Transpharyngeal approach for Eagle syndrome - case report and literature review

Symptomatic elongation of styloid process or mineralization of stylohyoid ligament is referred to as Eagle's syndrome, which usually presents as a vague head and neck pain radiating to jaws, pharyngodynia, difficulty in swallowing, dysphagia, otalgia, and sensation of foreign body in throat leading to wide range of differential diagnosis. Instead of many hypothesis and studies, the exact etiology of styloid process and role of ectopic calcification are unknown. History and physical examination plays a pivotal role in diagnosis and is confirmed by radiological investigation. Treatment modalities include both conservative and surgical management by intraoral and extra oral approaches

Effects of pre-operative submucosal dexamethasone injection on the postoperative swelling and trismus following surgical extraction of mandibular third molar

To determine the effects of pre-operative submucosal dexamethasone injection on postoperative swelling and trismus following surgical extraction of mandibular third molar. Randomized controlled trial. Department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry [AFID], Rawalpindi, from October 2009 to March 2010. A total of 100 patients aged 18 - 40 years with good periodontal health and mesioangular impaction were divided in two treatment groups [50 in each group]. Group-A received prophylactic 4 mg submucosal dexamethasone intraoral injection and Group-B acted as control group. Facial swelling and trismus were assessed at baseline, 2nd and 7th postoperative days. Data was analyzed using SPSS-10. There were 35 [70%] males and 15 [30%] females in group-A and 34 [68%] males and 16 [32%] females in group-B. Surgical time ranged from 30 - 50 minutes [mean = 40.62 +/- 4.886 minutes] for group-A and 33 - 50 minutes [mean = 42.12 +/- 4.543 minutes] for group-B. Administration of dexamethasone had statistically significant effect in reduction of swelling and trismus on second postoperative day [p < 0.05] in group-A. Pre-operative 4 mg submucosal dexamethasone injection was significantly effective in reduction of postoperative swelling and trismus

Frequency of p53 gene mutation and protein expression in oral squamous cell carcinoma

To determine the frequency of p53 gene mutation and protein expression in Oral Squamous Cell Carcinoma [OSCC] and to establish correlation between the two. Analytical study. Histopathology Department and Molecular Biology Laboratory, Armed Forces Institute of Pathology [AFIP], Rawalpindi, from May 2010 to May 2011. Thirty diagnosed cases of OSCC were selected by consecutive sampling. Seventeen were retrieved from the record files of the AFIP, and 13 fresh/frozen sections were selected from patients reporting to the Oral Surgery Department, Armed Forces Institute of Dentistry [AFID]. Gene p53 mutation was analyzed in all the cases using PCRSSCP analysis. DNA was extracted from the formalin-fixed and paraffin-embedded tissue sections and fresh/frozen sections. DNA thus extracted was amplified by polymerase chain reaction. The amplified products were denatured and finally analyzed by gel electrophoresis. Gene mutation was detected as electrophoretic mobility shift. The immunohistochemical marker p53 was applied to the same 30 cases and overexpression of protein p53 was recorded. Immunohistochemical expression of marker p53 was positive in 67% [95% Confidence Interval [CI] 48.7 - 80.9] of the cases. Mutations of the p53 gene were detected in 23% [95% CI 11.5 - 41.2] of the OSCC. No statistically significant correlation was found between p53 gene mutation and protein p53 expression [rs = - 0.057, p = 0.765]. A substantial number of patients have p53 gene mutation [23%] and protein p53 expression [67%] in oral squamous cell carcinoma [OSCC]

Bioresorbable versus titanium plates for mandibular fractures

To compare bioresorbable plates with titanium plates for treatment of mandibular fractures. Randomized controlled trial. Oral and Maxillofacial Surgery Department, Armed Forces Institute of Dentistry, Rawalpindi, from January to December 2010. Patients with mandibular fracture were randomly divided in to two groups. The control group received titanium plates while the experimental group received the bioresorbable plates. All the procedures were carried out under general anaesthesia using standard surgical techniques. Frequency of plate/screw breakage or loosening, development of infection, malocclusion, malunion, wound dehiscence, the need for hardware removal and any other technical difficulties were compared between the two groups using chi-square test with significance at p < 0.05. A total of 34 patients were included in the experimental group where 53 resorbable plates were applied. The control group consisted of 35 patients and received 52 titanium plates. The mean age in the experimental group and the control group were 31.35 +/- 11.16 years and 34.31 +/- 10.69 years respectively. Breakage of 16 screws and 03 plates was seen in the experimental group while no screw or plate broke in the control group. The results showed significant association of screw breakage with resorbable plates and plate removal with titanium plates. Bioresorbable plates can be used as an alternative to titanium plates in mandibular fractures but with caution. They are a good means to stabilize fractures in patients where growth retardation and hardware removal may be a consideration

