"Trans-zygomatic approach" for reduction & internal fixation of a malunited, medially dislocated condyle fracture in a geriatric patient with cervical spine injury.

The open reduction and internal fixation of medially displaced/dislocated condyle fracture is challenging due to inadequate visibility and access to the dislocated condyle. The common approach to reduction of such condyles is by inferior distraction of the mandible which facilitates visualization as well as instrumentation. However, this maneuver may be difficult, or contraindicated in patients with concomitant cervical spine injury where excessive manipulation of the mandible may predispose the spine to further trauma. Ramus osteotomies which are used when conventional reduction methods fail, facilitate reduction but are associated with additional incision, complications and surgical time. This case report presents an alternative method, the "trans-zygomatic approach" which was used effectively to reduce a dislocated and malunited condyle fracture in a geriatric patient with co-existent cervical spine injury. The approach facilitated precise reduction of condyle fracture with minimal impact on the cervical spine.

Use of knotless barbed sutures for closure of intraoral incisions for maxillofacial trauma: a randomised controlled trial.

The objective of this study was to assess the efficacy of knotless barbed sutures in intraoral wound closure for maxillofacial trauma in comparison with conventional (vicryl) sutures. This was a randomised controlled clinical trial involving 40 patients with isolated mandibular angle fractures who required intraoral incisions for open reduction and internal fixation (ORIF). The sample was randomised into the study group (20 patients) and control group (20 patients). Following fracture fixation by a standardised surgical protocol, the wound closure was done with bidirectional knotless barbed suture and vicryl for the study and control groups, respectively. The wounds were closed in layers (periosteum and mucosa). All operations were performed by a single surgeon. Outcome parameters measured were intraoperative wound closure time and wound healing using 'Landry's wound healing index' on the first, third, and seventh postoperative days. Statistically significant difference in suturing time was noted between the study and control group (p value <0.001). The study group demonstrated a mean (SD) suturing time of 9.46 (2.01) minutes, compared with the 17.61 (2.57) minutes in the control group. Wound healing was found to be better and statistically significant in the study group than the control group (p value<0.001). Knotless barbed suture is a promising alternative to vicryl for intraoral wound closure.

Evaluation of prolotherapy in comparison with occlusal splints in treating internal derangement of the temporomandibular joint - A randomized controlled trial.

PURPOSE: The aim of this study was to compare the efficacy of dextrose prolotherapy with that of occlusal splints in treating internal derangement of the temporomandibular joint. PATIENTS AND METHODS: A total of 34 patients with temporomandibular joint internal derangement classed as Wilkes stages II or III were recruited for the study, and were randomly divided into study and control groups with 17 patients each. The patients in these control and study groups were treated with splints and prolotherapy, respectively. Outcome parameters, such as pain, mouth opening, clicking and deviation, were assessed using the Helkimo clinical dysfunction index for a review period of 1 year. RESULTS: Nine patients in the study group had complete absence of pain, compared with only one patient in the control group. The results showed that patients who received prolotherapy demonstrated improvement in pain (p < 0.001), mouth opening (p = 0.032), and clicking (p < 0.001), but no significant difference in deviation was observed between the groups after 1 year (p = 0.862). CONCLUSION: Prolotherapy was found to be superior in providing long-term clinical relief, with reduction in pain and clicking along with improved mouth opening.

Effectiveness of knotless suture as a wound closure agent for impacted third molar - A split mouth randomized controlled clinical trial.

AIM AND OBJECTIVE: This study was aimed to compare the effectiveness of 3-0 knotless barbed suture (polydioxanone) with 4-0 polyglactin 910 (vicryl) in achieving wound closure after impacted mandibular third molar surgery. MATERIALS AND METHODS: Patients with bilateral mandibular third molar impaction of similar difficulty index enrolled in the split mouth study. Wound closure was done using 3-0 knotless suture (30 × 30 cm) for the study group and 4-0 polyglactin 910 (vicryl) for the control group following extraction. Samples were allocated on the basis of simple randomization. The clinical outcome parameters that were measured were (1) time taken to achieve wound closure and hemostasis (2) postoperative mouth opening (3) swelling and (4) Pain. Data analysis involved descriptive statistics and paired t-tests (p < 0.05). IBM SPSS software (v.20.0) was used. RESULT: A total of 25 patients participated in the study (14 males and 11 females) with the mean age of 25.6 years. The mean time taken for wound approximation was 2.45 min and 4.1480 min (p-0.026) for the study and control groups respectively. The difference in mouth opening (p-0.015), VAS score(p-0.24), and swelling (p-0.041) were statistically significant on the first post-operative day in the study group than the control group indicating reduction in pain (p < 0.0001), swelling (p-0.033) and improvement in mouth opening (p < 0.0001) on seventh post-operative day in the study group compared to the control group. CONCLUSION: Knotless suture is an effective alternative to conventional sutures for intra oral wound closure as it reduces suturing time, facilitates effective wound closure and minimises knot related complications.

