Comprehensive Management of Pediatric Orbital Fractures: A Case Series and Review of Literature.

Orbital fractures in the pediatric population are rare. A trapdoor fracture is a special anatomic type of orbital fracture associated with herniation of orbital contents and entrapment of extraocular muscles entrapment with no signs of any soft tissue trauma. A delay in diagnosis can lead to a life-threatening condition known as oculocardiac reflex, characterized by nausea, vomiting, bradycardia, and syncope. Many authors recommend early surgical intervention, but some patients may delay for various reasons. We hereby represent three cases of orbital fracture to prevent long-term persistent diplopia. Depending on the case scenario, two cases were operated on in which an autogenous iliac cortical graft was placed in one patient to prevent postoperative herniation of orbital content, and in one patient, only release of entrapped muscles was done. One patient was managed conservatively with a regular follow-up visit.

Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India.

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Super-selective Embolisation and Surgical Excision of the Facial Arteriovenous Malformation.

Vascular anomalies broadly include vascular tumours and malformations. Arteriovenous malformations (AVM), though rare in the oral and maxillofacial regions, can present with swelling, facial asymmetry, ulceration, and bleeding tendencies, which can be life-threatening. Thus, to minimise the associated life-threatening consequences, prompt and appropriate diagnosis of the lesion is necessitated. The management of the AVM is a therapeutic challenge for maxillofacial surgeons; however, technological advances in interventional radiology have gained a foothold. Super-selective embolisation of the feeder vessels with subsequent resection of the lesion is the most widely accepted approach for management. The present report describes a unique case of a facial AVM managed through a trans-oral approach without any post-operative sequelae.

Comparison of Surgical Decompression and Steroid Therapy for the Management of Traumatic Optic Neuropathy: A Systematic Review and Meta-Analysis.

Study Design: A systematic review and meta-analysis. Objective: Treatment of traumatic optic neuropathy (TON) has been a subject of debate for many decades due to the scarcity of evidence-based treatment protocols. This review compares surgical decompression (SD) and steroid therapy (ST) as treatment approaches in TON patients. Methods: A PRISMA-guided systematic review using PubMed, Embase, Ovid and Scopus databases was performed till the last search date of July 31st 2021. The outcome of interest was an improvement in visual acuity. A meta-analysis of the odds ratio was performed using a random-effect model and sub-group analysis based upon criteria for assessment of improvement in visual acuity. Results: Sixteen studies (including 1046 patients) were included in the review. The review could identify 590 patients treated with SD and 456 treated with ST. In addition, there was a second cohort of patients presenting with NLP (no light perception). A meta-analysis with a sub-group analysis revealed that there was statistically no significant difference between the two treatment approaches in terms of improvement in VA. Conclusions: There is no difference in treatment results of SD or ST for TON. Several treatment protocols and different criteria for assessing visual acuity led to difficulty in generating evidence for selecting the correct treatment approach.

Lobular Capillary Hemangioma Masquerading as Pyogenic Granuloma of Anterior Mandible: A Case Report.

Pyogenic granuloma (PG) is a reactive connective tissue disorder with female predilection, which exhibits a tumor-like mass with occasional bleeding and superficial ulceration. It most commonly occurs in the maxillary gingiva followed by the mandibular gingiva. It can also occur in extra gingival sites like buccal mucosa, labial mucosa, and palate. There are two histopathological types of PG, namely, a lobular capillary hemangioma (LCH) variant and a non-LCH variant. The various management methods include surgical resection or laser excision along with deep curettage, and there are various nonsurgical methods like local steroid injection, topical administration of various drugs, and sclerotherapy. During the surgical excision, there is a risk of bleeding, and the surgeon should be equipped for the same. The PG (both LCH and non-LCH variant) has an increased chance of recurrence because of which complete excision is mandatory along with the removal of the local irritants. In this case report, a 28-year-old female patient reported recurrent painless swelling in the lower front gums for the past nine months. The surgical excision was done in-toto along with the removal of local irritants (calculus). The swelling was sent for histopathological examination. The patient was kept on regular follow-ups. The patient was followed up continuously for nine months. The swelling did not recur after the excision. Hence, it was concluded that complete excision and removal of local irritants are extremely crucial to prevent a recurrence.

