Versatility of Transport Distraction Osteogenesis for Reconstruction of Lateral Mandibular Ablative Defects.

Introduction: The reconstitution of form and function after maxillofacial tumor resection or traumatic bony defects is a challenge when considering reconstructive options. The reconstructive options will depend upon whether the tissues to be replaced included bone alone or both bone and soft tissue (composite resection). Methodology: This study was carried out on nine patients who with benign tumors or cysts of the mandible that required segmental resection. Mandibular reconstruction using mandibular transport distraction osteogenesis was performed for all the cases. Depending on whether the condyle was spared or sacrificed, the type of mandibular transport distractor either fixed on the remnant condyle-ramus unit or had a condylar component replacing the resected condyles. Depending on the location of the defect, transport distraction was carried our anterior to posterior or posterior to anterior. Results: A total of nine cases of benign mandibular pathologies were operated. Segmental resection with condylar preservation was carried out in seven cases, segmental resection with condylar resection was carried out in two cases. In cases with condylar resection, the reconstruction plate of the distractor device had a condylar component. Anterior to posterior transport distraction was carried out in seven cases, and posterior to anterior transport distraction carried out in two cases. The amount of distracted bone ranged from 38 to 46 mm. Conclusion: Mandibular transport distraction osteogenesis offers a modality of reconstruction where the patient's native host bone is osteotomized and gradually distracted to induce the formation of regenerated osseous structure and soft tissue. Being cost-effective, not requiring a steep learning curve/long operative time, and not technically demanding as vascularized bone grafts/flaps, it is feasible in the Indian setup as a practical reconstructive option for benign jaw tumors.

The Anatomical Basis for Plate Fixation in BSSO to Minimize Condylar Torquing: A Comparative CT Study of Mandibular Advancement and Setback.

INTRODUCTION: Condylar displacement after bilateral sagittal-split osteotomy (BSSO) occur in the sagittal plane as clockwise/counter-clockwise rotation of the ramus, in the coronal plane as medial/lateral inclination, or in the axial plane as medial/lateral condylar torquing. The purpose of this prospective CT study was to evaluate the role of plate fixation in minimizing condylar torquing or rotational changes in the axial plane. MATERIALS AND METHODS: This prospective study was carried out on 26 patients, 13 of whom underwent advancement BSSO and 13 setback BSSO, without maxillary LeFort I osteotomies. All mandibular movements were symmetrical. Fixation of the osteotomized segments was achieved with a single 4-hole plate and monocortical screws. In case of mandibular setbacks, a straight plate was used, whereas an inset-bent plate was used for advancements. Computed tomography scans were obtained preoperatively and postoperatively to measure condylar rotation or torqueing in the axial plane. An increase in condylar angle on axial slices was considered as lateral condylar torquing, whereas a decrease was considered as medial condylar torquing. RESULTS: A mean medial condylar torquing of 0.2° was noted postoperatively in case of setbacks (p > 0.05 not significant). This suggested minimal condylar torquing, indicating that the proximal and distal segments maintained contact at the anterior vertical osteotomy fixed with a straight plate. In case of advancements, a mean lateral condylar torquing of 2.2° was noted postoperatively (p < 0.005, highly significant). This suggested that the proximal segment flare at the anterior vertical osteotomy site was maintained by inset-bent plate fixation. CONCLUSION: The gaps between the proximal and distal segments created by mandibular advancement and setback should be maintained. An attempt to close these gaps, especially in mandibular advancement, will result in an unfavourable axial condylar torque. Consequently, the areas of bony contact between the proximal and distal osteotomy sites created by mandibular advancement and setback should be maintained as well.

Utility of the Midface Degloving Approach for Extended Exposure in Maxillary Pathologies.

INTRODUCTION: A generous exposure of the midface region is essential for a comprehensive and thorough execution of midface surgical procedures, especially bilateral procedures. Traditional approaches to the midface the midface like the lateral rhinotomy and Weber-Fergusson/Dieffenbach incision with their modifications leave a visible scar, and they are limited in their unilateral exposure. The midface degloving approach with its exclusive intranasal and intraoral incisions leaves no external scars and lends excellent bilateral exposure of the maxilla, zygoma, paranasal areas and infraorbital margins from one side to the other. The midface degloving approach is mainly used to expose pathologies of the maxilla, nasal cavities, paranasal sinuses, nasopharynx, and the central compartment of the anterior and middle cranial base. This approach can also be used to treat midface trauma and perform high-level osteotomies. MATERIALS AND METHODS: We describe the midface degloving procedure for nine cases operated in the Department of Oral and Maxillofacial Surgery over a period of 7 years (2012-2018): seven maxillary tumors and two maxillary cysts. RESULTS: We obtained excellent exposure for all the cases using this approach. Complications included mild distortion of the lower lateral nasal cartilages and oro-nasal communication. CONCLUSION: The midface degloving approach lends excellent surgical access to the midfacial skeleton including the maxilla, the paranasal areas, the maxillary sinus, the zygoma, and infraorbital rims. The advantages of this approach besides its generous exposure, is the excellent cosmesis it provides leaving no external scars.

Comparison of primary and secondary closure with a buccal mucosal-advancement flap on postoperative course after mandibular impacted third molar surgery.

