Versatility of Transport Distraction Osteogenesis for Reconstruction of Lateral Mandibular Ablative Defects.

Introduction: The reconstitution of form and function after maxillofacial tumor resection or traumatic bony defects is a challenge when considering reconstructive options. The reconstructive options will depend upon whether the tissues to be replaced included bone alone or both bone and soft tissue (composite resection). Methodology: This study was carried out on nine patients who with benign tumors or cysts of the mandible that required segmental resection. Mandibular reconstruction using mandibular transport distraction osteogenesis was performed for all the cases. Depending on whether the condyle was spared or sacrificed, the type of mandibular transport distractor either fixed on the remnant condyle-ramus unit or had a condylar component replacing the resected condyles. Depending on the location of the defect, transport distraction was carried our anterior to posterior or posterior to anterior. Results: A total of nine cases of benign mandibular pathologies were operated. Segmental resection with condylar preservation was carried out in seven cases, segmental resection with condylar resection was carried out in two cases. In cases with condylar resection, the reconstruction plate of the distractor device had a condylar component. Anterior to posterior transport distraction was carried out in seven cases, and posterior to anterior transport distraction carried out in two cases. The amount of distracted bone ranged from 38 to 46 mm. Conclusion: Mandibular transport distraction osteogenesis offers a modality of reconstruction where the patient's native host bone is osteotomized and gradually distracted to induce the formation of regenerated osseous structure and soft tissue. Being cost-effective, not requiring a steep learning curve/long operative time, and not technically demanding as vascularized bone grafts/flaps, it is feasible in the Indian setup as a practical reconstructive option for benign jaw tumors.

M-Mode Echomyography of Facial Muscle Function Following Facial Reanimation with Temporalis Muscle Galea Pedicled Flap: Analysis of Ten Cases with Review of Literature.

INTRODUCTION: Facial palsy is a condition where the patients lack voluntary movement on the affected side of the face and are not able to convey their emotions. Besides that, they also succumb themselves to social isolation. Various techniques have been devised to overcome this devastating problem. The aim of this article is to evaluate and compare facial muscle function before and after facial reanimation with temporalis muscle galea pedicled flap by motion mode echomyography in patients with long-standing facial paralysis. PATIENTS AND METHODS: Ten patients with long-standing facial paralysis were included in the study (six patients with LMN palsy and four patients with facial weakness involving specific peripheral branches), and they subsequently underwent facial reanimation surgery with temporalis galea pedicled flap. These patients were followed postoperatively for a period of 1-2 years and were subjectively graded as excellent, good, fair and poor and objectively evaluated by M-mode echomyography, and the results were evaluated and statistically analyzed. RESULTS: Subjectively, out of 6 patients with LMN palsy, results were graded as excellent in 2 cases, good in 3 cases, fair in 1 case, and out of 4 patients with weakness in specific facial nerve branches, the subjective results were excellent in 2 cases, good in 1 case and fair in 1 case. Objectively, the effect of transposed temporalis galea on orbicularis occuli, levator labii superioris and orbicularis oris was found to be statistically significant in patients with LMN palsy. CONCLUSION: Our study proves the versatility of temporalis muscle galea pedicled flap in cases of long-standing facial paralysis by motion mode echomyography.

Utility of the Midface Degloving Approach for Extended Exposure in Maxillary Pathologies.

