Nasotracheal Intubation: An Overview

Introduction

Nasotracheal intubation is the commonest method used to induce anaesthesia in oral surgery patients. It has a distinct advantage of providing good accessibility for oral surgical procedures.

Anatomy and procedure

One must know the anatomy involved, the pathway and procedure of intubation, the pre-anaesthetic medication and complications which may be seen at the time of intubation. The surgeon must have the knowhow of the tube and the procedure which are explained in detail in the article.

Complications

Several complications can arise while performing the procedure which may be operator induced or arising due to anatomical variations.

Conclusion

It is prudent for the oral surgeon to know the basics of nasotracheal intubation in order to form a useful team member for management of complications arising from anaesthesia. Recent years have seen improvement in the armamentarium. These help negate the blindness of the procedure.     

Risk factors for postoperative complications following oral surgery

Objective

The objective of this study was to clarify significant risk factors for postoperative complications in the oral cavity in patients who underwent oral surgery, excluding those with oral cancer.

Material and Methods

This study reviewed the records of 324 patients who underwent mildly to moderately invasive oral surgery (e.g., impacted tooth extraction, cyst excision, fixation of mandibular and maxillary fractures, osteotomy, resection of a benign tumor, sinus lifting, bone grafting, removal of a sialolith, among others) under general anesthesia or intravenous sedation from 2012 to 2014 at the Department of Oral and Maxillofacial Reconstructive Surgery, Hiroshima University Hospital.

Results

Univariate analysis showed a statistical relationship between postoperative complications (i.e., surgical site infection, anastomotic leak) and diabetes (p=0.033), preoperative serum albumin level (p=0.009), and operation duration (p=0.0093). Furthermore, preoperative serum albumin level (<4.0 g/dL) and operation time (≥120 minutes) were found to be independent factors affecting postoperative complications in multiple logistic regression analysis results (odds ratio 3.82, p=0.0074; odds ratio 2.83, p=0.0086, respectively).

Conclusion

Our results indicate that a low level of albumin in serum and prolonged operation duration are important risk factors for postoperative complications occurring in the oral cavity following oral surgery.     

Evaluation of Inter Incisal Mouth Opening for Airway Maintenance in Oral Submucous Fibrosis

Purpose

Determination of difficult airway maintenance preoperatively holds a great significance in different intubation techniques and also surgical exploration of airway. No data is available for relation of airway maintenance and preoperative interincisal mouth opening in oral submucous fibrosis patients.

Methods

20 oral submucous fibrosis patients were evaluated pre operatively for general anaesthesia. Direct nasotracheal intubation, fiberoptic laryngoscopy guided intubation or awake blind nasal intubation technique, or combination of above techniques were used.

Results

Mean pre operative inter incisal mouth opening for direct nasotracheal intubation (nine patients) is 15.44 mm, fiberoptic guided laryngoscopy (six patients) is 9.0 mm and blind nasal intubation (five patients) is 5.2 mm.

Conclusion

Benefits of avoiding a surgical exploration of airway was significant.     

Surgical Interventions in Oral Submucous Fibrosis: A Systematic Analysis of the Literature

Background

Oral submucous fibrosis (OSMF) is a potentially malignant disorder of the oral cavity. The surgical management of this condition involves excision of the fibrotic bands and interpositional grafts to retain the increased oral opening. Various procedures and graft material have been utilised with differing success rates.

Objectives

The present review aims to collate and analyze from world literature the different modalities utilized in the surgical management of OSMF. The reasons for the choice of a particular surgical procedure, the study protocol, the average follow-up period and the results were scrutinized.

Materials and Methods

The PRISMA protocol was followed for the systematic review. Search engines and medical databases like Ovid, Medline, Pubgate, Researchgate, PubMed, Google etc. were tapped for information related to the subject. The search words “OSMF”, “surgical interventions in OSMF”, “flaps and grafts in treatment of OSMF” were employed for retrieval of data. An analysis of the treatment modalities, the reason for the selection of a particular modality, the organization of the sample selection and the follow-up periods including the proclaimed success rates was done.

