Correction of Secondary Alveolar Clefts with Iliac Bone Grafts.

INTRODUCTION: Cleft lip and palate deformities are one of the most common birth defects. The alveolar cleft requires bony repair to allow proper eruption of dentition. The purpose of this study is to evaluate success in the repair of alveolar clefts with iliac bone grafts. AIM: The aim of this study is to restore the function and form of both arches with a proper occlusal relationship and eruption of tooth in the cleft area. SUBJECTS AND METHODS: Five patients were selected irrespective of sex and socioeconomic status and whose age was within the mixed dentition period. The iliac crest is grafted in the cleft area and subsequently evaluated for graft success using study models, periapical, and occlusal radiographs. RESULTS: At the time of evaluation, teeth were erupted in the area and good alveolar bone levels were present. Premaxilla becomes immobile with a good arch form and arch continuity. There are no major complications regarding pain, infection, paresthesia, and hematoma formation at donor site without difficulty in walking. There is no complication regarding pain, infection, exposure of graft, rejection of graft, and wound dehiscence at the recipient site except in one case. CONCLUSIONS: Long-term follow-up is required to achieve maximum advantage of secondary alveolar grafting; the age of the patient should be within the mixed dentition period, irrespective of sex and socioeconomic status. It may be unilateral or bilateral.

Concentrated Bone Marrow Aspirate-Coated Hydroxyapatite for Reconstruction of Small-to-Moderate-Sized Mandibular Defects Caused by the Removal of Benign Pathologies.

PURPOSE: The aim of this study was to evaluate the bone regeneration potential of concentrated bone marrow aspirate (BMA)-coated hydroxyapatite (HA) for reconstruction of mandibular defects caused by the removal of benign pathologies. PATIENTS AND METHODS: This prospective clinical study included ten patients with histopathologically proven benign pathologies of the mandible measuring <5 cm anteroposteriorly, who were treated with enucleation or marginal resection, followed by autologous concentrated BMA-coated synthetic biphasic HA (HA and beta-tricalcium phosphate) graft placement. Clinical and radiological evaluations of grafted sites of the mandible were done at 1 week, 1, 3, and 6 months postoperatively using Irwin's radiologic staging and grayscale histogram. RESULTS: All patients (10/10, 100%) had proper incorporation of the graft with the normal adjacent bone. Grayscale histogram revealed the initial stages of graft resorption, followed by formation of new bone-grafted sites. No complications such as infection and total graft loss were encountered except for one patient who had partial wound dehiscence that responded well to local wound care and resuturing. CONCLUSION: Concentrated BMA-coated synthetic HA effectively promotes bone regeneration in small-to-moderate-sized defects of the mandible.

Autogenous Bone Marrow Aspirate Coated Synthetic Hydroxyapatite for Reconstruction of Maxillo-Mandibular Osseous Defects: A Prospective Study.

PURPOSE: This prospective study was conducted to evaluate the bone regeneration capacity of synthetic hydroxyapatite mixed with autogenous bone marrow aspirate when used as a bone graft substitute in maxillo-mandibular osseous defects. METHODS: This study included nine patients with histopathalogically proven benign osteolytic lesions in maxilla and mandible that were treated with enucleation or marginal resection followed by bone marrow aspirate coated synthetic biphasic hydroxyapatite (hydroxyapatite and beta tricalcium phosphate) graft placement. Incorporation of graft was assessed based on Irwin's radiologic staging. The efficacy of graft to form new bone was radiologically evaluated by observing the sequential changes of density at grafted site using gray scale level histogram which was processed in adobe photoshop 7.0 elements. Clinical assessment of recipient and donor sites was done. RESULTS: Based on Irwin's radiologic staging, at 6 month follow up period, obvious incorporation of graft with new bone was observed. Sequential changes in bone density measured by gray scale histogram revealed initial resorption followed by replacement of BMA coated hydroxyapatite with new bone formation. None of the patients eventually had complications like infection, wound dehiscence, graft loss at recipient sites at 6 months follow up period. CONCLUSION: Autogenous bone marrow aspirate in combination with synthetic hydroxyapatite is an effective option for accelerating bone regeneration in small to moderate sized jaw bone defects. This mixture provides all the three critical elements needed for bone regeneration (osteogenesis, osteoinduction and osteoconduction) with an added advantage of obviating donor site morbidity.

Management of Mandibular Angle Fractures: Single Stainless Steel Linear Miniplate Versus Rectangular Grid Plate-A Prospective Randomised Study.

