Nepalese Journal of Oral and Maxillofacial Surgery
Nepalese Journal of Oral and Maxillofacial Surgery is the official journal of Nepalese Association of Oral and Maxillofacial Surgeons; an annual publication in English language.
Nepalese Association of Oral and Maxillofacial Surgeons (NAOMS)
Copyright (c) 2023 Nepalese Journal of Oral and Maxillofacial Surgery https://creativecommons.org/licenses/by-nc/4.0
Oral and Maxillofacial Surgery: General Standard Operating Protocol for NABH
Pre-operative Virtual Planning Followed by Fabrication of Patient-Specific Guiding Instruments for Mandibular Deformity after Fibula Free Flap Reconstruction
Background: Corrective osteotomy for secondary mandibular reconstruction is complex, and it is extremely difficult to achieve desirable three-dimensional positioning. The authors present a case for repositioning the mandibular segments of mandibular deformity after fibula free flap reconstruction using computerassisted surgical simulation and patient-specific guiding instruments. Case description: A 69-year-old man developed severe mandibular deviation after segmental mandibulectomy and reconstruction with fibula free flap for basal cell carcinoma of the mental region. A virtual osteotomy was performed between the mandible and fibula on a 3D virtual model using simulation software. The proximal mandibular segments were placed in the ideal position using a 3D virtual model. The original contour of the mandible before the primary resection was used as a reference for repositioning. Patient-specific guiding instruments were fabricated for the pre-osteotomy and intraoperative positioning of the osteotomized mandible, enabling bone fragments to be repositioned and fixed using the pre-operative plan. Postoperative CT showed that the mandibular segments were precisely repositioned. Conclusion: In this case, virtual planning and patient-specific guiding instruments were useful in corrective surgery for mandibular deformity after fibula free flap reconstruction.
Abstracts from the 15th Joint Meeting of NAOMS and JSOMS
Single-stage Patient-specific Total Temporomandibular Joint Replacement with Simultaneous Correction of Dentofacial Deformity
End stage TMJ diseases severely affect the architecture as well as physiology of TMJ resulting in impairment in mastication, speech, airway support and esthetics requiring joint reconstruction to improve mandibular form and function. In cases of multiple prior operations and severe anatomical discrepancies from pathology, autogenous bone grafts often fail. Alloplastic total joint replacement has been evolving as a salvage procedure in such end stage TMJ diseases. Although stock prosthesis are available, patient specific prosthesis are preferred due to variability in mandibular anatomy and angulation of fit of condylar head to fossa. Advances like virtual surgical planning and 3D printing allowing patient- specific implants have increased the precision of preoperative planning with evolution of single step surgery. We present 2 cases; a case of left TMJ ankylosis in a 28 years old female with resultant dentofacial deformity and a case of left condylar prosthesis failure in a 45 years old female where patient specific temporomandibular joint prosthesis were used for joint reconstruction with concomitant Orthognathic surgery to correct facial deformity .Easy adaptation of prosthesis without need of alteration of bony surfaces, reduction in operating time with avoidance of second surgical site with added advantage of starting physical therapy on the following day of operation , uneventful postoperative recovery and replication of virtually planned treatment objectives were experienced in both cases. The aim of this report is to highlight “ patient specific TJR with simultaneous orthognathic surgery “ as an effective surgical option for the management of end stage TMJ diseases.
Total temporomandibular joint replacement
Background: Sialoliths are calcified structures found within the ducts of salivary glands, frequently located in the submandibular gland (84%), than in the parotid gland (13%). Diagnosis is based on history of pain and swelling associated with eating and conventional mandibular occlusal radiograph. Conservative management of salivary stones consists of salivary gland massage and use of sialagogues. Case description: 24 year female presented to the department with chief complain of swelling below left side of tongue since 10 month which was insidious onset, gradually progressive associated with swelling on eating. On clinical examination single, localized, well-defined swelling roughly oval approx. size about 5.5cm*3.5cm in maximum dimension on left side of floor of mouth extending antero-posteriorly from 31 to 37, mediolaterally from sublingual fold to mucogingival junction . Two hard granular structure of size approximately 3mm*4mm and 2mm*2mm dimension could be palpated lingual to 31 and 33. Mandibular occlusal radiograph revealed two non-homogenous radiopacities. First one was oval shaped, regular border size approximately 5mmx5mm on lingual aspect of 31, 5mm anterior to soft tissue shadow of tip of tongue and second one with irregular shape and border, size approximately 5mm*9 mm on lingual aspect 5mm posteriorly and laterally to the first one. Vitamin C was prescribed and patient was advised to take adequate fluid. Retrieval of both sialoliths was done by stimulating the salivary gland with the help of lemon and milking posterioanteriorly. Conclusion: Conservative management can be done in case of small and accessible calculi to prevent post-operative complications.
