'Y' Modification of the cutaneous incision of the preseptal transconjunctival approach for the management of zygomatico-maxillary complex fractures: A prospective clinical study.

AIM: The purpose of this clinical study was to evaluate the efficacy of the preseptal transconjunctival approach with Y modification of the cutaneous extension for the management of zygomaticomaxillary complex (ZMC) fractures. METHODS: This prospective interventional study was conducted at our institute from 2012 to 2020. The study included patients aged 15-65 years with displaced ZMC fractures. Patients with uncontrolled systemic conditions, infected and/or comminuted fractures were excluded. The variables evaluated were age, gender, mechanism of injury, fracture side, clinical features, surgical exposure time, adequacy of exposure, complications, scar evaluation scores and cosmetic outcomes. The parameters for comparison were operated versus non operated side Eye Fissure Index (EFI) and surgical exposure time was compared with respect to the types of scars. RESULTS: A total of 49 patients were included in this study. The average exposure time was 18.87 ± 1.92 min. The exposure of fracture site was excellent in 73.5 % and satisfactory in 26.5 %. The mean EFI of operated side was 34.2 ± 5.04 mm while that of non-operated side was 34.22 ± 5 mm. On comparison of the same there was no significant difference. Invisible scars were noted in 71.4 % and barely visible scars in 22.4 %. The comparison of exposure time with type of scars showed a significant association (p = 0.02). The complications noted were chemosis, lower eyelid edema, conjunctival granuloma and entropion. Cosmetic outcomes were fairly satisfactory. CONCLUSION: The Y modification of the transconjunctival approach can provide excellent surgical exposure without the need for a second incision. Although this approach is technique sensitive and requires experience, the advantages outweigh the learning curve. Since this approach has been widely studied, a systematized review is recommended to further substantiate its reliability and advantages.

Matrixmidface Preformed Orbital Implants for Three-Dimensional Reconstruction of Orbital Floor and Medial Wall Fractures: A Prospective Clinical Study.

Study Design: Prospective Interventional study. Objective: To evaluate the efficiency of Matrixmidface preformed Orbital plates for three-dimensional reconstruction of orbital floor and medial wall fractures. Methods: This prospective institutional clinical study was conducted on a group of 14 patients who underwent repair of orbital floor and medial wall fracture defects using Matrixmidface Preformed Orbital plates and open reduction and internal fixation of associated fractures. The following parameters were studied preoperative and postoperative enophthalmos, hypoglobus, orbital volume; correction of diplopia, intraoperative and postoperative complications. Results: All 14 patients were males aged between 19 and 42 years. The most common mode of injury was found to be road traffic accidents (RTAs) followed by self-fall and trauma at workplace. Orbital fractures were associated with other concomitant maxillofacial fractures in 12 patients (85.7%) while 2 patients (14.3%) had pure blowout fractures. Significant improvement of enophthalmos was noted from preoperative period to 1 week, 6 weeks, and 6 months postoperatively (P value .02, .01, and .01, respectively). Out of 11 patients with preoperative hypoglobus, 5 patients (45.45%) had persistent hypoglobus in the immediate postoperative period which reduced to 4 patients (36.36%) at 6 weeks postoperatively (p value .00). The postoperative orbital volume of fractured side ranged from 20.3 cm3 to 26.76 cm3 with a mean of 23.50 cm3 ± 1.74. The mean difference between the volumes of the repaired and uninjured sides was found to be .27 cm3 ± .39 (P value .02) denoting that the reconstruction of the orbit closely approximated that of the uninjured side. Conclusions: The Matrixmidface Preformed Orbital plate provides exceptional reconstruction of the orbital blowout fracture defects and ensures satisfactory results clinically and radiographically. The plate ensures an approximate recreation of topographical anatomy of the orbit and adequately restores the orbital volume. It provides adequate correction of asymmetry, hypoglobus, enophthalmos and attempts to restore eye movements, without causing any significant postoperative complication.

Changing Patterns of Zygomaticomaxillary Complex Fractures: A Retrospective Study.