INTRODUCTION: A generous exposure of the midface region is essential for a comprehensive and thorough execution of midface surgical procedures, especially bilateral procedures. Traditional approaches to the midface the midface like the lateral rhinotomy and Weber-Fergusson/Dieffenbach incision with their modifications leave a visible scar, and they are limited in their unilateral exposure. The midface degloving approach with its exclusive intranasal and intraoral incisions leaves no external scars and lends excellent bilateral exposure of the maxilla, zygoma, paranasal areas and infraorbital margins from one side to the other. The midface degloving approach is mainly used to expose pathologies of the maxilla, nasal cavities, paranasal sinuses, nasopharynx, and the central compartment of the anterior and middle cranial base. This approach can also be used to treat midface trauma and perform high-level osteotomies. MATERIALS AND METHODS: We describe the midface degloving procedure for nine cases operated in the Department of Oral and Maxillofacial Surgery over a period of 7 years (2012-2018): seven maxillary tumors and two maxillary cysts. RESULTS: We obtained excellent exposure for all the cases using this approach. Complications included mild distortion of the lower lateral nasal cartilages and oro-nasal communication. CONCLUSION: The midface degloving approach lends excellent surgical access to the midfacial skeleton including the maxilla, the paranasal areas, the maxillary sinus, the zygoma, and infraorbital rims. The advantages of this approach besides its generous exposure, is the excellent cosmesis it provides leaving no external scars.

Predictability and Feasibility of Total Alloplastic Temporomandibular Joint Reconstruction using DARSN TM Joint Prosthesis for patients in Indian subcontinent-A prospective clinical study.

PURPOSE: The aim of this study was to investigate the feasibility of a custom made alloplastic Temporomandibular Joint (TMJ) device design in patients undergoing temporomandibular (TM) Total Joint Reconstruction (TJR). OBJECTIVE: TMJ disease with functional and anatomic distortion dictates the need for TJR. There are various materials to reconstruct a TMJ. However, various factors, such as cost, availability of prosthetic joint, limit its use to tertiary health care center. Hence, we have investigated the feasibility and efficacy of the custom made alloplastic TMJ prosthesis (DARSN TM Joint Prosthesis) with the advantage of being acceptable financially and the overall Quality of life (QoL) diagnosed with TMJ ankylosis and End Stage Joint Disease (ESJD) selected from the study population. MATERIALS AND METHODS: The study group comprised of 20 patients with TMJ ankylosis or End Stage Joint Disease (ESJD) who needed TM TJR of which few subjects in the study population had history of failed previous surgery to the TMJ region. The patients underwent resection of the joint followed by TJR using the custom made alloplastic TMJ prosthesis. Various subjective and objective variables were evaluated such as the Jaw Function (JF), Inter-incisal opening (IO), Diet intake (DI), Quality of Life (QoL) using a Psychometric Modified Likert Scale and nutritional status of the patient using the Mid-Upper Arm Circumference (MUAC) as reference. RESULTS: All the subjective and objective variables showed significant improvement in the postoperative period as compared to the preoperative period. The JF score increased with a mean score of 6.25 (P<0.00001). Postoperative mean DI score was 3.15 (P<0.00001) and IO increased up to 29-38mm in 95% of the study population. The study population exhibited an improved overall QoL and nutritional status post-operatively. Follow up period of 1 year showed significant functional improvement among the study population. CONCLUSION: The results shows that the custom made alloplastic joint replacement is safe and effective and reliable alternative to treat patients with TMJ disease which restricts the normal function to a greater degree requiring TM TJR.

Zygomaticomaxillary "lateral swing" osteotomy for augmentation of midface deficiency.

INTRODUCTION: Various surgical modalities have been proposed for the augmentation of midface deficiency without correction of the occlusal component. They include autogenous bone and cartilage grafts, alloplastic materials, and osteotomies. We propose an innovative osteotomy technique for augmentation of the midface including the infraorbital rims, the zygoma, the anterior maxillae, and the paranasal areas without advancing the dental-bearing segment. MATERIALS AND METHODS: This procedure was carried out on a 21-year-old male patient who had a deficiency of the anterior maxillae including the infraorbital rims. His occlusion was in Class I molar relation. The surgical exposure was carried out through a midface degloving approach. This bilateral osteotomy encompasses the anterior maxillae and the zygoma; the osteotomy line running superiorly from the medial aspect of the infra-orbital rim to the root of the frontal process of maxilla. Inferiorly, the line runs above the apices of the maxillary teeth laterally underneath the zygomatic buttress, separating part of the zygomaticomaxillary suture posteriorly. Medially, the osteotomy line runs parallel to the piriform aperture. The osteotomy is pedicled on the zygomaticotemporal suture. A greenstick fracture at the zygomatic arch pedicled the osteotomized segment to the zygomatic process of the temporal bone. The entire segment was swung laterally outward, effectively separating part of the zygomaticomaxillary suture posteriorly. Fixation was achieved with a single 2-mm L-shaped, 4-hole plate with gap at the zygomatic buttress region. RESULTS: This osteotomy technique resulted in fullness of the anterior maxillae and infraorbital rims, with increased anterior and lateral projection of the zygoma. CONCLUSION: The zygomaticomaxillary "lateral swing" osteotomy is a reliable and stable technique for total midface augmentation not requiring occlusion correction.