Segmental Lefort I Osteotomy: An Upgraded Approach in Orthognatic Surgery for Midface Deformities
The treatment of dentofacial deformity often calls for a combined orthodontic and surgical approach to obtain satisfactory functional and aesthetic results with long term stability. The most frequent surgical procedure performed for correction of defects of maxilla is Lefort I osteotomy, both in its original form and with modern variations. Lefort I, specifically, is used to adjust the position of maxilla and maxillary teeth in three dimensions, either alone or in concert with other interventions to achieve these goals. Segmental Lefort I osteotomy , a modification of classical Lefort I osteotomy provides coordination of the premaxilla with the posterior segments while simultaneously enabling an improvement in transverse dimension. It is recommended for arduous anomalies like anterior open bite, vertical maxillary excess, transverse maxillary defeciencies. We present 2 cases: a case of vertical maxillary excess with skeletal class II deformity in a 20 year female and a case of anterior open bite with skeletal class I relation in a 36 year female. In both cases, segmental (two-piece) Lefort I with BSSRO were performed with additional genioplasty in former case. Through the combined orthodontic-surgical intervention pronounced skeletal, dental and occlusal improvement were achieved. The main purpose of this presentation is to highlight major advantages of segmental Lefort I osteotomy: single surgical intervention, reduced period of covalescence, psychological impact and treatment duration.
Vascularized Scapula Bone Graft using Angular Branch in Maxillofacial Reconstruction
The scapula flap is one of the most widely used osteocutaneous flaps in maxillofacial reconstruction. The nutritional vessel, the subscapular artery(SSA), is divided into the circumflex scapular artery(CSA) and the thoracodorsal artery(TDA), both of which supply the scapula bone and the skin. Therefore, the scapula flap can be harvested with the CSA or TDA and the SSA can be used as a vascular pedicle for composite flap. However, when using the SSA, this artery is in close proximity to the brachial plexus, and has many anatomical variations, and some of which are less than 3 cm, which can cause significant stress and risk for surgeon. Therefore, we prioritize the vascularized scapula bone using the angular branch and latissimus dorsi miocutaneous flap, where TDA can be harvested as the vascular pedicle; compared to scapula flap with CSA, scapula flap with TDA allows more freedom in skin and bone flap placement, more soft tissue volume, and a longer vascular pedicle. We report cases of scapula flap reconstruction using angular branch performed in our department and discuss its indications and limitations.
Salvage Therapy for Immunotherapy-Refractory Oral Cancer with Combination Chemotherapy
Cancer immunotherapy based on the blockade of immune checkpoint molecules such as PD-1, CTLA-4, and PD-L1 has opened new opportunities for recurrent or metastatic cancers that are refractory to other therapies. Currently, immune checkpoint inhibitors nivolumab and pembrolizumab, human monoclonal IgG4 antibodies targeting PD-1 on T-cells, have been clinically successful in prolonging the overall survival of patients with recurrent and/or metastatic oral cancer. However, the overall response rate in patients treated with immunotherapy is still low and the optimal therapy is largely unknown, especially in cases in which immunotherapy is no longer effective. Recently, salvage therapy with combination chemotherapy offers a novel insight into the treatment for immunotherapy-refractory cases. We present our experience of successful treatment of salvage therapy in immunotherapy-refractory oral cancer.