BACKGROUND: Limited research exists regarding the incidence and variations of zygomaticomaxillary complex (ZMC) fracture patterns and their correlation with the mechanism of injury. Hence, further research is indicated. PURPOSE: The purpose of this study was to analyze the different ZMC fracture patterns in relation to its etiology using computed tomography scans. STUDY DESIGN, SETTING, SAMPLE: This retrospective cohort study was conducted at a single institution. The medical records of maxillofacial trauma patients from 2016 to 2020 were analyzed. Patients from any gender and all age groups with complete records diagnosed with isolated ZMC fractures were included in the study. PREDICTOR VARIABLE: The primary predictor variable was the etiology of trauma. It was categorized as road traffic accidents (RTAs), falls, interpersonal violence, fall from height, sports injuries, etc. MAIN OUTCOME VARIABLES: The primary outcome variable was the ZMC fracture patterns observed and was defined as similar to or different from the classical fracture patterns. Any type of variation noted from the classical fracture lines was defined as the secondary outcome variable. COVARIATES: Covariates included demographic variables such as age, gender, the type of vehicle involved, the type of RTA, side of fracture, associated orbital fractures, and number of ZMC points fractured. ANALYSES: Descriptive and bivariate statistics were used to measure association between the predictor and outcome variables using multiple proportions χ2 test. Statistical significance was defined at P value of <.05. RESULTS: Out of the 232 scans assessed, a total of 163 cases were included in this study. A majority of the cases belonged to a range of 21 to 30 years and showed a male predilection. The most common mode of injury was found to be RTAs (88.3%). Most cases had fracture patterns different from the classical fracture patterns (65.64%). A statistically significant association was found between the types of ZMC fracture patterns and etiology of trauma (RTA P = <.0001, falls P = .0001, and interpersonal violence P = .0001). Five different variations in ZMC fracture patterns were found and had a statistically significant association with the classical fracture lines (P < .0001). CONCLUSION AND RELEVANCE: The authors conclude that the variations in fracture patterns encountered today may be attributed to the mechanism of injury. With due consideration to the limitations of this study, the authors suggest that the treatment plan may require slight modification based on the variation of the fracture pattern. Additional intervention may also be indicated.

Pattern of associated brain injury in maxillofacial trauma: a retrospective study from a high-volume centre.

The incidence of head injury in maxillofacial trauma patients varies widely in the literature. A good understanding of the patterns of association between these injuries would aid in efficient multidisciplinary treatment. The aim of this study therefore was to understand the associations between head injury and facial trauma by retrospectively analysing the records of patients seen at a tertiary care trauma centre. Demographic data were also described. Records of 4350 facial trauma patients over a five-year period were reviewed. A total of 3564 (81.9%) patients were victims of motor vehicle accidents (MVA). Male patients predominated, comprising 3711 (85.3%), and 36.6% were in the third decade of life. Facial fractures were seen in 2120 (48.7%), the most common being zygomatic fractures (60%). At the time of trauma, 2383 (57.3%) patients were under the influence of alcohol, and 2821 (87.8%) victims of two-wheeler MVAs were not using their helmet. Of all patients, 29.75% sustained a traumatic brain injury (TBI). Midface fractures were strongly associated with TBI. Maxillofacial injury may be considered a risk factor for TBI, and as such should immediately be suspected and investigated in all patients. Prompt recognition and management can improve outcomes in these patients.

Intra-alveolar extraction of linguoverted mandibular premolars - the Shetye technique: a technical note.

Extraction of premolars for orthodontic purposes may prove challenging when the tooth is blocked or lingualised. The standard buccal approach may prove difficult in such cases. A novel technique was used for 16 patients with healthy linguoverted mandibular premolars using maxillary extraction forceps. The ease of extraction increased and resulted in uneventful postoperative healing in all patients. The authors suggest this as a preferred technique for extracting mandibular premolars in linguoversion.

Efficiency of the 2-mm Titanium Lambda Plate for Open Reduction and Internal Fixation of Subcondylar Fractures of the Mandible: A Prospective Clinical Study.

