‘Frozen Eye’ ? Post Blowout Fracture Surgical Correction ? A Case Report

The Rationale: “Frozen Eye” is a very uncommon sequel after treatment of orbital blowout fractures requiring implant placement. Patient Concerns: The implant may faultily impinge on the ocular and extra?ocular muscle(s), causing the abnormality in the movement of the eye. Diagnosis: We present a 56?year?old male whose ocular implant impinged on muscle, causing “frozen eye” and had an infected implant. Treatment Outcomes: The same was removed and surgically corrected. The manuscript describes the details and discusses the possible mechanism that led to the “Frozen Eye”

Idiopathic Bilateral Mandibular Condylar Resorption Causing AnteriorOpen Bite - A Case Report

Introduction: Mandibular condylar resorption (MCR) is a rare pathological entity, often affecting young females. Patient Concerns: It is accompanied by pain, malocclusion and compromised quality of life including aesthetic perception. Due to this multiplicity of features, the diagnosis, treatment and management of MCR are always a challenge. Diagnosis: This article reports a 25?year?old female suffering from progressive temporomandibular joint pain and compromised aesthetics. This article describes the clinical and radiological findings of this case. Treatment: The possible aetiopathogenesis and treatment are described.

Hemifacial Hypertrophy – Report of 2 Cases

Hemifacial hyperplasia (HH) is a rare congenital condition involving enlargement of one or more tissues of the face. The treatment is surgically challenging and requires expertise. This manuscript aims to report two similar appearing HH but warranting different surgical treatment. A 19?year?old female and a 14?year?old boy presented with right facial asymmetry since birth and sought correction of the same. Surgical treatment was planned. Based on clinical history, diagnosis and imaging, HH was diagnosed. The first case was entirely a soft tissue abnormality that was treated with debulking while the second case had involvement of facial bones, necessitating surgical recontouring. The facial asymmetry was addressed. Healing was uneventful. Though the aesthetical concern and appearance of the two cases of HH were same, the treatment vastly differed. This was based on the source of asymmetry. Proper diagnosis and informed decision are a key for successful surgical outcome.

Rare case of granular cell tumour at 16 years – A case report

Rationale: Granular cell tumours (GCTs) of the tongue are a rare, soft tissue pathological entity at young ages. This case report aims to present one such case. Patient Concerns: A 16?year?old female patient sought treatment for a small, slow?growing, painless nodule in the dorsum of the tongue since six months. She underwent successful orthodontic treatment in recent past and is in the retention phase. Diagnosis: Excisional biopsy revealed the lesion to be a GCT under histopathology. Treatment: The patient was treated for an abnormal, small, slow?growing, painless nodule in the dorsum of the tongue. Outcomes: The patient had satisfactory esthetics and early diagnosis. The active intervention dispelled the confusion about the role of trauma and orthodontics appliance in the etiology of GCT in this particular case to the patient. Take?away Lessons: GCT can occur at any age. Early diagnosis and corrective surgery would help to avoid late complications.

Unusual Number of Phleboliths in a Lip Vascular Malformation – A Case Report

Rationale: Vascular malformation (VM) associated with jaws may cause jaw size discrepancy. Multiple phleboliths in VM are relatively rare. This case report aims to present one such case. Patient Concerns: A 33?year?old female patient sought surgical correction of her abnormally sized jaw and on examination, she was identified with VM. Diagnosis: Subsequent imaging tests revealed the presence of several phleboliths. Treatment: The patient was treated for an abnormal?sized mandible as well as partial removal of the superficial part of VM. Outcomes: The patient had satisfactory esthetics and there was less bleeding than anticipated. Take?away Lessons: VMs could cause jaw size discrepancy and the extent of the malformation could cause blood flow abnormalities leading to multiple phlebolith formation. Proper surgical planning and education of the patient are essential for successful treatment.

Maxillary rehabilitation after complete destruction by fungal osteomyelitis

Treatment of uncommon fungal infection such as Rhinosporidiosis is challenging, especially when occurring in a non-immunocompromised patient in non-invasive form. Extensive involvement, extending into maxillary jawbone would need aggressive, chemotherapeutic and surgical approach. There are few reports of successful rehabilitation of maxillary jaw with dental implants after treatment of such fungal infection. After adequate medical treatment, the iliac graft and recombinant bone morphogenetic protein-2 was effectively utilized to reconstruct the lost maxillary bone. Later, dental implants were placed, that osseointegrated well.

