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National Journal of Maxillofacial Surgery
 
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   Table of Contents - Current issue
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September-December 2022
Volume 13 | Issue 3
Page Nos. 319-499

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EDITORIAL  

Oral health and diabetes Highly accessed article p. 319
Kamlakar Tripathi, Richik Tripathi
DOI:10.4103/njms.njms_197_22  
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REVIEW ARTICLES Top

Immunotherapeutic and their immunological aspects: Current treatment strategies and agents Highly accessed article p. 322
Mayank Jain, Archana Mishra, Mukul K Singh, Hari Shyam, Shailendra Kumar, Pratap Shankar, Saumya Singh
DOI:10.4103/njms.njms_62_22  
Cancer is often caused by the immune system's inability to deal with malignant cells and allows them to progress and proliferate. Emerging cancerous cells constantly evade the immune system, and as a result, these cancerous cells acquire more mutations and exhibit the deadliest characteristics among malignant tumors. The importance of understanding tumor immunology, particularly the functions of tumor antigens and the immunosuppressive tumor microenvironment, is highlighted by the effectiveness of cancer immunotherapy therapies. Many innovative immunotherapy drugs that effectively battle cancer have been produced since the 1980s. At present, in cancer treatment, immunotherapy appears as a paradigm that targets immune checkpoints of tumor cells such as CTLA-4, PD-1, and monoclonal antibodies (MABs), although the treatment of cancer is classified into non-specific and specific types. Specific types define the antibody targeting cell receptors as a new cancer treatment modality. For a number of malignancies, checkpoint inhibitors, MABs, and their derivatives have become standard-of-care therapy. Other immunotherapy techniques, such as most cancer vaccines and cell-based therapies, are still in the experimental stage. Many new immunotherapy techniques and agents are being explored and evaluated in clinical trials, which is a good thing. Thus, this review discusses the role of checkpoint inhibitors and MABs in the treatment of tumor cells. Moreover, these findings help us to understand the mechanism of action of this class of therapeutics and provide support for the management of cancer treatment.
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Anti-fungal therapy: An overview for maxillofacial surgeons in post-covid-19 fungal infections Highly accessed article p. 330
Abhay Datarkar, Amit Bhawalkar, Surendra Daware, Archana Deshpande, Damyanti Walkey
DOI:10.4103/njms.njms_412_21  
India is well known as the diabetes “capital” of the world but now it is also becoming the mucormycosis “capital” of the world. Indian Council of Medical Research has formed an “Evidence-Based Advisory in The Time of COVID-19 on Screening, Diagnosis, and Management of Mucormycosis.” As per this advisory, an oral and maxillofacial surgeon forms an integral part of the team dedicated to fight this epidemic of mucormycosis. Also, there are other fungal infections such as aspergillosis which are getting reported in these patients affecting the paranasal sinuses and the jaws. Aggressive surgical debridement and a thorough knowledge of anti-fungal therapy are must in treating these fungal infections. The aim of this article is to give an overview on the available anti-fungal therapy required to manage the ever-increasing rise in fungal infections faced by maxillofacial surgeons in post-COVID-19 patients.
