Long term complications of costochondral graft reconstruction in temporomandibular joint ankylosis of the young- a systematic review.

Costochondral graft has been a popular reconstruction choice in the past for temporomandibular joint ankylosis in young individuals. However, accounts of growth hampering complications have also been observed. Our systematic review aims to compile all existing evidence to determine the occurrence of these unfavourable clinical outcomes as well as factors affecting them to provide a better judgement on further use of these grafts. A systematic review was conducted following PRISMA guidelines where databases like PubMed, Web of science and Google Scholar were searched for the purpose of data extraction. Observational studies performed on patients younger than 18 years of age with a minimum follow-up of one year were selected. Incidence of long term complications like reankylosis, abnormal graft growth, facial asymmetry and others were considered as outcome variables. Eight articles with a total of 95 patients were selected where complications like reankylosis (6.32%), graft overgrowth (13.70%), insufficient graft growth (22.11%), no graft growth (3.20%) and facial asymmetry (20%) were reported. Other complications like mandibular deviation (3.20%), retrognathia (1.05%) and prognathic mandible (3.20%) were also observed. Our review concludes that the occurrence of these complications was noteworthy. Thus use of costochondral graft for reconstruction in temporomandibular ankylosis in young patients holds significant risk in development of growth abnormalities. However, modifications in surgical procedure such as use of appropriate graft cartilage thickness and the presence and type of interpositional material can favourably affect the frequency and type of growth abnormality.

Management of paediatric ankylosis.

Temporomandibular joint ankylosis (TMJa) is one of the most crippling craniomaxillofacial pathological conditions characterized by replacement of normal architecture of temporomandibular joint (TMJ) with fibrous or bony tissue. The incidence of TMJa is most common in the paediatric population [first and second decades of life] and is commonly associated with maxillofacial trauma. Comprehensive management entails a thorough evaluation of the associated anatomy of the ankylotic mass and other pertinent details like the presence or absence of obstructive sleep apnoea. Categorizing patients based on these variables helps in selecting an appropriate surgical intervention. Various resective and reconstructive surgical techniques are discussed; along with their merits and demerits. Long-term physiotherapy, long-term clinical follow-up and appropriate family counselling are the essential pillars for success. In this review, the authors present an algorithmic approach to evaluation and management of paediatric TMJa. Appropriate recommendations are made based on evidence to select optimum surgical intervention.

Deep Learning Based Capsule Neural Network Model for Breast Cancer Diagnosis Using Mammogram Images.

Breast cancer is a commonly occurring disease in women all over the world. Mammogram is an efficient technique used for screening and identification of abnormalities over the breast region. Earlier identification of breast cancer enhances the prognosis of patients and is mainly based on the experience of the radiologist in interpretation of mammogram with quality of image. The advent of Deep Learning (DL) and Computer Vision techniques is widely used to perform breast cancer diagnosis. This paper presents a new Optimal Multi-Level Thresholding-based Segmentation with DL enabled Capsule Network (OMLTS-DLCN) breast cancer diagnosis model utilizing digital mammograms. The OMLTS-DLCN model involves an Adaptive Fuzzy based median filtering (AFF) technique as a pre-processing step to eradicate the noise that exists in the mammogram images. Besides, Optimal Kapur's based Multilevel Thresholding with Shell Game Optimization (SGO) algorithm (OKMT-SGO) is applied for breast cancer segmentation. In addition, the proposed model involves a CapsNet based feature extractor and Back-Propagation Neural Network (BPNN) classification model is employed to detect the existence of breast cancer. The diagnostic outcomes of the presented OMLTS-DLCN technique is examined by means of benchmark Mini-MIAS dataset and DDSM dataset. The experimental values obtained highlights the superior performance of the OMLTS-DLCN model with a higher accuracy of 98.50 and 97.55% on the Mini-MIAS dataset and DDSM dataset, respectively.

Role of Superficial Cervical Plexus Nerve Block as an Adjuvant to Local Anesthesia in the Maxillofacial Surgical Practice.