Results

The review resulted in a total of 56 articles on the subject from the sources mentioned above. A total of 995 surgically treated cases were included in the analysis. Interestingly the review revealed very few controlled clinical trials, most being random trials on surgical procedures in small groups of patients with very short follow up periods. The choice of procedure seems to be determined entirely by the preference of the operator/s.

Conclusions

There exist no definite protocols for the adoption of a particular treatment mode in OSMF. Adequate documentation and follow up need to be established to statistically analyse the results and proclaimed successes of various treatment modalities.     

<Emphasis Type="Bold">C</Emphasis>omparative Evaluation of the Intranasal Spray Formulation of Midazolam and Dexmedetomidine in Patients Undergoing Surgical Removal of Impacted Mandibular Third Molars: A Split Mouth Prospective Study

Purpose

The purpose of this prospective randomized single blinded split mouth study was to conduct a comparative evaluation of the efficacy of intranasal atomised spray formulation of Dexmedetomidine with Midazolam in patients undergoing surgical removal of bilaterally impacted mandibular third molars.

Methods

This prospective study was conducted in twenty volunteers. Each volunteer underwent the surgical removal of an impacted mandibular third molar at two separate appointments at an interval of two weeks. The first third molar surgery was conducted using either intranasal Midazolam (Group M) or intranasal Dexmedetomidine (Group D). At the second appointment the surgical procedure was performed using the sedative agent not used at the first appointment. The primary testing outcome variables were Plasma oxygen saturation (SpO2), pulse and blood pressure and Modified Observer’s Assessment of Alertness/Sedation (OAA/S) scale. These were recorded at predetermined intervals starting 10 min before the administration of local anaesthesia and continued up to 10 min after completion of the procedure. In addition surgeon’s opinion regarding the patient cooperation, event amnesia, post operative nausea & vomiting were obtained.

Results

The sample composed of twenty patients (M = 9 and F = 11). There was statistically no significant difference between Group M and Group D with respect to mean SpO2. Minor differences were however noted at 20 and 30 min after sedation. There was no significant difference between the groups with respect to mean pulse rate, blood pressure, OAA/S, event amnesia, post operative nausea and vomiting and patient cooperation.

Conclusion

We conclude that Midazolam and Dexmedetomidine are equivalent and can be used in minor oral surgery with minimal complications. These drugs can be used intranasally using nasal atomization device in routine outpatient basis in otherwise normal healthy but anxious patients. All procedures must however be performed in the presence of an anaesthesiologist and with ready availability of emergency drugs and equipment.

     

Comparative Analysis of the Anesthetic Efficacy of 0.5 and 0.75?% Ropivacaine for Inferior Alveolar Nerve Block in Surgical Removal of Impacted Mandibular Third Molars

Introduction

Ropivacaine belongs to pipecoloxylidide group of local anesthetics. There are reports supporting the use of ropivacaine as a long acting local anesthetic in oral and maxillofacial surgical procedures, with variable data on the concentration that is clinically suitable.

Materials and Methods

A prospective randomized double-blind study protocol was undertaken to assess the efficacy of 0.5 and 0.75 % ropivacaine for inferior alveolar nerve block in surgical extraction of impacted mandibular third molars. A total of 60 procedures were performed, of which thirty patients received 0.5 % and thirty received 0.75 % concentration of the study drug.

Results

All the patients in both the study groups reported subjective numbness of lip and tongue. The time of onset was longer for 0.5 % ropivacaine when compared to 0.75 % solution. 90 % of the study patients in 0.5 % ropivacaine group reported pain corresponding to VAS ≥3 during bone guttering and 93.3 % patients reported pain corresponding to VAS >4 during tooth elevation. None of the patients in 0.75 % ropivacaine group reported VAS >3 at any stage of the surgical procedure. The duration of soft tissue anesthesia recorded with 0.75 % ropivacaine was average 287.57 ± 42.0 min.

Conclusion

0.75 % ropivacaine was found suitable for inferior alveolar nerve blocks in surgical extraction of impacted mandibular third molars.     

