Use of T.M.J. Disc as a Soft Tissue Interpositional Graft Material for Functional Rehabilitation of Ankylosed T.M. Joint

Introduction

Many surgical techniques have been described for the treatment of TMJ ankylosis, but no strategy has been uniformly agreed upon underscoring the difficulty of the problem. Despite new guidelines and updated methods, treating patients with TMJ Ankylosis remains a challenge as the incidence of recurrence after treatment is soaring. This study exemplifies our experience in using an unsullied method to treat TMJ Ankylosis to restore the structure of TMJ in conjunction with convalescing secondary maxillofacial deformity.

Materials and Methods

A total of 56 cases of unilateral bony TMJ ankylosis were included in the study, and postoperative results of T.M.J disc as a soft tissue interposition graft was evaluated. The operative protocol comprised of (1) resection of ankylotic mass, (2) intraoral ipsilateral coronoidectomy or contralateral coronoidectomy when needed, (4) interpositioning disc as soft tissue graft, (5) interposing and fixing sternoclavicular or costocondral graft with lag screws and (6) early mobilization, aggressive physiotherapy.

Results

The study assessed patients with regular follow‐up checks for a period of 3 years. The average preoperative mouth opening was found to be 5.46 mm (range 2–10 mm). Mean post-operative mouth opening was 33.05 mm (range 24–43 mm), while 3 years post operative mouth opening (mean) was 39.75 mm. No cases of reankylosis were reported during this period suggesting it as a viable and satisfactory approach.

Conclusion

The use of TMJ disc as a soft tissue interpositional graft material is an effectual method for functional rehabilitation of ankylosis cases and serves as an effective means of preventing recurrence.

     

Treatment of intrabony defects with guided tissue regeneration in aggressive periodontitis: clinical outcomes at 6 and 12 months

Objective

The aim of this study was to compare clinical outcomes between guided tissue regeneration (GTR) and access flap (AF) surgery in patients with aggressive periodontitis (AgP).

Methods

Eighteen AgP patients with similar bilateral intrabony defects were treated in this split-mouth, single-blinded, randomised, controlled clinical trial. All patients presented with ≥3 mm intrabony defects and ≥5 mm periodontal pocket depths (PPD). In each patient, one defect was treated with a polyglycolide membrane according to the GTR principle, whereas the contralateral side was treated with AF. For both sides, a simplified papilla preservation flap was used. At baseline, 6 and 12 months post-surgery, the clinical attachment levels (CAL) and PPD were evaluated.

Results

At 6 and 12 months, at the GTR sites, the mean [95 % CI] CAL gain was 1.7 mm [1.1, 2.3] and 1.6 mm [0.9, 2.1], respectively, while the mean [95 % CI] PPD reduction was 2.3 mm [1.9, 2.8] and 2.4 mm [1.9, 2.8], respectively. Similar CAL (1.6 mm [1.0, 2.2] and 2.1 mm [1.4, 2.7]) and PPD (2.0 mm [1.5, 2.4] and 2.5 mm [2.0, 3.0]) outcomes were observed at the control sites at 6 and 12 months, respectively. Notably, at the GTR-treated sites, 13 subjects presented with various degrees of membrane exposure.

Conclusions

Both therapies were effective in the treatment of intrabony defects in AgP patients, and no statistically significant differences between them could be demonstrated, possibly as a result of the differing degrees of membrane exposure at the GTR sites.

Clinical relevance

Both periodontal regeneration and conventional periodontal surgery are effective treatments for AgP patients.

     

Immediate versus delayed aggressive physical therapy following buccal fat pad interposition in oral submucous fibrosis—a prospective study in Central India

Purpose

Oral submucous fibrosis is a disease of an Indian subcontinent with obscure aetiology and poorly treated with varying signs and symptoms. OSMF occurs at any age but is most commonly seen in teenagers and adults in the age ranging between 16 and 35 years. A number of surgical treatments have been used for the treatment of oral submucous fibrosis with unpredictable results.

Patients and method

In this study, 220 patients were randomly divided into two groups with mouth opening less than 16 mm and evaluated with immediate and delayed aggressive physiotherapy with buccal fat pad interposition after fibrotomy. Group A (n = 110) patients underwent aggressive mouth opening exercise from the next postoperative day while in group B (n = 110), patients underwent physiotherapy 7th day postoperatively. Pain and discomfort, mucosalization, infection, flap dehiscence and necrosis were noted. Patients were followed for 1 year on a regular interval basis.