Serum levels of various vitamins in periodontal health and disease- a cross sectional study.

Objectives: Vitamins are micronutrients that are required in small or trace amounts. They play an essential role in the metabolism and maintenance of tissue function. This investigation aimed to assess if a deficiency of certain essential vitamins is a risk factor for developing periodontitis. Methods: The subject population consisted of 100 subjects, 50 with generalized chronic periodontitis and 50 periodontally healthy volunteers. The following clinical parameters were measured: Gingival Index, pocket depth (mm); Clinical Attachment Loss (mm). Serum samples were collected and analyzed for levels of cis-ß-carotene, ß-cryptoxanthin, vitamin B 12, folate, vitamin D, and vitamin E. Individual data collected was summarized and analyzed using statistical software. Results: All the clinical parameters for periodontal status in the periodontitis group compared to healthy volunteers were highly significant (p < 0.0001). The mean levels of all the micronutrients, vitamin A precursors cis-ß-carotene and ß-cryptoxanthin, folate, vitamin B 12, D & E were lower in the periodontitis group than the healthy volunteers, although the difference was statistically significant only in case of ß-cryptoxanthin, Vitamin B12 and Vitamin D (p < 0.05). Conclusions: The findings of our study suggest that serum micronutrient levels especially Vitamin A, Vitamin B 12, and Vitamin D may be modifiable risk factors for periodontal disease. Providing an optimized combination of various vitamins in each meal in combination with sufficient measures of standard oral hygiene care may provide an important role in the prevention of periodontitis.

A rare case of solitary palatal myofibroma in a young pediatric patient.

Myofibroma (MF) is a benign spindle cell neoplasm rarely found in the oral cavity. It is common in males than females (2:1) and mostly seen to develop before 2 years of age with few cases reported in adults. This article reports a rare case of solitary MF of the hard palate in an 8-year-old female child; highlighting the clinical features, histopathology, differential diagnosis while emphasizing the importance of immunohistochemistry in establishing an accurate diagnosis and management of the same. The objective should be to differentiate benign versus malignant spindle cell lesions of smooth muscle, nerve tissue, fibrocytic, and histiocytic origin. Rapid growth of the lesion often raises suspicion of malignancy and may lead to misdiagnosis and inappropriate management.

Posterior cranial vault distraction osteogenesis: A systematic review.

Purpose: Posterior cranial vault distraction osteogenesis (PCVDO) has become the treatment of choice in specific indications within 12 years since its introduction in 2009. It is used to treat or prevent Intracranial hypertension secondary to craniosynostosis. However, there is still a lack of evidence describing this procedure's safety concerning the osteotomy line being close to the torcula. This systematic review aims to generate evidence regarding the safety of this new technique. Materials and method: A systematic search of Pubmed and Embase database were done without any time limit until the last search date of July 31, 2021. Articles focused on posterior cranial vault distraction osteogenesis were shortlisted using defined inclusion criteria. In addition, complications, volume gain, and distraction protocols in patients with craniosynostosis were assessed. Results: The review included 11 articles from 11 different centres. Of the Total 241 patients, 51 were non-syndromic patients, and 190 were syndromic patients. There were 242 procedures done on 241 patients. The proportion of patients with complications was 30%. Wound infection was the most commonly reported complication. PCVDO resulted in 20-25% volume gain and successfully prevented increased intracranial pressure (ICP). Conclusion: The systematic review has significantly identified a 30.606% incidence of complications in PCVDO. No mortality was linked directly to the Posterior cranial vault distraction osteogenesis procedure (PCVDO). The authors identified the evolution of many unique vectors and osteotomy designs customized for patients and practices for safe surgery. The effects of PCVDO on the anterior cranial fossa remain a topic of interest and require observational studies for better understanding.

Apical extrusion of debris with root canal instrumentation in primary teeth: A systematic review.

