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National Journal of Maxillofacial Surgery
 
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   Table of Contents - Current issue
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July-December 2019
Volume 10 | Issue 2
Page Nos. 127-275

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EDITORIAL  

From the desk of president, UPAOMSI p. 127
Gaurav Singh
DOI:10.4103/njms.NJMS_67_19  
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ORIGINAL ARTICLES Top

Ultrasound elastography as a potential diagnostic aid in oral submucous fibrosis p. 129
Sailesh Kumar Mukul, Subhash Kumar, Shweta Pandey, Ejaz Ahmad Mokhtar, Amit Kumar
DOI:10.4103/njms.NJMS_20_19  
Background: Oral submucous fibrosis (OSMF) is a well-recognized “potentially malignant” disorder. It mostly affects the productive population of young adults and adolescents. The diagnosis of oral submucous fibrosis is primarily clinical and subjective. The only objective diagnostic method for OSMF is tissue biopsy. This study was conducted to find the potential use of ultrasound elastography to objectively quantify the clinical presentation in accordance with severity of the clinical condition in OSMF. Materials and Methods: The study sample consisted of 27 clinically diagnosed and staged participants with OSMF. Transcutaneous ultrasonography was done by a single operator on GE Logiq E9 machine with a 6–15 MHz linear matrix probe. Color-coded scheme was used to qualitatively grade the eight different zones of oral mucosa with the use of stress–strain elastography. The grades ranged from 0 to 5, where 0 represented artifacts and color range from red to blue corresponded to varying degree of increasing tissue stiffness. Clinical stage 1, 2, and 3 corresponded to mouth opening of >30 mm, 20–30 mm, and <20 mm, respectively. The summative elastography score range as follows: 8–10, 11–14, and ≥15 represented the respective degree of tissue stiffness from soft, mild stiff to severe stiff. Results: The results obtained by Pearson's correlation between the elastographic grading and clinical grading came out to be 0.007, and it was highly significant. The sensitivity and specificity of the diagnostic method were 90.9% and 20%, respectively. Conclusion: The advantages of ultrasound elastography as a diagnostic tool over the subjective clinical method of diagnosis and staging of OSMF looks promising. Further studies should be conducted with a suitable specific transducer probe and with quantitative diagnostic elastography method.
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Health-related quality of life assessment for head-and-neck cancer patients during and at 3 months after radiotherapy – A prospective, analytical questionnaire-based study p. 134
Ahmad Masroor Karimi, Munish Gairola, Parveen Ahlawat, Sarthak Tandon, Manoj Pal, Nishtha Sachdeva, Muhammed Ismail Sharief, Kiran Dobriyal
DOI:10.4103/njms.NJMS_92_18  
Introduction: Health-related quality of life (HRQoL) is a more specific area of QoL that deals with the evaluation and assessment of the impact of the disease and its treatment-related morbidities on a patient's physical, psychological, and social aspects. The aim of the present study was to assess the HRQoL of patients with head-and-neck cancer (HNCs) during and at 3 months after completion of radiotherapy (RT) by intensity-modulated RT. Materials and Methods: This study was a prospective, longitudinal, observational, and self-completed questionnaire-based study that included 120 patients with HNC who underwent intensity-modulated RT. The questionnaire had adequate internal consistency. The questionnaires were given to each patient at the beginning of treatment (pretreatment), weekly visits during the course of RT (at the end of 1st, 2nd, 3rd, 4th, 5th, and 6th week), on the day of completion of RT, and then finally at 3 months after completion of RT. Thus, a total of successive nine time points were assessed. Results and Conclusions: One hundred and eleven patients completed the questionnaires at all nine time points. HRQoL usually decreases during treatment and then increases to pretreatment levels by 3 months after treatment. The Quality of Life Questionnaire, Core Module and Quality of Life Questionnaire, Head and Neck Module were found to be both valid and reliable. There was a significant QoL reduction for the patients throughout treatment in relation to functions and symptoms in the treatment of HNC. However, all the functions and most of the symptoms returned to baseline at the 3-month follow-up.