Results

At the end of 1-year follow up, the post-operative mean mouth opening in group A was 38.63 mm and 34.19 mm in group B. In group A, the immediate physiotherapy results in mild to moderate pain and discomfort to the patients as compared to no apparent pain in the group B. The mean mucosalization time in group A and group B was 4.2 and 5.1 weeks, respectively. Postoperatively, all patients achieve satisfactory mouth opening.

Conclusion

Immediate aggressive physiotherapy yields a comparatively superior result than delayed physiotherapy with respect to mouth opening in 1 year of follow-up.

     

Myositis ossificans traumatica of the temporalis muscle: a case report and diagnostic considerations

Background

The present paper reported the case of a trauma-related myositis ossificans, with focus on considerations for a differential diagnosis process.

Case report

A 50-year-old male with a severe painful limitation (12 mm) of jaw opening referred a trauma to the right temporomandibular joint (TMJ) area occurring about 40 days before. Posttraumatic TMJ ankylosis was ruled out on the basis of negative magnetic resonance and cone-beam computerized tomography findings, and the patient underwent treatment with arthrocentesis, botulinum toxin injections, and physiotherapy on the basis of two diagnostic hypotheses, viz., an anchored disk phenomenon or a myofibrotic contracture of the right masseter muscle due to prolonged myospasm. After 4 months, jaw opening was slightly increased to 23 mm, but limitation and pain persisted. A new CT was performed to investigate for the emerging clinical picture compatible with traumatic myositis ossificans of the right temporalis muscle. Once the diagnosis was confirmed, the patient underwent surgery for coronoidectomy. At the 6-month follow-up, mouth opening was increased to up to 35 mm and pain was absent.

Discussion

It is fundamental that patients suspected of having uncommon clinical pictures leading to mouth opening restriction are promptly referred to specialized centers, where the differential diagnosis process should be based on a comprehensive assessment taking into account for the potential etiologic factors described in the literature.

     

Outcome of amniotic membrane as an interpositional arthroplasty of TMJ ankylosis

Purpose

Temporomandibular joint ankylosis is a major disorder, mainly due to trauma and other reasons, which is responsible for the restriction of mandibular functional activities. The scope of the successful surgical correction of temporomandibular joint ankylosis with amniotic membrane is on the membrane’s being an interpositional material which we found not to elicit any host reaction, is capable of functional adaptation, and is very economical. Our purpose is to show the amniotic membrane as a suitable, biocompatible, and interpositional material alternative to the other materials, thereby reducing donor site morbidity.

Methods

A study was conducted in 13 patients with an age range of 10 to 35 years with unilateral and bilateral bony TMJ ankylosis confirmed by clinical and radiological evaluations. Preoperative and postoperative clinical assessments of TMJ functions were done. Amniotic membranes were collected from the tissue bank, sterilized by gamma radiation, and freeze-dried. Then, the prepared amniotic cap (10–15 layers of amniotic membrane) was placed over the condylar head and anchored loosely to the neck and the surrounding tissues with a 3/0 Vicryl suture.

Results

Measurements of postoperative maximum interincisal opening was taken with scale among the 13 patients. Preoperative interincisal distances ranged from 0 to 15 mm, and preoperative and immediate postoperative were 33–45 and 25–32 mm, respectively. Postoperative follow-up of interincisal opening after 1-, 6-, and 12-month intervals was found from 32 to 35 mm. Lateral excursions (left and right), protrusive movements, and functional recovery were all satisfactory.

Conclusion

Amniotic membrane graft as an interpositional material in temporomandibular joint ankylosis can be a good alternative as to prevent reankylosis and recover functionality.

     

Three-dimensional evaluation of the pharyngeal airway using cone-beam computed tomography following bimaxillary orthognathic surgery in skeletal class III patients

Objective

The study aims to evaluate the pharyngeal airway space (PAS) following bimaxillary surgery in skeletal class III patients and to compare the changes in PAS between genders using cone-beam computed tomography (CBCT).