Non-suturing microvascular anastomosis in maxillofacial reconstruction- a comparative study.

AIM: The aim of the study is to compare the advantages and disadvantages of non-suturing anastomotic methods over conventional microsuturing for microvascular venous anastomosis. MATERIALS AND METHODS: All patients reporting to the institute for hard and soft tissue reconstruction (Primary/secondary) were enrolled in the study. Patients with systemic comorbidities, peripheral vascular diseases, or anatomical aberration of the indicated donor site were excluded from the study. The patients selected for the study were randomly allocated to five groups of different techniques of venous anastomosis, namely Group I (conventional microsuturing), II (fibrin sealant reinforced microsuturing), III (couplers), IV (staplers), V (Laser Assisted Vascular Anastomosis (LAVA)). Intraoperative anastomotic time, flap ischaemic time, patency and leakage were the parameters that were assessed for all five groups. RESULTS: 80 Patients were randomly allocated to five groups and each group comprised 16 patients. The mean ischaemic time and standard deviation of Group I and Group II were 256.19 ± 10.622 min and 255.19 ± 11.083 min, and for groups III, IV, and V were 193.38 ± 9.972 min, 139.06 ± 6.413 min, and 139.31 ± 6.364 min respectively (p < 0.001). Mean anastomotic time and standard deviation were 19.813 ± 1.5366 min in Group I and 20.281 ± 1.6514 min in Group II. The non-sutured anastomosis groups III, IV, and V showed a mean anastomotic time of 5.375 ± 0.9876 min, 4.175 ± 0.7664 min, and 3.856 ± 0.867 min respectively (p value < 0.001). In Groups I and II, 18.8% of patients had delayed patency and in Groups III, IV and V, immediate patency was observed in all subjects (p value 0.030). In Groups I and II, 18.8% and 6.3 % of patients respectively had leakage, whereas all patients in Groups III, IV, V had no leakage from the anastomotic site (p value 0.119). CONCLUSION: Based on the results of the study, non-suturing techniques should be preferred over microsuturing technique whenever appropriate for venous anastomosis.

3D planning in mandibular fractures using CAD/CAM surgical splints - A prospective randomized controlled clinical trial.

This randomized controlled trial assessed the role of CAD/CAM splints in achieving anatomic reduction of fractured fragments and ideal occlusion, in comparison with conventional splints. Patients diagnosed with displaced mandibular fracture and post-traumatic malocclusion were allocated to study and control groups by simple randomization. A standardized surgical approach was followed to expose the fractures. Reduction of fractures was carried out using CAD/CAM and conventional splints in the study and control groups, respectively. The parameters assessed were: occlusion, interfragmentary separation, fit of the splint, patient comfort, and surgeon comfort. Mann-Whitney U tests were used to compare the study and control groups. To compare the groups pre- and post-intervention Wilcoxon signed rank tests were used. Chi-square tests were applied for proportion comparisons. The sample consisted of 30 patients. The study group demonstrated superior clinical outcomes with regards to intraoperative reduction of fracture (p < 0.001; mean - 3.93, SD - 1.43), and to achieving intraoperative occlusion (p = 0.483) and postoperative occlusion (p = 0.224). Statistically significant improvements in both patient comfort (p < 0.001; mean - 0.20, SD - 0.41) and surgeon comfort (p < 0.001) were found in the study group. In conclusion, CAD/CAM splints improve precision in fracture reduction and restoration of occlusion through a simple fabrication process.

Maxillofacial trauma in a pregnant patient: Contemporary management principles with a case report & review of literature.

