Occurrence of Second Oral Potentially Malignant Disorder following Excision of Primary Lesion: A Prospective Study of Cases from a Tertiary Care Centre.

Background: Early diagnosis and timely management of potentially malignant oral disorders may prevent malignant transformation and prompt diagnosis of frank malignancies favours better prognosis. The aim of this study was to evaluate the outcome of surgical management of oral potentially malignant disorders of the oral cavity and observe the prevalence of recurrence at the primary site and occurrence of another potentially malignant lesion in these patients. Methods: The study participants included patients who had undergone clinical oral examination, surgical excision of biopsy-proven cases of dysplastic oral potentially malignant disorders (leukoplakia, erythroplakia, non-healing ulcerative and erosive areas, etc.) who were on routine follow-up as per the standard guidelines. These patients were followed up closely during each monthly follow-up visit for the first year. The patients were then prospectively analysed for any recurrence of lesion. On follow-up visits, detailed clinical oral examination was done to note the prevalence of a new lesion in any oral cavity sub site other than the previous site. If a new lesion was detected, then biopsy followed by surgical excision was followed as per standard guidelines. The follow-up period after the second surgical intervention was 12 months. Results: Fifty patients with potentially malignant oral disorders underwent surgical excision. The majority of the study subjects were males (39/50) and 41 of them were below 65 years of age. Of 50 patients, 13 (26%) had second oral potentially malignant lesion other than the primary site. The rate of recurrence of the lesions at the primary site was 4% (2/50). Of these patients with recurrence, all had malignant transformation (2/2). Also, patients who were initially diagnosed with moderate dysplasia had a higher chance of recurrence. A second lesion at a site different from the primary lesion was seen in 26% of the cases. Conclusion: Surgical management of such lesions with one-centimetre oncological margins in all dimensions contrary to the routine five millimetre surgical margins reduces the chance of recurrence.

Decoding the influence of the immune system and immunotherapy targets on carcinomas: A hidden prism in oral cancer therapy.

In recent decades, understanding tumorigenesis and the complex interaction between the host and the immune system has been the pillar for significant advances in anticancer therapy. Conventional anticancer therapy (e.g., cut, burn, and cytotoxic drugs) involves multiple targeting of tumor cells. However, the tumor tissue microenvironment can present a dysregulated, stimulating, or subverted immune response which, in turn, reveals pro-tumor activities favoring tumor expansion and progression. Recently, new potential targets have been identified based on immunomodulatory therapies, which are crafted to re-establish the host anti-tumoral immune response. Clinicians should fully understand the intricate interactions between carcinogens, the tumor milieu, the immune system, and traditional anticancer therapies in order to progress and to overcome the refractory/recurrent challenges and morbidity of the disease. Thus, in this article, we highlight the complex milieu of the oral cancer immune response, pointing out potential therapeutic immunotargets for oral squamous cell carcinomas. The impact of traditional anticancer therapy on the immune system is also outlined.

An ubiquitous entity of post-COVID rhinomaxillary mucormycosis.

Introduction: Coronavirus disease-19 (COVID 19) has left a trail of morbidity and mortality on a global scale because of the nature of the disease and its sequelae. One of the earliest drugs used to prevent the spiralling down of patients with the effects of cytokine syndrome were corticosteroids, reducing mortality. However, with the unfortunate injudicious use of steroids, opportunistic infections have created havoc even in recovered patients. COVID-associated rhino mucormycosis has seen a sudden spike in its prevalence presenting as an endemic in the midst of a pandemic. Case Presentation: Our paper reports a case of a COVID-recovered patient who presented with bilateral disease involving the maxillary sinus and palate on one side and the zygoma and orbit on the other. Discussion: Diagnosing and treating maxillary or orbital or cerebral extensions of rhino mucormycosis requires a thorough judicious approach. Imaging, meticulous intra-operative evaluation, and aggressive medical and surgical treatment are necessary. Conclusion: This case report highlights a peculiar case of an asymmetrical bilateral presentation of post-COVID mucormycosis involving different anatomical spaces.

Oral mucositis: Current knowledge and future directions.

