Donor Site Morbidity in Patients Undergoing Maxillofacial Reconstruction Using Free Fibula Flap Versus Deep Circumflex Artery Flap-A Systematic Review.

Introduction: A systematic review of the literature on the donor site morbidity in patients undergoing Maxillofacial reconstruction was performed. The two widely used flaps namely free fibula flap (FFF) and DCIA flap were compared to answer the following questions: (1) Is donor site morbidity significantly different in patients undergoing maxillofacial reconstruction with FFF and DCIA flap? (2) Should donor site morbidity be considered as the criteria for choosing the flap for reconstruction. Materials and methods: The search strategy was based on PRISMA guidelines. Various electronic databases were searched. On reviewing the seven articles included in our systematic review, we found out oral squamous cell carcinoma to be the most common pathology leading to the defects in head and neck region requiring reconstruction with free flaps. Results: A total of 531 participants were investigated who underwent maxillofacial reconstruction using FFF and DCIA flap. The study included both the genders. The participants were assessed for short- and long-term donor site morbidity after the microvascular surgery. Mean age is 45-60 years. Three out of seven studies showed DCIA to have lesser complications at donor site than fibula group. While other two studies proved FFF to be better than DCIA. One study proved low donor site morbidity with regard to both the flap. Conclusion: The free fibula being the flap of choice in head and neck reconstruction has a comparable donor site morbidity to DCIA. The advantages of the iliac artery flap include natural curvature, abundant vertical and horizontal bone height for bone contouring and osseointegration, hidden scar, low incidence of wound healing problems and minimal effect on function and quality of life at long-term follow-up. Thus, it makes it the free flap of choice that one cannot avoid. This systematic review was registered at PROSPERO (CRD42021268949).

Unveiling rarity: Myoepithelioma in the minor salivary gland of buccal mucosa - A case report.

INTRODUCTION: Tumours of salivary glands are rare and have various histo-pathological subtypes. Myoepitheliomas were first classified by Sheldon et al. and the criterion to classify or diagnose it was first defined by Barnes et al. and Sciubba and Brannon. Myoepithelioma accounts for less than 1 % of all salivary gland tumours, 40 % of these tumours occur in the parotid gland while 21 % occur in the minor salivary glands. A case of myoepithelioma of a minor salivary gland of the cheek is described, emphasizing the problems of the differential diagnosis. PRESENTATION OF THE CASE: A 40-year-old female reported to the department with a complaint of a cheek bite on her right side for a few months. The physical examination showed a presence of lobulated whitish mucosa on the right buccal mucosa at the level of the occlusal plane, on palpation it revealed a non-painful mass approximately 1.5 cm in radius, mobile to bimanual palpation. An excisional biopsy was performed under local anaesthesia. Microscopic and immunohistochemistry confirmed the tumour to be a myoepithelioma of a minor salivary gland with the absence of definitive features of malignancy. DISCUSSION: Due to their infrequency and multiplicity of histopathology, myoepitheliomas present difficulties in diagnosis. Cellular varieties can be misdiagnosed as malignancies. A key to determining diagnostic criteria for myoepitheliomas is to study cellular morphology, cytoplasmic filament expression, and ultrastructural features of the tumour and apply this information to defining myoepitheliomas. CONCLUSION: Myoepitheliomas are rare tumours, utilization of immunohistochemical staining and electron microscopy are useful tools for the diagnosis of myoepitheliomas to ensure proper treatment and follow-up.

Comparative evaluation of use of reciprocating saw and bur in Le fort I osteotomy for superior repositioning of maxilla: A cross-sectional study.

Background: Traditionally bur has been used to carry out osteotomy. In a developing country like India, the cost of surgical treatment is the important factor in determining treatment plan. Although the use of bur is cost-effective and efficient, with the advent of newer technology, it is getting replaced with a saw. Aim: To evaluate and compare the use of reciprocating saw and bur in Le Fort I Osteotomy for superior repositioning of the maxilla. Materials and Methods: Patients referred from the Department of Orthodontics for the surgical correction of vertical maxillary excess (VME). They were divided into two groups. In group I, osteotomy was performed with Synthes Reciprocating Saw and in group II, bur was used. The parameters recorded in both the groups were time required for the completion of down-fracture, precision of the osteotomy cut (margins of the cut), and ease of superior repositioning. Data was collected from both the groups for comparison. Results: A total of 14 patients with VME were included in the study. They were divided into two groups. Seven study participants were allotted to each group. In group I, Synthes Reciprocating Saw was used while in group II, a bur was used to carry out the osteotomy cut. In group I, the average time required to complete the down-fracture of the maxilla was 3.5-4 min while in group II it was more than 8 min. The margins of the osteotomy cut were smooth and regular and there was bone-to-bone contact during superior repositioning in Group I. Conclusion: The combination of the use of a saw for inferior osteotomy and a bur for the superior cut would be more beneficial in the superior repositioning of the maxilla.