Tracheostomy and mandibular distraction in acute sleep apnea

Severe restriction of airway volume in the orofacial region, caused by temporomandibular joint (TMJ) ankylosis, may lead to obstructive sleep apnea (OSA). If the TMJ ankylosis is progressive, rarely, the caregivers may fail to notice the problem. Such patients may have only symptoms of snoring, daytime sleepiness, fatigue, inability to concentrate, and irritability. At times, emergency tracheostomy may be needed to increase the oxygen supply. Distraction osteogenesis (DO) is a less invasive surgical technique in the management of such OSA by correcting the reduced airway space. In DO, the angulation of the distractors and the pace of activation determine the success of the neo-generation of segments of bone. The formation of a well-corticated mandibular canal (MC) in the newly generated bone is an evidence of the success of the procedure. Such bilateral formation of the MC is not reported from this part of the world. We report a case of a 4-year-old boy who was struggling with OSA due to TMJ ankylosis. He was successfully treated by bilateral mandibular DO. The formation and cortication of the MC is discussed with emphasis on the neural regeneration.

Epiphora drainage by DCR – Long-term results

Background: Dacryocystorhinostomy (DCR) refers to the surgical procedure that is used to relieve the chronic obstruction of the nasolacrimal duct obstruction (NLDO). In a maxillofacial setting, NLDO may arise subsequent to a facial trauma or orthognathic surgery. There is a dearth of literature from this part of the world. This article intends to provide a single maxillofacial center experience in DCR. Materials and Methods: This is a retrospective, noncomparative, noninterventional, record audit type of study of all consecutive patients fulfilling inclusion and exclusion criteria. All patients with epiphora and diagnosed with lacrimal apparatus damage between 1 January 2008 and 31 December 2017 requiring DCR were considered for the study. Details of demographics, phase of treatment (primary/retreatment), types of bones involved, age, complications, period suffering from epiphora, and follow-up were obtained. All data were entered and analyzed using the Statistical Package for the Social Service (version 16; IBM). Descriptive statistics of the frequency and mean ± standard deviation (SD) as appropriate were presented. Chi-square test and one-way analysis of variance were used appropriately. P ≤ 0.05 was taken to be statistically significant. Results: In all, 83 patients fulfilled the inclusion and exclusion criteria. It is more common in males (n = 56, 67.47%) with a mean ± SD of 32.24 ± 10.80 (18–59 years) with 27 (32.53%) of them presenting primarily after fractures. Fracture was the most common pathology seen in 81.93% (n = 68) of cases, while the rest were as a result of orthognathic cases. Le Fort II and III set of bones contributed to 59% of cases, while the orbitonasal complex contributed to only three cases. NLD obstruction was seen in 68 (81.9%) of cases. On an average, the patients suffered for 9.3 ± 6.74 months (range 0.5–22 months) before seeking treatment and the average follow-up was 31.07 ± 11.69 months (range 15–54 months). Discussion and Conclusion: Fractures and surgeries involving nasal bones carry an innate risk of damaging the NLD system. The pattern of need for DCR and occurrence of NLDO in this part of the world have been described. The extent of the anatomical variations and need for proper surgical planning are highlighted.

Transzygomatic, transcondylar excision of the sarcoma of infratemporal fossa

Malignant peripheral nerve sheath tumor (MPNST) is a rare pathologic lesion in a patient with solitary neurofibroma. A 32-year-old man presented with a firm and slightly tender mass in the right infratemporal region involving the right preauricular and temporomandibular joint area. The patient has a history of removal of a solitary neurofibroma 22 years back in the same region. The lesion had enlarged rapidly over the past 3 months, and a spindle cell lesion was diagnosed through a superficial incisional biopsy. Surgical removal of the lesion using modified preauricular transzygomatic approach was done. Histopathologically, it was diagnosed as an MPNST.

Central giant cell granuloma – A case report

Central giant cell granuloma (CGCG) of the jaws is a benign, intraosseous, osteolytic lesion of debatable etiology. CGCG lacks in clinical and radiographical pathognomonic features to distinguish from common lesions occurring in this region. Histopathology still remains the predominant diagnostic modality to identify the disorder. Clinically aggressive lesions and atypical lesions can lead to early damage and may necessitate aggressive therapy to prevent recurrences. A case of an aggressive type of CGCG of the maxilla in a young adult male patient with diagnostic and treatment challenge is presented.