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Review of current vaccine development platform to prevent coronavirus disease Highly accessed article p. 337
Khushboo Arif, Shitanshu Malhotra, Shadab Mohammad, Somi Fatima, Sana Farooqui, Mohammad Saleem
DOI:10.4103/njms.njms_454_21  
On January 30, 2020, the World Health Organization (WHO) declared a severe respiratory disorder syndrome which originated in Wuhan city as a global public health emergency, and the pandemic declaration by the WHO was made on March 11, 2020. Persons infected with SARS-CoV-2 are frequently asymptomatic, yet they have high respiratory viral loads, and they are major purveyors of viral spread. These factors have led to the current explosion of COVID-19 hospitalizations and deaths. Vaccines could play an important role by preventing severe diseases and increasing population immunity and reducing the ongoing health crisis. There is wealth of information for the review available since it is a current topic of interest. Initially, Google Scholar was utilized to take an initial sample of what types of articles are available. We searched other databases such as PubMed, EMBASE, and COCHRANE LIBRARY for research articles published up to March 2021, with no language restrictions. We found seven peer-reviewed publications available on the efficacy of SARS-CoV-2 vaccines: AZD1222 (AstraZeneca/University of Oxford), a ChAdOx1-based vaccine with a reported efficacy of 70.4% and two mRNA-based vaccines: BNT162b2 (Pfizer/BioNTech) with a reported efficacy of 95% and mRNA-1273 (Moderna/NIAID) with a reported efficacy of 94.1%. Internet was used as a source because of its limitless networking of resources. Sources used from the internet were written by professionals in their fields and published on reliable sites, in referred publications, or on professional organization sites. The cited references were within the last 2 years.
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Sandwich osteotomy with interpositional grafts for vertical augmentation of the mandible: A meta-analysis p. 347
Rathindra Nath Bera, Sapna Tandon, Akhilesh Kumar Singh, Bappaditya Bhattacharjee, Sapna Pandey, Tomin Chirakkattu
DOI:10.4103/njms.njms_489_21  
Sandwich osteotomy is a technique for vertical augmentation based on the principle of a graft being placed between two pedicled native bones. The inherent vascularization helps in graft consolidation. The aim is to review the bone height gained, implant survival and pitfalls with sandwich osteotomy. The PICO model was used to identify the suitable studies for the review. Oxford level of evidence, Newcastle Ottawa Scale and Cochrane's tool for Systematic Reviews of Interventions was applied for identifying study quality. Meta-analysis was performed with the help of RevMan. Funnel plot was used to evaluate publication bias and bias during article selection. Difference in means was used as principal summary measure. Fixed effects model with inverse variance statistics was used. I2test statistics was applied to identify study heterogeneity. Forest plots were produced for the outcome variables with 95% confidence interval (CI) and overall treatment effects and subgroup effects at a significance level of 0.05. The overall implant survival rate ranged from 90%-100% and prosthetic survival rate from 87%-95%. An overall 6-10mm of bone can be gained in the anterior mandible and 4-8mm in the posterior mandible. A total of 1030 implants were placed of which 988 implants survived after the mean follow up periods (odds ratio: 0.77, 95% CI: 0.49-1.21). Implant survival is independent of the graft being used. Vertical augmentation in the posterior mandible is limited compared to anterior owing to the presence of inferior alveolar nerve and the keratinized tissue deficiency.
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ORIGINAL ARTICLES Top

Are olfactory and gustatory symptoms useful at predicting disease severity markers in COVID-19 infection? p. 357
Mojgan Falaki, Saeed Abdi, Shervin Shafiei, Mohammadreza Moslemi, Behrad Rahbani Nobar, Reza Tabrizi, Meysam Mohammadikhah, Hamidreza Moslemi
DOI:10.4103/njms.njms_38_22  
Context: The relationship between olfactory and gustatory dysfunction (OGD) and COVID-19 infection severity is still unclear. Aim: To investigate the correlation between OGD in COVID-19-infected individuals and RT-PCR results, chest CT scan abnormality, lymphocyte counts, hospital admission units, age, body temperature, and blood oxygen saturation. Setting and Design: Case–control study. Materials and Methods: The sample was composed of laboratory and chest X-ray confirmed COVID-19-infected patients from four hospitals. The patients were divided into case and control groups based on the presence of OGD symptoms. The predictor variable was OGD. The outcome variable was gender, hospital admission unit, chest CT scan abnormality, PCR, lymphocyte counts, age, body temperature, and blood oxygen saturation. Statistical Analysis Used: Bivariate statistics were computed and the P value was set at 0.05. Results: The sample consisted of 189 patients. Smell and taste disorders were found in 31.7% and 24.3% of patients, respectively. OGD was significantly correlated with positive PCR results (P < 0.001) and general unit admission (P < 0.05) during hospitalization. Additionally, patients with OGD had significantly lower mean age (P < 0.001), higher body temperature (P < 0.01), and blood oxygen saturation (P < 0.01). However, OGD was not correlated with gender, chest CT scan abnormality, or lymphocyte counts (P > 0.05). Conclusions: OGD symptoms can be used to detect COVID-19-infected patients. OGD can be used to predict less severe disease mainly by its correlation with the less amount of hospital care, more negative PCR results, higher body temperature, and higher blood oxygen saturation.
