The study aims to evaluate the efficacy of two doses of dexmedetomidine for sedation during awake fiberoptic intubation (AFOI). The study was designed in a prospective, randomized, double-blinded manner and carried out in an academic medical university. Forty young co-operative patients aged 15–45 years of either sex belonging to ASA class I-II, planned for elective maxillo-facial surgery formed the study group. All patients received midazolam 0.05 mg/kg, glycopyrrolate 0.2 mg, ondansetron 4 mg, and ranitidine 50 mg IV 15 min before as premedication, oxygen by nasal cannula, and topical local anesthetics to the airway. Patients were randomly assigned to one of the groups; dexmedetomedine 1 μg/kg IV (Group L), or dexmedetomidine 1.5 μg/kg IV (Group H). Observer’s Assessment of Alertness/Sedation (OAA/S) was assessed. Primary outcome measurements were: HR, MAP, SpO2 and EtCO2 and secondary outcome measurements were: intubation scores by vocal cord movement, coughing and limb movement, fiberoptic intubation comfort score, nasotracheal intubation score and airway obstruction score. On the first post-operative day, recall, level of discomfort during fiberoptic intubation, adverse events and satisfaction score were also assessed. There were no significant hemodynamic differences between the two groups. OAA/S was significantly better with dexmedetomidine 1.5 μg/kg (p < 0.05) and patients were significantly calmer, more cooperative and satisfied during awake fiberoptic intubation with dexmedetomidine 1.5 μg/kg with fewer transient adverse effects. Dexmedetomidine 1.5 μg/kg proved to be more effective for sedation for awake fiberoptic intubation.
Dexmedetomidine; Awake fiberoptic intubation
Mouth gags are surgical devices placed between the upper and the lower jaw to prevent the mouth from closing during operative procedures of the mouth or throat. Since the beginning of the use of mouth gags in medicine, a wide variety of different models has been invented and described. Till now, slipping, sliding and dislocation in the mouth are problems observed during use, especially of one-sided mouth gags. These problems were already discussed at the beginning of the ninteenth century. The need for introducing a suitable mouth gag is emphasized since then. A modification of the well known one-sided Denhart mouth gag is presented. The new Denhart–Hoefert mouth gag has pivotal pads, which allow to compensate movements in surgery without dislocation. These pivotal pads give a stable and better fixation to the teeth, to the edentulous jaws and enable also to fixate other instruments like tongue plates. The use of the Denhart–Hoefert mouth gag in practice showed a less frequency of sliding and dislocation, especially during manipulation. Besides the description of these modifications a short historic overview of the mouth gag discussion is presented.
Mouth gag modifications; Denhart–Hoefert mouth gag; Pivotal pads; Stability; Tongue plate; Denhart mouth gag
Fibro osseous lesions are benign mesenchymal skeletal tumours in which mineralized tissue, blood vessels and giant cells, in varied proportions replace normal bone. Included in this group are fibrous dysplasia (FD), cherubism, ossifying fibroma and osteoblastoma. Although fibro osseous lesions have similar histologic and radiographic features, they may exhibit a wide range of biological behaviours. Because the histologic appearance does not predict the rate of growth or prognosis, treatment is based on the clinical and biologic behaviour of the tumour. The term “Juvenile active ossifying fibroma”(JAOF) has been given to a less common, more aggressive variant of the central ossifying fibroma which occurs primarily in children and young adults. This lesion has been described in literature under variety of terms like “aggressive psammomatoid ossifying fibroma” or “juvenile ossifying fibroma”. We are presenting a case of Juvenile aggressive ossifying fibroma in a 17 years old girl who reported to our institute.
Ossifying fibroma; Mandible; Juvenile aggressive
To evaluate the efficacy of single dose Azithromycin as prophylactic antibiotic in surgical removal of mandibular third molar.
