Outcomes of extra oral versus intraoral approach for Mandibular angle fracture reduction.

OBJECTIVE: To compare the outcomes of intraoral versus extraoral approach in the treatment of mandibular angle fracture. METHODS: The randomised controlled trail was conducted at the Department of Maxillofacial Surgery, Mayo Hospital, Lahore Pakistan, from September 2016 to March 2017, and comprised patients of mandibular angle fracture who were divided into two equal extraoral group A and intraoral group B. . Baseline and post-operative data on 1st and 7th days as well as 3 months following the surgery was collected. Data was analysed using SPSS 20. RESULTS: Of the 100 patients, there were 50(50%) in each of the two groups. Mean age of group A was 32.28±7.79 years compared to 33.72±8.13 years in group B. There were 39 (78%) males in group A and 36(72%) in group B. The mean pain score at baseline in the groups was not significantly different (p=0.795). On the 7th day and 3 months post-operation, mean pain score was significantly lower in group A (p=0.002). Nerve complication in group A was significantly high compared to group A (p=0.005). CONCLUSIONS: Extra oral approach for the management of mandibular angle fracture is better with regards to pain while intra-oral approach is less associated with nerve complications.

Comparison of functional outcome after open and closed reduction of mandibular subcondylar fracture.

OBJECTIVE: To compare open reduction with internal fixation of mandibular subcondylar fracture with closed reduction in terms of adequate mouth opening. METHODOLOGY: The randomised clinical trial was conducted from March 2014 to February 2015 at the Oral and Maxillofacial Surgery Department, King Edward Medical University and Allied Hospitals, Lahore, Pakistan, and comprised patients who presented with unilateral subcondylar fractures. The patients were randomly divided into 2 groups. Group-A patients were treated with closed reduction and immobilisation and were discharged the same day, while Group-B patients were treated by open reduction with internal fixation and retained in ward for 1 day. Both were recalled for periodic follow-ups, and were compared in terms of achieving adequate mouth opening. Data was analysed using SPSS 20. RESULTS: Of the 70 patients, 35(50%) were in each of the two groups. The mean age in Group-A was 28.88±11.86 years compared to 28.22±10.80 years in Group-B (p>0.05). Mean mouth opening in the two groups were consistently positive, and significant at the last two follow ups(p<0.001). CONCLUSIONS: The difference in results of both treatment modalities was significant, indicating that open reduction and internal fixation should be the preferred treatment.

Bedside Ultrasonography: AUseful Tool for Traumatic Pneumothorax.

OBJECTIVE: To compare the diagnostic accuracy of bedside ultrasound and supine chest radiography for the diagnosis of traumatic pneumothorax. STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: PIMS and PAEC General Hospital, Islamabad, from November 2014 to August 2015. METHODOLOGY: Patients coming to emergency departments of the study centres, who had sustained chest injuries, were inducted. Their portable bedside ultrasound and supine chest radiographs were taken for assessing pneumothorax and subsequently CTchest was done for confirmation as gold standard. RESULTS: Based on CTfindings, sensitivity for ultrasonography and chest radiography was found to be 83.33% and 54.76%, respectively and specificity of 100% for both modalities. CONCLUSION: Ultrasound can be used as a useful and suitable adjunct to CTin trauma patients as it is easily available, non-invasive, bedside, easily examined with no radiation risk.

Fibromatosis of infratemporal space.

Fibromatosis is a rare benign mesenchymal neoplasm which primarily originates in the muscle, connective tissue, fascial sheaths, and musculoaponeurotic structures. It is commonly seen as abdominal tumour but in maxillofacial region, the occurrence of these tumours is very rare and exceedingly rare in infratemporal space. Often misdiagnosed due to its varied clinical behaviour, fibromatosis is benign, slow-growing, infiltrative tumour without any metastatic potential, but is locally aggressive causing organ dysfunction along with high recurrence rate. We report a case of fibromatosis involving the left infratemporal space in a 35-year-old female who presented with chief complaint of limited mouth opening for the preceding 4 years.

Role of neurotransmitter Substance P in progression of oral squamous cell carcinoma.

