Maxillofacial Surgery

Organizing craniofacial surgery teams Arun K Singh National Journal of Maxillofacial Surgery 2020 11(2):157-158

Oral mucositis Vibha Singh, Akhilesh Kumar Singh National Journal of Maxillofacial Surgery 2020 11(2):159-168 Oral mucositis is one of the most common complications of cancer therapy. It is a nonhematologic complication of cytotoxic chemotherapy and radiotherapy and reduces the quality of life. It is estimated that 40% the cases on standard chemotherapy may develop oral mucositis. Patients receiving radiation, especially in the cases of head and neck cancer, have 30%–60% chances of developing mucositis. Chemotherapy and radiotherapy interfere with the normal turnover of epithelial cells, leading to mucosal injuries. These injuries can also occur due to indirect invasion of Gram negative bacteria and fungi as most of the chemo-therapeutic agents will cause neutropenia and will give a favorable environment for the development of mucositis. The patient-related factors are also responsible for developing mucositis in chemo-induced and radiation-induced mucositis. Poor oral hygiene may also be responsible for bacterial super infection followed by chemotherapy. Mucositis is of two kinds: direct and indirect mucositis. Direct mucositis - The epithelial cells of the oral mucosa undergo rapid turnover in usually 7–14 days due to which these cells are more susceptible to the effect of the cytotoxic therapy which results in oral mucositis. Indirect mucositis – it can develop due to the infection caused by Gram-negative bacteria and fungal infection. There will be a greater risk for oral infection due to neutropenia. The onset of mucositis secondary to mylo-suppression varies depending upon the timing of the neutrophil count associated with chemotherapy agents but they typically develop around 10–21 days after chemotherapy administration.

Evaluating the role of local host factors in the candidal colonization of oral cavity: A review update Imran Khan, Tanveer Ahmad, Nikhat Manzoor, Moshahid Alam Rizvi, Uqba Raza, Shubhangi Premchandani National Journal of Maxillofacial Surgery 2020 11(2):169-175 Human oral cavity is home to a number of organisms, Candida albicans being one of them. This review article aims at understanding the correlation between the oral candidal colonization and the local host factors that may influence it with special emphasis on congenital craniofacial anomalies such as cleft lip and palate (CLP). Various scientific databases were searched online and relevant articles were selected based on the inclusion criteria. A comparative study was done to understand the interdependence of various factors (including CLP) and oral candidal colonization. The results revealed a strong association of certain local host factors which may influence the oral colonization of Candida species. Factors such as mucosal barrier, salivary constituents and quantity of saliva, congenital deformities like CLP, oral prostheses such as dentures/palatal obturators and fixed orthodontic appliances (FOAs) were identified. All these factors may directly affect the growth of Candida in the oral cavity. Although numerous studies have pointed a positive correlation between Oral Candidal colonization and local host factors such as oral prostheses, FOA, and oral mucosal barrier only one study has been done, in the Indian subcontinent with respect to the correlation of candidal colonization and CLP. After the evaluation of all the factors mentioned in various case studies, it can be concluded that the presence of local host factors such as orofacial clefts, dental prostheses, FOA, xerostomia, and atrophy of the oral mucous membrane lead to significant increase in candidal colonization, but since very few studies in regard to CLP have been done worldwide and in India, in particular, further studies are warranted.

Evaluation of osseintegration between traditional and modified hydrophilic titanium dental implants – Systematic analysis Geeta Arya, Varun Kumar National Journal of Maxillofacial Surgery 2020 11(2):176-181 The aim of the study was to conduct a systematic review to access the osseointegration between traditional and modified Hydrophilic Titanium Dental Implants for period of 10 years. PUBMed articles were searched from last ten years up to 15/12/2019 from which 24 studies included in this review. This systematic review compiles the data about osseintegration in hydrophilic titanium implants in human trials. It sheds light on the mechanism of integration of hydrophilic surfaces and numeric data to support the purpose of the review.