Trauma during pregnancy deserves special attention because of its management objectives, i.e. well-being of both pregnant woman and foetus. Maxillofacial trauma directly affects the nutrition of foetus by interfering with the normal functions in a pregnant woman such as mouth opening, mastication and breathing. Hence early restitution of form and function of maxillofacial skeleton is essential. However, the gravid status is associated with numerous anatomical and physiological changes which present with clinical dilemma related to imaging and treatment. A careful scrutiny of the patient's systemic and gestational status is absolutely essential before, during and after instituting any interventional procedures. We present a case of bilateral condyle fracture in a 30-year-old pregnant woman in the third trimester (32 weeks). She was treated with inter maxillary fixation using orthodontic brackets & elastics. After successful restitution of occlusion, the patient was advised aggressive physiotherapy which ensured normal mouth opening. Two weeks later, the patient delivered uneventfully. The patient was followed up at one month and 3 month and demonstrated restitution of normal occlusion, mouth opening and lower facial height. This article aims at analyzing the contemporary principles in management of maxillofacial trauma in a pregnant woman and clarifying the common misconceptions.

Evaluation of labial versus labio-inferior lines of osteosynthesis using 3D miniplate for fractures of anterior mandible: A finite element analysis with a pilot clinical trial.

PURPOSE: The fractures of anterior mandible are subject to severe torsional forces due to muscles acting in opposite directions. 3D miniplate has been suggested as a good alternative by some researchers. However, finite element model (FEM) studies indicate that labio-inferior positioning of two miniplates perpendicular to each other offers better stability as compared to labial positioning. This study aims at combining the advantages of a single 3D miniplate and labio-inferior positioning of two conventional miniplates, which was assessed by finite element analysis along with a pilot clinical trial. METHODS: Two FEM models were created using CT data of a 24-year-old patient with Angle class I occlusion: control model with labial plating and study model with labio-inferior plating. The models were processed with MIMICS® (materialise, Leuven, Belgium), CATIA® (Dassault Systemes) and finite element analysis softwares. Parameters adopted for analysis were (1) displacement (mm) of fracture fragments during each screw fixation, (2) lingual splay and post fixation stability of fracture fragments with masticatory load, and (3) stress distribution (MPa) across fracture fragments. Moreover, a pilot clinical trial including five patients with anterior mandible fracture was conducted. The fractures were managed by intraoral open reduction and 3D miniplate fixation in labio-inferior position. Intraoperative interfragmentary gap, post fixation lingual splay and radiographic fracture union and complications were assessed clinically. RESULTS: Labio-inferior plating demonstrated less displacement (mm) of fracture fragments during screw fixation (0.059 vs. 0.079) as well as after application of masticatory load (1.805 vs. 1.860). Negligible lingual splay and less stress distribution (MPa) across fracture fragments (1.860 vs. 1.847) were appreciated in the study group as compared to control group. Clinical trial support the favorable outcome related to intraoperative and postoperative assessment parameters. CONCLUSION: FEM analysis and clinical trial reveal better results with labio-inferior positioning of 3D miniplate when compared to labial positioning.

Zygomatic Hypoplasia in Patients with Non-syndromic Cleft Lip and Palate: A Case-Control Study.

BACKGROUND: Patients operated for cleft deformities may have zygomatic hypoplasia secondary to impaired growth of the maxilla. This has, however, not been evaluated in the past. SUBJECTS AND METHODS: This study was a prospective, case-control study. This included 32 patients, aged between 19 and 25 years, who were divided into cleft and non-cleft groups. The cleft group was further divided into unilateral clefts, bilateral clefts and isolated palatal clefts. In both groups, the zygoma was assessed and compared on both sides clinically using indirect photogrammetry and radiographically using 3D CT. The results were analyzed statistically using the unpaired t test. RESULTS: There was a significant difference in the zygomatic projection on cleft and non-cleft sides in the unilateral cleft group. There was no significant difference in the zygomatic projection of both sides in the other subgroups and the control group. CONCLUSION: The present study shows that there is a global effect of palato-alveolar cleft repair on the midfacial skeleton. Further studies are required to correlate the impact of age, gender and the technique of palato-alveolar cleft repair with the quantum of malar hypoplasia.

Management of an intraoperatively damaged endotracheal tube in a case of difficult airway using fibre-optic bronchoscope with minimal apnoea period.

Damage to the endotracheal tube (ETT) is common in head and neck surgeries, especially in maxillary osteotomy. Airway management in such a crisis is crucial as there is risk of aspiration of blood into lungs, hypoxia and apnoea. This case illustrates a patient with an anticipated difficult airway who had an intraoperative damage to the ETT and was successfully managed by re-intubation with fiberoptic bronchoscope in a minimal apnoea period of <15 s using a new technique.