Aim: To carry out clinical in vivo evaluation of efficiency of the 2-mm lambda plate for open reduction and internal fixation of condylar fractures. Materials and Methods: This prospective clinical study was conducted on a group of 16 patients who underwent open reduction for subcondylar fractures of the mandible and fixation using a 2-mm 7-holed titanium lambda miniplate. Results: The average surgical time was found to be 79.5 min. The ease of access was found to be adequate in 13 cases (81.3%). All patients showed a gradual improvement in mouth opening and occlusion over the post-operative follow-up period. The maximum mouth opening seen at 3-month follow-up was 54 mm. None of the patients had transient or permanent weakness of the facial nerve. In our study, we encountered one case of hardware failure (6.25%). Conclusion: The 2-mm lambda condylar miniplate provides an excellent stabilisation of the fractured subcondylar segments and ensures satisfactory results, confirmed both clinically and radiographically. The plate reduces the amount of surgical exposure needed and does not cause any significant post-operative complications.

A retrospective epidemiological review of maxillofacial trauma in a tertiary care centre in Goa, India.

PURPOSE: Trauma accounts for the leading cause of morbidity and mortality worldwide in the present day and may rightly be called the new pandemic. The prominent nature of the face exposes it to various traumatic injuries. A timely, prompt diagnosis along with employment of correct and quick treatment greatly improves the outcome for these patients. The aim of this retrospective study was to analyse the characteristics of maxillofacial injuries over a decade. METHODS: The data were collected manually from the medical records of patients who reported to the tertiary centre from 1 January 2011 to 31 December 2019. All injured patients irrespective of age/gender with complete hospital records of clinical and radiographical diagnosis of maxillofacial injuries were included. The demographic data, etiology, site and type of injury, and seasonal variation were analyzed. Data were tabulated into six age groups (0-7 years, 8-18 years, 19-35 years, 36-40 years, 41-59 years, and >60 years). Five etiological factors, i.e. road traffic accidents, falls, assaults, sports-related, and occupational accidents, were further evaluated based on genders. Facial injuries were classified into six types: panfacial fractures, mandibular fractures (subcategorized), midface fractures (subcategorized), dentoalveolar fractures, dental injuries, and soft tissue injuries. The monthly and seasonal variation of the injuries was also charted. Data were expressed as frequency and percent. RESULTS: A total of 10,703 injuries were included from the tertiary centre from the period of 2011-2019, including 8637 males and 2066 females, with the highest occurrence of the injuries between 19 and 35 years. Road traffic accident was the principal etiological factor of the maxillofacial injuries in both genders (80.5%). This was followed by falls (9.6%), assaults (8.0%), occupational accidents (1.2%), and sporting injuries (0.7%). Midface fractures amounted for 52.5% (5623 fractures), followed by mandibular fractures (38.1%). CONCLUSION: The current study describes a change in the incidence of injuries along with variation in the demographic data. The implementation of safety gears and stricter traffic laws along with public awareness may aid in the reduction of maxillofacial injuries.

New protocol for simplified reduction and fixation of subcondylar fractures of the mandible: a technical note.

The dilemma regarding the management of condylar fractures generally revolves around the surgical approach, implant design, and the surgeon's experience. Zide and Kent's guidelines streamlined the decision making process for condylar fractures. However, there exists no standardized protocol for reduction and fixation of condylar fractures. Here, we have described a detailed and stepwise protocol, common to any surgical approach, that would lead to predictable, reproducible, and repeatable results in every surgeon's hands.

Prediction of Soft-Tissue Changes Following Single and Bi-Jaw Surgery: An Evaluative Study.