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Treatment outcomes in poor metabolizers of cytochrome P450 2A6 with concurrent chemoradiotherapy in locally advanced head- and neck-squamous cell carcinoma p. 362
Deepa Aggarwal, Sudhir Singh, Mohammad Ali, Abhay Singh, Kirti Srivastava, Rajeev Gupta, Madan Lal Brahma Bhatt, Seema Devi
DOI:10.4103/njms.NJMS_312_21  
Introduction: Human Cytochrome 2A6 (CYP2A6) is involved in the oxidative metabolism of the nicotine to the inactive cotinine. CYP2A6 is a primary enzyme in nicotine metabolism, the enzyme has been proposed as a novel target for smoking cessation. Materials and Methods: A total of 70 male patients of locally advanced head- and neck-squamous cell carcinoma confirmed by histopathological examination were enrolled in this study. All patients received concurrent chemoradiotherapy (total dose of 70 Gray in 35 fractions in 7 weeks with concurrent tablet capecitabine 1250 mg/m2/day). Response assessment was based on response evaluation criteria in solid tumor criteria. Total ribonucleic acid (RNA) was isolated from the whole blood of all patients by TRI REAGENT BD (SIGMA USA) followed by real-time polymerase chain reaction assay which was done in studying messenger RNA (mRNA) expression of Excision Repair Cross Complementation Group 1 in blood lymphocytes of patient. Results: The most common stage prevalent was Stage IV A in 28 (56%) patients followed by Stage III in 16 (32%) patients. Out of 70, 20 (28.6%) patients defaulted for treatment, so the analysis was done in 56 patients. A total of 19 (34%) patients had a complete response (CR) and 17 (30%) patients had no response. In all the patients who had CR, posttreatment relative quantification (RQ) expression levels were high. Among nonresponders only three had higher RQ folds and the rest 14 had lower RQ folds. Conclusion: Posttreatment expression levels of CYP2A6 were found to be a better predictor for tumor response to the treatment than the pretreatment expression levels. Almost all the patients having higher RQ folds had CR and those having lower RQ folds had either no response or progressive disease on follow-up visits.
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Association of human papillomavirus and Epstein–Barr virus with squamous cell carcinoma of upper aerodigestive tract p. 367
Lity Dhar, Sarika Singh, JC Passey
DOI:10.4103/njms.njms_315_21  
Background: Cancers of the upper aero-digestive tract (UADT) are fifth most common cancer in the world with around 10,55,000 new cases and 7,25,000 deaths worldwide. Tobacco and alcohol act synergistically and are the two most important etiological factors responsible for about 75% of SCC. Studies have reported changing trends in the incidence of SCC showing an increasing shift in epidemiology attributed to the infection by viruses. The most commonly implicated viruses are the Human Papillomavirus (HPV) and Epstein-Barr virus (EBV). Aim and Objective: To study association of Human Papilloma virus (HPV) and Epstein Barr virus (EBV) with 100 newly diagnosed cases of squamous cell carcinoma (SCC) of upper aerodigestive tract (UADT) and correlate its association with clinical parameters, histomorphological grade and staging using immunohistochemical markers p16, LMP1, p53, p63. Materials and Methods: The study was conducted in the department of Pathology, Maulana Azad medical college and associated hospitals, New Delhi from September 2018-April 2019. Specimens was routinely processed. Immunohistochemistry (IHC) was done using p16, LMP1, p53, p63 monoclonal antibodies. Statistical Analysis Used: SPSS 20 software. The quantitative analysis was done using Pearson chi-square test. Probability values < 0.05 was be considered statistically significant. Results: HPV was present in 29% cases while EBV in 38% cases. Oral cavity was the most common site involved by both HPV and EBV. Co-infectivity was found in 4% cases. There was significant male predominance in both. HPV was more prevalent in age >45 years while EBV was equally distributed in <45 years and >45 years. Moderately differentiated squamous cell carcinoma was the commonest grade involved by both the viruses. A significant correlation was found between EBV and alcohol. p53 positivity had an inverse relationship with HPV positivity. P63 expression was higher in HPV and EBV positive cases. Conclusion: In resource constraint settings, p16 and Latent membrane protein 1 can be used as surrogacy markers for Human Papilloma virus and Epstein Barr virus along with p53 and p63 for its association with histomorphological grade and stage.
