Management of paediatric ankylosis.

Temporomandibular joint ankylosis (TMJa) is one of the most crippling craniomaxillofacial pathological conditions characterized by replacement of normal architecture of temporomandibular joint (TMJ) with fibrous or bony tissue. The incidence of TMJa is most common in the paediatric population [first and second decades of life] and is commonly associated with maxillofacial trauma. Comprehensive management entails a thorough evaluation of the associated anatomy of the ankylotic mass and other pertinent details like the presence or absence of obstructive sleep apnoea. Categorizing patients based on these variables helps in selecting an appropriate surgical intervention. Various resective and reconstructive surgical techniques are discussed; along with their merits and demerits. Long-term physiotherapy, long-term clinical follow-up and appropriate family counselling are the essential pillars for success. In this review, the authors present an algorithmic approach to evaluation and management of paediatric TMJa. Appropriate recommendations are made based on evidence to select optimum surgical intervention.

Modified Cut for Gap Arthroplasty in Temporomandibular Joint Ankylosis.

Temporomandibular joint ankylosis is a debilitating disease affecting the function, esthetics and psychology of the patient. Treatment of this condition aims at establishing not only the function and esthetics but also aims to prevent reankylosis. Among the different treatment modalities, interpositional gap arthroplasty followed by aggressive jaw physiotherapy is considered most effective. This is achieved by making two horizontal osteotomy cuts at a distance of 10-15 mm in the TMJ region. The gap is then interposed with an autogenous or alloplastic graft material. However, during the application of a jaw stretcher intraoperatively with the surgical site open and with the jaw wide open, a bony contact was seen to occur between the posterior aspect of the upper and lower osteotomy cuts. Taking this into consideration, the lower osteotomy cut is modified by making the posterior one-third cut divergent. This eliminates the bony contact during maximum mouth opening and thus prevents the chances of reankylosis as well.

A Randomized Control Trial Comparing Buccal Infiltration of 4% Articaine with Buccal and Palatal Infiltration of 2% Lignocaine for the Extraction of Maxillary Premolar Teeth.

INTRODUCTION: The use of articaine has been claimed to obviate the need for routine palatal local anesthetic injections on account of its better diffusion through soft and hard tissues as compared to other local anesthetic agents. OBJECTIVE: The objective of the study is to evaluate the efficacy of 4% articaine (with 1:100,000 adrenaline) infiltrated only buccally in the extraction of maxillary premolars for orthodontic reasons. MATERIALS AND METHODS: A double-blind randomized clinical trial with a split-mouth design, where each patient (n = 100) was part of two groups, was conducted. Experimental Group 1: single buccal infiltration of 4% articaine with 1:100,000 adrenaline (Septanest™ with adrenaline 1:100,000 by Septodont). Control Group 2: routine buccal and palatal infiltrations of 2% lignocaine with 1:200,000 adrenaline (Lox™ 2% with adrenaline 1:200,000 by Neon). The parameters studied were time to onset of anesthesia, pain during the extraction procedure (not during the injecting of the local anesthetic), and frequency of extra amount of local anesthetic injected. RESULTS: The difference was not statistically significant (P > 0.05) between the two groups with respect to all three parameters. This proves that a single buccal infiltration of articaine can be used as an alternative to lignocaine for the extraction of the maxillary premolar teeth in most of the cases. CONCLUSION: This proves that a single buccal infiltration of articaine can be used as an alternative to lignocaine for the extraction of the maxillary premolar teeth in most of the cases.

Pre-arthroplastic mandibular distraction osteogenesis for the correction of OSA in TMJ ankylosis: a prospective observational study of 25 cases.

