blinded randomized controlled clinical trial was to evaluate the efficacy of two local anaesthetic solutions, 'Plain lignocaine' and 'Lignocaine with vasoconstrictor', on pain during administration and post-extraction wound healing in patients undergoing therapeutic extractions. MATERIALS AND METHODS: Fifty patients indicated for therapeutic extraction of upper and lower premolars for orthodontic purpose were recruited for the study. Using a split-mouth study design, anaesthesia was achieved using lignocaine with adrenaline on the control side and plain lignocaine on the study side. Pain perception was measured by modified visual analogue scale and wound healing was assessed by Landry's Wound Healing Index. Sample allocation was done by simple randomization. The outcome parameters compared were (1) pain during administration of LA and (2) post-operative healing after extraction. Data analysis involved Chi-square test to compare proportions between treatment groups and independent sample t-test to compare mean values between treatment groups. SPSS version 22.0 was used to analyse the data. RESULTS: The study group demonstrated a statistically significant wound healing on day1 and day 3 between the study and control group with p < 0.001. In the control group 68% had severe pain, whereas only 2% had severe pain in the study group. The proportions between the two groups were statistically significant (p < 0.001). CONCLUSION: The patients who received Plain Lignocaine perceived less pain during injection of local anaesthetic solution when compared to patients who received lignocaine with vasoconstrictor. The early post-operative wound healing was better in patients anaesthetized by Plain Lignocaine.

Open reduction and internal fixation of zygomatic arch fracture by transbuccal instrumentation - A prospective clinical trial.

Background and Purpose: The zygomatic arch is important to maintain facial projection as well as width. Hence, restitution of its form by open reduction and internal fixation (ORIF) is indicated following its fracture, in certain clinical scenarios. The contemporary surgical approaches are cutaneous with associated complications. This observational clinical trial was designed to evaluate intraoral reduction and transbuccal fixation of zygomatic arch fractures. Materials and Method: Six patients requiring ORIF of the zygomatic arch were recruited for the study. The clinical parameters such as pain, swelling, mouth opening, facial nerve function, and scar were assessed in the pre-operative as well as post-operative period. Radiographic assessment of displacement and inter-fragmentary separation were studied on computed tomography (CT) images. Results: Mean pre-operative mouth opening was increased from 28.33 ± 6.80 to 36.83 ± 1.94 (P value 0.03). Mean pre-operative swelling was decreased from 34.63 ± 5.41 to 29.71 ± 2.73 (P value 0.02). The pain decreased by day 7 in all the patients (P value 0.01). No facial nerve injury (P value 1) or scar formation (P value 0.002) was encountered in our study. The inter-fragmentary separation as assessed by CT analysis revealed satisfactory outcome. Conclusion: Intraoral open reduction and transbuccal fixation is a simple, effective, and less invasive method to address zygomatic arch fractures with no complications.

Paradental cyst with hyaline ring granuloma masquerading as pericoronitis.

Paradental cyst is an odontogenic cyst associated with pericoronitis in partly erupted mandibular third molars. It is an inflammatory cyst common among the mandibular molars. The cyst is most commonly seen on the distal or distobuccal aspect of the third molars. The angle of tooth and food impaction has been postulated to be responsible for the development of the cyst in third molars. The source of the epithelium has been reported as reduced enamel epithelium. The paradental cyst is frequently misdiagnosed as a radicular cyst or dentigerous cyst. We report a case of paradental cyst in a patient with partially erupted mandibular third molar with food impaction and resulting hyaline ring granuloma.

External auditory canal injuries in maxillofacial trauma - Proposal of a symptom-based treatment algorithm with a report of twelve cases.

Purpose: Injury to the external auditory canal (EAC) may occur following facial trauma. They manifest as otalgia, ear bleeding, otorrhea, facial palsy, or altered hearing. But literature regarding its management is sparse. The study aimed to identify the incidence and types of EAC injury in facial trauma, grade their severity, and propose a symptom-based treatment algorithm. Patients and Methods: This was a prospective case series involving patients with signs/symptoms of EAC injury following maxillofacial trauma. The EAC was evaluated by clinical examination, imaging, endoscopy, and audiometry. Clinical findings were graded into mild, moderate, and severe. Treatment was matched to clinical findings according to the proposed algorithm. The outcomes of the study were incidence and types of EAC injury in facial trauma and resolution of presenting signs/symptoms. Data were analyzed for descriptive statistics using SPSS software (v26; IBM, Armonk, NY). Results: A total of 88 patients reported with maxillofacial trauma during a 6-month period. Signs/symptoms of EAC injury were observed in 41 patients, of which 12 (11 males and 1 female) were confirmed with a diagnosis of EAC injuries. Eight patients demonstrated only cartilaginous injuries while three had bony injuries. Treatment was successful in 11 out of 12 patients, with a best point estimate of 0.86 (Z score-1.959, 95% CI). Conclusion: Clinical findings of EAC injury mandate thorough investigation to ascertain the site and severity of the injury. Symptom-based treatment of EAC injuries produces an effective resolution of signs/symptoms and improved treatment outcomes.

Evaluating the efficacy of disc repositioning in the management of high condylar fracture - A prospective clinical trial.