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Evaluation of pre- and post-treatment masticatory and bite force efficiency in patients undergoing fixed orthodontic treatment and orthognathic surgery using T-Scan Novus occlusal analysis: A factorial randomized controlled trial p. 376
Raj Kumar Maurya, Preeti Bhardwaj, Harpreet Singh, Rajat Mitra, Oonit Nakra, Harsh A Mishra
DOI:10.4103/njms.njms_48_22  
Introduction and Background: Orthodontic and orthognathic surgical treatment require quantified occlusion finish to rule out any temporomandibular disorders. Hence, the present study was proposed to analyze the occlusal efficiency in patients undergoing fixed orthodontic and combined orthodontic–orthognathic surgery using digital occlusal analysis. Methodology: A randomized multi-arm controlled trial was conducted on 55 patients divided into four groups, that is, group I: class I crowding/proclination required extraction for fixed orthodontic treatment, group II: class II div 1 required orthodontic treatment and/or myofunctional therapy, group III: skeletal class II required combined orthodontic and orthognathic surgical treatment, and group IV: skeletal class III required combined orthodontic and orthognathic surgical treatment. The pre-treatment, before debonding, and 1 year after debonding assessment of occlusion were carried out using T-Scan. The repeated analysis of variance (rANOVA) test along with post-hoc analysis was carried out for intra-group and inter-group assessments using SPSS (version 21, USA). The significance level was set at a 'P' value less than 0.05. Results: rANOVA measurement in groups I, II, and III showed a significant difference with respect to maximum bite force difference between right and left sides, anterior and posterior region, and left lateral disclusion time. However, group IV showed a significant difference with respect to maximum bite force in the anterior and posterior region as well as right and left lateral disclusion time only. Further application of the post-hoc Tukey test found a significant difference between the To value to T1 and T2 among all four groups. Conclusion: Improved bite force was found in all malocclusion groups which was gradual in improvement from pre-treatment to post-treatment and a subsequent retention phase. The study also reported the utility of digital occlusal assessment devices as reliable, repeatable, reproducible, and user-friendly in the determination of dynamic occlusion.