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Microflora analysis in the postchemotherapy patients of oral cancer p. 141
Sunita Singh, Seema Singh, MB Tiwari, US Pal, Santosh Kumar
DOI:10.4103/njms.NJMS_7_19  
Background: To assess changes in oral microflora in dental plaque from cancer patients within 7 days of the first course of chemotherapy and the relationship of the changes with mucositis. Materials and Methods: Thirty cancer patients, divided into a test group undergoing chemotherapy and a control group not undergoing chemotherapy, were enrolled in this pilot study. Oral microflora was cultured from three samples of dental plaque at t0 (before chemotherapy), t1 (1 day after chemotherapy), and t2 (7 days after chemotherapy). Single and crossed descriptive analyses were used to establish prevalence, and the Chi-square test was used to establish the statistical significance of the differences observed in distributions (significance level: P < 0.05). Results: In most patients (55%), oral microflora consisted mainly of Gram-positive cocci, while the remaining 45% of the bacterial flora also had periodontal-pathogenic species. No Porphyromonas gingivalis appeared in the test group. Actinobacillus was the least frequently found bacterium among periodontal pathogens in the test group, while Fusobacterium nucleatum was the most frequently found. No significant differences were found in quantitative bacterial changes between t0, t1, and t2 in either the test or control groups, or between the two groups. According to World Health Organization scores, oral mucositis developed in 10 patients (66.6%) in the test group. Conclusions: The results of this pilot study indicate that there were no changes in microflora in dental plaque in cancer patients within 7 days of the first course of chemotherapy. No correlations between oral mucositis and specific microorganisms were assessed.
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Zygomaticomaxillary “lateral swing” osteotomy for augmentation of midface deficiency Highly accessed article p. 146
Thomas Zachariah, RS Neelakandan, Aparna Murugan
DOI:10.4103/njms.NJMS_53_18  
Introduction: Various surgical modalities have been proposed for the augmentation of midface deficiency without correction of the occlusal component. They include autogenous bone and cartilage grafts, alloplastic materials, and osteotomies. We propose an innovative osteotomy technique for augmentation of the midface including the infraorbital rims, the zygoma, the anterior maxillae, and the paranasal areas without advancing the dental-bearing segment. Materials and Methods: This procedure was carried out on a 21-year-old male patient who had a deficiency of the anterior maxillae including the infraorbital rims. His occlusion was in Class I molar relation. The surgical exposure was carried out through a midface degloving approach. This bilateral osteotomy encompasses the anterior maxillae and the zygoma; the osteotomy line running superiorly from the medial aspect of the infra-orbital rim to the root of the frontal process of maxilla. Inferiorly, the line runs above the apices of the maxillary teeth laterally underneath the zygomatic buttress, separating part of the zygomaticomaxillary suture posteriorly. Medially, the osteotomy line runs parallel to the piriform aperture. The osteotomy is pedicled on the zygomaticotemporal suture. A greenstick fracture at the zygomatic arch pedicled the osteotomized segment to the zygomatic process of the temporal bone. The entire segment was swung laterally outward, effectively separating part of the zygomaticomaxillary suture posteriorly. Fixation was achieved with a single 2-mm L-shaped, 4-hole plate with gap at the zygomatic buttress region. Results: This osteotomy technique resulted in fullness of the anterior maxillae and infraorbital rims, with increased anterior and lateral projection of the zygoma. Conclusion: The zygomaticomaxillary “lateral swing” osteotomy is a reliable and stable technique for total midface augmentation not requiring occlusion correction.
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Evaluation of use of distraction osteogenesis in mandibular retrognathia and its effect on soft and hard tissues and airway p. 153
Aditya Mohan Alwal, G Rajasekhar, Nandagopal Vura, M VS Sudhir, Srikanth Damera
DOI:10.4103/njms.NJMS_75_18  
Objectives: Bone distraction is the process of new bone formation between the surfaces of bone segments gradually separated by incremental traction of soft tissues. These adaptive changes in the soft tissues allow for greater skeletal movements while minimizing the potential relapse. In this study, we are reporting our clinical experience with mandibular distraction used to achieve simultaneous skeletal and soft-tissue correction with distraction osteogenesis (DO). Methodology: A total of five patients who reported to the department for the treatment of mandibular deficiencies were selected. Cephalometric studies were done preoperatively and postoperatively for hard tissue assessment. Predefined reference points were used for the clinical evaluation for the evaluation of soft tissues. Results were compared between preoperative and 1st-, 3rd-, 6th-, and 12th-month postoperatively. Results: The clinical observations in our study showed that there is a remarkable improvement in the facial esthetics. Cephalometric analysis has shown lengthening of the mandibular corpus and increase in the height of the vertical ramus. Certain minimal complications have also been noted. Conclusion: Despite the few complications, DO has become a popular surgical modality due to its many advantages.