A three dimensional (3D) musculoskeletal finite element analysis of DARSN temporomandibular joint (TMJ) prosthesis for total unilateral alloplastic joint replacement.

PURPOSE: The purpose of this study was to evaluate the strain and stress distribution for DARSN alloplastic unilateral temporomandibular joint (TMJ) prosthesis and the effects on contralateral natural joint using a finite element analysis (FEA). METHODS: The replacement of the TMJ may have complications like infection, failure of hardware, facial paralysis and perforation. The understanding of the mechanical forces exerted by muscles of mastication and jaw movement on the joint helps in identifying the regions on alloplastic TMJ with various maximum forces, which makes that area more prone for failure of hardware. A three dimensional structural FEA was applied using a validated finite element model (FEM) where the areas of stress and strain were evaluated in the alloplastic joint and the contralateral natural joint. As the pattern of stress and strain can be influenced by the materials used for alloplastic joint and geometry of the design, mechanical property of bone and the attached musculature were also considered while construction the FEM analysis. RESULTS: The forces of the muscles of mastication has a vital role on the amount of stress and strain present across the alloplastic joint. Masseter and temporalis exhibited the greatest resultant force on the alloplastic as well as the natural condyle with a magnitude of 272 N and 329 N. This study assessed the maximum stress and strain on the condyle-ramus unit and fossa. CONCLUSION: FEA shows that alloplastic DARSN TMJ prosthesis distributes stress and strain equally between the alloplastic joint site and the contralateral natural joint causing minimal adverse effects to the natural joint. FEA also evaluated the stress and strain on alloplastic component and resulted in drawing clinical implications for operating surgical team.

Partial thickness temporalis rotation for alloplastic temporomandibular joint - how I do it.

With increasing clinical evidence, the replacement of the temporomandibular joint with alloplastic joints is being increasingly accepted in severe degenerative diseases. There remains a risk of infection and a possibility of a failure of not just these prostheses but any alloplastic joint prosthesis post-operatively. Therefore, an extra precaution and additional coverage to the joint using partial thickness myo-temporalis rotation flap could be a useful option to minimize post-operative joint failure.

Reconstruction of a Post Traumatic Anterior Maxillary Defect by Transport Distraction Osteogenesis.

Rehabilitation of segmental defects of maxilla presents a reconstructive challenge to obtain an ideal osseous form and height with adequate soft tissue investment. Though variety of prosthetic and surgical reconstructive options like the use of vascularized and non vascularized bone grafts are available they produce less than optimal results. Bone transport distraction is a reliable procedure in various maxillofacial bony defect reconstruction techniques. We describe herein a technique of maxillary bone transport distraction using an indigenously designed, custom made trifocal transport distractor performed in a post traumatic avulsive defect of the anterior maxilla. Transport distraction was successful for anterior maxillary alveolar bony regeneration, with excellent soft tissue cover and vestibular depth, which also helped close an oroantral/oronasal fistula.

Disc Anchoring with an Orthodontic Mini-Screw for Chronic Meniscocondylar Dislocation of TMJ.