PURPOSE: This prospective study was conducted to evaluate the efficacy of stainless steel single linear miniplate with rectangular grid plate in the treatment of mandibular angle fractures. METHODS: This study included 30 patients who were allocated randomly into two groups of each. Group 1 patients were treated with single 2 mm × 4 hole linear stainless steel miniplate and group 2 patients with 2 mm × 4 hole rectangular grid plate. Patients were evaluated for fracture stability, occlusion, mouth opening, and complications at 1st week, 1 and 3 months post operatively. RESULTS: There were no significant differences between the two groups with respective variables statistically. In group 1 20 % (n = 3) had mild occlussal derangement 6.66 % (n = 1) patient had deranged occlusion at 1 week post operatively and 13.3 % (n = 2) had mild derangement at 1 month post operatively. In group 2 6.66 % (n = 1) had mild derangement at 1 week postoperatively. 20 % (n = 3) had limited mouth opening at 1 week in group 1 and 13.3 % (n = 2) in group 2. All patients in both groups achieved adequate mouth opening by the end of 3 month. None of the patients in both groups had plate fracture, screw loosening, non union or mal-union. CONCLUSION: Within the limits of the study, use of rectangular grid plates for fixation of mandibular angle fractures was reliable with low complication rates, easy adaptation and an effective alternative to conventional miniplates. Further clinical studies with larger sample size can derive a more comprehensive conclusion.

Preauricular transmasseteric anteroparotid approach for extracorporeal fixation of mandibular condyle fractures.

INTRODUCTION: Free grafting or extracorporeal fixation of traumatically displaced mandibular condyles is sometimes required in patients with severe anteromedial displacement of condylar head. Majority of the published studies report the use of a submandibular, retromandibular or preauricular incisions for the access which have demerits of limited visibility, access and potential to cause damage to facial nerve and other parotid gland related complications. PURPOSE: This retrospective clinical case record study was done to evaluate the preauricular transmasseteric anteroparotid (P-TMAP) approach for open reduction and extracorporeal fixation of displaced and dislocated high condylar fractures of the mandible. PATIENTS AND METHODS: This retrospective study involved search of clinical case records of seven patients with displaced and dislocated high condylar fractures treated by open reduction and extracorporeal fixation over a 3-year period. The parameters assessed were as follows: a) the ease of access for retrieval, reimplantation and fixation of the proximal segment; b) the postoperative approach related complications; c) the adequacy of anatomical reduction and stability of fixation; d) the occlusal changes; and the e) TMJ function and radiological changes. RESULTS: Accessibility and visibility were good. Accurate anatomical reduction and fixation were achieved in all the patients. The recorded complications were minimal and transient. Facial nerve (buccal branch) palsy was noted in one patient with spontaneous resolution within 3 months. No cases of sialocele or Frey's syndrome were seen. CONCLUSION: The P-TMAP approach provides good access for open reduction and extracorporeal fixation of severely displaced condylar fractures. It facilitates retrieval, transplantation, repositioning, fixing the condyle and also reduces the chances of requirement of a vertical ramus osteotomy. It gives straight-line access to condylar head and ramus thereby permitting perpendicular placement of screws with minimal risk of damage to the facial nerve.

Faciomaxillary fractures in a Semi-urban South Indian Teaching Hospital: A retrospective analysis of 638 cases.

BACKGROUND AND OBJECTIVE: The incidence of maxillofacial trauma is increasing at a very fast pace in developing countries like India and poses a major health burden. Hence, the epidemiological data of maxillofacial trauma during a 6 year period, was analyzed to study the characteristics, factors predisposing, and aid in advocating strict guidelines to prevent the same. MATERIALS AND METHODS: Data related to 638 cases with maxillofacial trauma, from January 2008 to December 2014 were reviewed retrospectively and the data regarding gender, age, etiology, anatomic location of fracture, alcohol consumption, associated head and other injuries, modality of treatment rendered and associated complications were analyzed with descriptive statistics. RESULTS: A total of 638 patients presenting with 869 maxillofacial fractures were analyzed. Most of them [344 (53.9%)] were young adults aged 18-40, whereas, 123 (19.2%) were 11 to 17 years, and 97(15.2%) adults. Men (79.4%) were more affected than women. Road traffic accidents remain the main etiology causing fractures in 470 (73.6%), whereas 397 (62.2%) had history of consumption of alcohol. Those with alcohol intoxication had multiple injuries. Mandible was more frequently involved with 360 (41.4%) fractures, and condyle being the most common site. A total of 374 (58.6%) underwent open reduction with internal fixation under general anesthesia. Prevalence of other injuries was noted in 207 (32.4%) and complications of fracture treatment in 41(6.4%) cases. CONCLUSION: Road traffic accidents under alcohol influence were most commonly associated with comminuted facial fractures with head injuries, frequently leading to death. Mandible was the most commonly fractured facial bone followed by zygoma.