Materials and methods

In all, 38 patients (16 male and 22 female) with skeletal class III malocclusion underwent bimaxillary surgery. CBCT scans were acquired approximately 1 month before surgery, 3 months after surgery, and 6 months after surgery. The oropharyngeal volume and the minimum cross-sectional area (CSA) were characterized using the InVivoDental imaging software package at each time point.

Results

The volume and minimum CSA decreased significantly postoperatively, which was maintained until 6 months postoperatively (p < 0.01). The location of the minimum CSA tended to move into the retropalatal and retroglossal areas postoperatively. A strong correlation between volume and minimum CSA was found. The amount of mandibular setback was not correlated with the change in the airway. By gender, significant decreases in both the volume and minimum CSA were found in females (p < 0.05) but not in males.

Conclusion

Bimaxillary surgery significantly affects PAS. Gender differences should also be considered when considering changes in PAS.

Clinical relevance

An awareness of the effects of bimaxillary setback surgery on the airway should be considered when implementing an orthognathic treatment plan.

     

Re-Assessment of Coronoid as a Graft for Condylar Reconstruction in TMJ Ankylosis Patients: A Prospective Study and Literature Review

Introduction

Treatment for TMJ ankylosis aims at restoring joint function, improving the patient’s aesthetic appearance and quality of life and preventing re-ankylosis. To rebuild a structurally and functionally satisfactory neocondyle is a challenging problem. Aim of this study is to re-assess the coronoid as a graft for condyle reconstruction.

Materials and Methods

Twenty patients of TMJ ankylosis without involvement of the coronoid process in ankylotic mass, coming in age group elder than 14 years were selected for the study over a period 3 years from 2011 to 2014. Clinical examination, radiographs, and photographs were used postoperatively to evaluate the grafts and TMJ function. After osteoarthrectomy coronoid process was detached and fixed with a 4 hole L-shaped titanium miniplate to form neo condyle.

Result

No donor site morbidity was observed as reported with other autogenous grafts. Satisfactory mouth opening was observed during follow up period with mean mouth opening 37.33 ± 4.20 mm except one case which required graft removal due to postoperative infection. Radiographically moderate amount of resorption of grafted coronoid process was observed in nearly all the cases however satisfactory mandibular function and occlusion was observed.

     

Where to position osteotomies in genioglossal advancement surgery based on locations of the mental foramen,canine, lateral incisor,central incisor,and genial tubercle

Purpose

The study aimed to provide precise measurements of anterior mandibular structural anatomy and to explore potential osteotomies for genioglossal advancement.

Methods

Cone beam computed tomography was used to analyze 33 randomly selected patients undergoing surgery for obstructive sleep apnea (OSA) between 2014 and 2016 at an academic surgical hospital. The locations of relevant mandibular structures were measured and statistical modeling was performed.

Results

Mean horizontal distances from midline to the mental foramina and the roots of the canine, lateral incisor, and central incisor were 22.11 ± 1.92, 13.56 ± 3.01, 6.19 ± 1.58, and 2.04 ± 0.87 mm, respectively. Mean vertical distances from the inferior border of the mandible were 15.15 ± 1.77, 17.11 ± 3.28, 20.48 ± 3.10, and 21.81 ± 3.49 mm, respectively. The superior border of the genial tubercle was 15.63 ± 2.75 mm, and the inferior border was 6.87 ± 3.29, from the inferior border of the mandible. The angle of decline of the best-fit line through the important structures was about 18° from the occlusion plane at the midline.

Conclusions

A straight line estimating the mental foramen, canine, lateral incisor, and central incisor tooth roots crosses at a mean of 22.3–22.6 mm above the inferior border of the mandible at the midline and has an angle of decline of about 18°. Potential osteotomies made parallel to and below this line result in tradeoffs between maximizing capture of the genioglossus muscle attachment and risk of dental/neurovascular injury.

     

A new approach to treat bone gaps after midfacial and zygomatic fractures with a collagen membrane

Purpose

The aim of the study was to analyze the eligibility of resorbable collagen membrane in the treatment of midfacial fractures to prevent gap formation and subsequent cheek tissue retraction.

Material and methods

We included nine patients (six males, three females; mean age 51; range 20–73 years; mean bone gap size 8.03 × 13.12 mm) in a retrospective study design. The defect size was assessed by ultrasound.