BACKGROUND: Oral squamous cell carcinoma (OSCC) is the most frequent type of head and neck cancers. OBJECTIVES: In the present study, we evaluated the expression and distribution of Substance P (SP) in different grades of OSCC and role of SP in its proliferation and progression. SUBJECTS AND METHODS: Forty OSCC biopsies were immunohistochemically analyzed by using SP antibody, including 29 male and 11 female cases. 35% were well differentiated, 35% moderately differentiated and 30% poorly differentiated OSCC. The majority of patients were in the age range of 41-80 years. 62% of the cases were positive for SP. SP positivity was expressed in the cytoplasm of the tumor cells. Most of the positive cases were from the tongue region. RESULTS: 93% of moderately differentiated, 92% of poorly differentiated and 8% of well-differentiated carcinomas were SP-positive, but SP expression intensity was highest in poorly differentiated cases (+3). More positive patients were males (68.96% of all male patients) with moderately and poorly differentiated OSCC. Among all positive cases, 48% were poorly differentiated, 48% moderately differentiated and 4% well differentiated. CONCLUSION: Strong expression of SP in poorly and moderately differentiated cases suggests a role of SP in the progression and development of tumor. Expression of SP in the current study increased as the proliferation of cells increased. Prevalence of oral cancer in males may be due to the fact that they smoke and use pan, chewing gum, beetle nut etc. in this region. SP antagonists can help in the reduction and inhibition of oral cancer. SP has a diagnostic value with sensitivity of 92.5% and specificity of 93.7%. The positive predictive value is 96.2% and the negative predictive value 88.2%.

Ophthalmic injuries in orbito-zygomatic fractures.

OBJECTIVE: To assess the frequency and severity of ophthalmic injuries in patients with orbito-zygomatic fractures. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: Oral and Maxillofacial Department, KEMU/Mayo Hospital Lahore, from January 2009 to December 2011. METHODOLOGY: Patients with orbito-zygomatic fractures were divided into three groups. Group-1 patients had fracture of floor/medial wall of the orbit (orbital-blow out fracture). Group-2 had comminuted orbito-zygomatic fractures. Group-3 had simple zygomatic bone fractures. Frequency and types of ocular injuries were determined on each group. RESULTS: There were 296 (260 male, 36 female) patients with mean age of 31.7 years. Group-1 (n = 20) had 28 ocular findings in 12 (60%) patients including diplopia (n = 10, 36%), enophthalmos (n = 6, 14%), and hyphema, vitreous hemorrhage, retinal hemorrhage, choroidal rupture, traumatic mydriasis, and commotio retinae in 2 cases, 7% each. In Group-2 (n = 106), 44 ocular findings were identified in 30 (28%) patients including diplopia (n = 10, 23%), enophthalmos (n = 4, 9%), commotio retinae (n = 10, 23%), reduced visual acuity (n = 6, 14%), retinal hemorrhage (n = 4, 9%) and corneal laceration, corneal abrasion, retinal detachment, traumatic mydriasis, and canthal laceration in 2 cases, 4.5%. In Group-3 (n = 170), 22 ocular findings were seen in 16 (9%) patients included diplopia (n = 10, 45%), enophthalmos (n = 4, 18%), and retinal tear, hyphema, angle recession, and traumatic mydriasis in 2 cases, (9%) each. CONCLUSION: Ophthalmic injuries are a common complication of orbitozygomatic fractures occurring in about 20% of patients in this study, most frequent in the orbital blow fractures subgroup. Ophthalmology consultation is recommended for patients presenting with midface fractures.

Management of comminuted but continuous mandible defects after gunshot injuries.

INTRODUCTION: Firearm injuries continue as a major public health problem, contributing significant morbidity, mortality, and expense to our society. There are four main steps in the management of patients with gunshot wounds to the face: securing an airway, controlling haemorrhage, identifying other injuries and definitive repair of the traumatic facial deformities. The objective of this study was to determine late outcome of two treatment options by open reduction and internal fixation versus closed reduction and maxillomandibular fixation (MMF) in the treatment of gunshot injuries of the mandible. METHODS: Sixty patients of gunshot injury were randomly allocated in two groups. In group A, 30 patients were treated by open reduction and internal fixation and in group B, 30 patients were treated by closed reduction and maxillomandibular fixation. Patients were discharged as the treatment completed and recalled for follow up. Up to 3 months after injury, fortnightly complications like infection, malocclusion, malunion of fractured fragments, facial asymmetry, sequestration of bone and exposed plates were evaluated and the differences between two groups were assessed. The follow-up period ranged from 3 months to 10 months. RESULTS: Patients treated by open reduction tended to have less complications as compared to closed reduction. CONCLUSION: Based on this study open reduction and internal fixation is the best available method for the treatment of gunshot mandible fractures without continuity defect.