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Extended cervicomastoid approach with sternocleidomastoid flap reconstruction for parotid surgery: A better esthetic technique p. 384
Priyanka Srivastava, Sunil Kumar, Abhishek Bahadur Singh, Manish Chandra, Hitendra Prakash Singh
DOI:10.4103/njms.njms_421_21  
Aim of the Study: The aim of the study is to compare the esthetic outcome of extended cervicomastoid approach with reconstruction with conventional approach (modified Blair's incision) for parotid surgery. Materials and Methods: 48 patients were enrolled and grouped into A: surgery through extended cervicomastoid incision with sternocleidomastoid reconstruction and B: surgery through modified Blair's incision. After parotid surgery, patients were followed up to 6 months on the basis of flap ischemia, patient satisfaction, and cosmesis (visual analog scale [VAS]). Results: In our study, preauricular depression over the face was present in 4.2% and 95.8% patients Group A and B at 6 months, respectively (P < 0.001) and retromandibular depression (70.8%) in Group B (P < 0.001). Subjective Frey's syndrome was present in 8.3% of patients of Group B (P > 0.05). The mean value of VAS between the two groups was 1.08 ± 0.28 and 3.29 ± 0.62 at 6 months (P = 0.001) while mean change was significantly (P = 0.03) higher in Group A (1.00 ± 0.00) as compared to Group B (0.20 ± 0.72) from postoperative to 6 months, respectively. Patient of Group A had good satisfaction level (62.5% and 91.7%) at 6 weeks and 6 months while Group B patients had fair satisfaction level (87.5%) at 6 weeks and poor satisfaction level 79.2% at 6 months. Conclusion: Parotidectomy through extended cervicomastoid incision with sternocleidomastoid flap reconstruction experienced lower rates of postoperative complications, flap necrosis, and gustatory sweating in comparison to cervicomastoid facial approach, and thus, the previous incision is esthetically superior that allows cheek contour reconstruction with no increase in operative time or postoperative complications.
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Comparative study of different distraction rates in separate retractions of canine: Randomized control trial p. 390
Ajit Vikram Parihar, Shivam Verma, P Subash, Akhilesh Kumar Singh
DOI:10.4103/njms.njms_430_21  
Introduction: Orthodontic treatment typically lasts 18–24 months, but depending on the conditions, it can take a longer duration. In recent years, accelerated orthodontics has been the subject of extensive research to shorten the duration of treatment. In distraction osteogenesis (DO), the surgically created joints are slowly and controllably displaced over time by gradual traction. This results in simultaneous growth of soft tissues and bone volumes at the osteotomy site. The DO field is currently experiencing a modern surge of research and development that has been able to implement numerous innovative and revolutionary distraction systems. In this study, we are comparing two different rates of dentoalveolar distraction. Materials and Methods: With the use of custom-made distractors, we will compare the different ranges of activation of distractors and their dental effects. Participants are separated into two groups based on 0.4 mm/day activation and 0.5 mm/day activation. Results: During the study period, the average tooth movement rate for Group 1 was 0.52 mm and for Group 2 was 0.58 mm. Group 1 completed canine distraction in 11.42 ± 1.81 days and Group 2 in 10.05 ± 1.68 days. Conclusions: Retraction days decreased in Group 2, due to increased activation of the distractor. The anchorage loss in Group 2 was higher than that in Group 1, which was 1.39 mm lower. Unlike decreased activation, the mean tooth movement of Group 1 is higher than Group 2.
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Comparison of autologous blood prolotherapy and 25% dextrose prolotherapy for the treatment of chronic recurrent temporomandibular joint dislocation on the basis of clinical parameters: A retrospective study p. 398
Sandeep Kumar Pandey, Manabendra Baidya, Anurag Srivastava, Himanshu Garg
DOI:10.4103/njms.njms_509_21  
Introduction: Prolotherapy is a nonsurgical regenerative injection technique and effective treatment method for the treatment of temporomandibular joint (TMJ) dislocation. Autologous blood and dextrose are commonly used agents for prolotherapy and the aim of this study is to compare the autologous blood injection prolotherapy and 25% dextrose prolotherapy for the treatment of chronic recurrent TMJ dislocation. Method: This is a retrospective cohort study of 20 patients with chronic recurrent TMJ dislocation who were treated by either autologous blood (Group A) or 25% dextrose Prolotherapy (Group B). After prolotherapy, the patients were kept on follow-up and evaluated for maximum mouth opening (MMO), pain at visual analog scale (VAS), mandibular movements, frequency of dislocation, and TMJ sound. The collected data were then statistically analyzed. Results: Group A showed better results in terms of reduction in MMO, mandibular movements as compared to Group B, and a statistically significant difference was found starting from 2 weeks post prolotherapy till 6 months follow-up. Whereas group B showed better results regarding reduction in pain intensity on VAS Scale at all follow-up visits. No statistically significant difference was found between both groups regarding reduction in the frequency of dislocation and TMJ sounds. Conclusion: Both autologous and dextrose prolotherapy gives promising results for the treatment of recurrent TMJ dislocation, however, regarding reduction in MMO and improvement in lateral and protrusive mandibular movements, autologous blood gave better results whereas 25% Dextrose was found to be more effective in terms of reduction of pain in recurrent TMJ dislocation cases.