Poor oral Hygiene may be the Sole Cause of Oral Cancer

Purpose

The purpose of this case–control study was to draw attention to the possibility that poor oral hygiene resulting from infrequent and inadequate use of chewing sticks might be the sole cause of oral cancer in 60 patients investigated in the maxillofacial units of two specialist hospitals in eastern Nigeria.

Methods

Sixty cases and 60 controls made up the study population. We matched them for age, gender, period of admission and study site. The interview of all the participants contained data on demographic factors, family history of cancer, tobacco habits, oral hygiene, dietary habits and use of alcohol. We took biopsies of the lesions for histo-pathological examination. We entered the collected data into Microsoft excel package and transported it to Stata for generation of statistical test.

Result

Poor oral hygiene due to infrequent tooth brushing was associated with primary oral cancer in this patient sample. On the other hand, frequent tooth brushing was related to healthy status.

Conclusion

In the absence of other known carcinogens, poor oral hygiene may be the single factor that caused oral cancer in these subjects. Research is needed to investigate the pathological mechanism that is associated with this risk factor.

Electronic supplementary material

The online version of this article (doi:10.1007/s12663-012-0359-5) contains supplementary material, which is available to authorized users.     

Comparison of Management of Mandibular Angle Fractures by Three Approaches

Background and Objectives

Various methods have been reported in the literature for treating mandibular angle fractures comparing extra oral, intra oral and transbuccal approaches for achieving the goals of restoration of anatomic form, maintenance of segment position and bony union.

Materials and Methods

This study was conducted to assess the simple and effective surgical approach in treating mandibular angle fractures and the outcome by means of three approaches i.e. intra oral, transbuccal and extra oral approaches.

Results/Conclusion

A total of 45 patients with mandibular angle fracture were divided into three groups. Group I—intra oral approach—15 patients, Group II—transbuccal with intraoral approach—15 patients, Group III—extra oral approach—15 patients. The results of our study found intraoral approach to be much better because it is simple, precise, duration is short, and post operative complications are less with minimal morbidity and pain.     

Evaluation of dental panoramic radiographic findings in edentulous jaws: A retrospective study of 743 patients "Radiographic features in edentulous jaws"

PURPOSE

The aim of this study was to determine the frequency of significant panoramic radiographic findings and eventual treatment requirements before conventional or implant supported prosthetic treatment in asymptomatic edentulous patients.

MATERIALS AND METHODS

A total of 743 asymptomatic edentulous patients were retrospectively evaluated using a digital panoramic system. We analyzed the radiographic findings, including impacted teeth, retained root fragments, foreign bodies, severe atrophy of the posterior maxillary alveolar bone, mucous retention cysts, soft tissue calcifications and radiopaque-radiolucent conditions.

RESULTS

Four-hundred-eighty-seven (65.6%) patients had no radiographic finding. A total of 331 radiographic findings were detected in 256 (34%) patients. In 52.9% (n=175) of these conditions, surgical treatment was required before application of implant-supported fixed prosthesis. However, before application of conventional removable prosthesis surgical treatment was required for 6% (n=20) of these conditions.

CONCLUSION

The edentulous patients who will have implant placement for implant-supported fixed prosthesis can frequently require additional surgical procedures to eliminate pathological conditions.     

Facial Candidal Abscess in a Patient with Unknown Type 2 Diabetes Mellitus

Introduction

Facial candidal abscess is an infection with a fungal cause which was presented in this case such a rarity. We report a rare case of facial abscess due to Candida species in a patient with unknown diabetes.

Materials and Methods

The patient presented with a longstanding firm swelling which occurred 2 weeks ago and did not show any improvement of healing process in spite of surgical and medical treatments. MRI examinations were conclusive and compatible with abscess, so she underwent surgical intervention. Facial candidal abscess was the final diagnosis.

Conclusions

We concluded that, in persistent abscesses, invasive candidiasis should be considered in the differential diagnosis of bacterial infections as it generally affects individuals with diabetes or general defects in the immune system, or those who use widespread antibiotics and steroids.     