Oral mucositis secondary to head and neck chemoradiation displays a complex molecular pathogenesis involving epithelial and microvascular injury, release of pro-inflammatory cytokines, and host-microbiome communications. These processes lead to oxidative stress and the release of reactive oxygen species that stifle the structural integrity of the oral mucosa, with emergence of erosions and ulcers. The consequences are malnutrition, psychological/psychiatric symptoms, poor quality of life, and occurrence of opportunistic infections. The latter pose a major challenge due to the risk of interruption of anti-neoplastic therapy, tumour recurrence and, ultimately, death. This article aims to present the clinical characteristics, molecular pathogenesis, and an overview of the predisposing factors and current management of oral mucositis. It is anticipated that the future direction of the management of oral mucositis will focus on evidence-based prehabilitation and pre- and per-chemoradiation therapy monitoring.

The Silicone Turkish Delight for Dorsal Augmentation in Rhinoplasty.

ABSTRACT: Rhinoplasties are the most challenging facial aesthetic procedures with the majority of the cases requiring dorsal augmentation either in the form of autogenous or alloplastic materials. Although autogenous grafts are the gold standard, these grafts have their innate issues such as donor site morbidity, occasional displacement, resorption, tendency to warp or develop sharp edges over time with increased perceptibility and clinical visibility of the graft with time. These issues were addressed by Erol in 2000 who advocated the use of finely diced autologous cartilage wrapped in a monolayer of surgical and termed it Turkish delight. This technique has been extensively modified by surgeons across the world with an attempt to forgo the use of autogenous grafts preventing donor site morbidity and replacing it with alloplastic materials. Silicon's inert nature, resorption resistance, absence of a secondary surgical site and economical value make it a widely utilized allograft augmentation option in Asian countries. The authors hereby present a modification of the original Turkish delight technique by utilizing diced silicone pieces amalgamated with 1 to 2 ml of autologous blood and wrapped in monolayer of surgicel (oxidized cellulose). The technique produced clinically stable results in 27 patients who were followed up for a period of 24 to 60 months (average 30 months). Improved pliability, negated risk of graft extrusion with no donor site morbidity are the key advantages of this technique over conventional autologous grafts and silicon block augmentation techniques. These results point towards the viability of the technique for performing dorsal augmentation in rhinoplasty.

Caution with carotids: A necessary cognizance.

Most aberrations in the cervical course of the internal carotid artery are generally encountered as incidental findings due to their asymptomatic nature. However these morphological variations if not identified intra operatively or pre operatively may lead to vascular accidents. It is essential to be aware of the existence of tortuosity, kinking, and coiling of these great vessels while considering patients for surgeries of head and neck cancer, pharyngeal resections, traumatic injury repair, etc. Our paper presents a case series of four patients in whom carotid dolichoarteriopathies were observed during the course of neck dissection. It aims to highlight the precautions required to avoid morbidity in such patients.

Reconstruction of buccal mucosa: A minimalist symbiotic approach with local flaps.

BACKGROUND: Buccal mucosa defects following resection of premalignant or malignant lesions require adequate reconstruction. Both locoregional and microvascular flaps have been extensively used based on operator and patient factors. This paper focuses on the outcomes of a simplified approach for reconstruction of large buccal mucosa defects with posterior extent using a combination of two loco regional flaps. METHOD: A combination of buccal fat pad graft and nasolabial flap was used to reconstruct large defects spanning the buccal mucosa extending to the soft palate or retromolar trigone areas. Post operative outcomes were noted in patients who underwent reconstruction using this combination technique. RESULT: This paper highlights the favourable results and ease of technique with this combination of flaps, i.e complete coverage of large buccal mucosa defects extending to critical areas such as soft palate, retromolar trigone or tonsillar pillars; avoiding sophisticated free flaps. Satisfactory healing with adequate functional and esthetic outcomes were seen. CONCLUSION: Defects post ablation of buccal mucosa lesions, larger than 5 cm × 5 cm, can be reconstructed using double local flaps. Buccal fat pad and nasolabial flaps heal excellently with nil morbidities and their combination provides a simple and an economical alternative option for reconstructive surgeons.

Treatment of the Complete Edentulous Atrophic Maxilla: The Tall Tilted Pin Hole Placement Immediate Loading (TTPHIL)-ALL TILT™ Implant Option.