PURPOSE: Infiltration techniques are used as an adjuvant to regional anesthesia. In this study, we evaluated the efficacy of the superficial cervical plexus nerve block, as an alternative to local infiltration techniques; in the management of mandibular fractures and peri-mandibular space infections. METHODS: A prospective randomized controlled trial was conducted on 24 patients having either mandibular fractures or peri-mandibular space infections; and were scheduled for surgery under regional anesthesia (eg, inferior alveolar nerve block, long buccal nerve block). The control group involved delivering a combination of regional anesthesia along with local infiltration. The experimental group received regional anesthesia with a superficial cervical plexus nerve block. The following parameters were studied: pain, onset and duration of anesthesia, time interval until first analgesic request, pulse rate and blood pressure [at different time intervals]. RESULTS: Intergroup comparison was done using unpaired t-test. Intragroup comparison was done using repeated measures ANOVA (for >2 observations), followed by a post hoc test. The superficial cervical plexus nerve block group showed highly statistically significant (P < .01) improvement in terms of intra-operative pain at 30 minutes, duration of anesthesia, intraoperative anesthetic requirement, time interval until first analgesic request and intraoperative diastolic blood pressure at 10 minutes. CONCLUSION: It can be concluded that the combination of a regional anesthesia technique with a superficial cervical plexus nerve block is an alternative and safe technique for patients undergoing surgery for mandible fractures and perimandibular space infections, with clear advantages over local infiltration.

Quality Assessment of Systematic Reviews of Temporomandibular Joint Ankylosis Surgical Treatment Outcomes.

AIM: Temporomandibular joint ankylosis (TMJA) management involves many surgical treatment modalities depending on the experience of the operator. A lot of literature has been published on various treatment modalities. Many systematic reviews (SRs) were published without any published prior protocol. So, the study aimed to evaluate the quality of SRs with meta-analysis of TMJA management. MATERIALS AND METHODS: Systematic reviews with meta-analysis were included for the quality assessment using AMSTAR (assessment of multiple SRs) and Glenny et al. checklist by two independent teams. The search was limited to the Medline database archival (from January 1980 to December 2018). RESULTS: The primary search identified 1,507 related articles. After activation of different filters, abstracts screening, and cross-referencing, finally, a total of six studies were assessed to make the overview up-to-date. CONCLUSION: The articles scored 8 to 11 with AMSTAR and 7 to 13 with the Glenny et al. checklist. None of the published reviews received maximum scores. The methodology and heterogeneity are essential factors to assess the quality of the published literature. CLINICAL SIGNIFICANCE: None of the included meta-analysis was registered or published protocol with Prospero or Cochrane before publication for better validity of the studies. The authors are advised to follow reporting criteria so that in the future it is possible to provide the standards of care for TMJA with the highest quality of evidence.

Current Orthognathic Practice in India: Do We Need to Change?

The last decade or so has seen paradigm shifts in the various aspects of orthognathic surgery. A lot of these changes are to do with digitalization of the orthodontic-surgical workflow, optimization of surgery-first protocols, virtual surgical planning-based 3D printing solutions and changing patient-health-care dynamics. The aim of this article is to provide evidence-based recommendations that are both practical and economically viable for the current orthognathic practice in India.

Unusually rare occurrence and recurrence of temporomandibular joint ankylosis and oral submucous fibrosis simultaneously in a patient: A surgeon's dilemma.

We here present a rare case of simultaneous occurrence and recurrence of TMJ ankylosis and submucous fibrosis in the same patient. Patient presented with limited mouth opening at both occasions. However, the diagnosis of submucous fibrosis was overlooked at the first presentation. The patient reported with recurrence of both the conditions after a period of 15 years. We presume that noncompliance of jaw exercises aggravated both the conditions as one led to the other. Since fibrosis sets in earlier than bony fusion, we theorized that the patient had acquired OSMF before TMJ ankyloses recurrence. The case was managed with release of fibrous bands intraorally followed by release of TMJ ankylosis and interposition with dermis fat graft. Physiotherapy is extremely essential when either pathology is treated in patients, especially when both are present in a single patient.