Rare granular cell tumor affecting a 13-year-old boy

Granular cell tumor (GCT) is a rare soft-tissue neoplasm, first described in 1926. GCT often manifests as a single, painless nodule that shows a slow enlargement in the cutaneous, subcutaneous, or submucosal tissues. It is commonly reported in adults in the third to sixth decade of life. This case report is of an incidental finding in a young boy, who was radiologically examined for orthodontic treatment purpose and found to have a radiolucent lesion in the mandible. The lesion was later diagnosed as GCT. Central GCT is rare, and the presentation in a child is even rare. Although GCT is reported to be benign, it can turn malignant in 2% of the cases and possibly metastasize too. The local recurrence within a year is characteristic for malignant GCT. The 1-year follow-up of the present case indicated no local recurrence. The case stresses the need for the frequent dental examination, specialist reference. GCT should be included in the differential diagnosis of head and neck masses, even when inside jaws. It shall be remembered that such tumors may arise in any atypical locations and there is a possibility of malignancy.

Surgical management of chronic temporomandibular joint dislocations

Temporomandibular joint dislocation is described as the movement of mandibular condyle out of the fossa beyond its anatomical and functional boundaries causing pain and discomfort. It is often managed by conservative methods, but in long-standing, chronic conditions, surgical treatment is the only option. The goal of surgical treatment is to reposition the condyle and prevent further recurrences. Materials and Methods: This retrospective analysis involving a single center and a surgeon with 19 patients and 23 joint surgeries performed over a 10-year period. Patients who fulfilled inclusion and exclusion criteria and had earlier undergone surgical correction with hook-shaped miniplates and miniscrews fixed with or without bone grafts formed the study group. Results: In all, 12 were female (mean age, 41.9 ± 12.07 years) and the rest 9 were male (mean age, 39.8 ± 13.6 years), ranging from 32 years to 58 years. All patients had the dislocation for an average period of 19.26 ± 12.6 months before the surgery. The mean maximal mouth opening (without pain) preoperatively was 17.78 ± 2.13 mm (12–25 mm) while postoperatively it was 32.28 ± 3.17 mm (27–37 mm). There were no immediate or late surgical complications in the follow-up period that ranged from 8 to 37 months. Discussion: When proper case selection is employed and properly done, using hook-shaped miniplates with or without bone graft is more cost-effective, giving excellent short- and long-term effects. Conclusion: The results in this Indian population are very similar to that reported from other parts of the world.

Comparison of soft‑tissue changes in simultaneous maxillomandibular distraction with mandibular distraction with second‑stage maxillary osteotomy.

Background: The purpose of this study was to compare the frontal lip cant changes in common facial asymmetry (FA) cases after simultaneous maxillomandibular distraction osteogenesis (DO) and mandibular DO with maxillary orthognathic surgery. Materials and Methods: Retrospective analysis of FA cases at tertiary craniofacial referral was performed. Patients of either gender with all medical imaging records and pre‑ and post‑operative (1 year) facial photographs in natural head position were included in the study. The lip cant change was assessed by the ratio of the linear dimension between affected and unaffected side labial commissures and the bi‑pupillary reference line. Difference between the pre‑ and post‑operative ratio was analyzed. Statistical analysis was performed for the outcome. P ≤0.05 was taken as significant. Results: The mean preoperative measured value of the affected side was 0.845 ± 0.036 while the postoperative value was 0.95 ± 0.032. The effective change was 0.11 ± 0.044. The postoperative ratio compared with simultaneous DO case was 0.98 ± 0.06 while that of mandibular distraction with orthognathic surgery was 0.92 ± 0.08 (P = 0.048). The mean change of the simultaneous DO case was measured as 0.114 ± 0.041 while the same for the mandibular distraction with orthognathic surgery was 0.069 ± 0.035 (P = 0.013). Discussion and Conclusion: The results indicate that the simultaneous DO yields more better frontal lip cant change between both halves than the mono‑DO with orthognathic surgery. The mean change is much higher in the simultaneous DO cases indicating a more effective correction and desired result. The biological reason and lip musculature mechanism behind the response in both conditions are discussed.

Surgical management of necrotizing sialometaplasia of palate.

Necrotizing sialometaplasia (NSM) is a rare benign, inflammatory disease of both major and minor salivary glands, although more commonly reported in the minor glands of the palate. The characteristic clinical presentation can perplex the clinician and may be mistaken for a malignant neoplasm, such as mucoepidermoid carcinoma, as well as invasive squamous cell carcinoma. The clinical and histological similarity between this entity and a malignant lesion may result in unnecessary or mis-treatment. Though clinically mimics malignancy, NSM is considered to be a self-limiting disease, and takes about 3-12 weeks to resolve. Majority of the case resolves itself or by supportive and symptomatic treatment. Surgical intervention is rarely required in NSM except the diagnostic biopsy. Herein we report the clinical, histopathological feature and surgical management of a case of NSM of hard palate in a young adult male.