Materials and Methods
The study was carried out as an open clinical trial on fifty (23 males & 27 females) patients chosen from the ones referred to our Oral & Maxillofacial Surgery Department for surgical removal of mandibular third molar (SRMTM). Pre-surgical evaluation of pain, swelling, lymphadenopathy, fever and purulent discharge from the surgical site were made. All patients were administered oral Azithromycin 500mg, 1 hour prior to the procedure. The patients were followed up clinically for a minimum period of 10 days post operatively. Evaluation for pyrexia, purulent discharge from surgical site, persistent pain &/or swelling & lymphadenopathy was done on 1st, 3rd, 7th and 10th postoperative day to determine SSI (surgical site infection). All patients received same set of post-operative medications (Tab. Diclofenac sodium (50mg) TID, Tab. Ranitidine 150 mg BID for 5 days) and set of instructions.
Surgical site infection was seen in only one patient (2%) out of the total fifty patients included in the study when oral Azithromycin was administered one hour prior to surgical removal of mandibular third molar.
Our study suggests that, giving antibiotics pre-operatively 1 hour before the SRMTM is beneficial to reduce/avoid SSI. The surgeon must consider all potential factors that may contribute to the post-operative complication and decide whether the benefits of antibiotic therapy outweigh its risks.
Prophylactic antibiotic; Impacted mandibular third molar; Azithromycin; Surgical site infection
Mandibular hypoplasia is a craniofacial malformation that can cause airway obstruction and may affect the eating process. This anomaly is common in many polimalformed Syndromes, including the Pierre Robin Sequence and the Moebius Syndrome. It is also common in cases related to the dysgenesis of the brainstem. In order to avoid tracheostomy, or to allow for early decannulation in severely affected children, external distraction devices were employed in 3 clinical cases to repair mandibular deficiencies. A successful external mandibular distraction induces the removal of the airway obstruction, allowing spontaneous ventilation without devices, an independent eating process with no need of nasogastric or gastrostomy tubes, apart from the linguistic and facial asymmetry improvement.
Mandible; Hypoplasia; Pediatric; Malformation; Distraction
This study aims to retrospectively analyze the incidence and pattern of cranio-maxillofacial injuries in the developing world in a hope to emphasize on authorities the need of improvising infrastructural facilities, medical and other. Hospital medical records with available radiographs of 6,872 patients treated for cranio-maxillofacial injuries at major trauma centres in Pune, India over a 22 year period (from July 1989 to June 2010) were reviewed. Relevant data pertaining to patients’ age, sex, cause of injury, sites of injury, associated injuries, anaesthesia, various treatment modalities and complications were recorded and analyzed statistically. A total of 6,872 patients sustained maxillofacial injuries of which 5,936 (86.4 %) were caused by road traffic accidents (RTA), followed by fall in 608 cases. Distribution pattern of sex revealed male predominance (M:F-2.5:1) and the third decade age group (2,416) sustained maximum cranio-maxillofacial injuries. Of 12,503 cranio-maxillofacial sites involved, mandible (6,456) predominated, while there was middle third involvement in 5,024 cases. Most of the patients (4,856) were treated with open reduction and internal fixation without maxillo-mandibular fixation and complications were noted in 320 patients. In comparison to similar recent studies reported in the literature, our findings show that RTA remains the most common cause of cranio-maxillofacial injuries with male preponderance. Also RTA remains the major preventable etiological factor of cranio-maxillofacial injuries, which should prompt authorities to take “Herculean effort” to implement rules and educate people.
Facial trauma; Maxillofacial injuries; Road traffic accidents; Retrospective statistical analysis
This study aims to evaluate efficacy of V–Y closure of upper lip incision on facial esthetics in comparison to simple continuous closure after Le Fort I advancement and superior repositioning of maxilla. Thirty-four patients were divided in two groups i.e. V–Y closure group (group I = 17 patients) and simple continuous closure group (group II = 17 patients). The preoperative and 1 year post-operative linear and angular changes of hard and soft tissue points of groups I and II were statistically compared. Labial changes were more favourable in V–Y closure group in comparison to simple continuous closure group in both the Le Fort I maxillary movements. The upturning and forward movement of the nose were seen in both the maxillary movements but these nasal changes did not differ significantly between the groups. It was observed that the technique of V–Y closure of upper lip delivers adequate results contributing to better facial esthetics when compared to simple continuous closure.