INTRODUCTION: Orthognathic surgery is carried out in the hard tissues; however, the patient perceives change in the soft tissue. It is important to accurately predict postoperative facial changes associated with each surgical procedure. This study aims to evaluate the changes in the soft tissues resulting from the movement of the hard tissue following single and bi-jaw surgeries. MATERIALS AND METHODS: An evaluative clinical study was carried out on a total of 34 subjects which consisted of 52 jaw surgeries. Maxilla and mandible were considered as a separate entity even in bi-jaw cases for evaluation. Surgical procedures performed were either bilateral sagittal split osteotomy, Le Fort I osteotomy or both. Pre- and post-surgical lateral cephalograms were compared to assess the soft-tissue change at various soft-tissue points and were labeled T1 and T2, respectively. The points on maxilla were Point A and PrS on upper lip. The points on mandible were PrI and Point B on lower lip and Pog and Gn on chin. RESULTS: All the points on the maxilla and mandible had a strong correlation between the hard and soft-tissue points except point PrS on upper lip. DISCUSSION: Facial appearance is an important parameter in the present times which influences the social and psychological development of an individual. What patient sees is the external soft-tissue drape whereas orthognathic surgery is carried out on bony components of the face. Thus prediction of soft-tissue changes following surgery is an important part of treatment planning.

The Resistance of Succedaneous Teeth to Periapical Infection: A Series of Seven Cases.

Pediatric dental procedures are carried out largely to prevent the adverse effects of primary teeth infection on succedaneous teeth (ST). The existing literature on how and when periapical infection (PI) from primary teeth affect ST is conflicted. A series of seven case reports on PI (abscesses and radicular cysts) from primary molars, until the eruption of the premolars, have been illustrated. The resistance of ST to PI based on their developmental stages is also discussed.

Surgical management of garre's osteomyelitis in an 8-year-old child.

Chronic non-suppurative osteomyelitis, also known as Garre's osteomyelitis is a well-described pathologic entity in dental literature. We present here a case report of a unilateral hard bony swelling of the lower jaw associated with infection. Radiograph revealed the pathognomic feature of 'onion skin' appearance. Surgical recontouring of the lower jaw was performed since there was no evidence of bone remodelling after removal of the infected tooth.

Direct maxillary sinus floor augmentation and simultaneous implant placement for rehabilitation of the severely resorbed posterior maxilla: A prospective clinical study.

AIMS AND OBJECTIVES: The aim of this prospective clinical study was to evaluate the success of one-stage direct (lateral) sinus lift procedure in severely atrophic posterior maxilla. MATERIALS AND METHODS: One-stage direct (lateral) sinus lift procedure was carried out at 15 sites in 13 patients. All patients included in the study presented with partially edentulous posterior maxilla with one or more missing teeth and residual bone height less than 5 mm. Three months after surgery, patients were evaluated to access increase in residual bone height, density of new bone formed and implant stability. Patients were also evaluated after 3 months of prosthetic placement for the success of implant-supported prosthesis. RESULTS: At 3 months post-operatively, increase in residual bone height was 8.31 ± 1.63 mm and the mean density of the newly formed bone around the implants was 417 ± 66.61 HU. All implants were stable and successfully osseointegrated, except one implant that was lost. The success rate of implant stability was 96.3% during the study period. CONCLUSION: Single-stage direct (lateral) maxillary sinus floor augmentation is a good treatment option with predictable outcome for patients with deficient alveolar bone in posterior maxilla.

Understanding Predictability Error in Orthognathic Surgery.

INTRODUCTION: Orthognathic surgery aims to improve the facial aesthetics while maintaining stable jaw form and function. Lateral cephalometry provides objective data used in pre-op mock surgery to predict movement of the maxilla and mandible during orthognathic procedures. PATIENT AND METHODS: A prospective cohort study was conducted on 30 adult orthognathic surgery patients. Mock jaw surgery predicted two-dimensional (horizontal and vertical) linear movement of maxilla and mandible. Operative procedures performed were bilateral sagittal split osteotomy and Le Fort I osteotomy. Seven-day pre-op cephalogram (T1) was compared to 7th day post-op cephalogram (T2) to assess hard tissue movement of point A (maxilla) and point B (mandible) using Cartesian (X-Y) plane. RESULTS: The difference between predicted values to the 7th day post-op outcome results was statistically insignificant (p value less than 0.001). CONCLUSION: Planning in orthognathic surgery using digitized two-dimensional cephalometric tracings and mock jaw surgery produces predictable results.