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Evaluation of efficacy 3Dimensional 4-hole trapezoid condyle plate for treatment of base of condyle fracture p. 405
Roger Paul, Bharathi Suvvada, Prasanna Polomarasetty, Sai kumar Thumu, PV Santosh
DOI:10.4103/njms.njms_506_21  
Aim: The aim of our study was to evaluate the effectiveness of open reduction and internal fixation of the base of condyle using a 3D 4-hole trapezoid condyle plate (4-HTCP). Materials and Methods: A group of 25 subjects of an age range of 21-52 years (mean 32.7 ± 8.7 years) were treated of which, 7(28%) were female and 18 (72%), were male. All the patients were examined according to standard protocol. A retromandibular approach was used in all the patients. Results: The time taken for operating on the condyle alone was recorded it was between 30 minutes to one hour in 5 (20%) patients, between one-two hours in 19 (76%) patients and greater than two hours in 1 (4%) patient. Time taken from reduction of fracture to placement of the last screw was recorded. In 15 (60%) patients the time taken was less than ten minutes, in 10 (40%) patients the time taken ranged from 10-15 minutes. 6 (24%) patients needed additional exposure to facilitate the procedure. Postoperatively all the patients were followed up for a minimum of 9 months and a maximum of 30 months (mean 19.5 ± 5.87 months). The range of mandibular movements was satisfactory. The maximum incisal opening was in the range of 25-37 mm (mean- 31.4 ± 3.38 mm)on the first post-operative day. 31.4 ± 3.4 mm 6 weeks postoperatively, 43.8 ± 4.3 mm 3 months postoperatively, 46.7 ± 2.9 mm 6 months postoperatively and 49.7 ± 4.5 mm 9 months postoperatively. Taking into consideration the transient hypofunction of the facial nerve (8%) and TMJ disorder (8%) the aggregate complication rate in our study was 16%. Conclusion: Our study concludes that 4HTCP is a reliable and rigid choice of osteosynthesis for the base of condyle fractures.
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Alveolar ridge split and expansion with simultaneous implant placement in mandibular posterior sites using motorized ridge expanders – modified treatment protocol Highly accessed article p. 411
Varsha S Manekar, SR Shenoi, Sunil Manekar, Janice Jhon
DOI:10.4103/njms.njms_417_21  
Purpose: “The purpose of the study is to evaluate alveolar ridge split and expansion (ARSE) with simultaneous implant placement in mandibular posterior implant sites using motorized ridge expanders.” Background: The ARSE is used in the management of horizontally deficient (narrow) alveolar ridge with optimum bone height available. The ARSE procedure in the posterior mandible has limited application as per literature. The successful cases reported are with extensive procedure of the osteo-mobilization with four corticotomies on buccal side. The authors presented the study of mandibular posterior implant sites using motorized ridge expanders. The ARSE performed here was by only crestal osteotomy simple osteo-condensation and immediate implant insertion. Materials and Methods: The study was prospective type. The sample size was 15 patients and 31 implant sites. The study population included partially edentulous patients between 18 years and 60 years indicated for implant-supported prosthesis. The outcome variables studied included gain in ridge width, cervical bone loss, success of implant, and survival rate. Successful surgical outcome was evaluated by Buser's criteria. The data collected was evaluated by differential statistics. Conclusion: The minimally invasive technique of one-stage ARSE performed with motorized ridge expander and insertion of implant in the same operative procedure decreases the morbidity, treatment time, number of surgical procedures, and the risk of complications, thereby, increasing patient acceptance. In this study, the authors have used this technique in the posterior mandible for narrow ridges (minimum 3 mm) and obtained promising results. The survival rate of the implants was 100% and the gain in ridge width was 3.2 mm. The author has also recommended the protocol according to bone density of mandible.