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Soft tissue growth changes from 8 to 16 years of age: A cross-sectional study p. 161
Ashish Kumar, Pradeep Tandon, Gulshan Kumar Singh, Gyan P Singh
DOI:10.4103/njms.NJMS_18_16  
Objective: The present cross-sectional study was conducted to evaluate and compare the soft tissue growth changes between males and females of two groups from 8 to 16 years. Materials and Methods: One hundred sixty skeletal class I lateral head cephalograms were screened aged between 8 to 16 years-Subjects were divided into two groups. Group I (8 to 12 years) and Group II (12 to 16 years) and further these groups were subdivided into male and female subgroups. Total eight linear and four angular parameters were studied. Results: All the parameters increased in their dimension while angle of total facial convexity including nose and Nasolabialangle decreases. Among the linear variables, Noseheight, Lip thickness at laberale inferious, Lip thickness at B point, Soft tissue chin thickness and Measurements of lips to E-plane were found significant for both subgroups. While rest of the linear variables like Upper lip height, Lower lip height, Nose depth and Sagittal depth also increased but this increase wasfound non-significant. Among the angular parameters angle of total facial convexity including nose and Nasolabialangle decreases and angle of facial convexity excluding nose, and Nose inclination increases with the age, and these changes were found non-significant. Conclusion: In this study, we observed that males showed a greater value of all parameters in comparison to females, and with the advancement of age, all the parameters increased, except for angle of total facial convexity and nasolabial angle.
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Inferior alveolar nerve canal position in relation to mandibular molars: A cone-beam computed tomography study p. 168
KC Vidya, Jugajyoti Pathi, Sanjeeb Rout, Alok Sethi, NC Sangamesh
DOI:10.4103/njms.NJMS_53_17  
Objective: This study was carried out to prevent the risk of iatrogenic injuries to the inferior alveolar nerve (IAN) canal associated with various surgical interventions in the area of mandibular molars, by using cone-beam computed tomography (CBCT). Materials and Methods: The present retrospective study was carried out by using CBCT of 100 patients between 18 and 40 years of age group. The linear measurements were made in relation to the 1st and 2nd mandibular molars on both the sides. Linear distances between buccal and lingual aspects to the mandibular, buccal, and lingual cortical bone thickness; IAN canal diameter; and the superior corticated border of the IAN canal from the periapex of the 1st and 2nd mandibular molars. The statistical evaluation was done using SPSS V.20 (SPSS: an IBM company), and P < 0.05 was considered statistically significant. Results: Both genders of all age groups showed statistically significant result (P < 0.00). All the linear measurements were statistically significant in relation to both the 1st and 2nd mandibular molars (P < 0.005), and also the bilateral comparison of the linear measurements showed statistically significant difference in relation to the mandibular 2nd molar (P < 0.03) and 1st molar (P < 0.04) among both the sexes. Conclusion: Clinicians should be aware of the proximity of root apices and cortical plates to the mandibular canal when performing surgical and root canal procedures in the posterior mandible to avoid serious nerve injuries.
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Efficacy of hybrid implants in oral and maxillofacial surgery: A clinical prospective study p. 175
Gaurav Mittal, Gagan Khare, Ritesh Garg, Abhishek Rathi, Siddharth Sharma, Dipika Raghaw
DOI:10.4103/njms.NJMS_61_17  
Aim: The present study was aimed to evaluate the efficacy of hybrid implants in replacement of missing teeth in either jaw. Materials and Methods: Twenty hybrid implants were placed in maxilla and mandible and the implants were assessed for pain,implant exposure, mobility, infection and wound dehiscence at first, third and sixth month postoperatively. Results: According to our study the statistical data showed that all the parameters which were seen clinically were nonsignificant. Conclusion: Hybrid implants being a new option in this field, our study provides a platform for further research with larger sample size with longer follow ups to be judgemental on their efficacy.
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Study on prevalence and sociocultural aspects of tobacco use in India p. 182
Sana Farooqui, Shadab Mohammad, Divya Mehrotra, Abbas Ali Mahdi, Sandeep Bhattacharya, GG Agarwal, Saurabh Srivastava
DOI:10.4103/njms.NJMS_82_18  
Aim: The present study focuses on the prevalence of tobacco use and aims to determine various sociocultural aspects of tobacco use in Indian population. Materials and Methods: The study sample comprised 384 participants. There were three study groups, and in each study group, there were 128 participants. Group A was tobacco users without oral precancer, Group B was tobacco users with oral precancer, and Group C was healthy individuals with no history of tobacco or areca nut use and oral precancer. Both male and female adults in the age group of 18 years and above visiting the Outpatient Department of Oral and Maxillofacial Surgery at King George's Medical University were recruited for the study. The study participants were explained in detail about the study, and informed consent was obtained through them. Data have been collected using a standard structured predesigned questionnaire. The questionnaire consisted of the details of the demographic profile of the study participants, details of tobacco use, and the major social and cultural reasons which motivated them to consume tobacco. Data were extracted from the case sheet, and the data were entered into a worksheet for the purpose of analysis. The analysis was performed using the commercially available Statistical Package SPSS. Conclusion: The rate of tobacco prevalence is very high among the Indian population, and a number of social and cultural factors are responsible for its use. To curb this problem, more studies could be done to find the causes responsible for its use.