Unilateral One Stage Nasolabial Flap for Reconstruction of the Lips

Background

Nasolabial flap (NLF) is one of the oldest described soft tissue flaps. Despite the great advances in maxillofacial reconstruction it still has a stable location in the reconstructive ladder of the face and oral cavity. Reconstruction of the lips, which are important structures that connect the oral cavity to the facial skin, with this flap is the interest of the surgeons.

Patients and Methods

Experience of the authors for reconstruction of the upper lip philtrum, correction of lower lip contracture and subtotal reconstruction of the lower lip with emphasis on simultaneous correction of the red lip (volume and color) is explained in five cases.

Results

Satisfactory functional and aesthetic results were obtained. Iatrogenic epidermoid cyst occurred in one patient.

Conclusion

One stage reconstruction of lateral lower lip defects with/without commissural involvement in full or partial thickness defects is possible by NLF. Supplementary flaps are needed when the vermilion needs simultaneous reconstruction.     

ORAL FINDINGS IN PATIENTS WITH APERT SYNDROME

Introduction:

The Apert syndrome is a rare disorder of autosomal dominant inheritance caused by mutations in the FGFR2 gene at locus 10q26; patients with this syndrome present severe syndactyly, exophthalmia, ocular hypertelorism and hypoplastic midface with Class III malocclusion, besides systemic alterations. Most investigations available on the Apert syndrome address the genetic aspect or surgical management, with little emphasis on the oral aspects.

Objective:

to investigate the oral findings, including dental anomalies, ectopic eruption of the maxillary permanent first molars and soft tissue alterations, in subjects with Apert syndrome.

Material and methods:

clinical and radiographic examination of nine patients with Apert syndrome, aged 6 to 15 years, not previously submitted to orthodontic or orthognathic treatment.

Results:

dental anomalies were present in all patients, with one to eight anomalies per individual. The most frequent anomalies were tooth agenesis, mainly affecting maxillary canines, and enamel opacities (44.4% for both). Ectopic eruption of maxillary first molars was found in 33.3% of patients; lateral palatal swellings were observed in 88.8% of patients.

Conclusions:

The occurrence of typical lateral palatal swellings agrees with the literature. The high prevalence of dental anomalies and ectopic eruption may suggest a possible etiologic relationship with the syndrome.     

Role of Collagen Impregnated with Dexamethasone and Placentrix in Patients with Oral Submucous Fibrosis

Purpose

To evaluate the versatility of the collagen membrane as both drug carrier and biologic dressing material to cover the raw wounds created after the surgical excision of fibrotic bands in oral submucous fibrosis.

Materials and Methods

The study comprises of ten patients. The patients of age group 20 to 50 years were selected. The collagen is reconstituted by injecting with dexamethasone and placentrix solution leaving a small overlap on to the remaining mucous membrane and the graft is sutured. Preoperative and post operative assessment was done regarding the improvement in mouth opening, decrease in burning sensation, change in colour of oral mucosa and clinically grading the extent of lesion.

Results

The results were found appreciable in seven patients while in the remaining three patients it showed relapse because of inadequate physiotherapy. All the ten patients were comfortable with intra oral collagen grafting. The collagen remained moist and supple intraorally, and remained in close contact with the underlying tissues, providing a strong mechanical barrier. The material was effective in attaining haemostasis, relieving pain and preventing extensive contracture.

Conclusion

In this study of short duration, the nature of collagen membrane was observed as both biological dressing material and drug carrier. It was found as a very suitable alternative to the other graft material mentioned for the repair of defects in the mucous membrane created by surgical excision of fibrous bands in oral submucous fibrosis.     

Goldenhar syndrome: clinical features with orofacial emphasis

Objectives

Goldenhar syndrome (GS) is a relatively common developmental disorder characterized by craniofacial anomalies in association with vertebral, cardiac, renal, and central nervous system defects. This paper describes GS features with special emphasis on oral characteristics.

Material and methods

The clinical features of 6 patients with GS aged 3 months to 12 years are described, and a brief review of the literature about this genetic disorder is presented.

Results

All patients demonstrated the classical triad of GS, including mandibular hypoplasia resulting in facial asymmetry, ear and/or eye malformation, and vertebral anomalies. In addition, renal and gastrointestinal abnormalities were observed in 2 patients. Regarding the oral involvement, 2 patients presented cleft lip and palate, and 1 patient had temporomandibular joint malformation. Malocclusion was found in all patients.