Results

After a healing period of 4 to 55 weeks, treatment resulted in a significant reduction of gap size (residual mean bone gap size 6.14 × 7.32 mm).

Conclusions

Native resorbable collagen membrane is a promising tool to reduce the size of bony gap in midfacial defects.

     

Intermittent or continuous ultrasonically activated irrigation: micro-computed tomographic evaluation of root canal system cleaning

Objectives

The aim of this study was to evaluate the efficacy of two passive ultrasonic irrigation (PUI) methods and conventional manual irrigation (CMI) in root canal system (RCS) cleaning.

Materials and methods

Artificial single-rooted teeth were used. Four lateral canals were made 2 and 7 mm short from the apex. Root canals were filled with a contrast solution. The specimens were divided into four groups (n = 8): PUI1—intermittent flushing; PUI2—continuous flushing; CMI1—at 1 mm; and CMI2—at 3 mm. Micro-computed tomographic images were obtained. New images were taken after the irrigation protocols enabling the evaluation of the contrast solution volume (in mm³) within RCS (main and lateral root canals) in comparison to the initial analysis. The comparison among groups was performed using ANOVA and Tukey’s tests with 5 % significance level.

Results

There was no difference among PUI1, PUI2, and CMI1 regarding the contrast solution removal from RCS (p > 0.05). These methods demonstrated greater cleaning than CMI2. At the apical third, CMI2 showed lower cleaning capacity when compared to the other methods (p < 0.05).

Conclusions

PUI with intermittent or continuous flushing and CMI with the needle placed 1 mm from the working length were efficient in cleaning the main and lateral root canals.

Clinical relevance

Root canal irrigation plays an important role in cleaning and disinfection of the RCS. Effective apical irrigation is an important procedure during root canal treatment. PUI and CMI (at 1 mm short) were effective in cleaning of the main and simulated lateral root canals.

     

A Giant Plunging Sublingual Dermoid Cyst Excised by Intraoral Approach

Objective

Dermoid and epidermoid cysts are rare cysts of the head and neck region, which should be considered in differential diagnosis of sublingual mass, constituting 0.01 % of all oral cavity cysts. There are suspected theories regarding the basis of the pathology.

Case Report

30-year-old male referred to our clinic with a chief complaint of sublingual mass which had been present for many years but the lesion enlarged over the past 3 years. MRI examination revealed a giant cystic mass which was 3.6 × 3.9 mm in diameter and medially located at sublingual region.

Treatment and Prognosis

Intraoral approach was preferred for surgery and no recurrence or complaints were detected during follow-up period.

Conclusion

When a cystic mass is detected on the floor of oral cavity, we must consider dermoid cysts for differential diagnosis. Surgery is the only treatment. If possible, intraoral approach should be preferred because of its perfect cosmetic results.

     

Comparison of two electronic apex locators on human cadavers

Objective

The aim of this study on human cadavers was to compare the accuracy of two electronic apex locators (EALs) Dentaport ZX (J. Morita Corporation, Tokyo, Japan) and Raypex 6 (VDW, Munich, Germany).

Materials and methods

Twenty-two single rooted teeth of four human cadaver heads were scheduled for this study. Before the extraction, an access cavity was opened and the crown was cut to establish a stable reference point for all measurements. The working length determination was performed with Dentaport ZX and Raypex 6 in the presence or not of 5.25 % sodium hypochlorite (SH) using a k-file 10. The teeth were then extracted and the real working length (RWL) was measured under a stereomicroscope at ×30 magnification. The difference between the two working lengths was calculated: positive values indicate measurements exceeding the foramen, while negative values indicated measurements short of the foramen. The data were analyzed with a t test analysis.

Results

The mean of distances was 0.33 ± 0.20 mm and 0.32 ± 0.2 mm for Dentaport ZX respectively in the presence or not of SH and 0.38 ± 0.20 mm and 0.39 ± 0.19 mm for Raypex 6. No statistical differences were found between the two devices (p > 0.05).

Conclusions

Both apex locators showed a high accuracy in the presence or not of SH.

Clinical relevance

Both electronic apex locators can be recommended for clinical use and their accuracy is not affected by SH.

