Frequency of concomitant injuries in maxillofacial trauma in a tertiary health care centre in India: A 5-year retrospective study.

PURPOSE: Road traffic accidents (RTA), assaults, falls, and sports-related injuries are the leading causes of maxillofacial trauma. Due to quite different geographical environment and fast urbanization, the use of various protective equipment is restricted in India. Thus, compared to other countries, there might be a significant difference in the pattern and frequency of associated injuries among subjects with maxillofacial trauma. The present study was conducted to identify the causes and pattern of various maxillofacial fractures and the frequency of other related injuries among subjects with maxillofacial trauma. METHODS: This is a cross-sectional retrospective study recording 2617 subjects with maxillofacial trauma. The patient demographics, causes of trauma, types of maxillofacial injury, and associated soft and hard tissue injuries were recorded. The types of maxillofacial and associated injuries were diagnosed from details of clinical examinations and the interpretation of various radiographs available in the file. The associated injuries were divided into head injury, other bony injuries, and soft tissue and vital structure injuries. Descriptive statistics and the test of proportion were used. A p value < 0.05 was considered as a level of significance. RESULTS: The maxillofacial injuries were significantly common in patients aged 16 - 45 years (66.7%) than in patients aged ≤ 15 and > 46 years (33.3%) (p < 0.001). The RTA was the most common cause of maxillofacial injury (n = 2139, 81.7%), followed by fall (n = 206, 7.9%), other causes of injury (n = 178, 6.8%), and assaults (n = 94, 3.6%). The maxillofacial injury by 2-wheel vehicle accidents was significantly higher than that by 4-wheel vehicle and other vehicle accidents (p < 0.001). There was a significant correlation between alcohol and RTA (p < 0.001). The head injury (n = 931, 61.1%) was the most common associated injury, followed by soft tissue and vital structures injuries (n = 328, 21.5%) and other bone injuries (n = 264, 17.3%). DISCUSSION: Head injury was the most common associated injury followed by soft tissue and vital structures and bone injuries among subjects with maxillofacial trauma. Clavicle fracture and injury to the lower extremities were the most common hard and soft tissue-associated injuries.

Effect of Single dose of Methylprednisolone Injection at Stylomandibular Ligament Insertion on Pain and Various Mandibular Movements Among Patients with Ernest Syndrome: A Pilot Study.

Insertion tendinosis of stylomandibular ligament or Ernest syndrome is a rarely encountered cause of orofacial pain. The pain in this disorder originates from the stylomandibular ligament insertion site and radiates to the temporomandibular joint (TMJ), neck, shoulder, and periauricular region. Ten subjects who had undergone surgery for mandible fractures diagnosed with Ernest syndrome were considered for the present study. The origins and insertions of the stylomandibular ligament were marked and palpated using fingertip and blunt probe. The Ernest syndrome was confirmed by injecting diagnostic local anesthesia injection. A single dose of 2 ml methylprednisolone (40 mg/ml) was injected at the insertion site of a stylomandibular ligament in each subject. The effect of methylprednisolone injection on pain and various jaw movements were assessed at 1-month and 6-months after the injection. The mean pain value ranks during rest & while mouth opening in the visual analogue scale (VAS) reduced significantly after single injection (P < 0.001). The mean mouth opening increased significantly from 23.3 ± 3.94 mm before the treatment to 36.1 ± 3.07 mm at 1-week and 35.4 ± 2.17 mm at 6-months after the treatment (P < 0.001). The mandible protrusive movement increased from 4.07 ± 0.74 mm before treatment to 5.06 ± 0.62 mm at 1-week and 4.94 ± 0.62 mm at 6-months after the injection, respectively. Single dose of methylprednisolone injection at the insertion site of the stylomandibular ligament was proved effective on pain and various mandibular movements among patients with Ernest syndrome.

Decrypting the occurrence of mucormycosis following dental extractions: A systematic review.

