Mandibular Reconstruction: Overview.

INTRODUCTION: Mandibular reconstruction has changed significantly over the years and continues to evolve with the introduction of newer technologies and techniques. PURPOSE: This article reviews the history of oromandibular reconstruction, biomechanics of mandible, summarizes the reconstruction options available for mandible with defect classification, goals in reconstruction, the various donor sites, current reconstructive options, dental rehabilitation and persistent associated problems. SUMMARY: Oromandibular reconstruction, although a challenge for the head and neck reconstructive surgeon, is now reliable and highly successful with excellent long-term functional and aesthetic outcomes with the use of autogenous bone grafts and current reconstructive options. The ideal reconstruction would provide a solid arch to articulate with the upper jaw, restoring swallowing speech, mastication, and esthetics. Autogenous vascularized bone grafts in combination with microsurgical techniques have revolutionized mandibular reconstruction in oral cancer surgery. Current trends in mandibular reconstruction aim to achieve reestablishment of a viable mandible of proper form and maxillary mandibular relationship while decreasing the need for invasive autogenous graft procurement. However the optimal reconstruction of mandibular defects is still controversial in regards to reconstructive options which include the donor site selection, timing of surgery and method of reconstruction.

Reliability of Incision Biopsy for Diagnosis of Oral Verrucous Carcinoma: A Multivariate Clinicopathological Study.

INTRODUCTION: Studies have reported 20 % of conventional squamous cell carcinoma in patients with verrucous carcinoma (VC), later these cancers were termed as hybrid VC. It is important to distinguish both while planning treatment since hybrid VC requires addressing regional lymphatics in addition to respective surgery. Information on odds of missing the foci of invasion on routine incision biopsy might be useful in this regard. PATIENTS AND METHODS: Records of all the patients surgically treated for oral cancer from Jan 2010 to Oct 2013 in a Tertiary Cancer Centre was analyzed. Patients diagnosed with primary VC or Verrucous Hyperplasia on incision biopsy were included in the study. Proportion of patients undiagnosed for invasive component on incision biopsy was calculated, multivariate analysis of the sample was performed to find associated cofounders. RESULTS: Fifty-five patients who reported with the diagnosis of VC (n = 53) or Verrucous Hyperplasia (n = 2) on incision biopsy were included in the study. Twenty-seven were diagnosed as VC and 28 as hybrid VC after excision. This corresponded to 51 % (n = 28) of cases missing invasive component on incision biopsy. VC was significantly more commonly seen in lip and in buccal mucosa, hybrid VC was more commonly seen in tongue and gingiva and this association was statistically significant (p = 0.031) in our study. CONCLUSION: Incision biopsy is extremely unreliable to diagnose and differentiate oral Hybrid VC from VC or Verrucous Hyperplasia. Caution is required while planning treatment of these patients regarding possibility of presence of conventional squamous cell carcinoma within these tumors.

Assessment of the Efficacy of Submental Intubation in the Management of Midfacial and Panfacial Trauma Patients.

INTRODUCTION: Securing an airway in maxillofacial injuries remains a challenge and is an important objective on the part of a maxillofacial surgeon to thoroughly understand its management. PURPOSE: The aim of this study was to evaluate the efficacy and complications of submental intubation in the management of midfacial/panfacial trauma patients where oro-endotracheal or naso-endotracheal intubation is contraindicated and tracheostomy can be avoided. PATIENTS AND METHODS: Twenty patients with maxillofacial injuries were selected for submental intubation who were admitted in Kamineni Hospital, Narketpally, Nalgonda during a 2 year period (2010-2012). The parameters used to assess the efficacy were; restoration of the occlusion, duration of the surgery, presence of scar, presence of infection, damage to vital structures or any post-operative salivary fistula. RESULTS: Submental intubation allowed reduction and fixation of all fractures without the interference of the tube during surgical procedure in all of the patients. There were no intra-operative complications and none of the patients required post-operative ventilation. There were no significant post-operative complications. However, in one of the cases (case 4) infection of submental wound was seen and in another case (case 11) salivary fistula was formed. Both the cases were appropriately managed without any difficulty. The submental scar was well accepted by all the patients. CONCLUSION: Submental intubation is a safe and extremely useful procedure in severe maxillofacial injuries. It presents a low incidence of operative and post operative complications. It allows both the surgeon and the anaesthetist to deliver a better quality of patient care.