Histopathological Diversity in Radicular Cyst: Institutional Case Series
Background: Radicular cysts are the most common inflammatory odontogenic cysts originating from cell rests of Malassez in periodontal ligament secondary to inflammation usually following dental pulp necrosis. Histopathologically, these lesions demonstrate the variations in the growth of the epithelial lining, metaplastic changes in the form of mucous cell, rushton bodies and ciliated columnar cells in the epithelium. Cholesterol clefts, juxta-epithelial hyalinization, russel bodies, foamy macrophages, multinucleated giant cells and odontogenic epithelial rests are the histopathological presentations found in connective tissue stroma. Case description: Total 59 cases of radicular cysts were histopathologically confirmed in our institution from December, 2017 to December, 2022. In this series, five cases of radicular cysts with varying histopathological features has been described. This diverse form of histopathology may signify aggressiveness, chronic nature of the lesion and adaptive mechanism of the host immune system determining the fate of the lesion. Conclusion: After excising such periapical lesions surgically, a routine histopathological evaluation is important to know the aggressive behavior and potential for malignant transformation. Distinct histopathological findings in the same lesion may provide an important insight into the knowledge of the morphological variations of radicular cysts. Keywords: cholesterol clefts; dental pulp necrosis; radicular cysts
Role of Pectoralis Major Myocutaneous Flap (PMMC) in Head and Neck Cancer Reconstruction
Background: Reconstruction following head and neck cancer surgery is a challenging task. The pectoralis major, the anterior trapezius, the posterior or vertical trapezius and the latissimus dorsi myocutaneous flaps have been described for reconstruction in head and neck region. Pectoralis Major Myocutaneous(PMMC) flaps were originally developed in 1947 for the reconstruction of cardiothoracic tissue defects. Ariyan reported the first use of the PMMC flaps in head and neck reconstruction in 1979. The pectoralis major myocutaneous (PMMC) flap can be used as either a pedicled or a free flap. The PMMC flap is considered a ‘‘workhorse’’ flap for soft tissue reconstruction of the head, face, and neck region. It is a versatile flap and widely used for the treatment of surgical defects following oral cancer and ablative resection. Although free flaps are nowadays considered “Gold Standard” of head and neck reconstruction, Pectoralis Major Myocutaneous(PMMC) Flap is still popular among cancer surgeons in developing countries for its many advantages and also due to lack of resources for free flaps in most of the centers ,large number of cancer patients with poor nutritional status and economic condition. This presentation describes the use of PMMC flap for the reconstruction of buccal mucosa carcinoma. Keywords: Pectoralis major myocutaneous flap, reconstructive surgery, cancer patients.
Influence of Orthognathic Surgery on Velopharyngeal Function in Patients with Cleft Palate
Introduction: In orthognathic surgery for cleft palate patients with maxillary undergrowth, it should be carefully planned because maxillary advancement affects velopharyngeal function (VPF). The purpose of this study was to evaluate whether the amount of maxillary advancement in Le Fort I osteotomy affects VPF in cleft palate patients. Subjects and methods: Six patients with cleft palate who underwent orthognathic surgery between 2019 and 2022 were included in this study. VPF was evaluated using a 4-grade based on the cleft palate language test and a nasalance score before and after surgery. The relationship between maxillary advancement and VPF was investigated. Results: In cases 1 to 4, surgeries were undergone with ideal amounts of maxillary advancement and VPF was not affected after surgeries. In case 5, mild insufficiency grade of VPF suggested that maxillary advancement might affect VPF, but 3 mm of maxillary advancement was planned and performed considering the patient’s chief complaint of improvement of facial appearance. As a result, mild exacerbation of VPF was observed after surgery. In case 6, the preoperative VPF insufficiency was mild, but the articulation disorder was observed. The maxilla was not surgically moved anteriorly, only with canting correction, to preserve speech function. As the result, there was no postoperative deterioration of VPF. Discussion: In orthognathic surgery for patients with cleft palate, it is necessary to consider the amount of maxillary advancement and formulate a treatment plan from viewpoints of occlusion, VPF, and facial appearance in addition to the patient’s chief complaint.