BACKGROUND: Mucormycosis is a life-threatening opportunistic infection. The present systematic review was done to provide to date summary of the frequency of rhino-orbital-mucormycosis (ROM) cases following a tooth extraction, as there was no systematic review present till now to highlight it. METHOD: The PubMed, PMC, Google Scholar, and Ovid Embase databases were searched thoroughly with appropriate keywords till April 2022 including the human population with language restrictions including English literature to collate case reports and case series regarding post-extraction Mucormycosis. All the details of the patient's characteristics were extracted and presented as a table and evaluated on different endpoints. RESULTS: In total, we identified 31 case reports and 1 case series that results in 38 cases with Mucormycosis. The majority of patients belong to India (47. 4%). There was male predominance (68.4%) and involvement of maxilla was the most. Pre-existing diabetes mellitus (DM)(55.3%) was an independent risk factor for mucormycosis. The median period for the onset of symptoms was 30(14-75) days. 21.1% of cases presented signs and symptoms of cerebral involvement allied with DM. CONCLUSION: Dental extraction can trigger ROM by rupturing the oral mucous membrane. Clinicians should pay attention to the non-healing extraction socket which may be an early clinical manifestation of it, which is the key to tackling this deadlier infection.

Intra-articular injection of hyaluronic acid versus platelet-rich plasma following single puncture arthrocentesis for the management of internal derangement of TMJ: A double-blinded randomised controlled trial.

The present study aimed to compare the efficacies of intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) following single needle arthrocentesis in patients with TMJ internal derangement. This double-blinded randomised controlled trial involved the enrolment of patients diagnosed with unilateral TMD, falling into either Wilkes' stages II or III. In Group A, single needle arthrocentesis was performed using Ringer's lactate serving as a control group; in Group B, intra-articular injection of 1 ml hyaluronic acid injection was given following arthrocentesis; and in Group C, autologous intraarticular injections of 1 ml of PRP was given after arthrocentesis, twice in two weeks' interval. The primary outcome variables were maximum mouth opening and pain, while TMJ clicking sounds formed the secondary outcome variable. All the outcome variables were assessed preoperatively (T0) and postoperatively after the second dose of injection at one month (T1), three months (T2), and six months (T3). The alpha level was set to p < 0.05. Ninety patients (N = 90) comprised the final sample size of the study with thirty patients(n = 30) in each treatment group. A statistically significant decrease in the management in mean pain scores was noted between T0 [mean scores were 7.30 ± 1.05 (Group A), 7.63 ± 1.12 (Group B), and 7.56 ± 1.04(Group C)] and T3 [mean scores were 2.66 ± 0.88 (Group A), 2.4 ± 0.72 (Group B), and 1.66 ± 0.66 (Group C)] time intervals between Group A and C(p < 0.001). Significant improvement was noted in preoperative maximum mouth opening (MMO) of Group A, B, and C which was 22.83 ± 3.58, 22.17 ± 4.07, and 21.37 ± 3.69, respectively to 28.90 ± 2.72, 32.17 ± 3.97, and 34.10 ± 3.80 mm, respectively at six months postoperatively (p < 0.001). A significant decrease in joint sounds was evident for all three groups(p = 0.003 for Group A, p < 0.001 for Group B, and p < 0.001 for Group C) across the time intervals. Moreover, Group C showed a significant decrease in the prevalence of joint sound compared to the other two groups at all-time intervals postoperatively when equated to baseline (p = 0.02 at T1, p = 0.009 at T2, and p = 0.002 at T3). Within the limitations of the present study, it can be concluded that intra-articular PRP may be preferable over HA whenever appropriate, following single needle arthrocentesis in the treatment of TMJ internal derangement.

Radicular variant of dens in dente (RDinD) in a patient undergoing radioisotope therapy.

Dense in dente is a developmental anomaly frequently encountered in permanent maxillary incisors, with a prevalence rate of 0.25-10%. Our review of the scientific literature on a radicular variant of dens in dente (RDinD) in permanent molar teeth identified only two reported cases with a confirmed diagnosis. Here, we report the third case of RDinD, in a 37-year-old woman presenting with nocturnal pain in the left maxillary second molar for 1 week. The patient had a medical history of surgery for papillary thyroid carcinoma followed by radioactive iodine therapy. We established a diagnosis of RDinD with an osteolytic lesion and transverse fracture line along the palatal root of the tooth by using cone beam computed tomography (CBCT). Extraction and periapical curettage of the lesion were performed, and the patient was followed up. In summary, we observed a rare clinical presentation of RDinD in the left maxillary second molar of a 37-year-old female patient.

Management of Covid Associated Mucormycosis of Mandible: A Mountain Beneath a Molehill-A Lesson Learnt.