Autogenous bone chip interspersed in PRF and PRP as an augmentative bio material in autogenous tooth transplant - A case report.

INTRODUCTION: Autotransplantation technique involves extraction of tooth from the recipient site and donor tooth without damage, placing and stabilizing donor tooth within same individual. The use of autogenous bone combined with platelet rich fibrin (PRF) and platelet rich plasma (PRP) seems to be favorable to achieve stable alveolar bone. Thus we provide an innovative adjuvant method for enhancing bone formation using PRF and inter-radicular bone with PRP as autogenous graft. PRESENTATION OF CASE: A 26 year old healthy female individual reported university teaching hospital to outpatient department of oral and maxillofacial surgery, with complain of decayed tooth. On clinical and radiographic examination it was diagnosed was chronic irreversible pulpitis with to left maxillary first molar. Looking at clinical profile, age and health status an autogenous tooth transplant was advised. DISCUSSION: Periodontal ligament, interradicular bone autografts, PRF and PRP has potential to induce formation of alveolar bone and is recommended in cases of atrophy of alveolar process. CONCLUSION: The solution mentioned can be hypothesized to improve - quantity and quality of bone formed, reduce the chances of ankylosis of the tooth, bone loss, sinus perforation.

Various Treatment Modalities in COVID-19 Associated Facial Mucormycosis and the Need for its Surgical Management: A Systematic Review.

Introduction: Mucormycosis emerged as a wildfire in post-covid-19 infected patients. Most frequently involved sites of mucormycosis are rhino-orbital, rhino-sinusal and rhino-orbito-cerebral. The hallmark sign of mucormycosis is tissue necrosis, which is often a late sign. The fatality rate of mucormycosis is 46% globally. Despite early aggressive combined surgical and medical therapy, the prognosis of mucormycosis is poor. Methods: We searched the electronic database of PubMed, web of science, Embase, Scopus and Google Scholar from Jan 2020 until December 2021 using keywords. We retrieved all the granular details of original research articles, case reports/series of patients with rhino-orbito-cerebral mucormycosis (ROCM), and COVID-19 reported worldwide. Subsequently, we analyzed the patient characteristics, associated comorbidities, location of mucormycosis, treatment given and its outcome in people with COVID-19. (Prospero registration-CRD42021256830, June 4, 2021). Results: Overall, 544 rhino-orbito-cerebral mucormycosis patients were included in our review with a history of Covid-19 infection. Out of which 410 patients had diabetes mellitus which has proven to be major contributing immunocompromised disease. Other diseases like hypertension, chronic kidney diseases, hypothyroidism, etc., were also attributed as an immunocompromised disease causing increased number of covid associated mucormycosis cases. We found out that total number of patients alive after taking only antifungal drug treatment were 25 in number, whereas total number of patients alive when antifungal drugs were combined with surgical intervention were 428 which was significantly higher. Conclusion: Our systematic review concluded that surgical debridement should be performed whenever feasible in parallel to antifungal treatment in order to reduce the mortality rate of COVID-19 associated rhino-orbito-cerebral mucormycosis patients.

Role of distraction osteogenesis and flip genioplasty to correct sleep apnea and aesthetics in long standing TMJ ankylosis - A case report.

INTRODUCTION AND IMPORTANCE: Temporomandibular joint (TMJ) ankylosis triad includes TMJ ankylosis, micrognathia, and obstructive sleep apnea (OSA) which is common in long-standing cases of TMJ ankylosis. Unilateral long-standing cases of TMJ ankylosis also result in a severe discrepancy in the midline of the chin. CASE PRESENTATION: A young adult female presented with restricted mouth opening and daylight sleepiness. Her AHI was mild and there was excessive facial disfigurement. Right-side TMJ ankylosis was diagnosed with compromised posterior airway space and Ramal height was also short on the affected side. Chin has severely deviated to the affected side. CLINICAL DISCUSSION: Treatment protocols for TMJ ankylosis are different for different case scenarios. A proper protocol derivation is a must looking into the clinical and radiographical examination of the patient. As mentioned in previous literature, anti-Kaban's protocol has been shown to provide good results. A genioplasty improves the chin midline deviation. CONCLUSION: A careful assessment and a proper treatment plan should be selected for the management and early relief of the symptoms of the patient. Thorough knowledge and update should be available to the operating surgeon to choose the correct treatment plan for the management of a triad patient.