Combined endoscopic and intra-oral approach for chronic maxillary sinusitis of dental origin-a prospective clinical study.

AIMS AND OBJECTIVES: The traditional Caldwell-Luc approach for maxillary diseases has been criticized for its shortcomings such as removal of a large amount of bone, numbness of the teeth, flap dehiscence, and recurrent sinusitis. On account of its minimal invasiveness and physiological approach, functional endoscopic sinus surgery (FESS) has come to replace the Caldwell-Luc approach for the treatment of chronic rhinosinusitis. Chronic maxillary sinusitis of dental origin (CMSDO) is a less common variant on the chronic rhinosinusitis spectrum whose treatment involves simultaneous management of both the diseased maxillary sinus and the dental source of infection. Thus, this study was undertaken to assess the efficacy of FESS when combined with an intra-oral approach for the treatment of CMSDO. MATERIAL AND METHODS: Eighteen patients with CMSDO in the age group of 18-50 years were treated with a combined endoscopic and intra-oral approach (buccal advancement flap with/without buccal fat pad) in this study. The patients were followed up for a total duration of 18 months. The primary outcome measurements were the SNOT-22 Quality of Life questionnaire and the Lund and Mackay CT Scan Scoring Criteria. The Friedman test was used to assess improvement in the above variables and the level of significance was set at 0.05. OBSERVATIONS AND RESULTS: There was a statistically significant reduction (p < 0.05) in both the above parameters at all post-operative intervals. Two patients presented with epistaxis (immediate post-operative phase) and synechiae (second week follow-up interval). Both complications were successfully resolved. Two patients showed recurrence at the 6th-month interval for which they underwent revision surgery successfully. Overall, results were maintained even at the 18th month follow-up interval. CONCLUSION: The endoscopic approach appears to be a reliable, minimally invasive technique associated with less morbidity and stable long-term results. Thus, a multi-disciplinary approach between maxillofacial surgeons and otolaryngologists is essential in the treatment of CMSDO.

Modified Cut for Gap Arthroplasty in Temporomandibular Joint Ankylosis.

Temporomandibular joint ankylosis is a debilitating disease affecting the function, esthetics and psychology of the patient. Treatment of this condition aims at establishing not only the function and esthetics but also aims to prevent reankylosis. Among the different treatment modalities, interpositional gap arthroplasty followed by aggressive jaw physiotherapy is considered most effective. This is achieved by making two horizontal osteotomy cuts at a distance of 10-15 mm in the TMJ region. The gap is then interposed with an autogenous or alloplastic graft material. However, during the application of a jaw stretcher intraoperatively with the surgical site open and with the jaw wide open, a bony contact was seen to occur between the posterior aspect of the upper and lower osteotomy cuts. Taking this into consideration, the lower osteotomy cut is modified by making the posterior one-third cut divergent. This eliminates the bony contact during maximum mouth opening and thus prevents the chances of reankylosis as well.

A Randomized Control Trial Comparing Buccal Infiltration of 4% Articaine with Buccal and Palatal Infiltration of 2% Lignocaine for the Extraction of Maxillary Premolar Teeth.