Oroantral Fistula Closure via Double Layer Closure Technique - A Case Series
Background: The oroantral fistula (OAF) is a pathological connection between the maxillary sinus and the oral cavity and is one of the unfortunate complications encountered in maxillofacial region. Among various surgical management techniques, closure with double layer flap method using Buccal Fat Pad (BFP) and Buccal mucosal flap to cover the defect has numerous advantages and encouraging results. Case description: Nine patients with oroantral fistula were operated in BPKIHS from year 2019 AD to 2022 AD using double layered flap closure. Patient’s age ranged from 18 years to 59 years, out of which seven were associated with first maxillary molar while two were associated with second maxillary molar. None of the patients reported with any major complications. The patients were kept under routine follow-ups. No recurrence is noted till date. We intend to discuss the technique of OAF closure, peri-operative protocol in this presentation. Conclusion: Double layer flap closure seems to be a viable and reliable option for closure of OAF.
N-cadherin in Oral Squamous Cell Carcinoma
Cadherins are a family of cell-cell adhesion molecules which can modulate phenotype and morphogenesis in a variety of tissues. Oral squamous cell carcinoma (OSCC) expresses the epithelial type cadherin (E-cadherin) in the intercellular junction. Histologically, two types of tumor cell migration can be observed in OSCC; the collective cell migration and the individual cell migration. In the former, large tumor nests maintain E-cadherin-mediated cell-cell contact and invade into surrounding connective tissue. The latter shows migration of isolated cells or small tumor nests. We immunohistochemically investigated the localization of cadherin in OSCC. E-cadherin expression was noted in all samples of OSCC irrespective of the histological differentiation of tumors. N-cadherin was expressed in 50% of poorly differentiated OSCC, and localized in cord-like tumor nests at the advancing front, where the cadherin subtype of tumor cells switched from E-cadherin to N-cadherin (the neural type cadherin). This finding suggested the epithelialmesenchymal transition (EMT), a phenomenon observed in the tissue morphogenesis during development, occurred in human OSCC tissue. Next, we studied roles of N-cadherin in tumor progression by in vitro assays using an E-cadherin(-)/Ncadherin(+) OSCC cell line. The cell line showed weak cell-cell contacts in the monolayer culture, and showed a high migration property by the Boyden chamber assay. In the suspension culture, however, they formed dense cell aggregates mediated by N-cadherin, and escaped from anoikis (apoptosis induced by loss of anchorage). Taken together, N-cadherin would be involved in the progression of OSCC via the enhanced migration and the survival in anchorage-deficient condition.
Mono-Cortical Mandibular Bone Grafting for Reconstruction of Alveolar Cleft
Objective: Alveolar bone grafting is well-established procedure for the management of patients with alveolar cleft. Grafting of the alveolar cleft is usually accomplished with cancellous bone from the ilium. However, the harvesting from the ilium show several physical impediments, so that we usually harvest the bone grafts from the mandibular symphyseal region as mono-cortical bone grafts. This study aims to assess and develop a mono-cortical bone grafting procedure for reconstruction of alveolar cleft. Material & Methods: Eighty-eight clefts of 75 consecutive Japanese patients who had been treated according to a strict clinical protocol. Mean age at bone grafting was 7 years 1 months. Bone grafting was performed by harvesting lateral cortical bone plates from the symphysis without particulate bone and then placing them on the labial and palatal openings of the alveolar process defect. Mean follow-up after bone grafting was more than 4 years. Status of the grafted area and eruption of cleft-adjacent teeth were assessed prospectively using computed tomography (CT) and periapical radiography. Results: At 6 months postoperatively, CT showed sufficient bone bridge formation at the cleft site in 83.0% of clefts. Periapical radiography showed ³75% of the root surfaces of cleft-adjacent teeth were covered with spanning bone in 93.2% of clefts. In 86.4% of clefts in which the cleft-adjacent canine was uncovered with bone during follow-up, the canines erupted spontaneously. Conclusion: The procedure is advantageous in that the quantity of bone required per unit volume of cleft defect is relatively reduced, and larger clefts can thus be treated.