E-cadherin expression, a valuable predictor of invasiveness in histological grades of oral squamous cell carcinoma

The aim of this study was to evaluate E-Cadherin expression in oral squamous cell carcinoma [OSCC] with its relation to histological grades. It was a quasi experimental study in which sixty diagnosed cases of oral squamous cell carcinoma were selected by purposive sampling technique. Fresh sections were prepared and re-diagnosed for relative histological grades by H and E staining, regardless of their previous diagnosis. E-Cadherin expression was assessed in terms of Intensity and Site of staining and its expression was recorded. The collected data were analyzed by SPSS version 17. The differential grades observed in 60 cases both with H and E and E-Cadherin staining methods were compared which showed a highly significant association, P-value < 0.001. A strong membranous E-Cadherin expression was observed in cells of well differentiated squamous cell carcinoma, which changed to heterogeneous [both membranous as well as cytoplasmic expression] in moderately differentiated SCC and became weak cytoplasmic to absolute negative in poorly differentiated OSCC. Intensity of E-Cadherin expression was also observed to be reduced, P-value < 0.001, with the advancing histological grades of oral squamous cell carcinoma. It was concluded that E-Cadherin expression provides accurate details of tumour behaviour at all levels in a given section which can be used to predict the prognosis of the disease more accurately

maxillofacial trauma management trends at Armed Forces Institute of Dentistry, Rawalpindi

The aim of this study was to evaluate and analyze current trends in the management of trauma in patients presenting to oral and maxillofacial surgery department of Armed Forces Institute of Dentistry. Rawalpindi from Jan 2008 to Dec 2010. In this retrospective study, data of 613 patients with maxillofacial fractures treated at oral and maxillofacial surgery department, Armed Forces Institute of Dentistry was reviewed and analyzed. The main parameters recorded were gender, pattern of facial bones fracture and treatment modality of fracture. Out of these 613 patients, 564 [92%] were males and 49 [8%] were females with a male to female ratio of 11.5:1. The mandible was the most common bone to be fractured, with 307 fractures [50.1%], followed by 116 fractures [18.9%] of zygomatic bone, 83 fractures [13.5%] of maxillary bone, 64 patients [10.5%] had panfacial trauma, 26 [4.3%] were having nasal fracture while Naso-orbito-ethmoid fractures [NOE] were seen in 15 [2.4%] cases. The management of the injured face has undergone major changes, outcomes are considerably better than 30 years ago as more comprehensive assessment and management is now possible

Pattern and presentation of oral white lesions

Oral white lesions are not uncommon and a significant number of patients are asymptomatic. The purpose of this study was to determine the pattern and presentation of oral white lesions in patients reporting at oral and maxillofacial surgery department of AFID. World Health Organization [WHO] guidelines for oral mucosal examination were used to record data of 100 patients who presented with oral white lesions. Biopsies were performed in lesions whose definitive diagnosis was deemed difficult purely on the basis of history and clinical examination. The mean age was 38 +/- 13years with 57[57%] males. Forty two [42%] patients were asymptomatic. The most frequent site was buccal mucosa [64%] and more than half of these lesions appeared white [57%] while others were yellowish white [18%], grey white [15%] and with areas of redness within the lesion [10%]. Among habits, smoking was most common. The most common lesion was lichen planus [28%] followed by frictional keratosis [15%] and oral submucous fibrosis [13%]. Other rare lesions were geographic tongue, mucosal burns, candidiasis. As some of these lesions are premalignant, it is imperative for the dental and medical professionals to familiarize with their pattern and presentation to effect early diagnosis and management