INTRODUCTION: The use of articaine has been claimed to obviate the need for routine palatal local anesthetic injections on account of its better diffusion through soft and hard tissues as compared to other local anesthetic agents. OBJECTIVE: The objective of the study is to evaluate the efficacy of 4% articaine (with 1:100,000 adrenaline) infiltrated only buccally in the extraction of maxillary premolars for orthodontic reasons. MATERIALS AND METHODS: A double-blind randomized clinical trial with a split-mouth design, where each patient (n = 100) was part of two groups, was conducted. Experimental Group 1: single buccal infiltration of 4% articaine with 1:100,000 adrenaline (Septanest™ with adrenaline 1:100,000 by Septodont). Control Group 2: routine buccal and palatal infiltrations of 2% lignocaine with 1:200,000 adrenaline (Lox™ 2% with adrenaline 1:200,000 by Neon). The parameters studied were time to onset of anesthesia, pain during the extraction procedure (not during the injecting of the local anesthetic), and frequency of extra amount of local anesthetic injected. RESULTS: The difference was not statistically significant (P > 0.05) between the two groups with respect to all three parameters. This proves that a single buccal infiltration of articaine can be used as an alternative to lignocaine for the extraction of the maxillary premolar teeth in most of the cases. CONCLUSION: This proves that a single buccal infiltration of articaine can be used as an alternative to lignocaine for the extraction of the maxillary premolar teeth in most of the cases.

The Pterygoid Hamulus Syndrome - An Important Differential in Orofacial Pain.

The purpose of this review was to document cases of pterygoid hamulus (PH) syndrome and to describe the various etiology, differential diagnosis, and management strategies so far reported in literature. Here, we also present two case reports of PH syndrome. A comprehensive search in PubMed/Medline database was done using MeSH terms such as "Pterygoid Hamulus," "Pterygoid Hamulus Syndrome," and "Hamular Bursitis" using various Boolean operators such as "AND" and "OR". Till date, 31 cases of this entity including the present cases have been found. Conservative management was followed in the earlier reported cases; however, most cases were treated by surgical resection.

Intraoperative Manipulation of Bony Segments: An Innovative Method.

INTRODUCTION: Various methods are deployed by an oral and maxillofacial surgeon to control the osteotomised/ fractured bony segments intraoperatively till the time a stable fixation in the desired position is achieved. Few of these include the use of bone holding crocodile forceps, towel clips, reduction forceps, wires, digital control (Thota and Mitchell in Br J Orthod 26(4):325, 1999). In our technique, we present the use of an IMF screw to manipulate bony segments intraoperatively. MATERIALS AND METHODS: We used this novel technique in a series of 12 patients. An IMF screw was fixed in the greatest bulk of the bony fragment so as to control it and hold it in the desired position in various surgical procedures. CONCLUSION: This technique was found to be minimally invasive and easy to perform to achieve a good hold and control of the bony segments.

Versatility of uniplanar prearthoplastic distraction osteogenesis in the correction of post-ankylosis facial deformities-a report of five different cases.

PURPOSE: Unilateral or bilateral ankylosis can lead to severe micrognathia and facial deformity that requires multiple, often, staged surgical corrections. To date, there is no ideal treatment modality that satisfactorily corrects the complex anatomy, restores the ramal height, and corrects the micrognathia and microgenia. Distraction osteogenesis has been acclaimed as a successful modality for the treatment of such deformities. It is a cost-effective approach with low morbidity and less relapse thus providing better functional and esthetic outcomes. It allows the surgeon to correct the deformity in various planes by using various devices by changing osteotomy designs and vectors, with simultaneous hard tissue and soft tissue reconstruction. PATIENTS AND METHODS: Here, we present a series of five cases where different types of distraction osteogenesis were combined with various other procedures to correct post-ankylotic facial asymmetry. In one case, simultaneous maxillo-mandibular distraction [Molina's technique] was used. RESULTS: All patients showed significant improvement in function and esthetics. Outcome assessment was made using clinical photographs and radiographs. CONCLUSION: Pre-arthroplastic distraction osteogenesis is a versatile cost effective approach that can be customized for every patient based on their needs.

Pre-arthroplastic mandibular distraction osteogenesis for the correction of OSA in TMJ ankylosis: a prospective observational study of 25 cases.