Comparative evaluation of salivary alpha amylase level for assessment of stress during third molar surgery with and without piano music and co-relation with pain catastrophizing scale: an in vivo study.

OBJECTIVES: Preoperative nervousness and anxiety are frequently encountered by individuals who undergo extractions of impacted wisdom teeth. The aim of the present study is to evaluate salivary alpha amylase (sAA) level in patients for assessment of stress during third molar surgery while listening to piano music and to determine its co-relation with pain catastrophizing scale (PCS). MATERIALS AND METHODS: Seven patients (four males and three females) indicated for surgical extraction of bilaterally impacted mandibular third molars were included. Pre-surgical patient assessments were completed, and three samples of saliva were collected during surgery-one at baseline, one 30 minutes after commencement of surgery, and one after suturing. Assessment was performed on both sides separately with and without piano music, and the samples were assessed for sAA level and correlated with the patient's self-reported PCS. RESULTS: Statistically significant results were obtained in patients who underwent surgical extraction while listening to piano music (P=0.046). The correlation of sAA level with PCS was not significant. CONCLUSION: Music demonstrated a beneficial effect on lowering the levels of stress and anxiety that a patient exhibits during any surgical procedure, and sAA can be a useful biomarker for similar assessments.

Evaluation of Presurgical Serum Cortisol Level in Patients Undergoing Major Maxillofacial Surgery.

BACKGROUND: Stress is an integral part of life. Anxiety levels may increase when it comes to being treated surgically due to road traffic accidents causing facial trauma, other pathologies or burns. The stress that is caused during a surgical procedure as well as during the treatment in debilitated patients or traumatic conditions is bound to cause disturbance in the metabolic and physiologic levels of cortisol. Therefore, a study was carried out to determine the cortisol levels just prior to surgery on the day of operation to quantify the stress levels and also aid in any preanesthetic medication changes for the patient undergoing maxillofacial surgery. AIM: To evaluate and compare pre-surgical serum cortisol levels in patients undergoing major maxillofacial surgery under general anaesthesia. OBJECTIVE: To evaluate the serum cortisol level of patient 3 days prior to surgery, on the day of surgery and to compare and evaluate the difference seen in both the obtained values. METHODS: A prospective, randomized, in- vivo study was carried out in the Department of Oral and Maxillofacial Surgery at a teaching dental hospital. A total of 32 patients were included in this study. Inclusion and Exculsion criteria was made along with pre-opertive assessment of the patient, informed consent was obtained from all patients involved in the study. Patient blood sample, at 8 am three days prior to surgery and on the day of surgery and sent for laboratory investigations. RESULT: Participants in this clinical study underwent treatment of various ailments like facial trauma, and miscellaneous pathologies like Dentigerous Cyst, Oral submucosa fibrosis, Osteomyelitis, Benign Tumor and Orthognathic surgery. The anxiety of the patients were assessed by serum cortisol level preoperatively and on the day of operation. A total of 32 patients, 26 male and 06 female were included in the study. There was statistically highly significant difference seen between the mean values obtained three days prior to surgery and on the day of surgery. CONCLUSION: We have concluded from this study that the serum cortisol level shows significant increase on the day of surgery. A future study can focus on association between increased levels of serum cortisol and postoperative wound healing where patients can be divided into two groups one receiving pre-operative stress reduction protocol and other not receiving the same.

The use of Velscope to assess cellular changes occuring in oral premalignancy.

OBJECTIVES: To improve visualization of suspicious lesions of the oral mucosa and to assess the accuracy of Velscope in assessing cellular changes occurring in oral premalignancy for early diagnosis. MATERIALS AND METHODS: In this prospective, randomized in-vivo clinical study a total of 250 patients who gave history of chewing tobacco were screened. The selection of the site of biopsy was taken based on the area of loss of fluorescence identified by the Velscope within the lesion. Routine blood investigations were done. A biopsy was performed to confirm the findings of clinical examination. The data was collected and analysed. RESULTS: Among 200 patients only 110 underwent incisional biopsy. Of these only 89 patients showed neoplastic changes. Of the control biopsies, none of them showed any dysplastic changes. Out of 106 who exhibited speckling under autofluorescence, only 89 showed dysplastic changes whereas only 17 showed no dysplastic changes. Out of these 17 specimens, the histopathological diagnosis of 5 was coated tongue, 3 were pigmented lesions, 3 were geographic tongue and 2 were mucositis. Of the remaining 4, the histopathological diagnosis of 1 was oral submucous fibrosis, 1 was lichen planus and 2 were frictional keratosis. CONCLUSION: False positive findings are possible in presence of highly inflamed tissues, and it is possible that use of Velscope alone may result in failure to detect regions of dysplasia, but it has its use definitely to improve clinical decision making about the nature of oral lesions and aids in decisions to biopsy regions of concern. Use of the scope has allowed practitioners to identify the best region for biopsy. It is much better to occasionally sample tissue that turns out to be benign than to fail to diagnose dysplastic or malignant lesions. However, poor specificity is a major limitation for using it as a screening tool.

