Comparison of three different approaches in treatment of mandibular condylar fractures - Our experience.

Background: The principal transfacial routes described to approach condylar process fractures are preauricular, retromandibular, high submandibular, and their various modifications. The selection of a specific surgical approach mainly depends on the level of condylar fracture, displacement/dislocation of the proximal segment and time elapsed from the date of trauma. Not too many studies proclaim a unanimous consensus on "gold standard" approaches for particular levels of fracture. Aim: This study was conducted with the aim to lay down guidelines for determining the ideal surgical approach for treating different condylar fractures based on different clinical situations. Methodology: This prospective study was conducted on 60 patients that underwent open reduction internal fixation of condylar fractures according to preset study design. Inclusion criteria were fracture displacement more than 10 degrees, dislocation, shortening of ramal height more than 2 mm. Patients having maxillofacial fractures other than mandible and condylar fractures in edentulous patients were excluded from this study. Results: The risk of facial nerve injury was more in endaural group and parotid fistula was more evident in retromandibular subparotid group but there was no statistical difference between the groups. The surgical scar was inconspicuous in all three groups. Excellent results were achieved in the other parameters such as mouth opening, range of motion, bite force, and occlusion with all the three approaches. Postoperative CT scan showed satisfactory anatomical reduction. Conclusion: This study concludes that the decision-making on the approach to be selected for any particular condylar fracture depends on the level of fracture, presence of fracture dislocation, and time elapsed from the date of trauma.

Simultaneous TMJ Ankylosis Release with Uniplanar Mandibular Distraction Osteogenesis for Correction of Facial Deformity and Obstructive Sleep Apnoea in Growing Patients: A Pilot Study.

Aim: To evaluate the efficacy of simultaneous TMJ ankylosis (TMJA) release with uniplanar mandibular distraction in the management of facial deformity, improvement in function and obstructive sleep apnoea in growing patients. Material and Methods: Ten patients in the age group of 5-15 years with unilateral/bilateral TMJA and mild to moderate OSA and short body length but ramus height within normal limits were treated with simultaneous ankylosis release and uniplanar mandibular distraction osteogenesis. Clinical, radiographic, and OSA parameters were evaluated and followed up for 1 year. Results: Average mandibular body length increased by 16.6 mm, mouth opening by 26.9 mm, SNB angle by 9.53°, pharyngeal airway space by 6.29 mm, chin discrepancy corrected by 5.05 mm, apnoea-Hypopnoea index decreased by 15.9, N┴Pog by 12.27 mm, oxygen saturation (Spo2) by 4.1%, and oxygen desaturation index by 17.89%. All clinical, radiographic, and OSA parameters improved and were statistically significant except for mandibular plane angle and with minimal complications. Conclusion: Simultaneous TMJA release with uniplanar mandibular Distraction osteogenesis may be recommended as the treatment of choice in growing patients with mild to moderate OSA and facial deformity, as it causes simultaneous correction of micrognathia, facial asymmetry, OSA and prevents the need for an additional surgery.

Arthrocentesis Versus Level 1 Arthroscopy in Internal Derangement of Temporomandibular Joint.

Introduction: Internal derangement of the temporomandibular joint is defined as an abnormal position of the articular disc in relation with mandibular condyle and articular eminence presenting as disc displacement with or without reduction. Methodology: This study was conducted on thirty patients diagnosed with Internal derangement of TMJ consisting of 8 males and 22 females averaging 34.6 years. Two groups Conventional Arthrocentesis (Group A) and Level 1 Arthroscopy (Group B) consisted of 15 cases each divided alternately. Clinical evaluation parameters included VAS for pain, maximal interincisal opening, deviation on mouth opening, range of motion including lateral excursion & protrusion movements recorded at 1 week, 1 month & 6 months postoperatively. Wilke's Staging according to MRI findings was recorded preoperatively and 6 months postoperatively. Results: At 6 month follow-up, average reduction in VAS for pain & deviation on mouth opening was 72.43% & 24.73% in Group A and 77.66% & 65.41% in Group B, respectively. Average increase in MIO, right & left excursion & protrusion movements was 29.55%, 31.33%, 20.12% & 32.45% in Group A and 34.94%, 41.37%, 39.29% and 36.51% in Group B, respectively. Improved results were obtained clinically for all Wilke's stages in both groups with more number of patients improving in Group B. Conclusion: On comparing results, improvement was observed in various clinical evaluation parameters of both the groups at 6 months follow-up. However, statistically significant & better results were obtained for the Arthroscopy group.

Versatility of Basal Cortical Screw Implants with Immediate Functional Loading.