Le Fort I osteotomy; V–Y closure; Nasolabial esthetics; Upper lip lengthening
The use of buccal fat pad as a graft for intraoral defects is an uncommonly reported procedure but, it has been frequently used for closure of oro-antral and oro-nasal communications. Buccal fat pad was used to reconstruct 3 medium sized defects due to tumoral resection and oro-antral communication. It was used as an unlined pedicled graft. Three cases are discussed along with anatomical aspect of the buccal fat pad. The findings support the view that the buccal fat pad is versatile, logical, convenient, and reliable method for the reconstruction of oral defects up to 4–5 cm in diameter and it healed within 4–5 weeks.
Buccal pad fat; Pedicled graft; Intraoral defect; Healing
The systemic effects of adrenaline administered during dental local anesthesia have been the subject of many studies. The purpose of this study was to investigate the haemodynamic and metabolic effects attributable to adrenaline injected during local anesthesia in dental extraction patients.
Apparently medically fit patients were included and randomized into two groups. Participants had breakfast before coming in for tooth extraction. The weight, height, blood pressure and pulse rate were measured and blood sample taken before administration of local anaesthetic injections. Blood pressure, pulse and blood sample were again taken at 15 and 30 min.
While the adrenaline group showed a modest increase between pre- and post-drug administration states, the control group showed no difference in median systolic blood pressures. Both groups showed a slight increase in diastolic blood pressure observed between pre- and post-drug administration states. Also both groups showed no significant difference in median pulse rate throughout. Although blood glucose values were widely dispersed in the pre-drug administration state in both groups, the control group showed no difference in median values throughout. However, a modest increase was observed in the adrenaline group between pre- and post-drug administration states, which persisted beyond 30 min.
The patients treated with local anesthesia with adrenaline showed a response similar to that observed in the control group.
Haemodynamic; Metabolic; Local; Anaesthetic; Tooth; Extractions
Trigeminal neuralgia (TN) is a debilitating ailment. Pharmacotherapy still remains the first line therapy for the management of TN. However, often the patients become refractory to the pharmacotherapy and need surgical interventions. There is a wide array of surgical treatment modalities available for TN and it is important to select the most appropriate surgery for a patient. This review evaluates the various surgical modalities by employing a comparative analysis with respect to patient selection, success rate, complications and cost effectiveness. For the evaluation, a critical review of literature was done with predefined search terms to obtain the details of individual procedures, which were then compared, under similar parameters. The results suggested that microvascular decompression seem to be the most effective treatment in terms of patient satisfaction and long term cost effectiveness. However, if patient factors do not permit, then the peripheral procedures may be employed as a substitute, though they have higher recurrence rate and complications and have relatively lower long term cost effectiveness. The newer modalities like stereotactic radiosurgery and botulinum injections have promising results and further refinement in these procedures will provide additional options for the patients suffering from TN.
Trigeminal neuralgia; Surgical modalities; Comparative evaluation
Condylar hyperplasia is a rare non-neoplastic pathology associated with overgrowth of the mandibular condyle. Presentation of condylar hyperplasia with bifid mandibular condyle has never been reported in literature. Early management of the hyperplastic disorders of the mandibular condyle can prevent occlusal canting and developing asymmetric deformities. We report a case of ‘Bifid Hyperplastic Mandibular Condyle’ in a 14-year-old male with emphasis on early surgical intervention. To best of our knowledge, the present case is the first reported case of bifid mandibular condyle with condylar hyperplasia and 66th reported case of bifid mandibular condyle in living human population.
Condylar hyperplasia; Bifid condyle; Mandibular condyle; Hyperplastic mandibular condyle
The ultimate goal in surgical endodontics is not only the eradication of periapical pathosis but also preservation of periodontal tissues using suitable surgical techniques. Treatment outcomes are no longer acceptable without considering the esthetic consequences of all involved dentoalveolar structures. It is critical that incisions and tissue elevations and reflections are performed in a way that facilitates healing by primary intention. The large variety of flaps available for periapical surgeries reflects the number of variables to be considered before choosing an appropriate flap design. In this study; Ocshenbein-Leubke (OL) and trapezoidal (TZ) flaps have been compared in terms of their efficacy and comfort. Twenty patients of ASA category I, between the age group of 12–40 years were randomly selected to undergo periapical surgery by utilizing one of two flaps. All the subjects were free of periodontal disease. Demographic variables were found to be statistically similar. OL flap was found to be better than TZ flap with respect to time of flap reflection, accessibility, duration of surgery and post-operative pain. The OL flap takes less time for reflection with nearly the same accessibility, less post-operative pain and less complication as compared to TZ flap. We conclude that OL flap gives better results when compared to TZ flap.
