Aims and Objectives
(1) To determine the incidence of inferior alveolar nerve (IAN) deficits following surgical extraction of mandibular third molar.
(2) To document recovery of IAN injuries.
Materials and Methods
A total of 400 lower third molars were extracted, 205 male patients and 195 females. All underwent extraction by the prescribed buccal approach. All cases were examined by one examiner preoperatively and postoperatively, at 7 days, one month, two months and six months. Two-point discrimination test (2-pd), brush stroke direction (BSD), contact detection, pin prick and thermal testing was carried out.
Results and Conclusion
One patient presented with IAN injury (0.25%). This single case of nerve injury was mesioangular, Level B, Class 2, impaction with a difficulty rating of 5. Levels A and B tests (2PD, BSD, Contact detection) were altered. In these tests, the IAN did not show any signs of recovery by six months. Level C tests (pin prick test, sharp blunt detection) showed that the nerve had recovered completely by two months.
Neurosensory deficits; Inferior alveolar nerve; Nerve injury; Impacted third molars
In the present study, 20 patients with mandibular fracture were included to evaluate the versatility of titanium 3D plate in comparison with conventional titanium miniplate fixation.
The patients were alternatively allocated to either the 3D plate group or Miniplate group. The patients were evaluated for the clinical assessment of mobility after fixation, pre and post-surgical occlusal relationship, adequacy of reduction on post operative radiograph and any post surgical complications.
All 25 fractures in 20 patients were found to be adequately fixed when checked intra-operatively. No post-operative IMF was required in either of the groups. The mean radiographic score at post operative time interval in Miniplate group was found to be 2.80 ± 0.42 and in 3D Plate was found to be 2.90 ± 0.32. The mean radiographic score at 3 months time interval in Miniplate group was found to be 2.70 ± 0.48 and in 3D Plate was found to be 2.70 ± 0.48. Radiolucency at 3 months period was found in 1 patient (10%) in the miniplate group and it was not found in any patients in the 3D plate group. None of the patients in both the groups had complications of non-union or mal-union. In miniplate group, 2 patients (20%) had infections and in 3D plate group 1 patient (10%) had infection. 3 patients in miniplate group had occlusal discrepancies (30%) and 1 patient in 3D plate group had occlusal discrepancies (10%). Overall, complications were found in 6 patients (60%) in miniplate group and 2 patients (20%) in 3D plate group. The data when compared was statistically significant (P < 0.05).
The 3D plating system was found to be advantageous over conventional miniplates. It uses lesser foreign material, reduces the operation time and overall cost of the treatment. Thus 3D plate can be used as an alternative to conventional miniplates. The system is reliable and effective treatment modality for mandibular fractures.
Mandible fracture; Miniplates; 3D plates
(1) To collect the data related to distribution of third molar impactions among rural population by clinical and radiological examinations. (2) To collect the information on distribution of third molar impactions among urban population by clinical and radiological examinations. (3) To compare the patterns of distribution of third molar impactions among rural and urban residents with respect to type of impaction, arch, gender and age.
A cross-sectional study was conducted in Dharwad district of Karnataka state located in South India involving 630 rural and 270 urban subjects as per demographic profile of India. A two stage sampling procedure was adopted in the selection of the sample.
Data was analyzed using STATISTICA-6.0. χ2 test was used to explore the association between different variables and third molar impactions. A P ≤ 0.05 was considered statistically significant.
14.92% of rural subjects and 27.40% urban subjects were reported to be suffering from third molar impactions.
The overall prevalence of third molar impactions among the study subjects was found to be 18.67%. A significant association was noticed between the ‘different arches’ and distribution of third molar impactions in both rural and urban population. Subjects with vertical impactions were found to be most common in both the groups.
Third molar impaction; Cross-sectional study; Demographic profile; Rural; Urban; Vertical impaction
Neurilemmoma is a rare nerve tumor seldom included in the list of differential diagnosis of soft tissue swelling in maxillofacial region. Arrival at a clinical diagnosis of schwannomas is rarely possible as there are hardly any characteristic clinical features to help in its and it is mostly established by histopathologic examination. We report an interesting case which had presentations similar to a sebaceous cyst but finally turned out to be a schwannomma.