     

Effect of Alveolar Segmental Sandwich Osteotomy on Alveolar Height: A Preliminary Study

Purpose

Bone loss following extraction is maximum in horizontal dimension. Height is also reduced which is pronounced on the buccal aspect. Various surgical procedures are available to correct the bone volume viz. GBR, onlay bone grafting, alveolar distraction and sandwich osteotomy. Sandwich osteotomy has been found to increase the vertical alveolar bone height successfully.

Objectives

The objective of the study was to assess the effect of alveolar segmental sandwich osteotomy on alveolar height and crestal width.

Materials and Methodology

A prospective study was undertaken from December 2012 to August 2014. Seven patients with 12 implant sites with a mean age of 36 years were recruited. All seven patients with 12 implant sites underwent alveolar segmental sandwich osteotomy and interpositional bone grafting. Alveolar bone height was assessed radiographically preoperatively, immediate post-op, and at 3 months post-op. Alveolar bone width was assessed radiographically preoperatively and at 3 months post-op. Statistical significance was inferred at p < 0.05.

Results

The mean vertical augmentation at immediate post-op was 6.58 mm (p = 0.001). The vertical augmentation that was achieved 3 months post-op was a mean of 3.75 mm which was statistically significant (p = 0.004). The change in alveolar height from immediate post-op to 3 month post-op was a mean 1.69 mm. The mean change in alveolar crestal width at 3 months was a mean of ?0.29 mm (p = 0.57).

Conclusion

Sandwich osteotomy can be used as an alternative technique to increase alveolar bone height prior to implant placement. Moderate alveolar deficiency can be predictably corrected by this technique.

     

Surgical defect coverage in oral submucous fibrosis patients with single-stage extended nasolabial flap

Purpose

Long standing oral submucous fibrosis (OSMF) is associated with involvement of the oral submucosa and the muscles of mastication leading to difficulty in mouth opening. Various surgical modalities are mentioned for release but each has its own limitations. The aim of the study was to evaluate the postoperative mouth opening in patients of OSMF after excision of fibrous bands followed by coronoidotomy and surgical defect coverage by extended nasolabial flap.

Methods

We evaluated the use of extended nasolabial flaps and coronoidectomy in the management of 11 randomly selected patients with histologically confirmed oral submucous fibrosis. They all had interincisal opening of less than 25 mm and were treated by bilateral release of fibrous bands, coronoidectomy or coronoidotomy, and extended grafting with a nasolabial flap.

Result

Their interincisal opening improved significantly from a mean of 8.68±7 mm to a mean of 36.75±4.05 mm at 6-month follow-up.

Conclusion

The procedure was effective in the management of patients with oral submucous fibrosis, the main disadvantage being the extraoral scars.

     

A preliminary study on plasma concentration achieved following intrapterygomandibular space injection of dexamethasone as a route of drug delivery with lignocaine inferior alveolar nerve block–correlation of clinical effects

Purpose

To determine the quantity of dexamethasone plasma concentration achieved following intrapterygomandibular space injection of dexamethasone when co-administered with inferior alveolar nerve block correlating with the clinical effects in the postoperative phase.

Objective

A preliminary prospective study to evaluate the dexamethasone plasma concentration achieved following intrapterygomandibular space injection of dexamethasone with 2% lignocaine inferior alveolar nerve block to achieve hemi-mandibular anesthesia for minor oral surgical procedures and derive clinical correlations.

Background

Dexamethasone is a glucocorticoid, chiefly used for the management of postsurgical sequelae like trismus and swelling in maxillofacial surgical practice. Conventionally, parenteral dexamethasone is administered via intravenous or intramuscular route. Intrapterygomandibular space injection is a novel route of steroid delivery described in literature. For minor oral surgical procedures in maxillofacial surgical practice requiring inferior alveolar nerve block, dexamethasone can be administered along with local anesthetic through a single injection as a mixture (twin mix).

Methods

Prospective double-blind randomized clinical trial was designed to evaluative plasma concentration of dexamethasone achieved following injection of a freshly prepared mixture of 1.8 ml of 2% lignocaine with adrenaline (1:200000) and 1 ml (4 mg) dexamethasone [2.8 ml solution of twin mix] in the pterygomandibular space. The 30 candidates included for the trial were randomly split into three study groups (ten each)—(1) control group (C); (2) intramuscular group (IM); (3) intraspace group (IS).