INTRODUCTION: Various surgical modalities have been tried for the correction of chronic recurrent dislocation of the temporomandibular joint. However, most of these techniques are aimed at creating an artificial block or removing any interference in the path of the translating condyle. Chronic dislocation can also be classified as meniscotemporal and menisocondylar, depending upon whether the dislocation occurs between the condyle-disc unit and temporal bone (meniscotemporal), or between the disc and condyle (meniscocondylar). Very few procedures address the primary issue of a malpositioned disc, which is the cause of meniscocondylar dislocation. MATERIALS AND METHODS: This study was conducted on 17 patients (27 joints) who reported with chronic dislocation of the temporomandibular joint, with MRI-proven meniscocondylar dislocation. After exposure of the condyle and disc through a standard pre-auricular incision, an orthodontic mini-screw was fixed to the posterior aspect of the condylar head and a 1-0 Prolene suture passed through the screw-head eyelet, plicating the posterior edge of the disc to the condyle. This ensured that the condyle and disc would move in unison. RESULTS: All the patients showed improvement in their symptoms of dislocation in the postoperative period, including seven patients in whom only a unilateral procedure was carried out. None of the patients had any recurrence till the 1-year followup. CONCLUSION: Our procedure addresses the fundamental etiology of meniscocondylar dislocation by anchoring the disc to the condyle by using an orthodontic mini-implant and correcting the condyle-disc disharmony. This technique is reliable, technically feasible, and cost-effective in the Indian set up.

Total Alloplastic Temporomandibular Joint Reconstruction for Management of TMJ Ankylosis.

INTRODUCTION: Temporomandibular joint (TMJ) ankylosis involves the fusion of the mandibular condyle to the glenoid fossa, the skull base. The dilemma with regards to treatment planning whether distraction is done before gap arthroplasty or as a simultaneous procedure or after gap arthroplasty is still a controversy. In an attempt to carry out both the procedures simultaneously there is loss of vector control of the distal segment and the risk of pseudoarthrosis at the osteotomy site. This combined problem could be overcome by the use of total alloplastic joint prosthesis which offers a firm posterior stop for the proximal segment and negates aggressive physiotherapy. MATERIAL AND METHODS: The reference literatures were retrieved from Pub Med and Science Direct database. Three case reports of bilateral recurrent TMJ ankylosis successfully treated with custom made total TMJ by the authors are illustrated. CONCLUSION: The purpose of this article is to review the world literature on various alloplastic joints available for TMJ reconstruction and to introduce our indigenous total joint prosthesis in the management of recurrent ankylosis.

Bifid hyperplastic mandibular condyle.

Condylar hyperplasia is a rare non-neoplastic pathology associated with overgrowth of the mandibular condyle. Presentation of condylar hyperplasia with bifid mandibular condyle has never been reported in literature. Early management of the hyperplastic disorders of the mandibular condyle can prevent occlusal canting and developing asymmetric deformities. We report a case of 'Bifid Hyperplastic Mandibular Condyle' in a 14-year-old male with emphasis on early surgical intervention. To best of our knowledge, the present case is the first reported case of bifid mandibular condyle with condylar hyperplasia and 66th reported case of bifid mandibular condyle in living human population.

Maxillary cementoblastoma--a rarity.

BACKGROUND: This paper highlights the unusual and rare presentation of a cementoblastoma in the maxilla. It also discusses a review on this odontogenic pathology. CASE REPORT: We present a cementoblastoma appearing in an atypical site in a young girl. The presenting clinical features with radiologic features are reviewed. Also discussed is an approach to radiological interpretation. To the best of our knowledge, this is only the seventeenth case to be reported in literature. DISCUSSION: Cementoblastoma is a benign true neoplasm which forms a mass of cementum or cementum-like tissue on the root surface of the tooth. As a maxillofacial practitioner, it is essential to consider cementoblastoma as one of the differential diagnosis, although rare, while considering maxillary swellings. The treatment remains fairly conservative, with an excellent prognosis.

Bilateral transmigration of mandibular canines: a rare occurrence.

Transmigration is a phenomenon in which an unerupted tooth migrates and crosses the midline. Transmigration of the mandibular permanent canine is a rare phenomenon. We report a case of bilateral transmigrated mandibular canines, which presented as pain in the lower anterior teeth.

Transport distraction osteogenesis for maxillomandibular reconstruction: current concepts and applications.