Does diagnostic accuracy of surgeon's perception outweigh frozen section analysis in determining intraoperative clear mucosal surgical margins in oral squamous cell carcinoma patients? Chetan Gupta, Nitin Bhola, Anendd Jadhav, Apoorva Mishra, Pawan Hingnikar, Chinmay Ghavat National Journal of Maxillofacial Surgery 2020 11(2):182-185 Introduction: The lucrativeness of the frozen section for intraoperative margin assessment in head and neck squamous cell carcinoma is debatable till date. The purpose of this study was to evaluate whether surgeon's perception by gross examination (GE) of margin is an alternative to frozen section. Aim: The aim was to compare the diagnostic accuracy (DA) of surgeon's perception of tumor-free mucosal and soft-tissue surgical margins intraoperatively assessed by GE and frozen section analysis (FSA). Methodology: A prospective, observational study was conducted on 59 histologically proven cases of oral squamous cell carcinoma. Two hundred and thirty-six mucosal margins were assessed by an experienced surgeon (ES) and thereafter subjected subsequently to FSA. These results were compared with the gold standard histopathology (HPE). The sensitivity (SS), specificity (SP), positive predictor value (PPV), negative predictor value (NPV), and DA of surgeon's perception by GE were calculated and subsequently compared with FSA and HPE using descriptive and inferential statistics. Results: The SS, SP, PPV, NPV, and DA of ES by GE were 80%, 99.12%, 80%, 99.12%, and 98.30%, respectively when compared to HPE, and the SS of 90%, SP of 98.32%, PPV, NPV, and DA were 69.23%, 99.57%, and 97.98%, respectively when compared with HPE. The results of the surgeon's perception by GE were comparable to the results of FSA. Conclusion: The study concludes that surgeon's perception by GE is upfront reliable alternative intraoperative method to FSA in places where FS is not available.

Rhinoplasty in secondary nasal deformities: Subjective and objective outcome evaluation Chandmani Tigga, Majumdar Swapan Kumar, Burman Subhasish, Mishra Siddartha, Hussain Mohsina National Journal of Maxillofacial Surgery 2020 11(2):186-192 Introduction: Secondary nasal deformities are associated with trauma and secondary cleft nose (after primary cleft nose surgery). Nasal deformities affect esthetic, function, and psychological status of the patient. The goal of the secondary rhinoplasty is to correct both form and function, so that this positively impacts on their facial appearance. Aims: The study aimed to evaluate the patient satisfaction (subjective outcome) by rhinoplasty outcome evaluation questionnaire (ROEQ) preoperatively and postoperatively and esthetic outcome (objective outcome) by surgical team in patients with secondary nasal deformities. Materials and Methods: Secondary rhinoplasty was done in 13 patients of traumatic and unilateral secondary cleft nose through the external approach. Objective outcome was assessed by surgical team with clinical measurement, radiograph (lateral cephalometric), and photographic documentation pre- and postoperatively. Clinical measurements include nasolabial and nasofrontal angle. The patients completed the ROEQ for the subjective outcome evaluation. Results: There was significant improvement of subjective outcome (83.30%) based on the ROEQ and objective outcome based on the clinical measurement. Conclusion: Our study suggests that secondary rhinoplasty in trauma and cleft patients leads to both subjective and objective improvement of the facial appearance.

Management of macrocystic lymphatic malformation at uncommon site with aqueous bleomycin sclerotherapy Ankur Bhatnagar, Vijai Datta Upadhyaya, Rajnikant Yadav, Basant Kumar National Journal of Maxillofacial Surgery 2020 11(2):193-198 Introduction: Lymphangioma are rare vascular malformation that results from maldevelopment of primitive lymphatic sacs. They are most frequently found in the neck and axilla, while intra-abdominal and mediastinal lymphangiomas are uncommon. Atypical site of cystic hygroma in pediatric age group are usually difficult to diagnose clinically but can be diagnosed easily by ultrasound. The aim of the study was to evaluate the result of the intralesional bleomycin for macrocystic lymphatic malformation (LM) presenting at atypical site Material and Method: All patients of LM of other than head& neck, axilla and abdomen presenting in pediatric age group were included in the study. Mainstay of diagnosis was ultrasound and was supplemented by CT scan wherever required. All patients were managed with intralesional bleomycin (ILB) and surgical excision was done only if primary therapy failed. Result: Total 15 cases of LM presenting at atypical sites were included in the study. Series include two case of cystic hygroma of breast, 4 cases of cystic hygroma of anterior chest wall, two case of substernal LM, three cases of LM of parotid gland, one case of inguinal region cystic hygroma and 4 cases involving submandicular area. Complete resolution was observed in 13 out of 15 cases, and two cases had less than 50% reduction in size and were managed with surgical excision after second session of ILB. Conclusion: Aqueous Intralesional bleomycin is a cost effective alternative to surgery even at rare sites of LM which provide better aesthetic outcome, and avoids complication associated with surgery.