Neurilemmoma; Schwannoma; Lemmoma
Aims and Objectives
This comparative study compares the primary and secondary healing after surgical removal of impacted mandibular third molars, evaluating and monitoring the extent of swelling and severity of pain and trismus.
Materials and Methods
60 patients (37 females, 23 males; age range 18–40 years) were included in the series. The patients were randomly subdivided into 2 groups of 30 each. All the patients were operated by the same operator under same clinical conditions. Group 1 had 30 patients who underwent primary closure. Group 2 had 30 patients who underwent secondary closure. Pain, swelling and trismus were evaluated for 1st, 3rd and 7th days after surgery with a VAS scale.
An analysis of immediate findings showed that the patients with primary closure experienced significantly greater pain, swelling and trismus than that was experienced by patients with secondary closure. When the subsequent findings were analyzed there was statistically significant difference in pain, swelling and trismus experienced between both the groups.
The findings of this study suggest that the procedure of choice after removal of impacted mandibular third molars is a secondary closure and healing by secondary intention. A secondary closure appears to minimize the postoperative edema, pain and trismus and thus contributes to enhanced patient comfort.
Third molar surgery; Primary wound closure; Secondary wound closure
Reconstruction of the facial skeleton remains a herculean task for a reconstructive surgeon, even with the availability of ample reconstructive options. Transport distraction osteogenesis is a novel reconstructive modality in the armamentarium of a maxillofacial reconstructive surgeon with obvious advantages of osteogenesis and histogenesis from the residual host tissues after tumor ablative surgeries or trauma and also, precludes donor site morbidity. This paper reviews the current concepts, principles involved and applications of transport distraction osteogenesis in maxillomandibular reconstruction.
Maxilla; Mandible; Maxillofacial surgery; Distraction osteogenesis; Transport distraction; Osteogenesis; Mandibular reconstruction
We present an unusual case of a frontal sinus mucocele with intracranial and intraorbital extension. We also discuss the diagnosis and current management principles of this unusual lesion.
Frontal sinus mucocele; Proptosis; Intracranial extension and intraorbital extension
While India boasts the largest collective experience in the surgical management of TMJ ankylosis, times are changing and Indian Surgeons will need to begin thinking about other TMJ disorders that have previously gone under the radar. A growing Indian middle class with greater access to health facilities will demand treatment for TMJ disorders like myofacial pain and dysfunction, internal derangement and osteoarthrosis which Oral & Maxillofacial Surgeons must be prepared to manage. The aim of this paper is to review the role of TMJ surgery and its place in the treatment armamentarium of temporomandibular disorders. Indications, rationale for surgery, risks vs benefits are discussed and complemented with examples of clinical cases treated by the author. As India moves up the economic ladder of success, TMJ disorders that have largely been confined to Western nations will begin to appear in the rising middle classes of India. Indian Oral & Maxillofacial Surgeons must be prepared to recognize and manage disorders which present with more complex symptomatology where the role of TMJ surgery is less clear cut.
Temporomandibular joint; Surgery; Arthroscopy; Indications; Techniques; Risks
Major oral and maxillofacial surgery procedures have been routinely performed on an inpatient basis in order to manage both, the recovery from anesthesia and any unpredictable morbidity that may be associated with the surgery. The use of inpatient beds is extremely expensive and if the surgical procedures could be done on an outpatient setting, it would reduce the costs and the need for inpatient care. The aim was to determine the length of hospital stay (LHS) and the factors which influence the LHS following orthognathic surgery at the Jordan University Hospital over 5 years (2005–2009).
This was a retrospective record review of patients who underwent orthognathic surgery at Jordan University Hospital between 2005 and 2009. The variables were recorded on a data capture form which was adapted and developed from previous studies. Descriptive and analytical statistical methods were used to correlate these variables to the LHS.