Aim: This study aimed to systematically review available literature of in vitro studies on apical extrusion of debris through rotary instrumentation in comparison to manual instrumentation in pediatric endodontics, and also to perform a comparison between various rotary instrumentation systems for assessment of debris extrusion. Materials and Methods: A comprehensive search was conducted on PubMed, Medline, Cochrane Library, Embase, Scopus, and Google Scholar without any language restriction and year of publication. A planned search strategy was made for PubMed and applied to other databases. After full-text reading, 7 articles were selected for quantitative synthesis. Modified CONSORT checklist of items for reporting in vitro studies of dental materials was used for quality assessment of included studies. Results: Root canal preparation with rotary instrumentation led to lesser apical debris extrusion than manual instrumentation. Self-adjusting file system was associated with the least debris extrusion among all included studies, followed by ProTaper Next, Kedo-S, ProTaper, K3, Mtwo, Revo-S, and Wave One. Conclusion: More apical debris extrusion was seen with manual instrumentation than rotary instrumentation. Furtrhermore, variance in debris extrusion was seen with different rotary file systems.

Reconstruction options in pediatric population with hemi or total mandibulectomy defects: A systematic review.

Purpose: Mandibular pathologies causing extensive defects in pediatrics is relatively rare, and sparse literature is available for the reconstructive options of the same. The main aim is to provide optimum esthetics and function. Materials and methods: PubMed, Cochrane CENTRAL, Embase, MEDLINE and Scopus databases were searched for articles published only in English language up to May 2021, involving reconstruction of hemi or total mandibulectomy defects in patients with the age of 8 years or less, associated with benign or malignant pathology. Primary outcome variable was the success of reconstruction. Qualitative analysis was performed using a microsoft excel-sheet. Results: Of the 2201 articles reviewed, only fourteen were selected for data extraction. 22 patients were included. Fifteen were benign, six were malignant pathologies, and one was not defined. Hemi-mandibulectomy was performed in twenty-one cases, while one underwent total mandibulectomy. Condyle was preserved in five cases, while was removed in nine. Single-stage reconstruction was done in nineteen cases, while second-stage reconstruction was done in the other three. Reconstruction was done with fibular graft in thirteen cases, while CCG was used in others with variable follow-up time. Though minor complications were observed, success was observed in all cases post reconstruction with either fibula or CCG graft, defined either by function, or growth. Conclusion: Irrespective of the age-group, nature of pathology and size of the defect, reconstruction should be considered with either fibula or CCG in single-stage, as they are equally efficacious, with minor complications. Well-defined reconstructive paradigm should be developed for pediatric mandibular reconstruction.

Advanced Platelet-rich Fibrin-mediated Regeneration of Necrotic Immature Permanent Teeth: A Clinico-radiographic Observational Study.

Aim: The objective of the study was to assess the regenerative potential of advanced platelet-rich fibrin (APRF) in the regenerative treatment of necrotic immature permanent teeth (NIPT) in the maxillary incisor region. Study design: After institutional review board clearance, 10 children aged between 8 and 14 years with NIPT in the maxillary incisor region undergoing APRF treatment were enrolled in a prospective clinico-radiographic exploratory observational study. Baseline clinical, radiographic, and vitality testing before the start of treatment were noted. Patients were followed up at 3, 6, and 12 months posttreatment. Results: After 3, 6, and 12 months of follow-up, all patients (100%) showed complete resolution of clinical signs and symptoms. All patients (100%) showed periradicular healing, and 9 out of 10 patients (90%) showed a clear hard tissue bridge formation at various levels in the root canal on postoperative radiographs. None of the patients (0%) showed a positive response to vitality testing. Conclusion: APRF is a promising biomaterial in regenerative endodontic treatment (RET). Future randomized trials can be planned to establish superiority or equivalence to conventional PRF. How to cite this article: Wakhloo T, Shukla S, Chug A, et al. Advanced Platelet-rich Fibrin-mediated Regeneration of Necrotic Immature Permanent Teeth: A Clinico-radiographic Observational Study. Int J Clin Pediatr Dent 2022;15(4):402-406.

Nasal symmetry after different techniques of primary lip repair for unilateral complete cleft lip with or without cleft of the alveolus and palate: A systematic review.