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A comparative study to evaluate the efficacy of Azadirachta indica (neem) and Curcuma longa (turmeric) in extraction socket p. 191
Vidhi Chhabra Rathi, Anshul Jain, Sanjeev Kumar, Rajratan Sonone, Suman Yadav, Shahid M Shaikh
DOI:10.4103/njms.NJMS_56_18  
Introduction: Herbal medicines have less side effects in comparison with traditional medicines, but side effects occur and are safer to use than conventional medications. Herbal medicines have two special characteristics that distinguish them from chemical drugs; use of crude herbs and prolonged usage. Aim: Evaluation of the efficacy of neem and turmeric in wound healing in orthodontic extraction sockets. Materials and Methods: 45 extraction sites were divided in 3 group of 15 each where apart from group left as control, remaining groups recieved Neem and turmeric extyracts respectively. the healing of extraction socket was assessed and compared with the control group. Results: Delayed wound healing was fouond in the control group as compared to the group recieving Herbal extracts. Conclusion: Herbal extract therapy should be administered in extraction sockets though a larger sample size may reveal more comprehensive picture.
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Prevalence of trigeminal neuralgia in Indian population visiting a higher dental care center in North India p. 195
Gaurav Katheriya, Akhilanand Chaurasia, Nida Khan, Javed Iqbal
DOI:10.4103/njms.NJMS_64_18  
Objectives: The present study aims to determine the incidence and prevalence of trigeminal neuralgia (TN) in study population and difference in prevalence of TN in urban and rural population. Materials and Methods: This retrospective study includes 1215 study participants with typical idiopathic TN. Data regarding the age of onset, gender, site of involvement, and clinical presentations were retrieved from clinical records of patients reported from January 2011 to January 2018. Results: The study population consists of 1215 study participants aged between 21 and 87 years, with a mean age of 50.62 ± 15.872 years. The mandibular nerve is involved in most of the cases (56.9%), followed by maxillary nerve (42%). The right side of the face (57.1%) is more involved than the left side (38.8%). TN was more prevalent (52.4%) in rural population than urban population (47.6%). Conclusion: TN is more common in females than males, the right side of the face is more involved than the left side, and it is more commonly found in rural population than urban population.
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Comparison of comma incision with Ward's incision in third molar extraction in terms of postoperative sequel – A clinical study p. 200
Ashiq Ali, Shahi Jahan Shah, Ajaz A Shah, Sehar Aslam
DOI:10.4103/njms.NJMS_39_18  
Objective: The objective of the study was to compare standard Ward's incision and comma-shaped incision and its influence on postoperative complications in surgical removal of impacted mandibular third molar. Materials and Methods: This was a prospective study. Fifty individuals divided into two groups with impacted mandibular third molars were recruited for the study. Twenty-five individuals were allocated to each group: a standard Ward's incision was made in Group A and a comma incision was made in Group B to reflect the mucoperiosteal flap, after which the common steps for removal of impacted third molars were followed. The postoperative parameters were recorded immediately on the postoperative days 1, 3, and 7. Observation and Results: The pain scores which were recorded on days 1, 3, and 7 in the surgical area with comma incisions were found to be significantly lower as compared to the pain scores in the area where standard incisions were made. Similarly, swelling was lesser with comma incision than with standard Ward's incision. There was a significant difference in mouth opening between the two incisions on day 1, but no significance was seen on days 3 and 7. All of these findings showed significant statistical differences. Summary and Conclusions: The results of the study showed that the new comma-shaped incision design was preferable over the conventional method (Ward's incision), considering the lesser degree of postoperative complications.