Incidence and Pattern of Multiple Mandibular Fracture: How Uncommon are they? A Retrospective Study
Objective: The objective of the study was to find out the incidence and pattern of multiple mandibular fractures among patients reporting to B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. Material and Methods: Data of patients who reported with mandibular fracture at BPKIHS from January 2021 to December 2022 were retrieved from the medical records. Incompletely filled and missing records were excluded. Pathological fractures were also excluded. Demographic variables, etiology for injury, and site of mandibular fractures were tabulated into Microsoft Excel sheet (2018) and analyzed. Results: The age of the patients ranged from 14 to 41 years with mean age of 25±5.5 years. Majority of patients were male (78%). Most of the injuries resulted from road traffic accident (64%). Other causes of injuries were physical assault (20%), and fall injuries (14%). Out of all reported cases 68% had multiple mandibular fracture. The injuries reported were fractures of parasymphysis together with fracture of angle (24%), among which 84% had from contralateral fractures whereas 16 % had ipsilateral fractures. Bilateral parasymphysis fracture was 12%, symphysis fracture together with bilateral condylar fracture was 14.7%. In patients with multiple fractures, 53 % had parasymphysis involvement, 34% had bilateral condylar involvement and 25% had angle involvement. Conclusion: Incidence of mandibular fracture was more common in male. Road traffic accident was the most common cause of mandibular fracture. Fracture of parasymphysis together with fracture of angle was the most common.
Local Flaps for Functional and Esthetic Reconstruction of Oro-Facial Defects - A Case Series
Background: Management of varied pathologic, traumatic and congenital lesions of oral and maxillofacial region demands resection in partial or total along with surrounding structures producing defects of varying sizes. Arguably, the greatest challenge within oral and maxillofacial surgery is reconstruction following major trauma or oncologic ablative surgery that restores pre- morbid quality of life. Even small facial defects can lead to cosmetic deformity and impacts significantly on patient’s psychological well-being if not reconstructed properly. Owing to the aesthetics and functional concern, oral and maxillofacial soft tissue reconstruction requires meticulous planning with team approach. And is a technically demanding and time-consuming process because of the specialized functions of the tissues involved. Among various reconstructive options, local flaps being located within the vicinity of the defect carry advantage of close resemblance to the missing skin in color and texture and the thickness can often be tailored to the needs of the defect. These local flaps can be advanced, transposed or rotated into position to reconstruct the defect. As these flaps heal, regaining of blood flow and cutaneous sensibility increases. Aim of this paper is to share an institutional based case series in using various local flaps for the reconstruction of oral and maxillofacial defects.
Intravenous Sedation in Dentistry: Can You Really Relax in Dentist’s Chair?
Background Dental-related anxiety and fear have long been an issue, and it keep millions of people away from the dental office every year. Despite the advances in pain control that has expanded our abilities to perform a wide range of dental treatment in a pain-free environment, many adult dental patients still have a great deal of fear about treatment evoked pain. For them, local anesthesia is not enough because while it numbs the pain, it does nothing to minimize the fear and other psychological factors. For this group of individuals, discussions concerning conscious sedation and perhaps general anesthesia appear reasonable when making treatment plans. The provision of adequate anxiety control is an integral part of the practice of dentistry. All patients deserve appropriate anxiety control for any dental procedure. As patient awareness of the risk of anaesthesia and the availability of sedation have increased, so the popularity of conscious sedation for dentistry has increased. It is important to recognize that there is no “one size fits all” sedation technique and no single technique will be successful for all patients. Intravenous sedation is more potent and quicker-acting than inhalation or oral sedation and is particularly effective for very anxious or phobic dental patients and for difficult surgical procedures. This presentation is about the conscious sedation techniques that we have been following in our department. The presentation will also share our experiences with management of anxious dental patients under conscious sedation.
Management of Impacted Maxillary Central Incisor: A Case Report
Background Impaction of maxillary permanent incisors is not a frequent case in the dental practice, but its treatment is challenging because of these teeth’s importance to facial aesthetics. Over-retained deciduous teeth, supernumerary teeth, ectopic eruption and crowding are the most common etiological factors. Careful planning and interdisciplinary approach are required for its management. Case Description A 22 years old male patient presented with the chief complaint of missing upper front tooth. The patient had no any history of medical problem and dental trauma. Intra oral examination revealed absence of 11. 12 21 22 were erupted. There was no apparent arch length discrepancy in both arches. No soft tissue bulging was present. OPG revealed impacted 11 along with the presence of odontome. Treatment plan included surgical removal of odontome and orthodontic traction of 11. After completion of alignment and levelling in upper arch, full thickness mucoperiosteal flap was raised followed by removal of odontome and bonding of lingual button on palatal aspect of 11. One week later orthodontic traction was started. After 4 months, 11 erupted into oral cavity. Lingual button was bonded on labial surface of 11. Couple force was applied for rotation correction. Bracket was bonded on 11 and traction was continued with 0.012 NiTi archwire. Conclusion Successful management of impacted central incisor is a clinical challenge. Early detection and exact localization of the impacted tooth, an appropriate surgical technique, and a light orthodontic force system can be an effective approach to successfully bring the tooth into occlusion.