Comparing intra-oral wound healing after alveoloplasty using silk sutures and n-butyl-2-cyanoacrylate.

OBJECTIVES: The need for proper wound closure is of paramount importance after any intra-oral surgery. Various wound closure techniques have been described in literature using traditional non-absorbable suture materials. These include like synthetic absorbable sutures, surgical staples and tissue adhesives. Cyanoacrylates are among the most commonly used biocompatible tissue adhesives. To evaluate and compare intraoral wound healing using 3-0 silk sutures and n-butyl-2-cyanoacrylate after alveoloplasty. MATERIALS AND METHODS: A total of 20 patients requiring bilateral alveoloplasty in the same arch (upper or lower) were included in this study. Patients with any pre-existing pathology or systemic disease were excluded. After alveoloplasty was performed, the wound was closed using 3-0 braided silk sutures on one side, and using n-butyl-2-cyanoacrylate bio adhesive on the other side. Patients were evaluated based on the following parameters: time required to achieve wound closure; the incidence of immediate and postoperative hemostasis; the time to the use of the first rescue medication; the side where pain first arises; and the side where wound healing begins first. RESULTS: Compared to 3-0 silk sutures, cyanoacrylate demonstrated better hemostatic properties, reduced operative time, reduced postoperative pain and better wound healing. CONCLUSION: These data suggest that cyanoacrylate glue is an adequate alternative to conventional sutures to close the surgical wound after alveoloplasty, and better than are 3-0 silk sutures.

Comparison of minimally invasive versus conventional open harvesting technique for iliac bone graft in secondary alveolar bone grafting in cleft palate patients: a systematic review.

This study evaluated and compared the donor site morbidity following minimally invasive and conventional open harvesting of iliac bone for secondary alveolar bone grafting in cleft palate patients. A thorough electronic search of PubMed, Google Scholar, EMBASE, and an institutional library and manual search of various journals was done; Inclusion criteria: 1) full-text articles using a minimally invasive or conventional open harvesting technique for iliac bone for secondary alveolar grafting in cleft palate patients and 2) articles published between January 1, 2001 and June 30, 2017 and Exclusion criteria: 1) articles published in languages other than English, 2) case reports, case series, animal studies, in vitro studies, and letters to the editor, and 3) full-text article unavailable even after writing to the authors. Preliminary screening of 274 studies excluded 223 studies for not meeting the eligibility criteria. Of the remaining 51 studies, 19 were removed for being duplicates. Of the remaining 32 studies, 15 were excluded after reading the abstract. Of the 17 studies that were left, 2 were excluded because they were in a language other than English, and 2 were excluded because the study group did not mention cleft palate patients. Thus, 13 studies providing results for a total of 654 patients were included in this qualitative synthesis. Minimally invasive bone graft harvest techniques are better than the conventional open iliac bone harvest method because they offer shorter operative time, decreased requirement for pain medications, less pain on discharge, and a shorter hospital stay.

An in vivo study comparing efficacy of 0.25% and 0.5% bupivacaine in infraorbital nerve block for postoperative analgesia.

BACKGROUND: Pain is an unpleasant sensation ranging from mild localized discomfort to agony and is one of the most commonly experienced symptoms in oral surgery. Usually, local anesthetic agents and analgesics are used for pain control in oral surgical procedures. Local anesthetic agents including lignocaine and bupivacaine are routinely used in varying concentrations. The present study was designed to evaluate and compare the efficacy of 0.25% and 0.5% bupivacaine for postoperative analgesia in infraorbital nerve block. METHODS: Forty-one patients undergoing bilateral maxillary orthodontic extraction received 0.5% bupivacaine (n = 41) on one side and 0.25% bupivacaine (n = 41) on the other side at an interval of 7 d. The parameters evaluated for both the bupivacaine concentrations were onset of action, pain during procedure (visual analog scale score [VAS]), and duration of action. The results were noted, tabulated, and analyzed using the Wilcoxon signed rank test. RESULTS: The onset of action of 0.5% bupivacaine was quicker than that of 0.25% bupivacaine, but the difference was not statistically significant (P = 0.306). No significant difference was found between the solutions for VAS scores (P = 0.221) scores and duration of action (P = 0.662). CONCLUSION: There was no significant difference between 0.25% bupivacaine and 0.5% bupivacaine in terms of onset of action, pain during procedure, and duration of action. The use of 0.25% bupivacaine is recommended.