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Decision-making in classifying gingival recession defects – A systematic review p. 206
Ajay Mahajan, Kanwarjit Singh Asi, Deepa Rayast, Mayum Negi
DOI:10.4103/njms.NJMS_71_18  
Background: Various classification systems have been devised to classify gingival recession defects (GRDs). Recent evidence has raised many questions on the use of currently popular classification systems. The purpose of this systematic review is to assess various classification systems in the light of the current scientific literature. Methods: A comprehensive and systematic search was done to identify literature related to classification systems for GRD. Sources included books, journals, and online database. The search was done using the predefined criteria; 337 articles were initially identified through online database PubMed (Medline) and 12 from handsearch, of which a total of 10 full text articles were finally selected. Results: The classification systems which were included in the review included the classifications given by Sullivan and Atkins, Miller, Smith, Nordland and Tarnow, Kumar and Masamatti, and Mahajan. The systematic review revealed that the Sullivan and Atkins classification system for gingival recession was the most useful classification system for clinicians till the year 1985 in which P. D. Miller introduced the classification system for marginal tissue recession. From 1985 to till date, the Miller's classification system is the most frequently used and popular classification system. Conclusion: None of the classification systems for GRD fulfilled the ideal criteria; however, some of the recently introduced classification systems have evolved as a more comprehensive and viable alternative to already established classification systems.
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A comparison of two doses of ketamine with dexmedetomidine for fiberoptic nasotracheal intubation p. 212
Arun Kumar, Sateesh Verma, Tanmay Tiwari, Satish Dhasmana, Vinita Singh, Gyan Prakash Singh
DOI:10.4103/njms.NJMS_86_18  
Background and Aims: Flexible fiber-optic intubation is considered to be the gold standard for management of difficult airway. Fiber-optic intubation does require effective sedation and blunting of airway reflexes for which various drug regimens have been utilized in the past. In a quest to find the noble drug combination, we combined ketamine and dexmedetomidine in two different doses, to evaluate the clinical efficacy and safety profile of ketamine and dexmedetomidine for fiber-optic intubation. Materials and Methods: This prospective randomized study was conducted in 72 patients of 20–50 years' age group of either sex with the American Society of Anesthesiologists Physical Status I and II with difficult airway. We compared two doses of ketamine 20 mg (Group I) and 40 mg (Group II) with a common dose of dexmedetomidine at 1 μg/kg body weight, given as an infusion over 10 min (a solution of 50 ml with normal saline). Sedation scores, hemodynamic variables in terms of blood pressure, heart rate (HR), and oxygen saturation were studied along with 24-h postoperative patient discomfort and recall of procedure. Results: Group II patients showed less variation from their baseline values in terms of HR (ranged between 0.73% and 4.75%) and mean arterial pressure (ranged between 0% and 3.97%) in comparison to Group I HR (ranged between 0.09% and 9.81%) and mean pressures (ranged between 0.3% and 10.38%). Discomfort during procedure (P < 0.001) and recall of procedure scale (P = <0.001) were found significantly better/lower in Group II as compared to Group I. Conclusion: Ketamine 40 mg in comparison to 20 mg with dexmedetomidine provides better hemodynamic conditions with better tolerance and lower recall to the fiber-optic intubation.
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Comparison of efficacy of sodium hyaluronate and normal saline arthrocentesis in the management of internal derangement of temporomandibular joints – A prospective study p. 217
J K Dayashankara Rao, Aadya Sharma, Rahul Kashyap, Khushboo Walecha, Vijay Siwach, Varun Arya
DOI:10.4103/njms.NJMS_26_16  
Purpose: The aim of the present study was to evaluate the efficacy of arthrocentesis with and without sodium hyaluronate (SH) injection in the treatment of patients with temporomandibular joint (TMJ) internal derangement. Materials and Methods: The study consisted of 20 patients with chief complaints of limited mouth opening, TMJ pain, and jaw deviation. Patients with disc displacement with reduction and closed lock were randomly divided into two groups. In Group 1, only arthrocentesis was performed, and in Group 2, arthrocentesis plus intra-articular injection of SH was performed. Arthrocentesis was performed under aseptic conditions using normal saline. Clinical evaluation was done for maximum mouth opening (MMO), TMJ pain, and jaw deviation before the procedure and 1 week, 2 weeks, 1 month, and 3 months following arthrocentesis. Results: The mean visual analog scale (VAS) score change was statistically significant in Group 1 and Group 2 for within the group analysis. There was statistically significant difference in VAS score between Group 1 and Group 2 at all time intervals postoperatively. The increase in MMO from preoperative to 3 months postoperatively was statistically significant for within the group analysis. There was a reduction in mandibular deviation in both Group 1 and Group 2, but the difference was not statistically significant. There was no statistically significant difference in deviation between the two groups. Conclusion: Arthrocentesis with SH is superior to arthrocentesis alone in treating patients suffering with TMJ internal derangement, who are refractory to conservative treatment.