Periapical surgery; Ocshenbein-Leubke flap; Trapezoidal flap
Platelet-rich plasma (PRP) is an autologous product that contains highly concentrated number of platelets in a small volume of plasma, derived from whole blood by gradient density centrifugation. It has been speculated that local growth factors in human platelets (insulin-like growth factor, IGF; transforming growth factor, TGF-β; platelet derived growth factor, PDGF) would enhance healing of grafts and also counteract resorption. The aim of this study was to evaluate efficacy of PRP on early healing after autogenous bone grafting. Of the twenty patients selected ten were treated with autogenous bone graft and PRP (PRP group) and other ten with autogenous bone graft alone (non-PRP group). PRP group consisted of two benign tumor of mandible, one post surgical defect, two unilateral alveolar cleft, one bilateral alveolar cleft with skeletal class III malocclusion, one maxillary hypoplasia, one oronasal fistula, one recurrent tumor of mandible, one multiple impacted mandibular teeth. Non-PRP group consisted of seven benign tumor of jaw, one keratocyst odontogenic tumor, one orbital blow out fracture, one residual traumatic defect. Biopsies were taken in the native bone, PRP treated grafted bone, grafted bone without PRP at 3 months to assess the maturity of bone. Radiographic imaging was performed by panoramic radiography at 3 and 6 months to evaluate bone opacity of grafted bone on comparison with native bone and computerized tomography at 6 months to evaluate grafted bone morphologically and to measure bone density in Hounsfield units. Microscopic results showed that significantly more matured bone was formed at PRP treated sites as that of native bone and immature bone in controls after 3 months of healing. Bone opacity of PRP treated bone grafts was close to that of native bone than that of non-PRP treated bone grafts on panoramic radiograph at 3 and 6 months. There was graft loss in three cases and graft resorption in one case of non-PRP treated bone grafts at 6 months. In PRP group the compact bone was clearly differentiated from cancellous bone as in native bone and thick in five cases, thin in five cases. In non-PRP group the compact bone was thin as a whole. Comparing native bone group and PRP group the CT value of PRP treated bone graft was more or less close to native bone group and comparing native bone group and non-PRP group CT value was low in non-PRP treated bone graft. Whereas when comparing PRP and non-PRP group CT value was higher in PRP group. Autologous PRP was a safe, biocompatible, effective, source for growth factors and carries no risk of transmissible diseases. It enhances and accelerates bone regeneration of autogenous bone grafts.
Platelet-rich plasma; Mandibular reconstruction; Nonvascularised bone grafts; Alveolar bone grafting; Hounsfield unit
Freeman-Sheldon syndrome (FSS), as first described by Freeman and Sheldon in 1938, is a morphologically well-defined syndrome that results in a dysmorphic status combining bone anomalies and joint contractures with characteristic facies. It is part of the nosologic group of pathologies currently known as distal arthrogryposis as reported by Hall et al. (Am J Med Genet 11:185–239, 1982 ). It is a rare disorder and its exact prevalence is unknown. Our objective is to report a case of FSS presenting with microstomia and add a brief review of the literature for similar cases.
Freeman-Sheldon syndrome; Multiple congenital contracture; Distal arthrogryposis type 2A; Microstomia
Autologous blood injection (ABI) is a conservative, non-surgical method of treating chronic temporomandibular joint (TMJ) dislocation. Although many clinicians have reported positive results, procedural success has not been evaluated according to dislocation type. This study investigated the success of ABI on chronic TMJ dislocation with respect to dislocation frequency. ABI was used to treat 27 joints in 17 patients. The patients were divided into two groups based on dislocation frequency: (A) at least twice a week on different days and (B) at least twice a day. The procedure was successful in 13 of the 15 injected joints (86.6 %) in group A and six of the 12 injected joints (50 %) in group B. This difference was statistically significant (p = 0.03814). Autologous blood injection had limited success in patients with very frequent dislocation, while it was useful for treating less frequently dislocated TMJs.