The opportunistic infection of post-Covid associated mucormycosis has been reported globally; however, it has reached alarming proportions in India. Mucormycosis of the mandibular region is rare, and only a few cases have been reported to date. Covid associated mucormycosis has not been reported in the literature before, and we are the first to report them. We report two patients who presented with tooth loosening with pus discharge a few weeks following recovery from Covid infection. After tooth extraction adjacent necrotic bony specimen was sent for calcofluor potassium hydroxide mount, which was found positive for broad pauciseptate hyphae. Although CT scan imaging demonstrated the involvement of a mandible segment, we found a much more extensive involvement in both cases during resection. There was intramedullary spread of the mucormycosis throughout the inferior alveolar canal, with pus discharge and foul odor. The management of covid associated mandibular mucormycosis consists of surgical debridement with antifungal therapy and control of the underlying disease. It became challenging because the radiological extent of the disease was different from the definite clinical extension of the lesion found during surgery. The authors recommend surgeons adopt a flexible approach during surgery to plan resection depending on the clinical judgment and not rely entirely on CT scans. And the reconstruction of the mandible will follow as per the extent of excision.

A novel prefabricated patient-specific titanium cranioplasty: reconsideration from a traditional approach.

OBJECTIVE: Patient-specific implants (PSI) for cranioplasty are expensive, and cost remains the limiting factor in low- to middle-income countries. The authors describe a novel, reproducible and cost-effective method of designing prefabricated titanium PSI cranioplasty. METHODS: Ten patients from June 2018 to December 2020 were included in this retrospective study. A three-dimensional stereolithography model was made on a custom-built 3D printer with variable layer heights to produce efficient and accurate details. A certain amount of defect in the temporal region was left uncovered to avoid complications related to temporalis muscle dissection. The stereolithography model with a cranial defect was reconstructed with modelling wax. The wax model was scanned with a blue light visible scanner. The digital data was transferred to the milling machine (Jayon Surgical®, Kerala, India), where a 1-mm-thick sheet of titanium was milled according to the specifications. RFCC scoring system was used for assessing cosmetic outcome. RESULTS: The mean duration of the surgery was 56.50 min, SD = 14.916 min (range 45-75 min). In 9/10 patients, the RFCC score was 4 points. No other complications were found at a minimum follow-up of 18 months in all patients. The cost per patient was approximately 30,000 INR or 400 US dollars. The average time required for us to get the PSI ready for surgery was about 15 days. CONCLUSION: The authors demonstrate a novel, cost-effective and reproducible method of PSI using titanium for cranioplasty.

Functional outcome of two different grafting techniques in the surgical management of oral submucous fibrosis: a comparative evaluation.

OBJECTIVE: To evaluate the functional efficacy of two different grafting techniques following the fibrotomy among subjects with oral submucous fibrosis (OSMF). DESIGN: Forty consecutively treated OSMF subjects between 20 and 40 years who had grades 3 and 4a OSMF and mouth opening < 15 mm were included in the present study. All the subjects were randomly divided into two groups. In Group I, all the subjects received a buccal pad of fat sandwiched with a nasolabial flap following fibrotomy. In contrast, Group II subjects received a buccal pad of fat combined with a collagen graft. The effect of two different surgical protocols on mouth opening was evaluated clinically before the surgery (T0) and 1 month (T1), 6 months (T2), and 12 months (T3) after the surgery. RESULTS: In Group I subjects, the mouth opening increased significantly (P < 0.001) from 10.90 ± 1.971 mm at T0 to 34.25 ± 3.127 mm at T1, but reduced marginally to 32.15 ± 3.422 mm at T2, and 31.30 ± 3.358 mm at T3. In Group II, the mouth opening increased significantly (P < 0.001) from 10.85 ± 1.725 mm at T0 to 28.90 ± 3.059 mm, 29.10 ± 2.808 mm, and 28.20 ± 2.285 mm at T1, T2, and T3, respectively. At the end of 12 months of follow-up, the mean value improvement in the mouth opening (T0-T3) was 20.4 ± 3.5 mm and 17.3 ± 2.9 mm in Groups I and II, respectively, and the difference was statistically significant (P = 0.006). CONCLUSION: The buccal pad of fat sandwiched with a nasolabial flap for the reconstruction following fibrotomy had a slightly better beneficial effect on the postoperative mouth opening among OSMF subjects.