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Efficacy of two-point fixation in the management of zygomatic complex fractures – A prospective clinical study p. 223
Gaurav Mittal, Ritesh Garg, Siddharth Sharma, Vidhi Chhabra Rathi, Rakesh Ranjan, Gagan Khare
DOI:10.4103/njms.NJMS_49_18  
Introduction: Anatomic disfigurement caused by zygomatic fracture warrants intervention tore establish facial symmetry. It is most predictably restored to pre morbid condition by ORIF. Aim: To evaluate the efficacy of 2 point fixation in Zygomaticomaxillary complex fractures. Material and Method: 20 patients with established ZMC fractures were operated using two point fixation method and followed up for upto 3 months. Results: 2 point fixation revealed satisfactory functional and esthetic results. Conclusion: 2 point fixation offers efficient outcome as compared to other modalities of management of ZMC.
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CASE REPORTS Top

Neuralgia-inducing cavitational osteonecrosis – Fact or myth, the debate persists p. 228
Yazad R Gandhi
DOI:10.4103/njms.NJMS_5_19  
Neuralgia-inducing cavitational osteonecrosis (NICO) is a debated condition characterized by cavitary lesions in the maxillary-mandibular region, often missed on conventional radiographs, and the golden standard for diagnostic measures is bone scintigraphy. It may arise secondary to trauma, such as dental extraction and endodontic treatment, and due to a low-grade chronic infection. NICO has been documented as a frequent cause of face pain involving the trigeminal nerve divisions. It may be severe, piercing pain, of short duration or even continuous pain of moderate intensity. It affects females with a greater predilection than males. A lack of awareness of the condition among health professionals is often put into the basket of atypical facial pain. Current studies describe ischemic alveolar bone marrow coagulation disorders as the cause for NICO, which may also be the result of thrombosis with or without hypofibrinolysis, which would obstruct vascular spaces impairing blood flow in the region. Treatment is decided on a case basis, depending on the clinicians' experience, on previous treatments, on the patient's general status, and more importantly, whether the site is edentulous or dentate. If surgical intervention is chosen, tissue should be sent for pathological examination. Over the years, with the advance of imaging diagnosis processes and the study and detection of genetic changes, one may also include as a cause of NICO the decreased bone marrow blood flow causing bone cavities. All of this was also associated with genetic mutations which would predispose patients to thrombophilia and hypofibrinolysis.
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Lip synechiae: A rare complication of azithromycin-associated Stevens–Johnson syndrome p. 232
Madan Mishra, Gaurav Singh, Amit Gaur, Abhivyakti Tewari
DOI:10.4103/njms.NJMS_24_19  
Stevens–Johnson syndrome (SJS) is a severe form of erythema multiforme, is a self-limiting acute inflammatory disease of multifactorial origin, but can also present as a chronic recurrent lesion. It causes a whole plethora of lesions, mostly mucocutaneous. It is a dermatologic emergency that occurs with a spectrum of severity and can result in severe morbidity and mortality. Lip adhesion is an unusual complication of healing in the lesions of SJS, for which only a few cases have been reported till date which not only causes esthetic morbidity but also impairs the proper functioning of the patient. The importance of this lesion also lies in its multifactorial and varied origin, this being the first case to report azithromycin as a causative drug, leading to SJS associated with lip adhesion. In this paper, we present a case report of SJS with lip adhesion, azithromycin being the causative drug, which was treated surgically with chalinoplasty. Along with it, the clinical features, its pathogenesis, the preventive measures, and the treatment modalities for the same including conservative as well as surgical have also been extensively discussed with a review of the existing English literature to date.
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Copper extraction: Dental consideration for Wilson's disease – An uncommon case report p. 235
Deepak A Pandyan, G V V Giri, K Shanthi, AK Suthanraj, Santosh Kumar
DOI:10.4103/njms.NJMS_60_18  
Wilson's disease is a very rare and inherited autosomal recessive disease of copper metabolism. The cause of the disease is mutation of the Adenosine triphosphate 7B (ATP7B gene). The ATP7B gene is responsible for biliary excretion of copper and incorporation of copper into ceruloplasmin. The imbalance in the copper metabolism leads to copper toxicity which primarily involves the brain, liver, the kidney, and the skeletal system. Early diagnosis and intervention is needed to prevent the mortality and morbidity of the disease. In this article, we focus on the evaluation and dental management of patients with Wilson's disease.