Ninety two patients were included in the study and 74% of them were females. The mean age was 23.7 years and the mean LHS was 4 days. The complexity of the procedure, length of operation time, intensive care unit (ICU) stay and year of operation were significantly correlated with a positive LHS (P < 0.05).
Patients’ hospital stay was directly related to the complexity of the orthognathic procedure, the operation time, time spent in ICU and the year in which the operation was done. There was a significant reduction in the LHS over the progressing years and this could be due to an increase in experience and knowledge of the operators and an improvement in the hospital facilities.
Orthagnathic surgery; Length of hospital stay; Factors responsible for length of stay
Successful management of temporomandibular joint (TMJ) ankylosis depends on adequate gap arthroplasty and interpositional graft; the objective is to produce a functioning pseudoarthrosis that prevents reankylosis and provides adequate mobility. Several interpositional grafts have been used for the treatment of temporomandibular joint ankylosis such as indigenous pterygomasseteric sling, temporalis muscle/fascia, auricular cartilage, fat and dermis-fat. Lateral thigh fascia lata (LTFL) graft is commonly used in neurosurgical practice and in other surgical specialities. We present a case of lateral thigh fascia lata used as interpositional graft for the treatment of a unilateral fibrous temporomandibular joint ankylosis.
Temporomandibular joint; Ankylosis; Lateral thigh fascia lata
Cystic hygroma or cystic lymphangioma is a congenital malformation of the lymphatic system that manifests itself as a soft, benign, and painless mass. It is widely accepted that they arise from the remnants of embryonic lymphatic tissue which retains the potential for proliferation. They grow in the fashion of sprouting and are capable of transgressing anatomical boundaries. They can occur almost at any anatomical site. However, 75–80% cystic hygromas are located in the head and neck region. In the neck, they are typically located within the posterior cervical triangle. The majority of cases (80–90%) are diagnosed under the age of two. We present a case of cervical cystic hygroma in a 6 year old male child which was surgically treated.
Cystic hygroma; Cystic lymphangioma
Determination of difficult airway maintenance preoperatively holds a great significance in different intubation techniques and also surgical exploration of airway. No data is available for relation of airway maintenance and preoperative interincisal mouth opening in oral submucous fibrosis patients.
20 oral submucous fibrosis patients were evaluated pre operatively for general anaesthesia. Direct nasotracheal intubation, fiberoptic laryngoscopy guided intubation or awake blind nasal intubation technique, or combination of above techniques were used.
Mean pre operative inter incisal mouth opening for direct nasotracheal intubation (nine patients) is 15.44 mm, fiberoptic guided laryngoscopy (six patients) is 9.0 mm and blind nasal intubation (five patients) is 5.2 mm.
Benefits of avoiding a surgical exploration of airway was significant.
Pre operative inter incisal mouth opening; Direct nasotracheal intubation; Fiberoptic guided laryngoscopy; Awake blind nasal intubation; Oral submucous fibrosis
The Dandy-Walker syndrome is a malformation of the brain that involves the mal-development of the cerebellum, associated with a cystic enlargement of this area, and frequently hydrocephalus. This malformation occurs in ~1 in 30,000 babies. It is seen mostly in females. Developmental anomalies like cleft lip, cleft palate, and cardiac malformation, orthopaedic and urinary structural abnormalities may also occur in 30% of the individuals. We report a case of Dandy Walker syndrome with Tessier 7 facial cleft with paramedian cleft palate in a 6 month old child. Surgical methods used to correct this anomaly include commissuroplasty, myoplasty of the orbicularis oris, and closure of the cleft cheek. Authors report a vermilion square flap technique that combines a lower lip mucocutaneous vermilion border flap with a lazy W-plasty to ensure a natural commissure and skin closure.