INTRODUCTION: In severe TMJ ankylosis cases, the lack of growth of the mandible creates an anatomically narrow airway with a reduced pharyngeal airway space [PAS] which predisposes these patients towards obstructive apnoea [OSA]. There is evidence in the literature that such patients experience severe discomfort during physiotherapy if such airway abnormalities are not corrected prior to ankylosis release. This eventually leads to non-compliance towards physiotherapy and increases the risk of re-ankylosis. OBJECTIVE: In our study, pre-arthroplastic mandibular distraction osteogenesis [DO] was used to increase the PAS and resolve the underlying OSA prior to releasing the ankylosis. MATERIALS AND METHODS: Twenty-five cases of TMJ ankylosis with micrognathia and OSA were included in this prospective observational sleep study. They were further divided into a paediatric group [14 subjects] and an adult group [11 subjects]. All cases presented with a history of onset of ankylosis during childhood [before the completion of craniofacial growth] as result of which there was a lack of forward growth of the mandible. Subjects included in our study underwent initial DO of the mandible followed by a second procedure for distractor removal and ankylosis release. Questionnaires, lateral cephalograms and sleep studies were taken pre-operatively (T0), immediate post-distraction to the desired length (T1) and 12 months post the distractor removal and ankylosis release (T2). The parameters studied were PAS width, apnoea hypopnea index [AHI], O2 saturation, mouth opening and mandibular advancement. RESULTS: The paediatric group variables were as follows: mean PAS width which increased from 3.5 mm [T0] to 9 mm [T2], mean AHI which decreased from 48.04 [T0] to 3.60 [T2], mouth opening which increased from 4.5 mm [T0] to 34 mm [T2] and mean O2 saturation which increased from 89.86% [T1] to 96.88% [T2]. The adult group variables were as follows: mean PAS width which increased from 5 mm [T0] to 11 mm [T2], mean AHI which decreased from 31.45 [T0] to 1.43 [T2], mouth opening which increased from 5 mm [T0] to 34 mm [T2] and mean O2 saturation which increased from 92.01% [T0] to 96.84% [T2]. Statistical analysis revealed that DO of the mandible significantly improved OSA by increasing the PAS which was evident by the lower AHI score. Mouth opening was also significantly improved post ankylosis release and maintained at the T2 interval. Ten subjects followed up beyond the T2 interval [mean 28 months post ankylosis release] and their data also revealed positive compliance towards physiotherapy, adequate mouth opening and maintenance of normal AHI. CONCLUSION: Pre-arthroplastic mandibular DO has proved to be a successful modality for treatment of OSA in TMJ ankylosis patients with stable results at 12 months. By resolving the narrow airway and OSA, compliance towards physiotherapy was improved thus reducing the risk of re-ankylosis in the long term.

To determine the efficacy of ultrasonography in the evaluation of bone fill at the regenerate site for mandibular distraction osteogenesis over clinical and radiographic assessment- An in vivo prospective study.

Until date conventional radiographs and computed tomography are the preferred diagnostic modalities to monitor the distraction osteogenesis regenerate. But these techniques do not detect the ongoing osteogenic process; moreover they obligate the patient to serial radiation exposure. In addition, anatomic overlap and metal artifacts obscure the virtual findings. In contrast, ultrasound is a noninvasive, efficient and an inexpensive way to evaluate bone healing. This study was conducted to test the efficacy of ultrasound in evaluating bone healing at the mandibular distraction site. Twenty patients underwent mandibular distraction. The wounds were assessed with an orthopantomograph and an ultrasound at the end of latency, mid distraction, end of distraction and post distraction periods i.e. 6 weeks, 8 weeks and 4months. Estimates of bone formation, using a semiquantitative radiological, ultrasonographic and intraoperative surgical bone fill scores were made. The correlation between intraoperative and ultrasonographic bone fill scores was statistically significant at 0.602, a total of 26 of the 31 sites correlated. Corresponding correlation between intraoperative and radiographic bone fill scores was 0.332, and only 13 of the 31 sites correlated. The results indicate that ultrasound is potentially an accurate noninvasive technique that is most useful in assessing the mandibular distraction regenerate.

Arch bars in the mouth for 17 years - A case report.