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Evaluation of the correlation between interleukin 1β levels in peri-implant crevicular fluid as an adjunctive diagnostic marker with clinical and radiographic parameters for assessing the peri-implant health status p. 421
Manish Khatri, Mansi Bansal, Komal Puri, Sourabh Mehrotra, Ashish Kumar, Mohd Rehan
DOI:10.4103/njms.njms_337_21  
Background: Interleukin-1β (IL-1β) is one of the most important cytokines that seems to have an important role in the inflammatory process in gingival and peri-implant tissues. As peri-implant crevicular fluid (PICF) provides with a more swift and objective measure of the disease activity, the present study was conducted to evaluate IL-1β level in PICF as a biochemical marker and to investigate its correlation with clinical parameters and radiological parameters. Materials and Methods: After evaluating all the patients following inclusion and exclusion criteria, 60 patients were selected for the study. After 3–4 months of implants placement, the implants were exposed following standard surgical procedure. PICF sample from implant site was taken 3 days after suture removal with gingival former still in place followed by measurement of clinical and radiological parameters. Results: There was significant increase in IL-1β levels in both the follow-ups from baseline with variable and minimal change in the clinical parameters and radiological parameters as well, which shows that IL-1β levels change significantly even when there is a minimal gingival inflammation. Conclusion: Therefore, IL-1β level in PICF can be used as an adjunctive diagnostic marker to clinical and radiographic parameters for assessing the peri-implant health status.
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Dredging: A conservative surgical approach for treatment of large cystic lesions of the jaws p. 430
Hiral Patel, Utsav Bhatt, Sonal Anchlia, Jigar Dhuvad, Zaki Mansuri, Dewanshi Rajpoot
DOI:10.4103/njms.njms_486_21  
Background: Treatment modalities of odontogenic cystic lesions of the jaws range from conservative to radical. “Dredging” may be considered the “middle path” between conservative and radical treatment options. It comprises three entities—decompression, followed by repeated scraping of the lesion, and finally, peripheral ostectomy providing margin clearance but without significant morbidity. Aim: To evaluate the outcome of “dredging” in the management of large cystic lesions of the jaws, without major resections and maintaining normal functions. Methodology: This prospective study was conducted on 30 patients. Inclusion criteria were odontogenic cystic lesions at least 2 cm in size either in the proximity of vital structures or in children with developing tooth germs or so large that upon enucleation, can result in pathological fracture. All underwent decompression followed by dredging performed at every 2 to 3 months intervals. Results: Drastic decrease in size of the lesion as measured on Cone Beam Computed Tomography (CBCT) and new bone formation was evident in all patients. The total Reduction Rate (RR) of the cystic lesions was 88.79% in 9.2 months. RR was highest in Calcifying epithelial odontogenic cyst (CEOC) followed by Unicystic Ameloblastoma (UA), Odontogenic Keratocysts (OKC), Dentigerous cyst (DC), and Radicular Cyst (RC) in CBCT. The mean speed of shrinkage was fastest in CEOC, followed by OKC, UA, RC, and DC after dredging. Shrinkage was higher in patients below 20 years of age (P 0.012) and patients with large cystic lesions (P 0.00447). Conclusion: The results suggest that dredging with regular, long-term follow-up can be a successful treatment method for large cystic lesions in young adults. This method includes the benefits of both conservative and radical treatment methods but lacks the disadvantages of either.