Surgical Correction of Craniofacial Fibrous Dysplasia Involving Orbits: A Unique Application of Patient-Specific Implants.

ABSTRACT: Craniofacial fibrous dysplasia is a slow-growing bony disorder causing asymmetry of the face; leading to aesthetic, functional, and psychological ramifications. Surgical recontouring is the most accepted form of treatment. Reconstruction of the orbit poses a serious challenge to the surgeon; hence the present study is intended to describe and evaluate a most anatomically accurate virtual treatment planning and defect-specific implant technique, enumerating postoperative functional and esthetic outcome. The study highlights a valid application of three-dimensional models and computer-guided surgical splints. The current study included 5 patients with craniofacial fibrous dysplasia involving orbits with a mean age of 19.6 years. Detailed pre- and post-operative ophthalmologic workup were documented for one year. All the participants showed improvement in eyeball position and movement. Visual acuity and intraocular pressure have returned to near normal values, and astigmatism was reduced significantly. No recurrence was noted in any of the subjects. The current technique was found helpful in reconstructing the complex orbital anatomy; however, long-term follow-up studies with a greater number of patients are recommended.

A rare maxillofacial manifestation of acute lymphoblastic leukemia in a 9-year-old child.

Acute lymphoblastic leukemia (ALL) is considered as the most common malignant neoplasm of childhood and the frequent cause of death from cancer before 20-years of age. The facial swelling mimicking a maxillofacial tumor is rarely associated with ALL. Clinicians should be aware of such rare manifestation of ALL. We present a case with an atypical mass in the facial region secondary to ALL, which resulted in diagnostic dilemma. Reports of such atypical swelling in patients with ALL are occasional. The swelling was aggressive and the disease had a fulminant course.

Efficacy of Prolotherapy in Temporomandibular Joint Disorders: An Exploratory Study.

INTRODUCTION: Temporomandibular joint (TMJ) disorders can be treated by both conservative and surgical approaches. Conservative interventions with predictable benefits can be considered as first-line treatment for such disorders. Dextrose prolotherapy is one of the most promising approaches in the management of TMDs, especially in refractory cases where other conservative management has failed. AIM: To study the efficacy of prolotherapy and to establish it as an effective procedure in patients with TMJ disorders, to provide long-term solution to chronic TMJ pain and dysfunctions. PATIENTS AND METHODS: We conducted a study on 25 patients suffering from various TMJ disorders who were treated with prolotherapy, the solution consisting of 1 part of 50% dextrose (0.75 ml); 2 parts of lidocaine (1.5 ml); and 1 part of warm saline (0.75 ml). The standard programme is to repeat the injections three times, at 2-week interval, which totals four injection appointments over 6 weeks with 3-month follow-up. RESULTS: There was appreciable reduction in tenderness in TMJ and masticatory muscles with significant improvement in mouth opening. The effect of the treatment in improving clicking and deviation of TMJ was found to be statistically significant (P < 0.05). There were no permanent complications. CONCLUSION: Our study concluded that prolotherapy is an effective therapeutic modality that reduces TMJ pain, improves joint stability and range of motion in a majority of patients. It can be a first-line treatment option as it is safe, economical and an easy procedure associated with minimal morbidity.

Aggressive Ossifying Fibroma of the Maxilla.

The aggressive ossifying fibroma is an uncommon benign fibro-osseous lesion which has been described in the literature under a variety of terms. This tumor is distinguished from standard ossifying fibroma based on its more clinically aggressive biological behavior, occurrence in children and young adults, and tendency to occur in different anatomic sites. We report a case of a 45-year-old female who presented with a unilateral swelling of the right middle face for 5 months. Clinical examination showed a mass extended over the right maxilla. Orthopantomogram and computed tomography scan were performed. Biopsy suggests a fibro-osseous lesion. The complete surgical excision of tumor was performed under local anesthesia. The histopathological examination revealed the diagnosis of an aggressive ossifying fibroma-trabeculae type. No recurrence was noted. Because of its aggressive and compressive nature, aggressive ossifying fibroma requires an early complete surgical excision. A long-term clinical and radiological surveillance is necessary to prevent recurrence.