Vertically unstable fractured mandibular segment with attached genial tubercles as a parameter for difficulty during intubation for general anaesthesia.

PURPOSE: It remains vital for the trauma management team including the anaesthetist and the operating surgeon to assess and evaluate the anticipated difficulty in intubation to secure airway and for administration of anaesthesia. This study assesses the difficulty in intubating patients with vertically unstable mandibular parasymphysis fracture with attached genial tubercles and associated musculature to the fractured segment. METHODS: Randomized sampling was done from the cases with maxillofacial trauma planned for a surgical procedure under general anaesthesia. The inclusion criteria was to prospectively identify ten patients each of unilateral unfavourable mandibular parasymphysis fracture with genial tubercle attached to the displaced segment, with bilateral unfavourable mandibular parasymphysis fracture with genial tubercle attached to the displaced segment and with unilateral favourable mandibular parasymphysis fracture with genial tubercle attached to the un-displaced segment. All the patients were intubated by a single anaesthetist, who documented the difficulty in nasoendotracheal intubation using Intubation Difficulty Scale. RESULTS: Nasoendotracheal intubation was found relatively easy in the study group with unilateral favourable mandibular parasymphysis fracture with genial tubercle attached to the un-displaced segment. Clinical difficulty in intubating the patients was maximum in the study group with bilateral unfavourable mandibular parasymphysis fracture with genial tubercle attached to the displaced segment. CONCLUSION: Displacement of fractured mandible and resultant displacement of the genial musculature should be considered as a vital parameter for assessing difficulty during intubation.

Trigeminocardiac Reflex: A Reappraisal with Relevance to Maxillofacial Surgery.

PURPOSE: The purpose of this paper was to undertake a review of literature on trigeminocardiac reflex in oral and maxillofacial online data-base and discuss the pathophysiology, risk factor assessment, presentation of the reflex, prevention, management with emphasis on the role of the attending anaesthetist and the maxillofacial surgeon. MATERIALS AND METHODS: The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review published clinical papers, abstracts and evidence based reviews on trigeminocardiac reflex relevant to oral and maxillofacial surgery. RESULTS: Sixty-five articles were found with the search term "trigeminocardiac reflex" in the literature searched. Eighteen articles met the inclusion criteria for this study. The relevant data was extracted, tabulated and reviewed to draw evidence based conclusions for the management of trigeminocardiac reflex. CONCLUSIONS: Conclusions were drawn and discussed based on the reviewed maxillofacial literature with emphasis on the anaesthetist's and the surgeon's role in the management of this detrimental event in maxillofacial surgical practice.

Comparative Analysis of the Anesthetic Efficacy of 0.5 and 0.75 % Ropivacaine for Inferior Alveolar Nerve Block in Surgical Removal of Impacted Mandibular Third Molars.

INTRODUCTION: Ropivacaine belongs to pipecoloxylidide group of local anesthetics. There are reports supporting the use of ropivacaine as a long acting local anesthetic in oral and maxillofacial surgical procedures, with variable data on the concentration that is clinically suitable. MATERIALS AND METHODS: A prospective randomized double-blind study protocol was undertaken to assess the efficacy of 0.5 and 0.75 % ropivacaine for inferior alveolar nerve block in surgical extraction of impacted mandibular third molars. A total of 60 procedures were performed, of which thirty patients received 0.5 % and thirty received 0.75 % concentration of the study drug. RESULTS: All the patients in both the study groups reported subjective numbness of lip and tongue. The time of onset was longer for 0.5 % ropivacaine when compared to 0.75 % solution. 90 % of the study patients in 0.5 % ropivacaine group reported pain corresponding to VAS ≥3 during bone guttering and 93.3 % patients reported pain corresponding to VAS >4 during tooth elevation. None of the patients in 0.75 % ropivacaine group reported VAS >3 at any stage of the surgical procedure. The duration of soft tissue anesthesia recorded with 0.75 % ropivacaine was average 287.57 ± 42.0 min. CONCLUSION: 0.75 % ropivacaine was found suitable for inferior alveolar nerve blocks in surgical extraction of impacted mandibular third molars.

A prospective randomized double-blind study to assess the latency and efficacy of twin-mix and 2% lignocaine with 1:200,000 epinephrine in surgical removal of impacted mandibular third molars: a pilot study.

INTRODUCTION: A prospective randomized double-blind study was conducted to assess the latency and duration of pterygomandibular nerve block with a mixture of 1.8 ml 2% lignocaine with 1:200,000 epinephrine and 1 ml of 4 mg dexamethasone and its impact on postoperative sequelae of surgical extraction of impacted mandibular third molars. MATERIAL AND METHODS: The study was conducted as a prospective randomized double-blind clinical trial on 20 patients with bilateral impaction of mandibular third molars. A total of 40 interventions were included for the study, 20 with 2% lignocaine with 1:200,000 epinephrine (study group C, control) and 20 with the twin-mix (study group T, twin-mix), with a gap of 1 month between two interventions in a single patient. After injection of the anesthetic solution, the time to anesthetic effect, duration of anesthesia, and the need to re-anesthetize the surgical site were recorded. A 10-point visual analog scale (VAS) was used to assess the overall pain intensity while injecting the study drug, during surgery, and in the postoperative period. pH of the test anesthetic solutions was also determined using a pH meter. RESULTS: Twin-mix was found to be more basic than 2% lignocaine with 1:200,000 epinephrine. Mean VAS value for the pain/sting on local anesthetic injection/block was less in study group T. Time of onset of the local anesthetic was significantly less for the study group T, 51 ± 17.5 s when compared with patients in study group C (P less than 0.0001). The duration of soft tissue anesthesia was longer for all the patients in the study group T. On comparative evaluation between study group C and study group T, patients in the control group had more sever swelling and reduction in mouth opening in the postoperative period. DISCUSSION: The addition of dexamethasone to lignocaine and its administration as an intra-space injection significantly shortens the latency and prolongs the duration of the soft tissue anesthesia, with improved quality of life in the postoperative period after surgical extraction of mandibular third molars.