Dandy-Walker syndrome (DWS); Tessier 7 malformation
Pain plagues daily activity and hence its management would require alleviation at both the mental and physical planes, thus, bringing about comfort. It includes delivering analgesics in parenteral or oral form, or patches depending on the intensity and availability. Best analgesic regimens are ones that offer broad coverage, easy to administer, safe and economical. A drug seemingly appropriate to treat moderate to severe pain would be Tramadol hydrochloride, a centrally acting synthetic opioid analgesic with lower opiate-like dependence than Morphine. Ketorolac, a pyrrolo-pyrrole derivative, possesses analgesic, anti-inflammatory and anti-pyretic activity would also appear equally suitable. Fifty adult ASA grade I and II patients undergoing surgery under GA in the Department of Oral & Maxillofacial Surgery, College of Dental Sciences, Davangere, were included. Ketorolac (30 mg IM) for 25 patients and Tramadol (100 mg IM) for 25 patients were administered at the time of skin closure and repeated after 8 and 16 h from the conclusion of surgery. Pain, using the VAS at the 2nd, 4th, 6th, 12th and 24th post-operative hour, was assessed and compared using χ2-test. Vitals were monitored and adverse events were looked for. Though both the drugs resulted in significant decrease in pain intensity from the 2nd to 24th post-operative hour, Tramadol always resulted in better pain control than Ketorolac at every post-operative hour (P < 0.050). To conclude, intramuscular Tramadol seemed useful in controlling pain following surgery, with better levels of tolerance than intramuscular Ketorolac. However, both the drugs produced mild side effects but did not appear to influence the outcome.
Maxillofacial surgery; General anesthesia (GA); Analgesia; Tramadol; Ketorolac; Visual analogue scale (VAS)
Parapharyngeal ganglioneuroma of hypoglossal nerve is very rare benign tumor arising from sympathetic nervous system producing mass and functional effect. We present a rare case in 4 year old girl with history of swelling and odynophagia in left side of neck. Extensive clinical, immunohistochemistry, and imaging of the swelling confirmed the diagnosis of ganglioneuroma after surgical excision.
Parapharyngeal space; Ganglioneuroma; Hypoglossal nerve
Congenital muscular torticollis results from shortening or excessive contraction of the sternocleidomastoid (SCM) muscle. The reported incidence varies between 0.4 and 1.9%. Various theories have been proposed, but its true aetiology remains obscure. The deformity is characterized by a practically painless, contracted cordlike SCM muscle, which pulls the head toward the side affected, narrows and draws the shoulder upward, forcing the chin in the opposite direction. Torticollis of congenital origin is a deformity not commonly met with in the practice of maxillofacial surgery. The rarity, lack of, or inadequacy of the previous treatment, together with the advanced age and marked deformity appear to warrant an investigation and report of the outcome. A case of congenital muscular torticollis is presented who reported at the age of 18 years and has been successfully treated by unipolar SCM release.
Mouth opening among different population has been shown to vary considerably and its range is specific for a given population. The present study is an attempt to calculate the normal mouth opening in adult Indian population.
A total of 894 adults, 463 males and 431 females, in the age range of 21 to 70 years were studied. The subjects were asked to open their mouth maximally till no further opening was possible. The distance from the incisal edge of the upper incisor teeth to the incisal edge of the lower incisor teeth was measured using a calibrated fiber ruler. To determine correlation of mouth opening with age a Pearson correlation analysis was performed and statistical significance was tested by the application of t test.
The mean maximal mouth opening for males was 51.3 mm (SD 8.3) (Range 39–70 mm). The mean maximal mouth opening for females was 44.3 mm (SD 6.7) (Range 36–56 mm). There was significant difference between the mouth opening of male and female in all the age groups with P value <0.05. A linear relationship was observed between the mouth opening and age in both males and females and the mouth opening decreased as the age increased.
The mean maximal mouth opening for Indian males is 51.3±8.3 mm and for females is 44.3±6.7 mm. The mouth opening seems to decrease with age. The mouth opening of females is significantly less than the males in all the age groups.