Effect of Formalin Fixation on Surgical Margins in Patients With Oral Squamous Cell Carcinoma.

PURPOSE: Formalin fixation causes shrinkage of surgical margins, which can result in the underestimation of tumor-free margins. The purpose of this study was to show the effect of formalin fixation on surgical margins. Another aim of this study was to evaluate surgical margin shrinkage after fixation of oral squamous cell carcinoma (OSCC) specimens of the gingivobuccal sulcus (GBS). MATERIALS AND METHODS: This was a cross-sectional study. The study sample consisted of OSCC specimens of the GBS after composite resection. The primary predictor variable was the length of the linear margin at various locations (anterior, posterior, medial, and lateral). The primary outcome variable was the percentage of change in each respective margin (anterior, posterior, medial, and lateral) after fixation in 10% formalin for 24 hours. Other variables were age, gender, use of smokeless tobacco, smoking status, and tumor staging. The difference between pre-fixation and post-fixation data was calculated using paired t test. RESULTS: The sample consisted of 15 patients (7 men and 8 women; age range, 55 to 65 yr) diagnosed with OSCC of the GBS. Shrinkage of surgical margins (decrease) occurred after fixation compared with margins before fixation. The average surgical margin shrinkages were 18.7% anteriorly, 14.9% posteriorly, 23.6% medially, and 23.9% laterally. This shrinkage was statistically significant (P < .001). CONCLUSION: Formalin fixation causes considerable shrinkage of surgical margins. This phenomenon should be considered by the pathologist before providing the final histopathology report.

Comparative Evaluation of Immediate Post-Operative Sequelae after Surgical Removal of Impacted Mandibular Third Molar with or without Tube Drain - Split-Mouth Study.

INTRODUCTION: Third molar surgery is one of the most common surgical procedures performed in general dentistry. Post-operative variables such as pain, swelling and trismus are major concerns after impacted mandibular third molar surgery. Use of passive tube drain is supposed to help reduce these immediate post-operative sequelae. The current study was designed to compare the effect of tube drain on immediate post-operative sequelae following impacted mandibular third molar surgery. AIM: To compare the post-operative sequelae after surgical removal of impacted mandibular third molar surgery with or without tube drain. MATERIALS AND METHODS: Thirty patients with bilateral impacted mandibular third molars were divided into two groups: Test (with tube drain) and control (without tube drain) group. In the test group, a tube drain was inserted through the releasing incision, and kept in place for three days. The control group was left without a tube drain. The post-operative variables like, pain, swelling, and trismus were calculated after 24 hours, 72 hours, 7 days, and 15 days in both the groups and analyzed statistically using chi-square and t-test analysis. RESULTS: The test group showed lesser swelling as compared to control group, with the swelling variable showing statistically significant difference at post-operative day 3 and 7 (p≤ 0.05) in both groups. There were no statistically significant differences in pain and trismus variables in both the groups. CONCLUSION: The use of tube drain helps to control swelling following impacted mandibular third molar surgery. However, it does not have much effect on pain or trismus.

Applications of coronoid process as a bone graft in maxillofacial surgery.

The coronoid process can be easily harvested as a donor bone by an intraoral approach during many maxillofacial surgery procedures. The purpose of this study was to evaluate the utility of autogenous coronoid process bone grafts for maxillofacial reconstructive surgery. Twelve patients, who underwent coronoid process grafts for reconstruction of maxillofacial deformities due to trauma, alveolar atrophy, or temporomandibular joint ankylosis, were included in the study. There were 3 orbital defects after extended maxillectomy, 1 blowout fracture of the orbit, 2 cases of reconstruction after temporomandibular joint ankylosis surgery, 1 case of additional chin augmentation following horizontal flip genioplasty, 1 defect of anterior wall of maxilla due to trauma, 2 mandibular defects, and 2 cases of bone augmentation for implants.We recommend the use of coronoid process of the mandible as a source for autogenous bone graft as it can provide sufficient bone in quantity and quality for selected maxillofacial reconstructions.