Management and Treatment Outcomes of Maxillofacial Fibro-osseous Lesions: A Retrospective Study.

INTRODUCTION: Fibro-osseous lesions are a diverse group of bone disorders and include developmental, reactive or dysplastic diseases and neoplasms. They share overlapping clinical, radiographic and histopathologic features and demonstrate a wide range of biological behaviour. AIM: To evaluate the characteristics, treatment and outcome of benign fibro-osseous lesions of the jaws. PATIENTS AND METHOD: All patients with fibro-osseous lesions of the jaws treated at the department of Oral and Maxillofacial Surgery of the Kamineni Institute of Dental Sciences from 2007 to 2013 were included in this study. RESULTS: Six males and four females were treated. Juvenile ossifying fibroma was most often encountered (40 %), and the mandible was the most frequent location (70 %). Main clinical feature in most of the cases was a painless expansile swelling with facial asymmetry, and radiologically mixed (radiolucent and radiopaque lesions) were seen in majority of cases. All cases were surgically treated and histopathologically confirmed. Segmental ostectomy was performed in six cases; maxillectomy was done in one case and excision along with margin in three cases. Mean follow-up was of 3.3 years with no recurrence. CONCLUSIONS: Fibro-osseous lesions, although sharing similar microscopic features, exhibit a variety of clinical behavior rendering their treatment highly individualized. Radical treatment is the choice to achieve an outcome without recurrence.

Study of Efficacy and the Comparison Between 2.0 mm Locking Plating System and 2.0 mm Standard Plating System in Mandibular Fractures.

PURPOSE: The purpose of this study was to evaluate the efficacy and comparison between 2.0 mm locking plate system and 2.0 mm Champy's titanium mini plating system in mandible fractures. MATERIALS AND METHODS: A total of 20 patients with mandibular fractures were selected and divided into two groups A and B on randomized basis. Group A was treated with open reduction internal fixation using 2.0 mm locking plates and group B with 2.0 mm Champy's titanium miniplates. All patients were followed up for 12 weeks postoperatively. RESULTS: Results of the study show less screw loosening, less precision in plate adaptation and less alteration of the osseous or occlusal relationship upon screw tightening in group A. Chi square test was applied to compare the results between the two groups. Statistical analysis did not show significant difference of incidence of malocclusion between the two groups (p value = 0.606). Statistical analysis using un-paired t test showed significant difference of working time between the two groups (p value = 0.00296). When comparing the overall complication rates according to plates used, the χ(2) test showed no statistically significant difference between the locking and nonlocking plates (p > 0.05). CONCLUSION: It is observed in our study that the locking plate/screw system offers significant advantages over the conventional plating system. The precise adaptation required for using conventional plates is not needed when this locking plate/screw system is used. Locking plate/screw system provides better stability than the conventional plate/screw system.

Myofibroma-a rare entity with unique clinical presentation.

Myofibroma and myofibromatosis is a well-recognized spindle cell neoplasm that occurs predominantly in infants and young children. They have been described under different names since 1951. These lesions are a benign fibroblast and myofibroblast proliferation containing a biphasic presentation of spindle shaped cells surrounding a central zone of less differentiated cells focally arranged in a hemangiopericytoma like pattern. Classically these lesions are described in children younger than two, with 2/3rd present at birth and rarely in adults. Controversy exists as to an autosomal dominant or recessive inheritance or to a sporadic occurrence. Presented here is a unique case of myofibroma involving the mandible in a 11 year-old male patient. Clinically it mimicked more like a beningn tumor and not exhibiting any of its classical signs. The diagnosis could be established only after complete excision of the lesion and histopathological examination. There was no recurrence after a follow up period of 4 months.