AIM: A severely atrophied maxilla presents serious limitations for conventional implant placement and the reconstruction of which requires extensive surgical treatments. This original article presents an overview of this evidence-based technique used for maxillary rehabilitation. BACKGROUND: Growing patients' needs to regain proper oral function with limited surgical effort presents a challenge to the surgeon for implant placement in harmony with the planned prosthesis. Different techniques and protocols have been put forward through the ages to improve implant survival, osseointegration, and quality of life. A new technique-Tall Tilted Pin Hole Immediate Loading (TTPHIL-ALL TILT™ technique)-utilizes angulated long bicortical tapered implants placed in a flapless way in immediate loading with screw-retained prosthetic solutions. TECHNIQUE: TTPHIL-ALL TILT™ technique involves flapless subcrestal bicortical placement of a total of six tall threaded tilted implants engaging the nasal cortex and the pterygoid pillars, rigidly splinted maintaining adequate anteroposterior spread, achieving proper primary stability, fit for immediate loading. Screw-retained prosthetic solutions are provided with the elimination of distal cantilever. CONCLUSION: The TTPHIL-ALL TILT™ technique can facilitate surgical rehabilitation of patients with maxillary resorption, as an alternative to other graft less and grafting procedures. CLINICAL SIGNIFICANCE: TTPHIL-ALL TILT™ technique provides a graftless solution for the challenging resorbed maxillary edentulous ridges. By following this protocol, primary stability is achieved which gives way for immediate loading satisfying the patient's functional and aesthetic needs.

The influence of the mandibular gonial angle on the occurrence of mandibular angle fracture.

BACKGROUND/AIMS: Angle fractures represent the largest percentage of mandibular fractures. They pose as a unique entity because of their codependent morphological dynamic factors, rendering the understanding of the mechanism, and treatment challenging. The aim of this study was to analyze the association between the mandibular gonial angle and the risk of mandibular angle fracture while highlighting its clinical relevance. MATERIALS AND METHODS: A retrospective analysis of radiographs of patients treated for mandibular fractures was done. The factors studied were as follows: the presence of a high gonial angle and an impacted third molar. The outcome was mandibular angle fracture. The gonial angle was measured using Planmeca Digital Software 3.7.0.R. Status of the third molar was also noted. Data obtained were analyzed using SPSS 22 (IBM Corp, Armonk, NY). RESULTS: The sample comprised 70 mandibular fractures (32 angle fractures and 38 non-angle fractures). The mean gonial angle in the angle fracture group was 128.5 ± 5.4º which was 10.2° larger than in the non-angle group (mean 118.5 ± 4.4º; P = 0.0001). Patients with a high gonial angle were 8.7 times more likely to sustain an angle fracture than those with normal or low gonial angles. A statistically significant relationship between the presence of impacted third molar and patients sustaining mandibular angle fractures was noted (P = 0.0001). CONCLUSION: Subjects with a high gonial angle and an impacted third molar are at an increased risk for mandibular angle fracture due to direct and indirect morphological factors.

Chronic recurrent osteomyelitis: A surgeon's enigma.

BACKGROUND: Chronic recurrent forms of osteomyelitis of the mandible with their morbid clinical course have long been considered a challenge to maxillofacial surgeons in terms of both diagnosis and treatment. Various classifications and treatments have been established through the ages to define and manage the inflammatory symptoms occurring in adults and children. This paper discusses two such entities occurring in an adult and a child, highlighting the diagnostic and treatment challenges of recurrent osteomyelitis. METHODS: A thorough workup which included clinical, radiographic, blood investigations was done, followed by administration of antibiotics and anti-inflammatory with or without surgical debridement/adjuvant therapies. Correlation of our findings and treatment plan was done with evidence-based literature and practice. RESULTS: Complete resolution of symptoms with radiographic evidence was achieved in both the cases. In the recurrence period, long-term steroids, NSAIDs, antibiotics resulted in better outcomes. CONCLUSION: The evidence-based protocol for osteomyelitis stresses on short inpatient stays predicated on efficient literature. Thorough clinical and radiographic evaluation with aggressive medical management and surgical intervention when necessary can result in longer symptom-free periods. Thus understanding the disease, recurrence pattern and response to therapy is essential.