GATA6 Regulates the Expression of Annexin A10 Associated with the Epithelialmesenchymal Transition of Oral Squamous Cell Carcinoma
Oral squamous cell carcinoma (OSCC) can degrade oral function and quality of life. The development of cervical lymph node metastases is associated with poor survival of OSCC patients. Epithelial-mesenchymal transition (EMT) is a process where cells acquire molecular changes that facilitate cell motility and invasion, and has been known as associated with tumor metastases. EMT changes also play a major role in the induction of lymph node metastasis in OSCC. GATA6 suppresses dedifferentiation and EMT in human pancreatic ductal adenocarcinoma cells but promotes EMT in cholangiocarcinoma. However, in OSCC, the expression and function of GATA6 in EMT and lymph node metastases are not clear. Therefore, this study aimed to clarify the targets of GATA6 in OSCC cells and whether the change in GATA6 expression affects EMT in OSCC cells, as well as the association between GATA6 and lymph node metastasis. The results showed that GATA6 knockdown OSCC cells promoted EMT and increased lymph node metastasis compared with control cells, whereas the overexpression of GATA6 inhibited the induction of EMT and reduced lymph node metastasis. In addition, annexin A10 (ANXA10) was identified as the target gene for GATA6, and ANXA10 suppressed the expression of Vimentin in the EMT in the OSCC. Therefore, the GATA6/ANXA10 cascade may represent a potential therapeutic approach for the treatment of lymph node metastases in patients with OSCC.
Elective Neck Dissection in Squamous Cell Carcinoma of Oral Cavity: Our Experiences
Objectives The present study was carried out to assess the efficacy of elective neck dissection (END) in oral Squamous cell carcinoma (OSCC) with clinically and radiographically negative neck (N0). Materials and methods The present retrospective study, carried out in the department of oral and maxillofacial surgery of dhulikhel hospital included the records of OSCC patients in whom END was carried out between the period of January 2016 to December 2022. The study included only the patients with N0 neck who had undergone END. The histopathological records post neck dissection was studied to determine the nodal status. Descriptive statistics was calculated and recorded. Results Out of 30 patients operated, 21 met our criteria of inclusion. Out of 21 patients, 14 (66.6%) were male and 7 (33.3%) were female. Supra-omohyoid neck dissection was done in 18 (85.7%) patients. Out of 21 neck dissections, 11 (52.4%) had histopathological evidence of nodal metastasis. Level I B was the most common node involved. Conclusion It is advisable to consider elective neck dissection in Oral cancer with clinically and radiographically negative neck node.
Application of International Research Diagnostic Criteria in Clinical Setting for Diagnosis and Treatment Planning of Temporomandibular Joint Disorders
Background Temporomandibular joint disorders (TMD), while getting increased attention in modern periods, still challenges clinicians for proper diagnosis and treatment plan. A proper protocol for examination of TMD is yet to be established in clinical settings in countries such as ours, with challenges such as patient compliance, economic factors and lack of proper infrastructures are still making huge impact in diagnosis and treatment. A proper study for standardizing examination and determining treatment in context of our society is felt wanting. Case description Here we present cases who came to OMFS opd, IOM for any perceived problem of temporomandibular joint. Any OPD cases who visited OMFS OPD, IOM with complaint provisionally diagnosed as originating from TMJ or referred for same from other departments were taken for study. Diagnosis was selected from algorithm and treatment was planned according to diagnosis and availability of treatment options. Results of treatment was noted in subsequent follow ups. Conclusion A standardized examination pattern for TMJ disorders can result in proper diagnosis with high sensitivity and specificity. A proper diagnosis will lead to greater efficiency in treatment planning, increasing confidence of patient for treatment. Exploring various treatment options in context of society leads to better outcome as well.