Evaluation of Non-vascular Fibula Graft for Mandibular Reconstruction.

INTRODUCTION: Functional and cosmetic defects in maxillofacial region are caused by various ailments like trauma, neoplasm, developmental, infections and iatrogenic causes. Reconstruction of these defects with free flaps remains the gold standard but demerits like need for surgical expertise and equipment, prolonged duration of surgery, compliance of the patient and increased cost are associated with microvascular reconstruction. Hence reconstruction with nonvascular bone grafts can be considered when defect is nonirradiated and <9 cm and with sufficient soft tissue cover available. PURPOSE: To retrospectively evaluate clinical, radiological outcome and complications encountered with mandibular reconstruction using non vascular fibula graft. PATIENTS AND METHODS: This retrospective study included 7 patients who were treated in the Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital, Nellore, AP between 2011 and 2013 with histologically proven benign osteolytic lesions of mandible that require a segmental mandibulectomy and primary reconstruction using autogenous non-vascularised fibular graft. The clinical case records of the patients and personal patient assessment forms (Quality of Life Assessment Forms) were analysed. They were recalled every 3rd, 6th and 9th month after surgery for evaluation of clinical, radiological outcome of the graft and complications occurring at recipient and donor sites. RESULTS: In all the 7 patients, the lower border continuity was maintained except in one where the graft was dislodged. Tongue movements in all the patients were unrestricted. Jaw movements were affected in cases of ramus defects with slight deviation to operated side and reduced mouth opening. Radiological observations revealed no significant changes in 3 months except for slight reduction in graft height. The radioopaque bridging with continuity of lower border of mandible was noticed in 6th month indicating the take of the graft. This was achieved in every case except in one where the graft was lost due to dislodged reconstruction plate. In 9th month the edges of the graft i.e., graft to native mandible junction showed more resorption (3 mm) especially where there is >2 mm of gap. Whereas increase in height of graft in other areas especially in graft to graft junction was seen. Significant graft resorption was seen in two cases. There were no major complications associated with the donor site. CONCLUSION: Avascular fibula graft although a second choice to vascularised fibula, is a favourable option for mandible defects of 6-10 cm under optimum conditions especially in developing countries where financial and/or surgical resources are limited. An attempt for primary reconstruction with this is never futile as it prevents aesthetic deformity even in the event of failure and thus makes secondary reconstruction easy. However in order to confirm the results a prospective study with large scale of patients is necessary.

Three-dimensional assessment of unilateral subcondylar fracture using computed tomography after open reduction.

OBJECTIVE: The aim was to assess the accuracy of three-dimensional anatomical reductions achieved by open method of treatment in cases of displaced unilateral mandibular subcondylar fractures using preoperative (pre op) and postoperative (post op) computed tomography (CT) scans. MATERIALS AND METHODS: In this prospective study, 10 patients with unilateral sub condylar fractures confirmed by an orthopantomogram were included. A pre op and post op CT after 1 week of surgical procedure was taken in axial, coronal and sagittal plane along with three-dimensional reconstruction. Standard anatomical parameters, which undergo changes due to fractures of the mandibular condyle were measured in pre and post op CT scans in three planes and statistically analysed for the accuracy of the reduction comparing the following variables: (a) Pre op fractured and nonfractured side (b) post op fractured and nonfractured side (c) pre op fractured and post op fractured side. P < 0.05 was considered as significant. RESULTS: Three-dimensional anatomical reduction was possible in 9 out of 10 cases (90%). The statistical analysis of each parameter in three variables revealed (P < 0.05) that there was a gross change in the dimensions of the parameters obtained in pre op fractured and nonfractured side. When these parameters were assessed in post op CT for the three variables there was no statistical difference between the post op fractured side and non fractured side. The same parameters were analysed for the three variables in pre op fractured and post op fractured side and found significant statistical difference suggesting a considerable change in the dimensions of the fractured side post operatively. CONCLUSION: The statistical and clinical results in our study emphasised that it is possible to fix the condyle in three-dimensional anatomical positions with open method of treatment and avoid post op degenerative joint changes. CT is the ideal imaging tool and should be used on a regular basis for cases of condylar fractures.

Transoral versus extraoral approach for mandibular angle fractures: A comparative study.