The aim of this systematic review was to establish the effect of different surgical repairs for the lip on nasal symmetry. PubMed, Scopus, Embase, Cochrane CENTRAL, and Ovid databases search was performed initially for only English-language articles, in patients with unilateral complete cleft lip with or without cleft alveolus and palate (UCCLAP) who were younger than 1 year of age and undergoing cleft lip repair, and are published from the earliest data available up to December 31, 2020. The primary outcome variable was nasal symmetry, with reported complications being secondary variables. A qualitative synthesis was provided. A total of 19,828 records were obtained, and 17 articles were selected for final review. Assessment of the risk of bias of the included randomized controlled trials (RCTs) (N-1) was done with the Cochrane Risk of Bias 2 (RoB-2) tool, and the ROBINS-I tool was used for non-randomized studies (n = 14). Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was applied to evaluate the quality of the body of evidence. The majority of the included studies compared the triangular repair with the rotation advancement (RA) techniques, and preferred RA or its modifications. In terms of the nasal symmetry, the Fisher repair proved to be superior to the RA technique. Neither RA nor straight line repair was superior to one another. The Delaire technique may be preferred over the modified RA. Also, satisfactory outcomes were observed with simultaneous lip-nose repair. This systematic review examined a plethora of techniques, and the heterogeneity between studies was very high regarding type of surgery, method of nasal symmetry assessment, and length of follow-up, thus producing low-quality evidence; therefore, results should be interpreted with caution. Future research requires RCTs with larger sample sizes and appropriate length of follow-up, and surgeries preferably performed by a single experienced surgeon.

Silver Diamine Fluoride Versus Atraumatic Restorative Treatment in Pediatric Dental Caries Management: A Systematic Review and Meta-analysis.

INTRODUCTION: The objective was to compare the clinical efficacy of silver diamine fluoride (SDF) and atraumatic restorative treatment (ART) in arresting active caries in primary teeth and first permanent molars in children. MATERIALS AND METHODS: The study protocol was registered in PROSPERO (CRD42020205675). A systematic search was performed in PubMed, Scopus, Embase, Cochrane Library, and gray literature for randomized controlled trials (RCTs) published in English language with a minimum follow-up of 6 months, comparing the caries arrest potential of SDF with ART in primary teeth and first permanent molars in children. The risk of bias and quality assessment of the studies was done using the Cochrane Collaboration Tool and Joanna Briggs Institute Critical Appraisal Tool. Data analysis was performed using RevMan software; the outcomes were summarized in meta-analysis (MA) using the random-effects model, and the odds ratio (OR) at 95% confidence interval (CI) was computed. RESULTS: A total of 1059 studies were identified, out of which 562 remained after removal of duplicates. Eight studies were considered for full-text eligibility, and four studies were included in the qualitative review. Three out of four studies were conducted on primary dentition, whereas one study was done on erupting first permanent molars in children. MA of the two studies compared 30% SDF with ART in primary molars at 12 months and revealed the OR to be 2.02 (95% CI: 0.86-4.71; I 2 = 62%; P = 0.10). CONCLUSION: The current review points to the lack of solid evidence comparing SDF with ART for arresting active caries in primary teeth, especially in the first permanent molars. No statistically significant difference between 30% SDF and ART in primary molars at 12 months was found in the present review. Well-designed RCTs are required to determine a minimum concentration of SDF which is effective and safe for caries arrest in children.

Relapse and temporomandibular joint dysfunction (TMD) as postoperative complication in skeletal class III patients undergoing bimaxillary orthognathic surgery: A systematic review.