Distraction osteogenesis for correcting maxillo-mandibular deformities

To determine the effectiveness of distraction osteogenesis [DO] for correcting maxillofacial deformities. Case series. Department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry, Rawalpindi, from June 2008 to November 2010. Patients with diverse maxillofacial deformities were selected for the study. In all cases, intraoral distractors were used. Mandibular osteotomies were done using submandibular incision and maxillary osteotomy was done using standard vestibular incision. In paediatric patients, DO was started on third postoperative day while in adults, a 7-day latency period was followed. Distraction was carried out at a rate of 0.5 mm twice daily [1 mm/day]. Distractors were removed after a consolidation period of 2 months. A total 7 cases were operated for DO. Out of these, 3 were males and 4 females. The age ranged from 2-24 years [mean 12.57 +/- 9.48 years]. Five patients had their deformity owing to temporo mandibular joint [TMJ] ankylosis, one had congenital micrognathia and one patient had skeletal class-III deformity. Five patients underwent mandibular DO, one underwent maxillary DO and in one case simultaneous maxillo-mandibular DO was carried out. Amount of distraction varied from 9.0 mm to 19.2 mm [mean 15.04 +/- 4.33 mm]. Mean follow-up was 18.14 +/- 5.39 months. Distraction osteogenesis can be employed satisfactorily to correct diverse maxillofacial deformities like retrognathia, facial asymmetry and skeletal class-III

Efficacy of greater auricular nerve infiltration anesthesia in patients having less than optimal analgesia after conventional inferior alveolar nerve block for surgical removal of mandibular third molar

The aim of this study was to determine efficacy of greater auricular nerve infiltration anesthesia in patients having less than optimal analgesia after conventional inferior alveolar nerve block for surgical removal of mandibular third molars particularly those fallig in category calss 2, position B and C. It was a Quasi-Experimental study done in Minor Oral Surgery Department at Armed Forces Institute of Dentistry, Rawalpindi from 19th August 2010 to 10th June 2011. Conventional inferior alveolar nerve block was given to 40 patients. Out of these 14[35%] patients had no pain while 26[65%] experienced pain in the angle of mandible area. These 26 patients were given greater auricular nerve infiltration which relieved pain in 21 patients [80.8%] while 5[19.2%] patients remained symptomatic [p=0.007]. Based on this study it was concluded that intraoperative analgesia is enhanced by greater auricular nerve infiltration in patients complaining of less than optimal analgesia after conventional inferior alveolar nerve block during mandibular third molar surgery

Immunohistochemical expression of protein p53 in oral epithelial dysplasia and oral squamous cell carcinoma

The study was carried out to determine the frequency of p53 protein expression in oral dysplastic lesions and oral squamous cell carcinoma and to compare them in both the lesions. Sixty cases [30 each] of oral epithelial dysplasia [OED] and oral squamous cell carcinoma [OSCC] were retrieved from the record files along with their paraffin blocks at the Armed Forces Institute of Pathology, Rawalpindi including twenty fresh/frozen sections. The immunohistochemical marker p53 was applied using Streptavidin-Biotin technique. Staining and intensity of the marker was recorded and frequencies were compared in both the lesions. Protein p53 expression was seen in 60% of oral epithelial dysplastic lesions and 67% of oral squamous cell carcinomas. The results signify the importance of p53 for the early diagnosis and early treatment of dysplastic [precancerous] lesions

Oral submucous fibrosis: reconstruction with nasolabial flap

The main objective of the study was to evaluate the efficacy of Nasolabial Flap in the reconstruction of oral sub mucous fibrosis. Case series. Oral and Maxillofacial Surgery Department, Armed Forces Institute of Dentistry, Rawalpindi from Jan 2008 to Dec 2009. A total of 5 patients with moderate to severe degree of oral submucous fibrosis were treated surgically and the reconstruction was done using bilateral nasolabial flaps. Four patients were male and one patient was female. The mean age of the patients was 24.6 years. Pre-operative mouth opening was measured before the procedure. Similarly per-operative and post operative mouth openings were also recorded and compared with the pre operative mouth opening. Pre-operative openings ranged from 8mm to 18mm [mean= 12.3mm]. After 6 months of post operative follow up and vigorous physiotherapy exercises, patients were able to maintain mouth openings ranging from 32mm to 39mm [mean =34.5mm]. Paired t-test was used to analyze the results and the value was found to be statistically significant. [p<0.05]. Bilateral Nasolabial flap is a satisfactory treatment modality for oral submucous fibrosis both functionally and esthetically

Correction of airway obstruction in congenital micrognathia by mandibular distraction osteogenesis

Varying degrees of upper airway obstruction is almost universally present in patients of congenital micrognathia which needs to be corrected as early as possible. This allows appropriate feeding and growth and prevents long-term complications such as pulmonary hypertension and cor pulmonale. We report the case of a tracheostomy-dependent, 4-year-old child with congenital micrognathia who was treated with mandibular distraction osteogenesis. This is the treatment of choice for surgical correction of mandibular hypoplasia and for the challenging airway management in infants. Once a bone length of 2 cm was achieved through distraction osteogenesis, the child was completely relieved of respiratory obstruction and tracheostomy tube was removed through the process of decannulation