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Unusually rare occurrence and recurrence of temporomandibular joint ankylosis and oral submucous fibrosis simultaneously in a patient: A surgeon's dilemma p. 238
Neelam N Andrade, Trupti Gandhewar, Neha Aggarwal, Paul C Mathai
DOI:10.4103/njms.NJMS_58_17  
We here present a rare case of simultaneous occurrence and recurrence of TMJ ankylosis and submucous fibrosis in the same patient. Patient presented with limited mouth opening at both occasions. However, the diagnosis of submucous fibrosis was overlooked at the first presentation. The patient reported with recurrence of both the conditions after a period of 15 years. We presume that noncompliance of jaw exercises aggravated both the conditions as one led to the other. Since fibrosis sets in earlier than bony fusion, we theorized that the patient had acquired OSMF before TMJ ankyloses recurrence. The case was managed with release of fibrous bands intraorally followed by release of TMJ ankylosis and interposition with dermis fat graft. Physiotherapy is extremely essential when either pathology is treated in patients, especially when both are present in a single patient.
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A rare case of bilateral oblique facial cleft and accessory maxilla with repaired unilateral cleft lip and palate p. 241
Veerendra Prasad, Rais Ahmed, Arun Kumar Singh, Vijay Kumar
DOI:10.4103/njms.NJMS_67_18  
Cleft lip and palate (CLP) are commonly occurring birth defects which occur due to failure of fusion of various developmental processes of the face, leading to a visible defect in the lip and palate. In severe cases, this defect may extend over the face, thus causing facial clefts. The present case of a 7-year-old girl is unique in the sense that she has right and left side facial clefts of different severity with bilateral accessory maxilla, extra set of dentition, unilateral CLP of the right side, and a double soft palate. Other less associated findings in the case are severe maxillary protrusion, complex open bite, downward and backward rotation of mandible, and incompetent lips with apparently no limb deformities. With some relevant data in hand, we present this case for various suggestions and best possible treatment plan.
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Maxillary schwannoma – A case report of a rare tumor p. 245
Pushpchander Swami, Rushik Raval, Vinod Kumawat, V Nyklesh
DOI:10.4103/njms.NJMS_1_16  
Schwannoma or neurilemmoma is a neurogenic tumor. Intraoral schwannoma is rare and intraosseous schwannoma involving maxilla is even rare. We present one such rare case of maxillary sinus schwannoma extending to the nasal cavity, infratemporal fossa in a 22-year-old male. Wide excision of the lesion with subtotal maxillectomy of the right side was done using Weber–Fergusson approach. The patient made a good postoperative recovery. The relevant literature on the presentation, radiology, and management of schwannoma of maxillary sinus is discussed.
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Trigeminal neuralgia secondary to cerebellopontine angle tumor: A case report and brief overview p. 249
Chander Prakash, Nishi Tanwar
DOI:10.4103/njms.NJMS_2_19  
Trigeminal neuralgia (TN) is a paroxysmal shock-like pain restricted to innervations of the areas of one or more branches of the trigeminal nerve, often set off by light stimuli in a trigger zone. Pain attacks occur spontaneously and can also be triggered by a nonpainful sensory stimulus to the skin, intraoral mucosa surrounding the teeth, or tongue. The pathogenesis of TN is uncertain and typically is idiopathic, but it may be due to a structural lesion. Some pathologies include traumatic compression of the trigeminal nerve by neoplastic or vascular anomalies and intracranial tumors or demyelinating conditions such as multiple sclerosis. This case report describes an epidermoid cyst at the cerebellopontine angle in a 25-year-old young man with otherwise classical unilateral TN. The case highlights the difficulties of diagnosis and the importance of a multidisciplinary approach in making the correct diagnosis in symptomatic as well as classical TN.
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Eagle's syndrome mimicking dental pain: A case report with a novel surgical approach p. 253
Ravinder Singh Bedi, Jitender Kumar Aurora, Himanshu Chauhan, Arpita Komal
DOI:10.4103/njms.NJMS_73_18  
PAIN in the craniofacial and neck region can be both intriguing and equally frustrating for the surgeon. This is principally because there is a multitude of related pain syndromes in this region, many of which are lacking in physical signs. Diagnosis then becomes even more dependent on an accurate description of the pain in terms of character, localization, duration, radiation, relieving and exacerbating factors. Familiarity and identification of a more obscure causative factor in a particular case lends itself not only to liberate the patient but also an increased awareness of the practitioner for the need to consider the coinciding minute diagnostic points of otolaryngology, ophthalmology and rhinology besides dentistry and oral surgery. The characteristic elongation of a styloid process may explain some occasions of pharyngeal, ear pain and sometimes headache, which have defied exhaustive diagnostic studies. A large spectrum of signs and symptoms has been mentioned in various reports of Eagle's syndrome. Diagnosis can be made with careful clinical evaluation and confirmed with radiographs showing an elongated styloid process or calcification of the stylohyoid complex. Styloidectomy is the procedural choice for Eagle's syndrome having high success rate. In our case, the intraoral approach for styloidectomy was not the routine one, for which the post-operative outcome was exceptionally good without any complications.