Comparative evaluation of crestal bone level in patients having low level of Vitamin D treated with dental implant with or without Vitamin D3 supplements Pooja Garg, Pankaj Ghalaut, Kiran Dahiya, Reena Ravi, Anshu Sharma, Poonam Wakure National Journal of Maxillofacial Surgery 2020 11(2):199-206 Introduction: Vitamin D has been shown to play a vital role in bone mineral homeostasis by stimulating the intestinal absorption of calcium and phosphate. The critical role of Vitamin D in bone metabolism triggered the need to evaluate the effect of Vitamin D deficiency and hence replacement of the same on osseointegration of dental implants. This prospective study evaluated the crestal bone level in patients having low level of Vitamin D treated with dental implant with or without Vitamin D3 supplements. Materials and Methods: A prospective clinical study was conducted on 32 patients based on the inclusion and exclusion criteria. Patients were divided into two groups on the basis of Vitamin D level < 30 ng/ml (Group I: patients receiving Vitamin D3 supplements, i.e., cholecalciferol 1 g sachet 60,000 IU/month) or <30 ng/ml (Group II: not receiving Vitamin D3 supplements). The crestal bone level measurements were made with the help of Digimizer Image Analysis, MedCalc software. Results: All implants showed clinically acceptable crestal bone level at interval of 1 week (baseline), 3 months, and 6 months. There was a statistically nonsignificant difference seen for the values between the groups (P > 0.05) for all other values at various time intervals. However, there was a statistically significant/highly significant difference seen for the values between the groups (P < 0.01, 0.05) for 3 months distal with higher values for Group I as compared to Group II. Conclusion: From the study, it can be concluded that cholecalciferol has systemic effects on accelerating bone formation around titanium implant.

Evaluation of polycaprolactone scaffold for guided bone regeneration in maxillary and mandibular defects: A clinical study Charudatta Naik, N Srinath, Mahesh Kumar Ranganath, DN Umashankar, Himani Gupta National Journal of Maxillofacial Surgery 2020 11(2):207-212 Objective: This study was carried out to assess bone regeneration following the use of polycaprolactone (PCL) scaffold in maxillary and mandibular osseous defects. Materials and Methods: This prospective study included ten patients with maxillary or mandibular osseous defects present due to enucleation of periapical cysts or alveolar clefts requiring bone grafting and for lateral ridge augmentation that were treated with PCL scaffold. The patients were assessed clinically for pain, swelling, infection, and graft exposure at 1 week, 3rd, and 5th month postoperatively and were also evaluated radiographically for bone fill using intraoral periapical and/or panoramic radiographs at 4th, 6th, and 9th month postoperatively. Results: PCL scaffold was used in a total of six alveolar clefts and three cases of periapical cysts and one case of lateral ridge augmentation. Nine out of ten cases demonstrated wound dehiscence and scaffold exposure in the oral cavity. Radiographically, on comparison to the control regions, all these nine cases failed to demonstrate appreciable bone density gain. Only one case of radicular cyst in the mandible was recorded to have satisfactory healing. Conclusion: Although PCL scaffold has the potential for bone regeneration in osseous defects, the scaffold exhibited marked tendency for dehiscence in intraoral defects that significantly affected bone healing. A long-term study designed with a larger sample size and categorization of the defects is required to assess its efficacy in varied defects. Moreover, comparative evaluation of PCL and autogenous or alloplastic bone grafting material could provide assenting results.

Graftless crestal hydraulic sinus lift with simultaneous implant insertion Varsha Sunil Manekar National Journal of Maxillofacial Surgery 2020 11(2):213-218 Background: The posterior maxilla is always a challenge for dental implant restoration. The presence of maxillary sinus and reduced subantral bone height are the limitations for implant insertion. The need of the hour is to make the surgical procedures simple, minimally invasive, andpredictable. Can we perform the sinus lift and simultaneous implant insertion by minimally invasive,simple, cost-effective, and less time-consuming technique? With this in consideration, the author carriedout this study for graftless crestal hydraulic sinus lift (CHSL) and simultaneous implant insertion in partially edentulous posterior maxilla for 26 implants. The aim is to evaluate the clinical and radiological success of graftless CHSL with simultaneous implant insertion. Material and Method: The sample size was 17 patients and 26 implants were inserted. The clinical as well as radiological follow-up was done for 1 year. The outcome variables were the gain in bone height and implant survival. Result: Mean Bone height Gain is 5.6 mm; Mean torque used 32 nm, Mean age of the patient was 53 years. The literature shows a success of graftless lateral and osteotome-mediated sinus lift. The concept is the blood filling the gap around the implant in tented sinus lining can eventually result in the ossification to form bone. Until now, no study has demonstrated the bone formation in the peri-implant area of CHSL with simultaneous implant insertion. CHSL, a minimally invasive sinus lift surgery is very encouraging, easy to master, and predictive. The simultaneous implant insertion acts to retain the elevated sinus lining by tenting. It also reduces treatment time. After a sinus lifting procedure, the compartment around the implants under the sinus mucosal lining in the sinus floor is filled with a blood clot from surrounding bleeding. Blood clot can be considered autologous osteogenic graft material, to which osteoprogenitors can migrate, differentiate, and regenerate bone. Conclusion: The graftless CHSL is predictable and safe for the sinus lift. The gain of up to 5–6 mm of subantral bone is possible.

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