Results

The mean plasma dexamethasone concentration at 30 min postinjection in group IM was 226.41?±?48.67 ng/ml and for IS group it was 209.67?±?88.13 ng/ml. Post hoc (Bonferroni-Holm test) intergroup comparison for plasma dexamethasone concentration (IM and IS) was found statistically insignificant (P?=?0.605).

Conclusion

Intraspace route of drug administration can be utilized to deliver dexamethasonized local anesthetics safely with predictable clinical effects in the patients requiring mandibular minor oral surgery under local anesthesia.

     

Accuracy of two-dimensional pharyngeal airway space prediction for bimaxillary orthognathic surgery

Purpose

The aim of this retrospective study was to evaluate the accuracy of two-dimensional (2D) virtual surgical planning (VSP) of pharyngeal airway space (PAS) in patients submitted to bimaxillary orthognathic surgery.

Methods

This study was conducted with lateral cephalograms acquired through cone-beam computed tomography records of 33 patients, divided into group 1—patients submitted to maxillary advancement and mandibular setback (n?=?17) and group 2—patients submitted to maxillomandibular advancement (n?=?16). Records were taken 1 to 2 months prior to surgery, which was used to perform the 2D VSP (T_p), and 6 to 8 months after surgery (T₁). In Dolphin Imaging software, the anteroposterior size of the PAS was calculated at the level of four craniometric points: A, occlusal plane (Mx), B, and pogonion (Pog). Two previously calibrated examiners performed these measurements. Statistical analyses were conducted using Kendall and t tests at a 5% level of significance.

Results

There was a concordance between the two examiners at all points and times. In group 1, points A and B have statistically significant differences between the PAS measurements performed in T_p and T₁, while in group 2, none of the PAS points showed statistically significant differences when comparing T_p to T₁.

Conclusions

2D computer-based cephalometric prediction in Dolphin Imaging software offers a good orientation to professionals during the surgical procedure of bimaxillary surgeries since its use is considered clinically relevant in daily practice.

     

Correction of whistle deformity using autologous free fat grafting: first results of a pilot study and review of the literature

Purpose

Whistle deformities are frequent sequelae after surgical correction of cleft lip, trauma, or tumor excision. The aim of this study was to examine the role of autologous free fat grafting in the reconstruction of whistle deformity.

Patients

Fifteen patients with whistle deformity were enrolled in this pilot study. The mean follow-up period was 19 months. Liposuction was done followed by the replantation of an average of 2.2 ml autologous fat per patient (range 0.7–4 ml). An overcorrection was performed in all patients.

Results

All the patients showed improvements in whistle deformity. The mean resorption rate was 53% (range 30–80%). Three patients (20%) were not satisfied with the postoperative result. Six complications were assessed (4× feeling of pressure [27%], one hematoma [7%], one recurrent pain [7%]), but a major complication did not occur.

Review

We also present a review of the literature with different techniques that were described in the last 20 years.

Conclusion

Autologous free fat graftings for reconstruction of whistle deformity represent a reliable method with a low complication rate. However, the resorption rate is unpredictable. If necessary, several autologous fat transplantations should be conducted at an interval of at least 6 months.

     

Musculoskeletal Changes as a Sequel to Advancement Genioplasty: A Long-Term Cephalometric Prospective Study

Aims

The aim of this study was to evaluate cephalometrically the stability of hard tissues and soft tissue changes of advancement genioplasty 2 years after surgery.

Methods

A prospective study was conducted which comprised of 25 patients, who underwent advancement genioplasty alone with no other orthognathic surgical procedures. Immediate pre-operative, 6 months postoperative, and 2 years postoperative lateral cephalograms were compiled and assessed.

Results

The mean surgical advancement planned was around 8 mm. Six months post-surgery, the relapse rate was 15% of the surgical advancement which was considerably reduced in the following 18 months to 7%. The ratio of soft tissue to bony advancement at pogonion was 0.9:1. There are significant alterations in the soft tissue profile in terms of decrease in the soft tissue thickness, facial convexity angle, deepened mentolabial sulcus and minimal increase in the lower lip height.

Conclusion

Advancement genioplasty was considered as a relatively stable procedure, if adequate muscular pedicle and internal rigid fixation were maintained. The present study was of 2 years, and we can expect further changes in the hard and soft tissues, which are clinically irrelevant.