Conclusion

Our orofacial findings correlate with the reported cases in the literature, and point out that after diagnosis GS patients need to be examined for systemic abnormalities.     

Attitudes of a group of Brazilian orthodontists towards the diagnosis and management of primary headache (migraine): an electronic-based survey

Objectives

The aim of this study was to investigate the knowledge and attitudes of orthodontists in the diagnosis and management of migraine without aura.

Material and Methods

Participants were dentists, recruited among members of the Brazilian Association of Orthodontics and Facial Orthopedics (ABOR). An e-mail was sent to all ABOR members, with a link to a website, especially prepared for this research. Dentists were presented to a report of a fictional patient fulfilling diagnostic criteria for a primary headache disorder, known as migraine without aura. Participants were asked to describe how they would relieve the patient''s pain. Professional procedures were classified as "adequate" or "inadequate" according to the answers given.

Results

161 valid answers were received (18.8% response rate). Of them, 36% of the actions were considered to be "adequate" procedures, while 64% were "inadequate". The results yielded 12 main procedures, based on common characteristics. Eighty-two orthodontists suggested orthodontic treatment with or without orthognathic surgery, and some suggested using stabilization appliances prior to the orthodontic treatment.

Conclusions

The majority of participants proposed inadequate therapies, and 51% suggested orthodontic correction of occlusion, including orthognathic surgery. Educational activities on migraine should also target orthodontists.     

Peripheral Osteoma of the Maxillofacial Region Diagnosis and Management: A Study of 06 Cases

Background

Osteomas are benign neoplasm often associated with facial asymmetry, pain and surface ulceration. Peripheral osteomas are more common in the cranio-maxillofacial region. It is prevalent at younger age but maximum seen in the sixth decade, with a female to male ratio is 1:2. The aim of this study was to review the clinical presentations and management protocol of such lesions in cranio-maxillofacial region.

Materials and Methods

The study was conducted at Command Military Dental Centre (EC) during May 2004 to May 2007. Six serving soldiers and their families (four males, two females), age group ranging between 13 and 56 years, mean age 34.5 years were recruited in this study. The tumors were excised using extra oral, intra oral and combined approaches; no complications were reported during post op period.

Results

All the cases were operated under GA through extra oral, intra oral and combined approaches with satisfactory results. HPE report was benign in all our cases with no post operative complications reported during follow up.

Conclusion

Cranio-maxillofacial osteomas are exclusively benign tumors and not very common entities. Proper diagnosis and precision management alleviates symptoms without any post surgical complications. In our series of six cases the tumors were diagnosed and managed as per standard surgical protocol with excellent result.     

Detection of Sulphate-Reducing Bacteria and Others Cultivable Facultative Bacteria in Dental Tissues

Aim

To detect for the presence of sulphate-reducing bacteria (SRB) and evaluate the possible association between SRB and cultivable facultative bacterial of oral sites with different periodontal conditions.

Methods

The study was carried out on 9 samples from different oral sites in 8 patients (two samples were collected from the same patient). Material was collected using modified Postgate E culture medium, indicated for the growth and isolation of SRB. In addition, a reducing solution for anaerobic bacteria was used as a transport solution for facultative bacteria and identified by polymerase chain reaction amplification (PCR) and sequencing of the 16S rRNA gene.

Results

SRB was found in 3 patient samples: the first in a root fragment, the second in a root fragment and a healthy tooth with vertical bone loss and a mobility degree of 3; and the third in a healthy tooth extracted for orthodontic treatment. In the final patient, the cultivable facultative species Lactobacillus casei was identified. Other facultative bacterial species were identified in patient 5 (Kurthia Gibsonii) and patient 7 (Pseudomonas aeruginosa).

Conclusions

The detection of SRB in different dental tissues with distinct periodontal features demonstrated that new studies need to be developed in order to determine the true role of SRB in the oral microbiota. In addition, it was possible to verify the presence of Lactobacillus casei together with SRB in one sample.