Arch bars are commonly used in maxillofacial surgery but their intraoral presence for an extremely long period is quite uncommon or rare. So when such a patient reports and denies having any complaints all these years, the question that presents is, how is this possible? What kept the patient so long? A review of the existing literature shows, despite being common in trauma care, failure to follow-up has not received the due attention. This study retrospectively reviews the various factors implicated for failure to follow-up and the proposed corrective measures. The objective is to identify such potential patients beforehand thereby facilitating efficient trauma care.

Adult Rhabdomyoma of the Tongue in a Child: Report of a Case and a Literature Appraisal.

Rhabdomyoma, by definition is a benign muscle tumour.. Rhabdomyomas constitute 2% of all myogenous neoplasms. This tumour is in incongruence with other benign soft tissue tumours, in that it is rarer than its malignant counterpart. They are broadly categorised as cardiac and extra-cardiac. Three different subtypes exists as 1) the adult type, 2) the fetal type and 3) the genital type, the adult type being the most common.[1] AR (Adult Rhabdomyoma) generally occurs in the 4th and 5th decade with a male predilection.[2] There have been very few presentations of this lesion in the paediatric age group. Here we present a case of lingual adult rhabdomyoma in an 11 year old girl.

Low-dose methotrexate in rheumatoid arthritis: a potential risk factor for bisphosphonate-induced osteonecrosis of the jaw.

Bisphosphonate-induced osteonecrosis of the jaw [BIONJ] is a relatively new pathological condition which was first described in the year 2003. The prevalence of BIONJ in patients on oral formulations is around 0.05% within the first 3 years and increases up to 0.2% after 4 years of consumption. Proven systemic risk factors like anemia, uncontrolled diabetes, corticosteroid therapy, and chemotherapy in neoplastic diseases [e.g., high doses of methotrexate up to 30 mg daily] significantly increase the chances of acquiring BIONJ. We present three patients with osteoporosis and rheumatoid arthritis [RA] who consumed oral bisphosphonates [alendronate] for less than 1 year and developed BIONJ within 2 to 5 months of undergoing a traumatic dental procedure. The patients also gave a history of consuming low doses of methotrexate [disease-modifying anti-rheumatic drugs] up to 20 mg weekly for 4 to 10 years. No history of steroid consumption was given by any of the patients. This case series highlights the possibility of rheumatoid arthritis and low-dose methotrexate being potential risk factors for BIONJ. This may be on account of the synergistic effect of methotrexate and bisphosphonates and the pro-inflammatory state created by RA which increased the risk of acquiring BIONJ.

Inflammatory myofibroblastic tumour: A case report and a clinical update.

The Inflammatory myofibroblastic tumor (IMT) is a heterogeneous group of rare lesions consisting predominantly of inflammatory cells and myofibroblastic spindle cells. Head and neck IMTs account for 14 to 18% of extra-pulmonary IMTs [lungs being the most commonly affected regions]. On account of its ambiguous clinical presentation, an IMT needs to be differentiated from other infectious, granulomatous, autoimmune and neoplastic lesions on the basis of histopathologic findings and immunohistochemical analysis. In this article, we report a case of IMT that presented in the anterior mandible that was treated by peripheral resection. Follow-up at 1 year showed satisfactory healing and no signs of recurrence. A special emphasis has been placed on the disputed nosology of this lesion and the latest therapeutic modalities.

Melanotic neuroectodermal tumour of infancy - A rare entity.

Melanotic neuroectodermal tumour of infancy (MNTI) is rare, rapidly growing, pigmented neoplasm of neural crest origin. It is generally accepted as a benign tumour despite of its rapid and locally destructive growth. It primarily affects the maxilla of infants during the first year of life. Surgical excision is considered as the treatment of choice. The recurrence rate varies between 10% and 15%, and malignant behaviour has been reported in 6.5% of cases. We report a case of MNTI, associated with an erupted primary tooth in a 5-month-old male child. We discuss the clinical, radiographic and histologic features of this rare tumour, as well as its surgical management and the follow-up.