Autologous blood injection; Chronic temporomandibular joint dislocation
The immune system is central in the body’s defense against non-self. Immunoglobulins and acute phase proteins have been reported to play active roles in carcinogenesis. This prospective longitudinal study was carried out to determine the state of humoral immunity in Nigerian oral cancer patients relative to controls. Twenty newly diagnosed untreated cases of oral squamous cell carcinoma recruited from our centre were included in the study. The controls included 20 apparently healthy and HIV negative volunteers. Serum immunoglobulin classes and acute phase proteins were measured using immunoplates. IgA and ceruloplasmin showed statistically significantly elevated levels in the patients compared with controls, while increases in IgM and IgG were insignificant. The raised levels suggest a role for immunoglobulin A and ceruloplasmin in the mechanisms involved in oral cancers. Findings from this study are similar to that reported elsewhere in the literature. Further work is needed to ascertain the role and usefulness of immunoglobulins and acute phase proteins in staging, disease monitoring, therapy and prognostication.
Immunoglobulins; Acute phase proteins; Oral cancers
The purpose of the study was to compare the soft tissue changes after maxillary advancement in patients with maxillary deficiency associated with cleft lip and palate (CLP) by two approaches—anterior maxillary distraction (AMD) and advancement LeFort I osteotomy (ALO). Twenty patients with maxillary hypoplasia associated with cleft lip and palate who had undergone either LeFort I osteotomy or distraction osteogenesis with maxillary advancement were included in this study. Lateral cephalogram taken at various intervals of time were used to evaluate soft tissue and hard tissue changes over time. In both groups, vertical as well as horizontal changes in pronasale was well observed. A substantial increase in nasal parameters was noted in case of AMD group in comparison to ALO. Though maxillary advancement was evident in both the groups, a significant and consistent change was observed in AMD. Significant vertical and horizontal changes were seen with respect to subnasale and labrale superius in AMD group. Soft tissue as well as hard tissue relapse was greater in ALO group than AMD group. Significant soft tissue and hard tissue changes were clearly observed in both the groups, but the treatment results were more consistent in cases treated with AMD. Hence AMD could be considered as a better treatment of choice in cases of maxillary hypoplasia associated with cleft lip and palate.
Anterior maxillary distraction; Maxillary hypoplasia; Cleft lip and palate
Oral submucous fibrosis is a chronic, debilitating disease characterized by gradually increasing fibrosis of oral cavity and pharynx, mainly the buccal mucosa, resulting in trismus. Various flaps have been used to reconstruct the surgical defects following excision of fibrous bands. It is inevitable to prevent these flaps from trauma by occlusion. The main objective of the authors is to introduce a technical innovation used to protect the flaps in the post-operative period. Here, we propose an easy and economical method to protect the flaps.
Oral submucous fibrosis; Appliance; Necrosis; Flap trauma
This study was conducted to compare and evaluate the pain associated with administration of Nasopalatine blocks using a disposable insulin syringe and the conventional disposable 3 mL syringe.
Materials and method
Forty patients requiring intraalveolar extractions of maxillary central incisors were randomly assigned to two groups of 20 patients each; one (Group A) received the nasopalatine block with a standard 3mL syringe and the other (Group B) received the block with an insulin syringe. Patients were asked to rate the pain associated with the injection on a visual analog scale (VAS) and the results were analysed using a Chi Square Test.
The mean VAS score for Group A and B was 1.55 and 1 respectively. Chi Square value was calculated to be 8.603 (degree of freedom= 3, P value= 0.0351). There were no differences in the effectiveness of anesthesia between the groups.
Pain associated with administration of the nasopalatine blocks may be significantly mitigated by using the Insulin syringe.
Nasopalatine nerve block; Incisive nerve block; Local anaesthesia
The management of orbital injuries is one of the most interesting and difficult areas in facial trauma. The improper reconstruction of the orbit frequently results in ophthalmic complications. Though a number of materials are available for use in orbital wall reconstruction, at present titanium mesh could be considered to be the ideal orbital floor repair material.