Reconstruction of the facial skeleton remains a herculean task for a reconstructive surgeon, even with the availability of ample reconstructive options. Transport distraction osteogenesis is a novel reconstructive modality in the armamentarium of a maxillofacial reconstructive surgeon with obvious advantages of osteogenesis and histogenesis from the residual host tissues after tumor ablative surgeries or trauma and also, precludes donor site morbidity. This paper reviews the current concepts, principles involved and applications of transport distraction osteogenesis in maxillomandibular reconstruction.

Orofacial granulomatosis: a clinicopathologic correlation.

Orofacial granulomatosis is an uncommon disorder, but has been increasingly recognized in the past decade. It causes significant morbidity in the patient including oral ulcerations, enlargement of soft tissues which are often persistent and painful. This necessitates early medical intervention. We report one such case of a female patient who presented with a persistent upper lip enlargement. She had visited multiple general dental practitioners and general physicians but was undiagnosed. Ultrasonography proved an adjunctive tool in diagnosis. She was treated with a combination of topical and intra-lesional steroids. A 1-year follow-up did not show any evidence of recurrence.

Comparison of morbidity following the removal of mandibular third molar by lingual split, surgical bur and simplified split bone technique.

BACKGROUND: The methods frequently used for surgical removal of impacted third molars are bur technique, lingual split and simplified split bone technique. The morbidity rates following the use of these different surgical techniques are not completely resolved. The use of a surgical method with minimum postoperative complication is needed. AIM: This study was conducted to compare the morbidity rates of the three different surgical techniques and their efficacy with regard to postoperative pain, swelling, labial and lingual sensation. MATERIALS AND METHODS: Ninety patients with a symptomatic impacted mandibular third molar with the age range of 14-62 years were divided into three groups of 30 patients each for surgical bur technique, lingual split technique and simplified split bone technique. All patients were operated by the same surgeon under local anesthesia (2% lignocaine) in the dental chair. The severity of pain and swelling was recorded on a visual analogue scale and the presence or absence of sensory disturbance at 6, 24, 48 hours and seven days after operation. The pain was scored according to a visual analogue 4-point scale. Patients were asked to indicate which side was more swollen and to record this assessment on the swelling scale. RESULTS: Lingual split technique was more painful than the other two techniques. Surgical bur technique had more swelling than the other two techniques. Labial and lingual sensations were not altered in all the techniques. CONCLUSION: The simplified split bone technique had the least morbidity than the lingual split and surgical bur technique.

Correlation of clinical and MRI findings of tempero-mandibular joint internal derangement.

The most common clinical features of tempero-mandibular joint internal derangement are correlated with the MRI findings of shape of the disc in an attempt to find the etiology of tempero-mandibular joint internal derangement. In this study, the clinical parameters of pain, muscle tenderness, clicking with in the joint (like early, middle and late) are correlated with the MRI findings of disc shapes. (like biconcave, thick, lengthened, folded, adhesion). The study reveals any trauma that leads to muscle tenderness results in internal derangement of tempero-mandibular joint.

Efficacy and safety of the first parenteral selective COX-2 inhibitor, parecoxib sodium, in adult patients with postoperative pain.

Parecoxib, a prodrug of valdecoxib, a selective COX-2 inhibitor, has been recently introduced for the treatment of moderate to severe postoperative pain. This prospective, open, multicentric study enrolled 260 patients undergoing orthopaedic, gynaecological, dental and general surgery. Postoperatively, patients were treated with parecoxib, 40 mg IM/IV. There was a statistically significant decrease in the mean pain intensity score (p<0.05). At the end of 24 hours, 89.6% of total cases had a very good to total relief of pain. The mean duration of analgesia was 19.26 hours and mean time of onset of analgesia was 16.25 minutes ranging from 11-20 minutes. The laboratory values were within normal limits. The drug was well tolerated. There was no report of any hypersensitivity reaction. This study suggests that parecoxib, in a dose of 40 mg IM/IV, is an effective and safe option for the management of postoperative pain.