Experience of Secondary Commissuroplasty for Lip Morphology and Function after Lip Reconstruction
Patients who have undergone lip reconstruction due to oral cancer often develop deformities of the oral commissure on the affected side. We report our experience with two cases of secondary commissuroplasty for lip morphology and function after lip reconstruction. Case report Case 1 54-year-old male. He was referred to our department in July 2019 for swelling of the right upper lip. He was diagnosed with clear cell carcinoma by biopsy. After tumor resection, upper lip reconstruction was performed with Estlander flap. The oral commissure on the affected side became drooping, thick and round. At 6 months postoperatively, secondary commissuroplasty was performed according to the Barsky technique. One year after surgery, the patient had a symmetrical lip and good lip closure. Case 2 A 58-year-old male, He underwent lower lip reconstruction with an Estlander flap after excision of the right lower lip at another Hospital in April 2020. Histopathological diagnosis was adenoid cystic carcinoma. In May 2020, he was referred to our department for lip revision. The oral commissure on the affected side became small and round. At 6 months postoperatively, secondary commissuroplasty was performed according to the Barsky technique. Six months after surgery, the patient had a small volume of the lower lip near the oral commissure on the affected side, but the lip was symmetrical and the lip closure was generally good. Discussion The ingenuity of the Barsky method and the differences between Case 1 and Case 2 after secondary commissuroplasty are discussed.
Comprehensive Management of a Cleft Patient: A Multidisciplinary Approach
Background Management of a cleft patient is not limited to surgical repair of lip and palate. Nasoalveolar molding begins within a few days after birth followed by Cheiloplasty and Palatoplasty by age one. Orthopedic interventions and orthognathic surgeries will follow at different stages of life as the child grows into an adult. Thus surgical and non-surgical support continues as required till adulthood and further. Description Our goal is to provide as much of multidisciplinary interventions to a cleft patient as possible. Here is a series of cases to demonstrate the same.
The Usefulness of Cervical Island Skin Flap for Intraoral Repair of Oral Surgery
Oral cancer is typically treated with surgical excision, and this frequently results in a large defect and severe functional problems. Local flap reconstruction is applicable to restoring appearance and function, and it causes less surgical stress than a vascularized free flap. In 1969 Farr et al reported the cervical island skin flap for the reconstructions of oral cancer. This flap is due to short operating time, low morbidity, and good functional and aesthetic results. This flap is not only an alternative to microvascular flaps but also an excellent reconstructive choice especially in cases where free tissue transfer cannot be carried out. We have also used this cervical island skin flap in selected cases. The operations that the wide broad platysma was included in the base of flap showed better results recently. Hence, cervical island skin flap should be considered as a choice of local flap for oral reconstruction depending on the defect size of oral cavity. In this presentation, we would like to show some cases that we experienced recently.
Diffuse Large B- Cell Lymphoma of Oropharyngeal Area: A Case Series
Background Lymphomas are a group of malignant neoplasms originated from lymphoid hematopoietic system and the second most common malignancy of the head and neck region. Extranodal Non-Hodgkin Lymphoma (NHL) was first described as a distinct entity by Isaacson and Wright in 1983. The head and neck are the second most common sites for extranodal NHL. Oral cavity is an uncommon site for NHL which accounts for 0.1 to 3% of the cases. Diffuse large B cell lymphoma (DLBCL) is the most common lymphoma in head and neck region. Case description We report three cases of Diffuse large B cell lymphoma a variant of NHL. Three patients within a age range of 6th to 7th decade, presented with a chief complaint of mass in oropharyngeal area associated with pain and swelling in neck. On histopathological examination of the provided incisional biopsies, Poorly differentiated carcinoma and non-Hodgkin lymphoma were given as the differential diagnosis. However immune-histochemical analysis confirmed the diagnosis as Diffuse large B-cell lymphoma. Conclusion Although non-Hodgkin’s lymphoma is uncommon in the oral cavity, it should always be considered in the differential diagnosis of intraoral malignant diseases of head and neck swelling. Pertinent immuno-histochemical analysis is important for the early diagnosis and good prognosis of the disease.