Zygomatico-coronoid Ankylosis as Sequel of Inadequate Treatment.

Temporomandibular joint ankylosis may be true or false. Most commonly, trauma and inflammatory conditions lead to this condition. Zygomatico-coronoid ankylosis is a rare extra-articular (false) form of ankylosis of the jaw. This condition may follow treated or untreated midface fractures. Coronoid process locking may be overlooked because attention is generally focused on temporomandibular joint. A review of literature has reported 16 cases of this disorder. The true incidence of this condition may be even higher. In this paper, we present an unusual case of posttraumatic bony ankylosis of the right coronoid process of the mandible with the zygomatic arch in a 30-year-old male. This bony ankylosis was produced by a mass of heterotopic bone formed, following inadequate treatment of midfacial fracture. Extra-oral ostectomy of the ankylotic mass followed by immediate postsurgical aggressive physiotherapy produced good long-term functional outcome.

Traumatic pseudoaneurysm of the superficial temporal artery.

Aneurysms of the facial vasculature due to various accidental, violent, and surgical injuries have been reported since mid-17th century. Approximately 386 pseudoaneurysms of the superficial temporal artery (STA) have been reported in the literature since 1644. Traumatic pseudoaneurysm of the STA is a rare lesion. It manifests as a painless pulsatile mass in the temporal region following trauma. The unusual incidence and confusing presentation require the clinicians to have a thorough knowledge of its presentation and diagnosis. We present a case of traumatic pseudoaneurysm of the STA, which developed a few weeks later, after sustaining blunt trauma to the head. We have also reviewed the anatomical challenges and pathophysiology that promotes the formation of pseudoaneurysm and the optimal approach to diagnose and manage the lesion. Pulsatile lesions or lesions that are continuous with the STA should be regarded with extreme caution. The sole treatment modality is surgical resection of the pseudoaneurysm. This will avoid any future complications such as hemorrhage or compression of adjacent nerves and vessels.

Impacted Foreign Bodies in the Maxillofacial Region-A Series of Three Cases.

Penetrating injuries to the maxillofacial region are very common. Foreign bodies embedded deep in the maxillofacial region due to these injuries pose a challenge to an oral and maxillofacial surgeon. These objects may become a potent source of pain and infection. Early diagnosis of these foreign bodies can be achieved by the use of plain radiographs, ultrasonography, computed tomographic scans, and magnetic resonance imaging. Once diagnosed and located, these foreign bodies should be removed. Here, we report three such cases where early diagnosis of these foreign bodies embedded in the maxillofacial region lead to their early and successful removal without complications.

An unusually large aggressive adenomatoid odontogenic tumor of maxilla involving the third molar: A clinical case report.

Adenomatoid odontogenic tumor (AOT) is a rare tumor comprising only 3% of all odontogenic tumors. It is a benign, encapsulated, noninvasive, nonaggressive, slowly growing odontogenic lesion associated with an impacted tooth. These lesions may go unnoticed for years. The usual treatment is enucleation and curettage, and the lesion does not recur. Here, we present a rare case of an unusually large aggressive AOT of maxilla associated with impacted third molar. The authors also discuss clinical, radiographic, histopathologic, and therapeutic features of the case. Subtotal maxillectomy with simultaneous reconstruction of the surgical defect with temporalis myofascial flap was planned and carried out.

Unusually Large Peripheral Osteoma of the Mandible - A Rare Case Report.

Osteoma is a benign tumor which is composed of mature compact or cancellous bone. Osteoma may be periosteal (arising from surface of the bone) or endosteal (develop in the medullary bone) or combination of both. Here, we present a case of unusually large osteoma present on the lingual surface of the mandible in a 40-year-old female patient. The lesion had grown slowly for 15 years and caused intra-oral swelling leading to difficulty in mastication, speech and tongue movements. Under general anesthesia, local complete surgical excision was performed.