Immediate implant in single rooted teeth ‑ Study on primary stability and bone formation.

Background: Dental implants (DI) are emerging as an alternative to dentures. Immediate placement of DI for esthetic concern has been always in demand. This is a retrospective analysis of the success rate of immediately placed DI in freshly extracted single‑rooted tooth socket, by clinical, radiographical, soft and hard tissue changes in a follow‑up period of 1 year. Materials and Methods: Retrospective analysis of all cases of immediate DI placed in the single rooted socket was performed. Cases were selected based on previously established inclusion and exclusion criteria. Age, gender, tooth, jaw, cause of impending tooth loss, tooth diameter along the cervical margin, the width of keratinized gingiva (WKG), and radiographic measures were performed for up to a year. Descriptive statistics and comparison of means were presented. P ≤ 0.05 was taken as significant. Results: Of the 324 immediate DI placed in 207 patients during the study period, 61 fulfilled the criteria. There were 49.2% males 31.15% had dental caries, 61% involving maxilla. The mean age of patients was 34.82 ± 7.97 years. Mean extraction socket diameter was 4.6 ± 1.78 mm. From complete stability of DI, the WKG decreased from baseline to 3 months period and regained at 12‑month follow‑up. The difference was statistically significant (P = 0.01). The same trend was noticed in the distance of the mesial and distal papilla as measured in the probe (P = 0.075). Radiographical changes also reflected a similar trend. Discussion: The success of DI, in terms of clinical and radiographical parameters, in an immediate DI placed in a single rooted fresh extracted socket, gives adequate clinical results.

Fate of third molar in line of mandibular angle fracture ‑ Retrospective study.

Aim: The study aimed to answer for the question whether a tooth in line of fracture predispose to complications such as infection and thereby warranting removal of the plates. Materials and Methods: Surgically rehabilitated patients for unilateral angle of mandible fractures at author’s center from 2000 to 2013 were considered in this study. During the study period, about 116 cases fulfilled the inclusion and exclusion criteria, and hence included in this study. All patients were treated by open, rigid fixation. Results: During the fracture reduction and immobilization, 52.6% (n = 61) cases, the third molar was extracted and in 47.4% (n = 55) cases, the tooth was preserved. Only two cases of infection that required the plate removal occurred by 3 months and another one case within the next 6 months. When the tooth in question was removed, infection did not occur. In all, 52.72% (n = 29) of the 55 cases preserved were needs to be extracted for various reasons. The most common being periodontal causes followed by periapical pathology. Statistically the relationship between demographic data and outcome measures were analyzed using Chi‑square test bivariate statistics. A P ≤ 0.05 was taken as significant. Conclusion: The present study fails to identify any concrete factors that would predict the failure of the retained third molar that were involved in the line of mandibular fractures. The proof presented here, especially with low complication rates indicate that all impacted third molar along the line of fracture be removed and unless necessary, the partially erupted teeth would also be extracted. In such a situation, the rate of infection and survival of the third molar would have been entirely different.

Dental implants for severely atrophied jaws due to ectodermal dysplasia.

The aim was to present the successful esthetical and functional rehabilitation of partial anodontia in a case of severe ectodermal dysplasia with complete atrophy of the jaws. A 17‑year‑old male with Class III malocclusion with partial anodontia sought dental implant treatment. His expectation was that of Class I occlusion. The challenge in the case was to match the expectation, reality, and the clinical possibilities. Ridge augmentation was performed with a combination of rib graft and recombinant human bone morphogenetic protein‑2. Simultaneously, 6 implants (Nobel Biocare™ ‑ Tapered Groovy) were placed in maxillary arch and 10 in the mandible. Simultaneous placement ensured faster and better osseointegration though a mild compromise of the primary stability was observed initially. After adequate healing, Customized Zirconia Procera™ system was used to build the framework. Zirconia crown was cemented to the framework. Radiological and clinical evidence of osseointegration was observed in all 16 dental implants. Successful conversion of Class III to Class I occlusion was achieved with the combination of preprosthetic alveolar ridge augmentation, Procera™ Implant Bridge system. Abnormal angulations and or placement of dental implants would result in failure of the implant. Hence conversion of Class III to Class I occlusion needs complete and complex treatment planning so that the entire masticatory apparatus is sufficiently remodeled. Planning should consider the resultant vectors that would otherwise result in failure of framework or compromise the secondary stability of the dental implant during function. A successful case of rehabilitation of complex partial anodontia is presented.