An Unusual Presentation of Adenomatoid Odontogenic Tumor: A Case Report
Background Adenomatoid odontogenic tumor (AOT) is uncommon, nonaggressive neoplasms of odontogenic epithelium. It is also known as two-third (2/3rd) tumor as 2/3rd occur in maxilla, 2/3rd occur in females, 2/3rd cases are associated with unerupted/impacted tooth and 2/3rd teeth affected are canines. Case description A 17-years female reported to department with complaint of swelling in lower front region of jaw since 9 months which was sudden in onset, gradually progressive. On examination single, localized, well-defined, oval, firm, non-tender swelling present with no discharge on palpation. Size was approximately 8cm×4cm extending mesial of 35 to mesial of 44 and from crest of marginal gingiva to the depth of buccal vestibule. 33 was missing and grade 3 mobility w.r.t. 31, 32, 41, 42, 43. Expansion of buccal and lingual cortical plate with displacement of teeth present. Panoramic radiograph revealed single, localized, well-defined, oval, corticated, unilocular radiolucency with flecks of radioopacity interspersed within radiolucency. Tooth displacement and external root resorption present w.r.t. 32-43 with transmigrated 33. Discontinuity of inferior border of mandible seen w.r.t. 31-34 region. Provisional diagnosis of Dentigerous cyst (DC) w.r.t. 33 was made with differential diagnosis of Adenomatoid odontogenic tumor (AOT) and Calcifying odontogenic cyst (COC). Biopsy followed by histopathological examination confirmed the diagnosis of AOT. Conclusion Based on our clinical findings, provisional diagnosis of DC was given but histopathological examination diagnosed as AOT. So, whenever we encounter a lesion in young patients with unerupted tooth in anterior mandible region AOT should be kept as a part of differential diagnosis.
Background Adenoid ameloblastoma is the new entity added to the odontogenic lesions. The name ‘adenoid ameloblastoma with dentinoid’ was introduced by the Armed Forces Institute of Pathology in 1994 by Brannon. There was no official recognition of this entity as shown in the WHO classification of odontogenic tumors from 1992 to 2017, which can illustrate the diagnostic challenges. It can be considered a hybrid odontogenic tumor showing histopathological features of both ameloblastoma and adenomatoid odontogenic tumor (AOT). The lack of BRAF mutation and the finding of nuclear β catenin reactivity doubt their relation to an ameloblastoma and currently WHO 2022 has identified it as a new entity classified under benign epithelial odontogenic tumors and defined as an epithelial odontogenic neoplasm composed of cribriform architecture and duct-like structures and frequently includes dentinoid. It usually presents as a painless swelling with prevalent in the 4th decade of life, and with a slight male predilection. The tumor shows more aggressive behavior and high recurrences rate due to a high Ki67 proliferation index. Case description Here, we report a case of 35-years-old male who presented with a chief complaint of swelling in the lower anterior region of jaw since 1 month. Intraoral examination revealed localized swelling of 3x2.5 cm in diameter that extended from 33 to 43. Radiographic examination showed mixed radiolucent and radiopaque area. Conclusion Clinical and radiographic presentation of adenoid ameloblastoma is not diagnostic and a histopathological examination is necessary not only for confirmation but also for its identification of a new variant.
Quad Zygomatic Implants: A Graftless Solution to the Atrophic Edentulous Maxilla
Oral rehabilitation of atrophic edentulous maxilla poses a great challenge to both surgeons and prosthodontists. Although procedures like sinus augmentation and bone grafts are of routine use to increase bone volume to allow anchorage, the long duration of the wait for rehabilitation during graft consolidation and the healing period has resulted in a shift of focus from maxilla to zygoma for anchorage. Zygoma implant has proven to be an effective management option for atrophic edentulous maxilla as well as for maxillectomy defect. Apart from relieving surgeons from the hassles of graft harvesting and donor site morbidity, excellent initial stability offered by zygoma implant allows immediate loading resulting in the early return of function and esthetics of the oral cavity. Severe resorption of alveolar bone in all three zones of the maxilla (anterior, premolar, molar) can either be managed by a combination of two zygoma implants with two anterior implants or via quad zygoma. We present a case of a 42-year completely edentulous male who presented for fixed full mouth rehabilitation. This paper aims to highlight the use of quad zygomatic implants for the rehabilitation of the atrophic edentulous maxilla.