INTRODUCTION: In severe TMJ ankylosis cases, the lack of growth of the mandible creates an anatomically narrow airway with a reduced pharyngeal airway space [PAS] which predisposes these patients towards obstructive apnoea [OSA]. There is evidence in the literature that such patients experience severe discomfort during physiotherapy if such airway abnormalities are not corrected prior to ankylosis release. This eventually leads to non-compliance towards physiotherapy and increases the risk of re-ankylosis. OBJECTIVE: In our study, pre-arthroplastic mandibular distraction osteogenesis [DO] was used to increase the PAS and resolve the underlying OSA prior to releasing the ankylosis. MATERIALS AND METHODS: Twenty-five cases of TMJ ankylosis with micrognathia and OSA were included in this prospective observational sleep study. They were further divided into a paediatric group [14 subjects] and an adult group [11 subjects]. All cases presented with a history of onset of ankylosis during childhood [before the completion of craniofacial growth] as result of which there was a lack of forward growth of the mandible. Subjects included in our study underwent initial DO of the mandible followed by a second procedure for distractor removal and ankylosis release. Questionnaires, lateral cephalograms and sleep studies were taken pre-operatively (T0), immediate post-distraction to the desired length (T1) and 12 months post the distractor removal and ankylosis release (T2). The parameters studied were PAS width, apnoea hypopnea index [AHI], O2 saturation, mouth opening and mandibular advancement. RESULTS: The paediatric group variables were as follows: mean PAS width which increased from 3.5 mm [T0] to 9 mm [T2], mean AHI which decreased from 48.04 [T0] to 3.60 [T2], mouth opening which increased from 4.5 mm [T0] to 34 mm [T2] and mean O2 saturation which increased from 89.86% [T1] to 96.88% [T2]. The adult group variables were as follows: mean PAS width which increased from 5 mm [T0] to 11 mm [T2], mean AHI which decreased from 31.45 [T0] to 1.43 [T2], mouth opening which increased from 5 mm [T0] to 34 mm [T2] and mean O2 saturation which increased from 92.01% [T0] to 96.84% [T2]. Statistical analysis revealed that DO of the mandible significantly improved OSA by increasing the PAS which was evident by the lower AHI score. Mouth opening was also significantly improved post ankylosis release and maintained at the T2 interval. Ten subjects followed up beyond the T2 interval [mean 28 months post ankylosis release] and their data also revealed positive compliance towards physiotherapy, adequate mouth opening and maintenance of normal AHI. CONCLUSION: Pre-arthroplastic mandibular DO has proved to be a successful modality for treatment of OSA in TMJ ankylosis patients with stable results at 12 months. By resolving the narrow airway and OSA, compliance towards physiotherapy was improved thus reducing the risk of re-ankylosis in the long term.

Juvenile Hyaline Fibromatosis.

Syndromes, especially if they occur early in the growth phase can be very debilitating and cause severe restriction of function. Juvenile hyaline fibromatosis is one such disorder. Our case report presents a girl child who was diagnosed with this debilitating condition. The case presented with both - general characteristic features of this condition such as subcutaneous nodules and flexion deformity of the joints, as well as local manifestation in the form of gingival overgrowth. Thorough clinical and radiological investigations were done to arrive at the diagnosis which was supported conclusively with histopathology of the biopsied gingival lesions. A combination of both medicinal as well as surgical therapeutic modalities was used. This case report is an effort to comprehensively document the etiology, clinical features, and prognosis of this syndrome. There being no permanent cure for the condition, the case report highlights the unique management protocol employed by us in the form of intralesional steroid therapy with endocrine consultation and the local surgical gingival excision carried out in an attempt to optimize the quality of life for our patient.

Arch bars in the mouth for 17 years - A case report.

Arch bars are commonly used in maxillofacial surgery but their intraoral presence for an extremely long period is quite uncommon or rare. So when such a patient reports and denies having any complaints all these years, the question that presents is, how is this possible? What kept the patient so long? A review of the existing literature shows, despite being common in trauma care, failure to follow-up has not received the due attention. This study retrospectively reviews the various factors implicated for failure to follow-up and the proposed corrective measures. The objective is to identify such potential patients beforehand thereby facilitating efficient trauma care.

Melanotic neuroectodermal tumour of infancy - A rare entity.

Melanotic neuroectodermal tumour of infancy (MNTI) is rare, rapidly growing, pigmented neoplasm of neural crest origin. It is generally accepted as a benign tumour despite of its rapid and locally destructive growth. It primarily affects the maxilla of infants during the first year of life. Surgical excision is considered as the treatment of choice. The recurrence rate varies between 10% and 15%, and malignant behaviour has been reported in 6.5% of cases. We report a case of MNTI, associated with an erupted primary tooth in a 5-month-old male child. We discuss the clinical, radiographic and histologic features of this rare tumour, as well as its surgical management and the follow-up.