OBJECTIVES: The aim of this study was to determine Relapse and TMD as postoperative complication in skeletal class III patients undergoing bimaxillary orthognathic surgery. MATERIALS AND METHODS: Data was obtained by database searching using The Cochrane Central Register of Controlled Trials (central), PUBMED, SCOPUS, EMBASE, Google scholar, National Medical library, New Delhi. The titles and abstracts of the electronic search results were screened and evaluated by two observers for eligibility according to the inclusion and exclusion criteria. RESULTS: 5261 articles were retrieved for the review. Among these, 3474 duplicate articles were removed. 418 studies were selected based on the eligibility criteria. For the present review, 30 articles were included after elimination according to the inclusion criteria. The Prisma diagram flowchart demonstrates our selection scheme. Quality assessment criteria to evaluate the studies were decided by two review authors in accordance with CONSORT guidelines. Each study was assessed using the evaluation method described in the Cochrane Handbook for Systematic Reviews. Among the 30 studies included in the review, marked degree of relapse in the mandible was noted from 3 months - 1 year postoperatively in 8 studies, 5 studies reported both TMD prevalence and relapse, whereas only 4 studies reported TMD disorder alone. CONCLUSION: Complications of relapse and TMD are associated with bimaxillary orthognathic surgery procedures. More RCTs and CCTs are needed in this regard to get better quality evidence. This review was registered with PROSPERO: CRD42020211342.

Modified anterior maxillary distraction using "Winged Osteotomy": A technical note.

Hypoplasia of the maxilla is common in cleft lip and palate (CLP) deformities. Orthognathic surgery has been the traditional method of correction in such developmental anomalies since 1970's, with Le-Fort I advancement as its long-established management modality, which results in significant speech alteration and relapse rate. In contrast, anterior maxillary distraction (AMD) has the advantage of lesser chances of relapse, velopharyngeal insufficiency, and alteration of speech. This modified AMD technique carries a handful of its advantages as it is an easier procedure compared to the Le-Fort I osteotomy as it gives positive soft tissue changes by improving the projection of the nose and the upper lip, normalizes naso-labial angle, and changes the facial prominence from concave to convex simultaneously as it gives nasolabial and sub-malar prominence post-operatively due to the extension of horizontal cuts up to to the zygomatic region, leading to lesser complications. Also, the hollowing caused by the conventional AMD osteotomy cuts is eliminated by the extension of the winged osteotomy.

Intestinal-type Adenocarcinoma Presenting as a Mandibular Mass: An Unusual Presentation.

Intestinal-type adenocarcinoma is an aggressive malignancy with the rare possibility of metastatic spread to the mandible. We represent a case of a 30-year-old female patient who reported with a chief complaint of a right mandibular mass for 4 months. Orthopantomogram X-ray observed an ill-defined lytic lesion with severe periosteal reaction. Incisional biopsy revealed "colonic variant of intestinal-type adenocarcinoma." Expression of cytokeratin 20 and caudal type homeobox transcription factor 2 (CDX-2) markers was seen on immunohistochemistry. Biochemical markers such as serum cancer antigen 125, serum alkaline phosphatase, and serum carcinoembryonic antigen were raised. Contrast-enhanced computed tomography of the thorax and abdomen suggested cavitary lesions in the bilateral lungs, right adrenal gland, and mediastinum. Positron emission tomography revealed multiple lesions in the body, hence confirming the diagnosis. The patient was kept on palliative chemotherapy. It is concluded that prompt diagnosis and initiation of treatment increases the chances of survival in such cases.

Massive posterior cranial vault erosion and its reconstruction: A peculiar presentation of "mega cisterna magna".

Dandy-Walker (DW) complex is a rare central nervous system malformation, commonly associated with complex non-neurological conditions, defined by four variants with characteristic anatomic features, still inadequately known for its etiological aspects. "Mega Cisterna Magna" (MCM) is a type of DW complex which is represented by an enlarged posterior cranial fossa. Though reduction cranioplasty has been reported in enlarged posterior cranial fossa malformations, however we report a peculiar case of MCM with massive posterior cranial bone erosion, presenting completely asymptomatic at an age of 8 years, without any associated co-morbidities till date, nor with any evident occipital mass at birth. Survival of the child till this age is an exception in itself, but this can probably be explained by the presence of the giant defect of the posterior cranial bone, which must have acted like a vent and prevented the elevation of the ICP. Hence no symptoms were observed till date. Ventriculo-peritoneal (VP) shunting was done to drain the accumulated fluid, followed by massive cranioplasty, which was challenging and was performed with autologous cranial and fibular bone grafts, along with alloplastic titanium mesh, and thus achieving marked aesthetic improvement with satisfactory bone healing at a 3-year follow-up.