Reconstructive management of the rare bilateral oral submucos fibrosis using nasolabial flap in comparison with free radial forearm flap--a randomised prospective trial.

BACKGROUND: Oral sub mucous fibrosis is a rare chronic, progressive, pre malignant collagen disorder of oral mucosa in people of Asian descent characterized by trismus, blanching and stiffness of mucosa, burning sensation in mouth and hypomobility of soft palate and tongue with loss of gustatory sensation. Betel nut chewing is the most common etiological agent. Surgery remains the main stay in severe cases and aims at release of fibrotic bands and resurfacing the raw areas with different options. Reconstruction can be done by using nasolabial flap or radial free forearm flap. The purpose of this study was to compare the mouth opening after the reconstruction with either nasolabial flap or radial free forearm flap.METHODS This study was carried out on fifty (50) patients with oral sub mucous fibrosis. Twenty five (25) of these were reconstructed by nasolabial flap and twenty five (25) were reconstructed by radial free forearm flap. At different intervals of their post-operative visits, they were evaluated for the interincisal distance and the difference between the two groups was assessed.RESULTS Average increase in interincisal distance was greater in patients reconstructed with radial free forearm flap compared with patient reconstructed by nasolabial flap i.e. 18.96 mm and 15.16 mm respectively with 'P' value > 0.05.CONCLUSIONS Based on the results of this study, there was no significant difference in mouth opening after reconstruction with radial forearm free flap compared to nasolabial flap [corrected].

Evaluation of postoperative discomfort following third molar surgery using submucosal dexamethasone - a randomized observer blind prospective study.

BACKGROUND: Surgical removal of impacted lower third molar is still the most frequent procedure done by Oral and Maxillofacial surgeons and is often associated with pain, swelling and trismus. These postoperative sequelae can cause distress to the patient as a result of tissue trauma and affect the patient's quality of life after surgery. Use of antiseptic mouthwashes, drains, muscle relaxants, cryotherapy, antibiotics, corticosteroids and physiotherapy seems to decrease postoperative discomfort. Among them corticosteroids are well-known adjuncts to surgery for suppressing tissue mediators of inflammation, thereby reducing transudation of fluids and lessening edema. The rationale of this study is to determine the effectiveness of submucosal injection of dexamethasone in reducing postoperative discomfort after third molar surgery. PATIENTS AND METHODS: 100 patients requiring surgical removal of third molar under local anesthesia were randomly divided into 2 groups, group I receiving 4 mg dexamethasone as submucosal injection and the control group II received no steroid administration. Facial swelling was quantified by anatomical facial landmarks. Furthermore, pain and patient satisfaction, as well as neurological score and the degree of mouth opening were observed from each patient. RESULTS: Patients receiving dexamethasone showed significant reduction in pain, swelling, trismus, a tendency to less neurological complaints and improved quality of life compared with the control group. CONCLUSIONS: Submucosal injection of dexamethasone is more efficient to manage postoperative discomfort after removal of third molars compared to no steroid administration.

Assessment of cervical lymph node metastasis for therapeutic decision-making in squamous cell carcinoma of buccal mucosa: a prospective clinical analysis.