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Refractory sjogrens syndrome: Is parotidectomy justified? p. 257
Arjun Gurmeet Singh, Meenaxi V Umarani, Sidramesh Muttagi
DOI:10.4103/njms.NJMS_50_15  
Primary and secondary Sjogrens syndrome (SS) is the classification used, according to the American-European Consensus Group Criteria. Salivary and lacrimal gland dysfunctions are the usual hallmark of the disease, but the involvement of other exocrine glands and extraglandular manifestations of the disease do occur. In rare cases, few patients are refractory to the conventional therapy and due to the sudden increase in size of a mass and the esthetic and psychological concerns of a “cancerous growth,” the surgical treatment modalities have to be modified. There is a significant lack of contemporary literature on the indications for surgery in refractory SS, and the option should be given in patients with esthetic concerns, risk of malignancy, and to improve the overall quality of life.
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Treatment of extraoral submental sinus tract associated with large periapical lesion of traumatized lower central incisors teeth by periapical surgery and demineralized freeze-dried bone allograft p. 260
Awadhesh Kumar Singh, Anurag Saxena
DOI:10.4103/njms.NJMS_22_17  
The purpose of present case report was to observe the effect of demineralized freeze-dried bone allograft (DFDBA) when combined with periapical surgery for the treatment of extraoral submental sinus tract associated with large periapical lesion of traumatized lower central incisors teeth. A patient complains of extraoral submental draining sinus tract since 6 months due to trauma of lower central incisors teeth 1 year back. Radiographical investigation showed large periapical lesion associated with lower central incisors teeth. The patient was planned for treatment by periapical surgery and DFDBA. The treatment process includes elevation of full-thickness flap, debridement of periapical lesion, root canal treatment, defect fill with DFDBA, and suturing of full-thickness flap at its original position. Complete resolution of extraoral submental sinus tract was achieved after 1 week, and periapical lesion was repaired after 1 year. Thus, DFDBA was effective for the treatment of extraoral submental sinus tract associated with large periapical lesion of traumatized lower central incisors teeth.
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Intraosseous schwannoma of the mandible and schwannoma of the spinal cord: A rare presentation of schwannomatosis – Case report and review of the literature p. 267
Remesh Vasudevan, Raja K Kutty
DOI:10.4103/njms.NJMS_49_16  
Schwannomatosis is a recently recognized distinct form of neurofibromatosis (NF). It is a rare condition, the incidence of which varies between 1/400,000 and 1/1.7 million. An important feature of schwannomatosis is the presence of multiple intracranial, spinal, and peripheral schwannomas in the absence of acoustic neuromas. Schwannomatosis presenting with intraosseous schwannoma of the mandible is even rarer, and only a few cases have been reported. It usually affects individuals in the third to fifth decade of life. Usually, it is sporadic in origin, but in 20% of patients, it can be familial. As a diagnostic criterion, NF2 gene is not involved in schwannomatosis. We report a case of a 48-year-old male presenting with facial pain and difficulty in chewing, and subsequent development of spastic paraplegia. Magnetic resonance imaging scan of head and neck revealed mass lesion involving infratemporal region on the left side, intraosseous lesion of the mandible, and multiple mass lesions in the neck. Acoustic nerves were not involved. Mutagen-induced chromosome sensitivity analysis test suggested no predisposition for malignancy. His clinical features are suggestive of schwannomatosis, which is a recently recognized distinct form of NF.
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Maxillary and mandibular unusually large radicular cyst: A rare case report p. 270
Vinayakrishna Kolari, H T Arvind Rao, Taniya Thomas
DOI:10.4103/njms.NJMS_6_18  
Radicular cysts are the most common odontogenic cyst. It is an inflammatory cyst associated with the root apex of a nonvital tooth. Most radicular cysts are small but can reach a large size causing displacement of surrounding structures. Here, we present a rare case of huge radicular cyst in both maxilla and mandible in a 36-year-old patient.
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Oral submucous fibrosis: Are we doing enough? p. 274
Ankita Chugh, Shruti Khatana, Vinay K Chugh
DOI:10.4103/njms.NJMS_63_18  
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