Background: The purpose of this study is to evaluate the survival rate of the basal cortical screw (BCS) implant system inserted in healed edentulous ridges (E) or extraction sockets (ES) with immediate loading functional protocol in varying clinical situations. Methods: A total of 125 BCS implants were placed in 14 patients, immediately loaded and observed for 20.07(± 4.23) months. Ninety-four were placed in E sites and 31 were placed in ES sites. They were evaluated for bone loss, soft tissue shrinkage around the prosthesis, improvement in quality of life (QOL), and their survival after 1 year. Results: Total of 121/125(96.8%) implants survived while 4/125(3.2%) failed at the end of follow-up. Average bone loss after 1 year was 0.33 mm (E) and - 1.57 mm (ES), average soft tissue shrinkage was 0.50 mm (E) and 1.42 mm (ES) and average Patient's Global Impression of Change (PGIC) scale score was 6.36(± 0.63) at 1 year. The complications observed were mobility {3(2.4%)}, pain/discomfort {1(0.8%)} and fracture of abutment at the neck {1(0.8%)}, prosthesis loosening {2(9%)} and requirement of relining {3(13%)}. No periimplantitis was observed. Conclusion: This is the only study to report the marginal bone loss and soft tissue changes around BCS implants and an index-based improvement in QOL of such patients. The BCS implant system with immediate functional loading protocol is a versatile modality to rehabilitate a single tooth, a segment or a full arch with healed ridges as well as extraction sites; it gives high success rate and minimal complications.

Dredging: A conservative surgical approach for treatment of large cystic lesions of the jaws.

Background: Treatment modalities of odontogenic cystic lesions of the jaws range from conservative to radical. "Dredging" may be considered the "middle path" between conservative and radical treatment options. It comprises three entities-decompression, followed by repeated scraping of the lesion, and finally, peripheral ostectomy providing margin clearance but without significant morbidity. Aim: To evaluate the outcome of "dredging" in the management of large cystic lesions of the jaws, without major resections and maintaining normal functions. Methodology: This prospective study was conducted on 30 patients. Inclusion criteria were odontogenic cystic lesions at least 2 cm in size either in the proximity of vital structures or in children with developing tooth germs or so large that upon enucleation, can result in pathological fracture. All underwent decompression followed by dredging performed at every 2 to 3 months intervals. Results: Drastic decrease in size of the lesion as measured on Cone Beam Computed Tomography (CBCT) and new bone formation was evident in all patients. The total Reduction Rate (RR) of the cystic lesions was 88.79% in 9.2 months. RR was highest in Calcifying epithelial odontogenic cyst (CEOC) followed by Unicystic Ameloblastoma (UA), Odontogenic Keratocysts (OKC), Dentigerous cyst (DC), and Radicular Cyst (RC) in CBCT. The mean speed of shrinkage was fastest in CEOC, followed by OKC, UA, RC, and DC after dredging. Shrinkage was higher in patients below 20 years of age (P 0.012) and patients with large cystic lesions (P 0.00447). Conclusion: The results suggest that dredging with regular, long-term follow-up can be a successful treatment method for large cystic lesions in young adults. This method includes the benefits of both conservative and radical treatment methods but lacks the disadvantages of either.

Arthrocentesis Followed by Autologous Blood Injection in the Treatment of Chronic Symptomatic Subluxation of Temporomandibular Joint.

Introduction: Temporomandibular joint subluxation is defined as self-reducing partial dislocation of the TMJ during which the condyle passes anterior to the articular eminence. Material and Method: The study consisted of 30 patients, 19 females and 11 males with 14 unilateral and 16 bilateral cases of chronic symptomatic subluxation. Treatment consisted of arthrocentesis followed by 2 ml of autologous blood injection into upper joint space and 1 ml into pericapsular tissues using an autoclaved soldered double needle with single puncture technique. Parameters evaluated were pain, maximum mouth opening, excursive jaw movements, deviation on mouth opening and quality of life, hard and soft tissue changes on X-ray TMJ view and MRI. Results: At 12 month follow-up, average reduction in maximum interincisal opening, deviation on mouth opening, range of excursive movements on right and left sides and VAS scores were 20.54%, 32.84%, 29.59%, 27.37% and 74.53%, respectively. Out of 93.3% who responded to therapy, 66.7%, 20% and 6.7% responded after 1st, 2nd and 3rd AC + ABI, respectively. Remaining 6.7% patients had persistent painful subluxation and underwent open joint surgery. 93.3% patients responded to therapy, 80% were relieved of painful subluxation, 13.3% had painless subluxation and kept on follow-up. X-ray TMJ and MRI did not show any hard and soft tissue changes. Conclusion: A soldered double needle, single puncture, AC + ABI are a simple, safe, cost-effective, repeatable and minimally invasive nonsurgical therapy for treatment of CSS without any permanent radiographically evident soft or hard tissue changes.