PURPOSE: The purpose of this study was to compare primary and secondary wound closure with a buccal mucosal-advancement flap technique on the postoperative course after mandibular impacted third molar surgery. METHODS: The study was conducted on 150 patients who required surgical removal of impacted mandibular third molars under local anesthesia. The study subjects were divided into three groups of 50 patients each, based on the type of closure over the third molar socket. Patients in group I underwent primary closure of the socket with hermetic suturing of the flap, including the vertical release. In group II, a secondary closure was performed, leaving the socket communicating with the oral cavity. In group III, a buccal mucosal-advancement flap technique was employed to achieve primary closure of the flap over the socket while leaving the anterior vertical release, generously patent. All the patients were assessed for pain using the visual analogue scale (VAS), swelling, and mouth opening at postoperative intervals of 2, 4, and 7 days. The wound healing was assessed on day 7. RESULTS: Patients in the buccal mucosal-advancement flap group had significantly less pain and swelling and increased mouth opening compared with primary and secondary closure. Wound dehiscence was seen in 18 patients and alveolar osteitis in 4 patients in primary closure. Delayed wound healing with food accumulation was seen in 6 patients in secondary closure. No complications of flap dehiscence or breakdown were observed in the buccal mucosal-advancement flap group. CONCLUSION: This study concludes that the buccal mucosal-advancement flap technique was a superior closure technique with less pain, swelling, trismus, and satisfactory wound healing compared with both primary and secondary closure after mandibular third molar surgery.

Zygomaticomaxillary "lateral swing" osteotomy for augmentation of midface deficiency.

INTRODUCTION: Various surgical modalities have been proposed for the augmentation of midface deficiency without correction of the occlusal component. They include autogenous bone and cartilage grafts, alloplastic materials, and osteotomies. We propose an innovative osteotomy technique for augmentation of the midface including the infraorbital rims, the zygoma, the anterior maxillae, and the paranasal areas without advancing the dental-bearing segment. MATERIALS AND METHODS: This procedure was carried out on a 21-year-old male patient who had a deficiency of the anterior maxillae including the infraorbital rims. His occlusion was in Class I molar relation. The surgical exposure was carried out through a midface degloving approach. This bilateral osteotomy encompasses the anterior maxillae and the zygoma; the osteotomy line running superiorly from the medial aspect of the infra-orbital rim to the root of the frontal process of maxilla. Inferiorly, the line runs above the apices of the maxillary teeth laterally underneath the zygomatic buttress, separating part of the zygomaticomaxillary suture posteriorly. Medially, the osteotomy line runs parallel to the piriform aperture. The osteotomy is pedicled on the zygomaticotemporal suture. A greenstick fracture at the zygomatic arch pedicled the osteotomized segment to the zygomatic process of the temporal bone. The entire segment was swung laterally outward, effectively separating part of the zygomaticomaxillary suture posteriorly. Fixation was achieved with a single 2-mm L-shaped, 4-hole plate with gap at the zygomatic buttress region. RESULTS: This osteotomy technique resulted in fullness of the anterior maxillae and infraorbital rims, with increased anterior and lateral projection of the zygoma. CONCLUSION: The zygomaticomaxillary "lateral swing" osteotomy is a reliable and stable technique for total midface augmentation not requiring occlusion correction.

Disc Anchoring with an Orthodontic Mini-Screw for Chronic Meniscocondylar Dislocation of TMJ.

INTRODUCTION: Various surgical modalities have been tried for the correction of chronic recurrent dislocation of the temporomandibular joint. However, most of these techniques are aimed at creating an artificial block or removing any interference in the path of the translating condyle. Chronic dislocation can also be classified as meniscotemporal and menisocondylar, depending upon whether the dislocation occurs between the condyle-disc unit and temporal bone (meniscotemporal), or between the disc and condyle (meniscocondylar). Very few procedures address the primary issue of a malpositioned disc, which is the cause of meniscocondylar dislocation. MATERIALS AND METHODS: This study was conducted on 17 patients (27 joints) who reported with chronic dislocation of the temporomandibular joint, with MRI-proven meniscocondylar dislocation. After exposure of the condyle and disc through a standard pre-auricular incision, an orthodontic mini-screw was fixed to the posterior aspect of the condylar head and a 1-0 Prolene suture passed through the screw-head eyelet, plicating the posterior edge of the disc to the condyle. This ensured that the condyle and disc would move in unison. RESULTS: All the patients showed improvement in their symptoms of dislocation in the postoperative period, including seven patients in whom only a unilateral procedure was carried out. None of the patients had any recurrence till the 1-year followup. CONCLUSION: Our procedure addresses the fundamental etiology of meniscocondylar dislocation by anchoring the disc to the condyle by using an orthodontic mini-implant and correcting the condyle-disc disharmony. This technique is reliable, technically feasible, and cost-effective in the Indian set up.

Relative risk for concussions in young female soccer players.

The objective of this study was to determine the relative risk and reported symptoms of concussions in 11- to 13-year-old, female soccer players. For this, a survey to compare the reported incidence of concussion in age-matched female soccer players to nonsoccer players was performed. The survey included 342 girls between the ages of 11 and 13: 195 were involved in an organized soccer team and 147 were not involved in organized soccer but were allowed to participate in any other sport or activity. A total of 94 of the 195 soccer players, or 48%, reported at least one symptom consistent with a concussion. The most prevalent symptom for these girls was headache (84%). A total of 34 of the 147 nonsoccer players, or 23%, reported at least one symptom consistent with a concussion in the previous six months. These results determined that the relative risk of probable concussions among 11- to 13-year-old, female soccer players is 2.09 (p < .001, α = .05, CI = 95%). This demonstrates that the relative risk of probable concussions in young female soccer players is significantly higher than in a control group of nonsoccer players of the same sex and age.