Normal; Mouth opening; Indian; Age; Sex
Solitary fibrous tumor (SFT) is a rare benign tumor that occurs most frequently in the pleura. It is considered rare in the maxillofacial area. Two new cases of SFT of the buccal vestibule are reported. The previously reported cases of oral SFT are reviewed. The tumors were composed of spindle–shaped cells that were arranged haphazardly and were positive for CD-34, BCL-2, CD-99 and vimentin. Although rare, SFT should be included in the differential diagnosis of oral soft tissue tumors. The clinical presentation and imaging can provide the clinician a better tool for preoperative diagnosis.
Solitary fibrous tumor; Soft tissue neoplasm; Mandible; Oral cavity; CD34; Immunohistochemistry
Aims and Objectives
Internal derangements are the commonest disorders of temporomandibular joint (TMJ). Different treatment modalities including conservative and surgical methods have been proposed to treat the same. Arthrocentesis is gaining popularity in the treatment of internal derangement of TMJ. Being minimally invasive it does not have the demerits of surgical approaches and at the same time is producing better results than conservative approaches. This study evaluates and compares corticosteroid and sodium hyaluronate after arthrocentesis in the treatment of internal derangement of TMJ.
Materials and Methods
Sixteen patients with internal derangement were randomly selected and divided into 2 groups (8 in each group). Arthrocentesis of the upper joint space was then performed using Ringer lactate under local anaesthesia followed by injection of either betamethasone or sodium hyaluronate into the joint. Clinical data was collected in the form of pain (visual analog scale), maximum mouth opening, joint sound and deviation before and after treatment up to 6 months.
Both groups of patients were benefited from the treatment at the 6 month follow up and there was slightly less intensity of pain in sodium hyaluronate group compared with corticosteroid group. Maximum mouth opening was also increased in both groups. A decrease in clicking and deviation were seen in both groups. There was no statistically significant difference between betamethasone and sodium hyaluronate.
Intra articular injection of corticosteroid or sodium hyaluronate after arthrocentesis had considerable effect on the TMJ. Both betamethasone and sodium hyaluronate can be used after arthrocentesis with similar results.
Temporomandibular joint; Arthrocentesis; Betamethasone; Sodium hyaluronate
The gold standard for surgical correction of both uni- and bilateral coronal synostosis remains to this day, the “standardised bilateral fronoto-orbital advancement and reshaping” based on the “tongue in groove” technique developed by Tessier. It consists of bilateral frontal craniotomy for suture release and decompression, combined with creation of a “supraorbital bar” as a bilateral orbital complex by osteotomising the orbital roof (anterior cranial base), supraorbital ridge and upper lateral orbital rims bilaterally. This is followed by a bilateral advancement and remodelling of the frontal region as well as the orbital region bilaterally which is then rigidly fixed in position, the supraorbital bar to the face (at the fronto-zygomatic region and the fronto-nasal region) and the reconstructed forehead to the supraorbital bar. In this study, a slightly modified procedure was employed for correction of the right sided unilateral coronal synostosis, using a bifrontal craniotomy combined with unilateral orbital osteotomy (creating a unilateral supraorbital bar/bandeau), followed by radial osteotomies/kerfing, reshaping and advancement of the bifrontal calvarial segment. This was followed by the “tongue in groove” advancement of the right orbital segment (unilaterally). We preferred to spare osteotomising the contralateral (that is, the left) orbital region as it was not involved by compensatory growth deformity, and the frontal bossing/bulging was restricted to the upper forehead region alone. A gratifying aesthetic outcome and perfect symmetry was achieved using this technique. There were also no complications like wound infection or dehiscence, CSF leak, bone loss from resorption, damage to orbital contents or brain, recurrence of the dysmorphology or residual deformities or asymmetrics of the orbital region or forehead. Gratifying cosmetic results were seen using this modified technique and it was found that bilateral frontal reshaping and unilateral orbital advancement together with kerfing the frontal segment followed by fixation using resorbable implants is an effective strategy to not only permit remodelling of the skull and face thus correcting the cosmetic deformity, but also to increase the intracranial volume within the anterior cranial vault, without the need for any graft placement.
Plagiocephaly; Craniosynostosis; Fronto-orbital advancement; Biodegradeable implants