Geminated Supernumerary Premolar Impacted in the Palate: A Report of a Rare Case and Review of the Literature.

Supernumerary teeth are dental anomalies characterized by the presence of an excessive number of teeth in relation to normal dentition. Among these, the supernumerary premolars have a prevalence of 0.29% to 0.64%, making it a very rare finding. On the other hand, gemination is a developmental disturbance in the shape of the teeth where a partial cleavage of a single tooth germ results in the formation of a singular root and a singular pulp chamber but two partially or totally separated crowns. Although these anomalies as individual entities are fairly common in clinical practice, the occurrence of both anomalies in a single tooth is an extremely rare occurrence. We hereby report a rare case of impacted geminated supernumerary premolar in a 45-year-old female patient. A thorough search of the literature revealed that only four cases listing this anomaly have been reported in the literature thus deserving a mention. In addition to the case presentation, the authors have also reviewed the existing literature on this anomaly.

The Palatal Elevation Technique (PET) for Intra-alveolar Extraction of Grossly Decayed Maxillary Third Molars.

Intra-alveolar extraction of maxillary third molars always poses a challenge to dental practitioners owing to limited accessibility and minimal space for dental forceps application. Dental elevators facilitate the extraction of such teeth. In the traditional technique as described in the literature, the elevator is always introduced from the mesiobuccal aspect of the tooth to engage the space between the interdental bone and the offending tooth to use it as a fulcrum. However, certain situations prevent proper application of the elevator from the buccal aspect of the offending tooth to bring about luxation. One such situation is a grossly decayed third molar tooth, especially from the mesiobuccal aspect with destruction of the tooth substance extending below the cementoenamel junction. Another such situation is observed in patients presenting with thick and inextensible cheeks but a good interincisal opening. In either situation, it becomes very challenging to achieve a good purchase for luxation of the offending third molar. The authors have therefore described a modified technique of tooth elevation, the palatal elevation technique (PET), using the palatal bone instead of the buccal bone as the fulcrum which was observed to be effective in such situations. In the authors' view, PET is simple and quick and can effectively be employed as an alternative to the traditional technique of tooth elevation in all cases that require an intra-alveolar extraction of maxillary third molars.

Use of 3D printed model as an aid in surgical removal of a rare occurrence of a compound odontome in the anterior mandible associated with impacted teeth.

The use of 3D printing in the medical field has been well documented, with significant developments in fabrication of tissues, organs, customized prosthetics, implants, and anatomical models as well as pharmaceutical research. Its use in dentistry, however has been limited mainly to maxillofacial surgery and reconstruction, orthognathic surgery and trauma. Compound odontomes are usually prevalent in the anterior maxilla, however, their occurrence in the anterior mandibular region is rare. This case report highlights the effective usage of 3D printing as an aid in the surgical removal of a compound odontome and impacted incisors in the mandibular anterior region. The surgery was carried out under general anesthesia. A full thickness muco-periosteal flap was reflected and the compound odontome along with the impacted incisors were removed. The defect was restored using a mixture of autogenous scrapes harvested from the chin, xenograft and platelet-rich fibrin. Wound closure was done using 4-0 vicryl. A CBCT scan taken 1 year later confirmed uneventful healing and complete bone regeneration of the surgical defect. Key words:3D printing, model, compound odontome, impacted, incisors.

A comprehensive management protocol to treat cleft maxillary hypoplasia.

AIM: To describe a comprehensive management protocol to treat cleft maxillary hypoplasia specific to the patient's age, degree of hypoplasia and presence or absence of velopharyngeal incompetence (VPI). MATERIALS AND METHODS: A total of 359 patients suffering from cleft maxillary hypoplasia were retrospectively studied from January 2004 till June 2015. Lateral cephalograms were taken to assess the degree of deformity and advancement achieved at three intervals. Patients were treated by four treatment modalities: Facemask therapy, Anterior maxillary advancement, Total maxillary osteogenesis and LeFort I advancement. RESULTS: 359 patients of cleft maxillary hypoplasia were treated and followed up for a mean of 25 ± 3.6 months. Group I had 20 patients, all in the pre-pubertal age group with less than 11 mm discrepancy. 25% of patients in this group had relapse; Group II: 196 patients who were all above 11 years of age and included all grades of hypoplasia, only 6.25% patients had relapse; Group III had 36 patients all with severe form of hypoplasia and were above 5 years of age. Relapse in this group was 16.6%; Group IV had 102 patients who were above 16 years of age and had mildmoderate severity of hypoplasia. Relapse rate was 18.75%. CONCLUSION: Extensive literature search and our institutional study has helped us formulate a protocol that delineates the most appropriate treatment modality for a specific age group and degree of hypoplasia also considering the effect of treatment on velopharyngeal incompetence.

Tooth-Borne Anterior Maxillary Distraction for Cleft Maxillary Hypoplasia: Our Experience With 147 Patients.