INTRODUCTION: Mandibular fractures represent approximately two-thirds of all the maxillofacial fractures (nearly 70%) out of which fractures of mandibular angle represent for 26-35%. AIM OF THE STUDY: The aim of this study is to compare the transoral and extraoral (submandibular) approaches for fixation of mandibular angle fractures. OBJECTIVES OF STUDY: The objectives of the following study are to evaluate ease of accessibility, time taken for the procedure, ease of anatomic reduction and complications. MATERIALS AND METHODS: A prospective study was carried out in 30 patients reporting to the Department of Oral and Maxillofacial surgery, Narayana Dental College and Hospital, Nellore, Andhra Pradesh during the period of months from November 2011 to August 2013 who were randomly divided in two groups based on computer generated simple randomization chart. Group I patients underwent transoral reduction and fixation and Group II patients underwent extraoral reduction and fixation. The ease of accessibility was analysed by visual analogue scale by the operating surgeon, time taken from incision to closure with digital clock, difficulty level index of surgeon based on the time taken for the procedure and approach related complications. RESULTS: The ease of accessibility in Group I was good in 53.3% while in Group II patients approached extraorally it was good in 86.7%. Group I patients approached transorally showed a mean of 49.7 min while that of Group II patients approached extraorally showed a mean of 73.4 min. Group I had a minimum difficulty level index in 60%, moderate difficulty level in 33.3% and severe difficulty level in 6.7% while Group II had a minimum and moderate difficulty level in 46.7% and severe difficulty level in 6.7%. There was 1 (6.7%) complication reported in each group. CONCLUSION: The statistical analysis of this study concludes that fracture line starting anterior to mandibular third molar and ending at anteroinferior border of the insertion of the masseter muscle or posterior body of mandible can be approached transorally. Fracture line starting posterior or distal to the third molar or posterior to the insertion of the masseter muscle to the angle of the mandible or fracture line extending high in the ramus, extraoral approach provides a better choice for reduction and fixation of the fractured segments with restoration of anatomical and functional occlusion.

A Clinician's Role in the Management of Soft Tissue Injuries of the Face: A Clinical Paper.

INTRODUCTION: Injuries of the facial soft tissues may be due to road traffic accidents, industrial injuries, domestic and interpersonal violence, dog bites, human bites, war injuries etc. They may be described depending on the depth of involvement of the soft tissue and/or region since it gives the clinician the method of treatment. The soft tissue injuries must take into the underlying skeletal injury into account since these injuries if carelessly handled they leave deformed scarring in the most precious and beautiful part of the body. MATERIALS AND METHODS: Various patients reporting to the department of Oral and Maxillofacial Surgery, Narayana Dental College and hospital, Nellore were included in the study. Injuries in the various aspects of face at various anatomical areas has been presented with the mode of management. CONCLUSION: The maxillofacial surgeon while attending these cases should avoid the need for revision by having a thorough knowledge of the anatomy, physiology of the soft tissues and treat them accordingly after following good clinical and radiological examination.

Sympathetic ophthalmia: a review of literature.

Sympathetic ophthalmia (SO), also known assympathetic uveitis, is a rare bilateral granulomatous panuveitis that occurs after a penetrating injury to an eye. After injury from either surgery or accident, a variable period of time passes before a sight-threatening inflammation develops in both the eyes. The disease usually responds rapidly to corticosteroid therapy, but recalcitrant cases may require the addition of other immunosuppressive agents. A severely injured eye with no prognosis for vision should be enucleated within 2 weeks of injury to prevent SO. The purpose of this article is to highlight the risks of SO associated with the orbital fractures involving soft tissue components of the orbit. Though unusual, a maxillofacial surgeon, while operating on the orbital walls involving the soft tissue disruption, has to be aware of this condition so that the postoperative complications related to vision can be avoided.

Cutaneous sinuses of cervicofacial region: a clinical study of 200 cases.

PURPOSE: To evaluate the sinuses in the cervicofacial region and to identify the focus of infection. It is also to help the clinician in differentiating the sinuses' of odontogenic and nonodontogenic focus of infection. MATERIALS AND METHODS: The study has been conducted in 200 patients, aged between 11 and 77 years for a period of 6 and a half years at Narayana Dental College and Hospital, Nellore. History of present illness, clinical, radiological and laboratory examinations were carried out on all the patients. RESULTS: Majority of the cervical sinuses are of odontogenic origin (80%) and non-odontogenic being (20%) of the cases. CONCLUSION: The literature reveals that many cases have been misdiagnosed and inappropriately treated by many specialties of Medicine and Surgery wherein the odontogenic foci of infection is the main etiological factor for cervicofacial sinuses. A proper diagnosis is important and forms a key to the successful management of these sinuses in the head and neck region.