Orofacial reconstruction with local flaps at AFID

Reconstruction of oral cavity is often a difficult challenge as it involves the restoration of both the cosmetics and preoperative function. Understanding the oral cavity anatomy as well the functional capacities of its various subunits is required to achieve good results. The stage of the disease and extent of resection are the most significant parameters that must be kept in mind before planning for reconstruction. Aim was to evaluate the success rate of various local flaps in oral reconstruction as well as to conclude whether or not the reconstruction method influences postoperative quality of life. This is a descriptive study carried out at Armed Forces Institute of Dentistry, [AFID] Rawalpindi. Sample size comprises of 24 subjects, 16 males and 8 females, who reported to the diagnostic department of AFID from 15 March 2007 to 15 March 2010. A total of 24 patients with oral squamous cell carcinoma were treated in 3 years, out of them 16 [66.7%] were male and 8 [33.3%] were female. The peak incidence was in the 6[th] and 7[th] decade of life [37.5%]. The most common site involved was the alveolus 37.5% in the reported cases followed by tongue [25%] and buccal mucosa [25%]. In 8 [33.3%] patients local resection was performed, in 4 [16.7%] patients resection along with neck dissection was done. In 12 [50%] patient tumour resection followed by neck dissection and immediate reconstruction was also done out of these 12 patients nasolabial flap reconstruction was done in 6 patient [25%], Karapandzic in 4 [16%] patients, and fan flap in 2 [8%] patients. No complication noticed other than wound dehiscence [2 patients], microstomia and circumoral scarring [1 patient]. Mean hospital stay was 7 days

Management of facial gunshot wounds

To determine pattern and presentation in terms of site of injury, airway, associated injuries; and management of facial gunshot wounds. Case series. Oral Surgery Department, Armed Forces Institute of Dentistry, Rawalpindi, between January 2001 and December 2008. All patients with gunshot wounds of the face managed at the Oral Surgery Department during the study period were included by convenient sampling method. Patients were treated by a multidisciplinary team of maxillofacial surgeon, otorhinolaryngologist and plastic surgeon. Descriptive statistics were used to determine frequencies and mean+SD for qualitative and quantitative variables respectively. A total of 38 patients with gunshot wounds to the face were identified. Age ranged from 15 to 42 years with mean of 28+4.98 years. There were 32 [84%] males and 06 [16%] females. Twenty two [57%] patients required airway management. The most frequent site involved was mandible in 25 [65%] patients while midface was involved in 13 [35%] patients. Open reduction and internal fixation [ORIF] was performed in 17 [44%] patients, while 21 [56%] patients were managed conservatively. Out of 38 patients, 15 [39%] patients had some complications; trismus, sinusitis and infection being the most frequent [10.5% each]. Facial gunshot wounds frequently involve mandible with more likely requirement of establishment of emergency airway and open reduction and internal fixation [ORIF]. Early management of gunshot wounds results in better psychosocial profile, aesthetics, reduced hospital stay and early return to function

Ameloblastomas - seven years clinical audit

To determine the pattern and presentations of ameloblastoma in patients reporting to Armed Forces Institute of Dentistry [AFID], a descriptive study was undertaken from June 2002 to June 2009. A total number of 34 Ameloblastoma patients who were treated at the institute were analyzed. Their mode of presentation, site involved, various age groups and gender distributions, histological patterns, clinical and radiological features, treatment offered and follow up was recorded. The age range was from 15 to 65 years with mean age of 37.6 years. Out of 34 patients, 24 [70.6%] were males and 10 [29.4%] were females. Majority of tumours, 28 [82.3%] were present in mandible and the most common site was angle of the mandible 13[38.2%]. Clinically most common feature was swelling without pain and was experienced by 19 [55.9%] patients. Radiographically, there were 19 [55.9%] patients with multilocular radiolucency and 11 [32.4%] patients with unicystic appearance while 4 [11.8%] patients had typical honeycomb appearance. The most common histological pattern was follicular, seen in 21 [61.8%] patients. Enucleation with curettage was carried out in most of the cases 11 [32.4%], marginal resection was done in 10 [29.4%] cases, segmental resection was performed in 7 [20.6%] patients and radical resection with reconstruction was done in 6 [17.6%] patients. Ameloblastoma is one of the most common odontogenic tumour mostly occur in lower jaw. It is locally invasive and have high rate of recurrence therefore early diagnosis, complete excision with safe margins followed by reconstruction and long term follow up is required for psychological and emotional well being of the patient