PURPOSE: To evaluate the results of anterior maxillary distraction for its efficacy and long-term stability in the management of cleft maxillary hypoplasia in a large series of patients with a long-term follow-up extending to 4 years. MATERIALS AND METHODS: One hundred sixty-four patients at least 10 years old with cleft maxillary hypoplasia who presented to the authors' unit from January 2009 through October 2014 were evaluated retrospectively, irrespective of gender, type of cleft lip and palate, and amount of advancement needed. Anterior maxillary distraction using a tooth-borne distractor appliance was carried out in all patients and all patients were followed up to 4 years (range, 1 to 4 yr) to evaluate the stability of the procedure and to document any relapse using digitalized lateral cephalograms taken before distraction, immediately after distraction (T2), and at the last follow-up visit (T3; range, 1 to 4 yr). Seventeen patients were subsequently lost to follow-up; therefore, a complete set of records was available for 147 patients. In a subset of 50 patients, perceptual speech assessment was carried out preoperatively and 6 months postoperatively by 2 speech pathologists using the Perkins scoring system that allowed the evaluation of 5 parameters (velopharyngeal insufficiency, resonance, nasal air emission, articulation, and intelligibility). None of these patients underwent speech therapy during the course of evaluation. The development of complications intra- or postoperatively was noted. The data were tabulated and analyzed. RESULTS: An advancement ranging from 4.0 to 13.1 mm (mean, 9.42 mm) was achieved in all patients. One hundred forty patients (95.23%) showed stable results on lateral cephalograms and when T2 values were compared with T3 values. Seven patients (4.76%) exhibited skeletal relapse in various linear and angular measurements assessed on lateral cephalograms. At 6-month follow-up, improvements of 62% (n = 31), 64% (n = 32), 50% (n = 25), 68% (n = 34), and 70% (n = 35) in velopharyngeal insufficiency, resonance, nasal air emission, articulation, and intelligibility, respectively, were observed, with worsening of all parameters in 1 patient (2%). An overall complication rate of 25.17% (n = 37) was noted, with bleeding being the most common intra- and postoperative complication noted in 15 patients (10.2%). No serious consequences related to any complication were noted. CONCLUSION: Anterior maxillary distraction can be considered a suitable treatment option for the management of mild to moderate cleft maxillary hypoplasia because the anteroposterior deficiency can be addressed at a young age, immediately after the eruption of the maxillary second premolars. Stable long-term results with negligible skeletal relapse are possible with this technique, with an added advantage of unhampered or even improved velopharyngeal function.

Management of Lip Pits in Van der Woude Syndrome: A Clinical Classification With Difficulty Index.

PURPOSE: Numerous case reports have been published on lip pits in Van der Woude syndrome explaining the morphology and genetics in detail; however, thus far, no article has focused on the classification of lip pits as an aid in surgical management. Although the procedure for lip pits in Van der Woude syndrome appears straightforward, even in the best of hands, the excision can be very challenging with no guarantee of esthetically desirable results. Therefore, we have devised a classification based on a difficulty index in the management of lower lip pits to assist in predicting the treatment outcome before surgery, as well as to offer the choice of a particular technique in a specific situation. MATERIALS AND METHODS: We reviewed 19 cases of Van der Woude syndrome having lower lip pits that were operated on at our unit from May 2005 to June 2015 with a minimum follow-up of at least 6 months. The data analyzed included the patient's age and gender, location of the lip pits with regard to their proximity to the white skin roll, number of lip pits, presurgical depth of the lip pits, and discharge of mucous secretion from the pits, as well as timing of lip pit excision. Four techniques of excision were performed via routine excision, modified routine excision, vertical wedge excision, and inverted-T lip reduction. The data were tabulated and analyzed. On the basis of our experience in managing lip pits, a clinically relevant classification with a difficulty index was then proposed. RESULTS: Among the 12 patients having preoperative involvement of the white skin roll, 8 had distortion of the white skin roll when operated on by either routine excision (n = 2), modified routine excision (n = 3), or inverted-T lip reduction (n = 3). The remaining 4 patients had no distortion of the white skin roll after surgery when the vertical wedge excision technique was performed. The 7 patients who had no distortion of the white skin roll preoperatively presented with esthetic results when operated on by either the routine excision, modified routine excision, or inverted-T lip reduction technique. In 2 patients with a presurgical pit depth greater than 6 mm, mucocele formation was observed after surgery. Using the data obtained, we proposed a classification based on 2 parameters: involvement of the white skin roll and presurgical depth. A difficulty index also was proposed using these same variables. CONCLUSIONS: Classification and evaluation of the difficulty of lip pit excision are essential in planning the surgical treatment to give improved esthetic results. This proposed classification and difficulty index will provide the operating surgeon with a standardized scheme to evaluate the difficulty of the excision as well as to predict the overall outcome of the procedure before surgery.

Perceptual Speech Assessment After Anterior Maxillary Distraction in Patients With Cleft Maxillary Hypoplasia.

PURPOSE: To assess speech outcomes after anterior maxillary distraction (AMD) in patients with cleft-related maxillary hypoplasia. MATERIALS AND METHODS: Fifty-eight patients at least 10 years old with cleft-related maxillary hypoplasia were included in this study irrespective of gender, type of cleft lip and palate, and amount of required advancement. AMD was carried out in all patients using a tooth-borne palatal distractor by a single oral and maxillofacial surgeon. Perceptual speech assessment was performed by 2 speech language pathologists preoperatively, before placement of the distractor device, and 6 months postoperatively using the scoring system of Perkins et al (Plast Reconstr Surg 116:72, 2005); the system evaluates velopharyngeal insufficiency (VPI), resonance, nasal air emission, articulation errors, and intelligibility. The data obtained were tabulated and subjected to statistical analysis using Wilcoxon signed rank test. A P value less than .05 was considered significant. RESULTS: Eight patients were lost to follow-up. At 6-month follow-up, improvements of 62% (n = 31), 64% (n = 32), 50% (n = 25), 68% (n = 34), and 70% (n = 35) in VPI, resonance, nasal air emission, articulation, and intelligibility, respectively, were observed, with worsening of all parameters in 1 patient (2%). The results for all tested parameters were highly significant (P ≤ .001). CONCLUSION: AMD offers a substantial improvement in speech for all 5 parameters of perceptual speech assessment.