Evaluation of Vertical Bone Gain Following Alveolar Distraction Osteogenesis in the Anterior Edentulous Mandible: A Clinical Study.

AIM AND OBJECTIVES: To calculate the gain in bony height and volume of the distracted upper segment using an extraosseous unidirectional device to improve the retention of the future prosthesis. MATERIALS AND METHODS: Ten cases with completely or partially edentulous but severely or considerably resorbed anterior mandibles were managed by vertical alveolar distraction osteogenesis. All the patients were evaluated preoperatively, intraoperatively and post-operatively for various parameters clinically and radiographically i.e. on OPG, lateral cephalogram and on CT scan, at different time intervals. In all cases there was increase in vertical bone height. RESULTS: The study showed mean vertical bone gain (VBG) on OPG as 8.2 mm. The mean VBG on lateral cephalogram was 8.1 mm. The mean VBG on CT scan at right canine was 8.35 mm, at left canine was 8.2 mm and at midline was 8.27 mm. CONCLUSION: Alveolar distraction osteogenesis is a predictable method for restoring alveolar ridges prior to implant placement or prosthesis. Distraction osteogenesis is ideally suited for recreating missing tissue in the anterior esthetic zone by increasing vertical bone height as well as good width and soft tissue growth.

Achieving the prediction results by visualized treatment objective following anterior maxillary segmental osteotomy. A retrospective study.

This study used the manual visualized treatment objectives (VTO) as a tool to evaluate the predictive value of the computer-assisted VTO. Presurgical cephalometric tracing predictions generated by oral and maxillofacial surgeons and computer-assisted VTOs were compared with the postsurgical outcome as seen on lateral cephalometric tracings. Ten measurements of the predicted and actual postsurgical hard tissue landmarks were compared statistically. A paired Student's t test showed that in nine of ten measurements, there were no statistically significant differences in the mean values of manual VTO (MVTO). Statistically significant differences were found in one of the four linear measurements (cant of upper lip P - 0.0001). For computer assisted (CAVTO) Student's t test showed that in nine of ten measurements, there were no statistically significant differences in the mean values. Statistically significant differences were found in one of the four linear measurements (nasolabial angle, P  - 0.0001). From these data, it appears that both VTOs demonstrated good predictive comparative outcome, and are equally predictive, but CAVTO is precise.

Surgical Management of Oro-Antral Communications Using Resorbable GTR Membrane and FDMB Sandwich Technique: A Clinical Study.

The paper describes a new technique for closure of the oro-antral communication, in which both hard (bone) and soft tissue closure was achieved. The technique uses a Guided Tissue Regeeration (GTR) membrane and Freez Dried Mineralized Bone (FDMB) allograft for closure of the defect. Aim of the study was to assess the advantages of the surgical management of oro-antral communications using resorbable GTR membrane and FDMB sandwich technique. A total 10 patients were selected in whom dental extractions were complicated by formation of oro-antral communication (OAC). The resorbable guided tissue regeneration membrane (PERIOCOL-GTR) and freeze dried mineralized bone allograft material was used. Some cancellous granules of freeze dried bone allograft was sandwiched between sheaths of appropriately trimmed collagen membrane which was previously sutured together on three sides using 3/0 resorbable polyglycolic acid suture (vicryl). The fourth side was then adequately closed using the same suture after the bone graft had been inserted, thus creating a closed sandwich. The prepared sandwich was then tucked into the OAC in such a way that it formed a convexity towards the sinus and a concavity towards the alveolar bone. The rough surface of the sandwich is faced to the alveolar bone and additional bone graft is filled into this concavity. Suturing done without tension. Post-operative orthopantomogram was taken to radiologically quantify the amount of bone grafting/augmentation and closure of oro-antral fistula. There was an average of 11.84 mm bone formation after 6 months, the average width preserved and obtained was 6.9 mm. By the end of 4 months there was evidence of bone formation in 7 subjects and in three subjects bony trabeculae formed was almost similar to the adjacent bone. By the end of 6 months follow-up of 7 subjects showed trabeculae indistinguishable from the adjacent bone. The study was done in 10 patients with a follow-up period of 6 months and found to be excellent in the formation of new bone. The technique is simple and excellent for closure of the oro-antral communications especially when subsequent placement of end osseous implant is considered without the need of donor site surgery for bone grafting.