BACKGROUND: Cervical metastasis has a tremendous impact on the prognosis in patients with carcinomas of the head and neck and the frequency of such spread is greater than 20% for most squamous cell carcinomas. With emerging evidence, focus is shifting to conservative neck procedures aimed at achieving good shoulder function without compromising oncologic safety. The purpose of this study was to analyze the pattern of nodal metastasis in patients presenting with squamous cell carcinoma of buccal mucosa. MATERIALS AND METHODS: This was a prospective clinical analysis of patients who were histologically diagnosed with squamous cell carcinoma of the buccal cavity and clinically N1 and had not received treatment anywhere else. Patients were analyzed for age and sex distribution, tumor staging, location, and metastasis. RESULTS: The incidence of metastatic lymph node in T4 (n=44) was the highest, that is, level I was 100% (44/44), level II was 43.18% (19/44), level III was 15.90% (7/44), and level IV was 4.5% (2/44). Level V was free of metastasis. Among T3 (n=10) lesions, incidence of metastasis in level I was 100% (10/10), level II was 20% (2/10), and level III, IV, and V were free of metastasis. Among T2 (n=6) lesions, incidence of lymph node metastasis in level I was 100% (6/6) and all other levels of lymph nodes were found free of metastasis. CONCLUSION: Lymphatic spread from carcinoma of the buccal mucosa is low. Involvement of level IV is seen in only 3% of patients. A more conservative approach to the neck in patients with carcinoma of the buccal mucosa is recommended.

Surgical treatment of zygomatic bone fracture using two points fixation versus three point fixation--a randomised prospective clinical trial.

BACKGROUND: The zygoma plays an important role in the facial contour for both cosmetic and functional reasons; therefore zygomatic bone injuries should be properly diagnosed and adequately treated. Comparison of various surgical approaches and their complications can only be done objectively using outcome measurements which in turn require protocol management and long-term follow up. The preference for open reduction and internal fixation of zygomatic fractures at three points has continued to grow in response to observations of inadequate results from two point and one point fixation techniques.The objectives of this study were to compare the efficacy of zygomatic bone after treatment with ORIF using 2 point fixation and ORIF using 3 point fixation and compare the outcome of two procedures. METHODS: 100 patients were randomly divided equally into two groups. In group A, 50 patients were treated by ORIF using two point fixation by miniplates and in group B, 50 patients were treated by ORIF using three point fixation by miniplates. They were evaluated for their complications during and after surgery with their advantages and disadvantages and the difference between the two groups was observed. RESULTS: A total of 100 fractures were sustained. We found that postoperative complication like decreased malar height and vertical dystopia was more common in those patients who were treated by two point fixation than those who were treated with three point fixation. CONCLUSIONS: Based on this study open reduction and internal fixation using three point fixation by miniplates is the best available method for the treatment zygomatic bone fractures.

Modern surgical management of tongue carcinoma - a clinical retrospective research over a 12 years period.

OBJECTIVES: In this retrospective study, we present a clinical review of our experience with tongue cancer in order to obtain valid criteria for therapeutic decision-making. MATERIALS AND METHODS: Between August 1999 and June 2011, a total of 398 patients with squamous cell carcinoma of the tongue were treated at the Department of Oral and Maxillofacial Surgery, King Edward Medical University Lahore Pakistan. Data concerning patient characteristics, clinical and pathologic tumour characteristics and treatment strategies and their results were obtained from a retrospective review of medical records. The average follow-up was 4.6 years. Statistical analysis for survival was calculated by the method of Kaplan and Meier. RESULTS: There were 398 total patients. The mean age at diagnosis was 49.5 years,. 224 (56.3%) were male and 174 (43.7%) female (male/female ratio = 1.3:1).332/398 patients received surgical treatment, whereas 66 patients were excluded from surgical treatment and received primary radio (chemo) therapy after biopsy. Tongue carcinoma patients treated by non surgical treatment modalities had 5 years survival rate of 45.5% and patients with surgical intervention had survival rate of 96.1%. CONCLUSIONS: We recommend categorical bilateral neck dissection in order to reliably remove occult lymph node metastases. Adjuvant treatment modalities should be applied more frequently in controlled clinical trials and should generally be implemented in cases with unclear margins and lymphatic spread. CLINICAL RELEVANCE: This study provides modern treatment strategies for the tongue carcinoma.

Reconstruction of mandibular defects - clinical retrospective research over a 10-year period -.