Materials and Methods
The study involved patients with symptomatic zygomatico-orbital fractures requiring orbital wall reconstruction. Under general anaesthesia the floor of orbit was explored and reconstructed with contoured titanium mesh after repositioning of the entrapped orbital contents. The patients were on periodic follow-up for 6 weeks where clinical and radiographic data were recorded.
Ten male patients age ranging from 22 to 53 years (mean 29.88 years) received titanium implants for impure orbital fractures (eight patients) and pure orbital floor fractures (two patients). The main cause of fractures was road traffic accidents. They also complained of enophthalmos (n = 7), diplopia (n = 4), infraorbital nerve paresthesia (n = 6), dystopia (n = 1) and epiphora (n = 2). No implant extrusion or infection was seen. The symptoms were corrected in six patients with enophthalmos, three with diplopia, four with infraorbital nerve paresthesia and all patients with epiphora. Dystopia persisted post-surgically in one patient.
Titanium orbital implants were used to confirm titanium as a useful repair material for orbital floor fractures. Their use leads to less morbidity as no donor site operation is needed. Also it provides favourable healing as it is biocompatible.
Orbital blowout; Titanium mesh; Diplopia; Orbital floor fractures
Temporomandibular joint dislocation is defined as the movement of condyle out of the fossa and the advancement of the posterior surface of the condyle in front of the articular eminence. If this condition becomes chronic, surgical treatment is the only option. The goal of surgical treatment is to reposition the condyle and prevent further recurrences. In this study, a retrospective analysis is presented examining 73 patients and 83 joints that were treated with hook-shaped miniplates and miniscrews fixed to otolog bone grafts. Records were obtained from archives of the Uludag University Medical Faculty, Plastic, Reconstructive and Aesthetic Surgery Department. The duration of postoperative follow-up was 3–30 months. In one case, the miniplate was fractured, and in two cases, abscesses existed. This study aims to emphasize that using miniplates and otolog bone grafts is more cost effective.
Temporomandibular joint; Recurrent dislocation; Bone graft; Miniplate and miniscrews
Odontomas are the most common benign tumours of odontogenic origin. Due to their hamartomatous nature, they are usually asymptomatic but can cause impaction of one or more teeth. They consist microscopically of all the tissue types found in a developed tooth. We present a case of a large sequestrating complex odontoma resulting in facial asymmetry, cellulitis, pain and partial loss of function. This case has significance, as odontomas of this large size have rarely been reported.
Complex odontoma; Radiographic features; Odontogenic; Hamartoma; Sequestration
Giant Cell Tumour (GCT) is a rare benign, osteolytic, pseudocystic solitary localized lesion. The lesion is common in skeletal structure but not as common in craniofacial skeleton. They are composed of sinusoidal and vascular spaces filled with blood and surrounded by fibrous tissue septa. There is a controversy as to whether it is a distinct radiological and pathological entity or a pathological change superimposed on a preexisting lesion. We present a case of a 19 year old female patient who reported with swelling and pain in the right mandible associated with pain and gradual increase in size since 4 years. On the radiographic study expansive, multilocular lesion extending to right coronoid process was observed. Incisional biopsy showed the lesion to be a dental cyst, however, enucleation with curettage of the cyst confirmed it to be GCT. GCT are non neoplastic but locally aggressive tumors with occasional rapid growth that may be differentiated from other multilocular lesions like ameloblastoma, giant cell granuloma and sarcomas. There have been reports which have appeared regarding its pathogenesis, response to treatment. However many questions remain regarding its treatment and prognosis.
Giant Cell Tumour (GCT); Osteolytic; Pseudocystic; Multilocular
Cyanoacrylate tissue glue has been widely used in different surgical applications. It is easy to apply and can save considerable time and effort. Reports including series of oral and maxillofacial cases are yet to be well documented. We report our experience using cyanoacrylate tissue glue in the head and neck region in 165 patients. We have used it for indications including orbital floor graft fixation, cleft lip and palate repair, oral dressing, skin graft fixation, nasal splinting, immobilisation of traumatised teeth, management of chyle leak during neck dissection and wound closure. We have not had any complications from using cyanoacrylate. It is found to be safe and effective in different indications it is used for without undue hazards. The role of cyanoacrylate in oral and maxillofacial surgery needs further research.
Cyanoacrylate; Maxillofacial; Glue; Applications