A prospective study involving the use of platelet rich plasma in enhancing the uptake of bone grafts in the oral and maxillofacial region.

ABSTRACT: Platelet-rich plasma (PRP) is an autologous product that contains highly concentrated number of platelets in a small volume of plasma, derived from whole blood by gradient density centrifugation. It has been speculated that local growth factors in human platelets (insulin-like growth factor, IGF; transforming growth factor, TGF-ß; platelet derived growth factor, PDGF) would enhance healing of grafts and also counteract resorption. The aim of this study was to evaluate efficacy of PRP on early healing after autogenous bone grafting. Of the twenty patients selected ten were treated with autogenous bone graft and PRP (PRP group) and other ten with autogenous bone graft alone (non-PRP group). PRP group consisted of two benign tumor of mandible, one post surgical defect, two unilateral alveolar cleft, one bilateral alveolar cleft with skeletal class III malocclusion, one maxillary hypoplasia, one oronasal fistula, one recurrent tumor of mandible, one multiple impacted mandibular teeth. Non-PRP group consisted of seven benign tumor of jaw, one keratocyst odontogenic tumor, one orbital blow out fracture, one residual traumatic defect. Biopsies were taken in the native bone, PRP treated grafted bone, grafted bone without PRP at 3 months to assess the maturity of bone. Radiographic imaging was performed by panoramic radiography at 3 and 6 months to evaluate bone opacity of grafted bone on comparison with native bone and computerized tomography at 6 months to evaluate grafted bone morphologically and to measure bone density in Hounsfield units. Microscopic results showed that significantly more matured bone was formed at PRP treated sites as that of native bone and immature bone in controls after 3 months of healing. Bone opacity of PRP treated bone grafts was close to that of native bone than that of non-PRP treated bone grafts on panoramic radiograph at 3 and 6 months. There was graft loss in three cases and graft resorption in one case of non-PRP treated bone grafts at 6 months. In PRP group the compact bone was clearly differentiated from cancellous bone as in native bone and thick in five cases, thin in five cases. In non-PRP group the compact bone was thin as a whole. Comparing native bone group and PRP group the CT value of PRP treated bone graft was more or less close to native bone group and comparing native bone group and non-PRP group CT value was low in non-PRP treated bone graft. Whereas when comparing PRP and non-PRP group CT value was higher in PRP group. Autologous PRP was a safe, biocompatible, effective, source for growth factors and carries no risk of transmissible diseases. It enhances and accelerates bone regeneration of autogenous bone grafts.

Reparative giant cell granuloma of the maxilla.

Giant cell reparative granuloma accounts for 1-7% of all benign lesions of the jaw. It often arises in the maxilla followed by mandible and affects children and young adults. It is usually a slow-growing lesion. The fast growing lesions are rare and despite the innocent histological appearance, has an aggressive behavior mimicking a malignant lesion. In the present report, the clinical features, diagnosis, and surgical treatment of an unusually large aggressive variety of reparative giant cell granuloma found in the cheek with extensions into maxilla, antrum, and infratemporal region in a 23-year-old female is described. The impact of delay in correct diagnosis on massive enlargement of the lesion, the importance of computed tomography-guided biopsy in the diagnosis of such inaccessible lesions, and the role of a general dentist in the early detection are also emphasized.