BACKGROUND: Functional and cosmetic defects in the maxillofacial region are caused by various ailments and these defects are addressed according to their need. Simplicity of procedure, intact facial function and esthetic outcome with the least possible donor site morbidity are the minimum requirements of a good reconstruction. Oro-mandibular 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. Reconstruction of trauma- or mandibular oncologic defects with bony free flaps is considered the gold standard. However the the optimal reconstruction of mandibular defects is still controversial in regards to reconstructive options which include the donor site selection and the timing of surgery. The purpose of this study was to determine the outcome of different osseous reconstruction options using autogenous bone grafts for mandibular reconstructions. METHODS: This study was carried out on 178 patients with mandibular bone defects. They were reconstructed with autogenous bone grafts from different donor sites. At post operative visits they were evaluated for functional and cosmetic results. RESULTS: The success rate found in this study was around 90%. Only 7.6% of the cases showed poor results regarding facial contours and mouth opening. All other patients were satisfied with their cosmesis and mouth opening at the recipient sites was in the normal range during last follow-up visits. Donor sites were primarily closed in all cases and there was no hypertrophic scar. CONCLUSION: Based on this study, autogenous bone grafts are a reliable treatment modality for the reconstruction of mandibular bone defects with predictable aesthetic and functional outcomes. As the free vascularized fibular flap has the least resorption and failure rate, it should be the first choice for most cases of mandiblular reconstruction.

Cervical lymph node metastases in squamous cell carcinoma of tongue and floor of mouth.

Oral squamous cell carcinoma has high chances of cervical lymph node metastasis. This case series describes the distribution of cervical lymph nodes in 50 cases of squamous cell carcinoma of tongue and floor of mouth. The mean age was 47.28±10.5 years. Thirty positive metastatic lymph nodes were found; 90% occurring at level I-II mostly in T4 size but also in T1 and T2 cases. The distribution of involved lymph nodes in oral cancer affects the neck dissection extent and is, therefore, an important pre-operative feature.

Reconstruction of mandibular defects with autogenous bone grafts: a review of 30 cases.

BACKGROUND: Multitudes of options are available for reconstruction of functional and cosmetic defects of the mandible, caused by various ailments. At the present time, autogenous bone grafting is the gold standard by which all other techniques of reconstruction of the mandible can be judged. The purpose of this study was to evaluate the outcome of different osseous reconstruction options using autogenous bone grafts for mandibular reconstruction. METHODS: This Interventional study was conducted at Department of Oral and Maxillofacial Surgery, King Edward Medical University/Mayo Hospital Lahore, from January 2008 to July 2009 including one year follow-up. The study was carried out on thirty patients having bony mandibular defects. They were reconstructed with the autogenous bone grafts from different graft donor sites. On post-operative visits they were evaluated for outcome variables. RESULTS: Success rate of autogenous bone grafts in this study was 90%. Only 10% of the cases showed poor results regarding infection, resorption and graft failure. CONCLUSION: Autogenous bone grafts, non-vascularised or vascularised, are a reliable treatment modality for the reconstruction of the bony mandibular defects with predictable functional and aesthetic outcome.

Reconstruction of mandible by free fibular flap.

OBJECTIVE: To determine the results of using the free vascularized fibular flap for comprehensive reconstruction of postresection or post-traumatic mandibular defects. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Oral and Maxillofacial Surgery, King Edward Medical University, Lahore, from March 2007 to June 2009. METHODOLOGY: The study group consisted of patients who underwent reconstruction of continuity defects of the mandible using a fibular vascularized free flap. Indication for mandibular resection were squamous cell carcinoma of the floor of the mouth and alveolar ridge in 5 cases, ameloblastome of the mandible in 6 cases, odontogenic keratocyst in 3 cases, defect due to fire arm injury in 2 cases and central giant cell granuloma of the mandible in one case. The type of reconstruction performed was primary reconstruction in 11 patients and secondary in 6 patients. RESULTS: There were 17 patients including 14 males and 3 females with mean age of 40 years. All flaps except three survived. One patient died due to complications related to blood transfusion. Of those, 2 completely failed, one due to the unfavourable recipient bed of the patient with fire arm injury and other due to venous thrombosis. Donor site morbidity was low; there was some compromise in the ankle function but none of the patient complaint of foot drop. Simple problems with wound healing such as dehiscence and delayed wound healing developed in 5 patients, which usually required only local antiseptic treatment. After the operation patient began oral feeding and walking with some aid in fourth week and became completely ambulant in 8 weeks. CONCLUSION: In this small series the free fibula flap was a versatile and reliable option for microvascular reconstruction of large mandibular defects. It provided a large quantity of bone, which could be easily shaped and passively adapt to the remaining mandible and for an implant-based prosthetic restoration.