AIM: The aim of the study was to assess the role of disc repositioning in treating high condylar fractures. MATERIALS AND METHODS: Patients who reported to the Department of Oral and Maxillofacial surgery with high condylar fractures were recruited for this study, and randomized into two groups. The study group underwent 'disc repositioning during ORIF', while 'ORIF without disc repositioning' was performed for the control group. Patients were assessed for pain, mouth opening, clicking, and mandibular deviation (Helkimo clinical dysfunction Index), preoperatively and postoperatively (immediate and at 3 months). The position of the disc was assessed by MRI preoperatively and at 3 months postoperatively. RESULTS: 24 patients were included in the study, and divided equally into test (N = 12) and control (N = 12) groups. Descriptive statistics were used to find the means and standard deviations of the parameters, and inferential statistics to assess p-values, using an independent-sample t-test. At 3 months after surgery, 10 patients in the test group demonstrated absence of pain (mean 0.1 ± 0.3), while only one patient was pain free in the control group (mean 5.2 ± 2.3). There was a significant improvement in mouth opening in the study group (mean 37.4 ± 3.4) in comparison with the control group (mean 22.5 ± 9.5). The study group demonstrated favourable surgical outcomes for all parameters (p < 0.0001), aside from clicking. CONCLUSION: Within the limitations of the study, disc repositioning in high condylar fractures appeared to demonstrate a positive effect on TMJ function, and hence should be considered in appropriate indications.

Template guided extra oral vertical ramus osteotomy for facial deformity correction - a technical note.

OBJECTIVE: To assess the efficacy of template as a guide in performing extra-oral vertical ramus osteotomy. METHODS: A 21-year-old male patient, reported with complaints of facial asymmetry and restricted mouth opening due to ankylosis involving the right TMJ. Interpositional arthroplasty along with extra oral vertical ramus osteotomy and coronoidectomy was planned to correct the ankylosis of TMJ and facial asymmetry. An acrylic template was used as a guide for performing the osteotomy. Intra operative accuracy of the osteotomy and post-operative neurosensory functioning of inferior alveolar nerve was assessed subjectively and objectively by static two-point discrimination test. RESULTS: In a follow up period of six months, no subjective and objective sings of neuro sensory impairment were reported. CONCLUSION: Using a template as guide in making vertical ramus osteotomy, avoids intra operative damage to the inferior alveolar nerve.

Management of Zygomatic Arch Fractures by Intraoral Open Reduction and Transbuccal Fixation: A Technical Note.

Fractures of the zygomatic arch are common due to its anatomical prominence. The post-traumatic restoration of the arch form is important to maintain the midfacial symmetry and anteroposterior projection of the face. Open reduction and internal fixation (ORIF) of fractured arch is indicated in specific clinical presentations. The traditional methods of ORIF of zygomatic arch fractures require cutaneous incisions, which are associated with complications such as scarring and facial nerve injury. This article presents a simple technique of "intraoral reduction and transbuccal fixation" of the arch that negates the problems associated with the conventional approaches to ORIF.

Inferior Repositioning of Coronoid Process for the Treatment of Temporomandibular Joint Subluxation/Dislocation.

Subluxation/dislocation of the temporomandibular joint (TMJ) is characterized by transient locking of the jaw following wide mouth opening. The etiology of the condition is multifactorial relating to hard-tissue or soft-tissue components of the joint. Myriad treatment procedures have been described in the literature, each with its own advantages and disadvantages. We present a new intraoral technique of coronoid repositioning for the treatment of TMJ subluxation/dislocation.

Zygomatic Arch Osteotomy for Open Reduction and Internal Fixation of Medially Displaced/Dislocated Condylar Head in High Condylar Fractures.

PURPOSE: Open reduction and internal fixation of high condylar fractures is challenging. The difficulty gets compounded when the condylar head is medially displaced or dislocated. The surgical procedure is limited by inadequate visibility and restricted access to the fractured condyle for proper reduction and fixation. When conventional methods of reduction fail, "osteotomy-osteosynthesis" is performed to retrieve and fix the fractured condylar head. However, they are extensive surgeries and associated with morbidity. METHODS: This article presents a novel technique "zygomatic osteotomy (ZO)" performed on a cadaver to facilitate retrieval of the displaced head and achieve ideal reduction and fixation. A comparison of the existing techniques with the proposed ZO has been done in detail. CONCLUSION: The "ZO" technique is easy to perform with less potential for complications.

Efficacy of Exclusive Lingual Nerve Block versus Conventional Inferior Alveolar Nerve Block in Achieving Lingual Soft-tissue Anesthesia.

OBJECTIVE: The aim of this randomized clinical trial was to assess the efficacy of exclusive lingual nerve block (LNB) in achieving selective lingual soft-tissue anesthesia in comparison with conventional inferior alveolar nerve block (IANB). MATERIALS AND METHODS: A total of 200 patients indicated for the extraction of lower premolars were recruited for the study. The samples were allocated by randomization into control and study groups. Lingual soft-tissue anesthesia was achieved by IANB and exclusive LNB in the control and study group, respectively. The primary outcome variable studied was anesthesia of ipsilateral lingual mucoperiosteum, floor of mouth and tongue. The secondary variables assessed were (1) taste sensation immediately following administration of local anesthesia and (2) mouth opening and lingual nerve paresthesia on the first postoperative day. RESULTS: Data analysis for descriptive and inferential statistics was performed using SPSS (IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp. Released 2013) and a P < 0.05 was considered statistically significant. In comparison with the control group, the study group (LNB) showed statistically significant anesthesia of the lingual gingiva of incisors, molars, anterior floor of the mouth, and anterior tongue. CONCLUSION: Exclusive LNB is superior to IAN nerve block in achieving selective anesthesia of lingual soft tissues. It is technically simple and associated with minimal complications as compared to IAN block.