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Periodontal status of patients with nontubercular respiratory diseases hospitalized in a tertiary care hospital p. 437
Ajay Kumar Verma, Anuj Kumar Pandey, Abhaya Gupta, Umesh Pratap Verma, Surya Kant, Ram Awadh Singh Kushwaha, Arpita Singh, Hemant Kumar, Shyam Chand Chaudhary
DOI:10.4103/njms.njms_384_21  
Background: There is strong evidence that periodontal disease (PD) is related to various systemic diseases including respiratory diseases. Dental plaque is the primal cause of PD, and it can also be used as a reservoir of lung pathogens. After inhalation, it can cause a variety of respiratory infections. In addition, low nutritional status and immuneosuppression due to treatment or disease progression may affect the oral health of the hospitalized patients with nontubercular respiratory diseases. Here, we aimed to assess the periodontal status in hospitalized patients with nontubercular respiratory problems. Materials and Methods: We have enrolled 100 hospitalized nontubercular respiratory ill patients and 100 periodontal patients in this study. Periodontal clinical parameters, namely plaque index (PI), gingival index (GI), pocket probing depth (PPD), and clinical attachment level (CAL) were evaluated in both the groups. Modified Kuppuswamy's socioeconomic scale was utilized to assess the education, occupation, and monthly family income. Results: Sociodemographic profile was comparable in both the studied groups. Hospitalized patients with nontubercular respiratory diseases had more severe PD (PPD and CAL) and poorer oral hygiene (higher PI), although the GI was lower compared to patients in the periodontal group. In addition, compared with patients in the high-income group, low-income patients are at greater risk of periodontal infections. Conclusions: Our data show that the prevalence of periodontal infections in hospitalized patients with non-tubercular respiratory diseases is higher, indicating that there is an association between PD and respiratory diseases.
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Biomechanical evaluation of different fixation techniques following modified sagittal split ramus osteotomy using buccal step: An in vitro study p. 443
Pratik Dhananjay Warade, Rajesh Kshirsagar, Prasamita Mishra, Pranave Prasad, Amruta Sardeshmukh
DOI:10.4103/njms.njms_321_21  
Objective: This study was to evaluate the efficacy of three different designs of rigid fixation using polyurethane hemimandible replicas following modified sagittal split ramus osteotomy with buccal step. Materials and Methods: Forty-eight polyurethane hemimandible replicas have been used. Following the osteotomy and fixation, each specimen has been mounted on a Universal Testing unit using a prefabricated customized jig and has been tested to a range of vertical forces starting from 0 N on the incisal edge of lateral incisor and lateral forces of on lateral surface of mandibular first molar. Progressive load has been applied until a deflection of 10 mm was observed. SPSS version 20 has been used for analyzing the data. The biomechanical stability of different osteosynthesis has been compared using a one-way ANOVA with post hoc Bonferroni test. P ≤ 0.05 will be considered statistically significant. Results: After advancement of 7 mm, comparison of vertical load and lateral load among different miniplate systems showed that load was maximum in bicortical screws in inverted L pattern followed by T-shaped miniplate system and was least in single six-hole straight plate (0.001) at P ≤ 0.05. Conclusion: Our study concludes that bicortical screws in inverted “L” pattern are more resistant to lateral load as well as on the application of vertical load when compared to other fixation techniques and statistical difference was evident.
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Comparative evaluation of efficacy of skin staples and conventional sutures in closure of extraoral surgical wounds in neck region: A double-blind clinical study p. 449
Narayan Dutt Pandey, Ashok Kumar Singh, Amit Kumar Choudhary, Gitanjali Jina, Amar Thakare, Narendra B Supe
DOI:10.4103/njms.njms_305_21  
Background: The development of the skin stapling technique for surgical wound closure is less time-consuming than the conventional sutures. Aim: This study aims to evaluate the efficacy of skin staples and 4-0 prolene conventional suture in closure of extraoral surgical wounds in neck region in elective maxillofacial surgery. Materials and Methods: The study was conducted on a total of 60 patients, who were equally divided into three groups. In Group 1, wound closure was done using skin staples; in Group 2, wound closure was done using 4-0 prolene suture, and in Group 3, wound closure was done using both skin staples and 4-0 prolene suture. These groups were compared in terms of rate of wound closure; early postoperative pain; pain on the removal of staple and suture; rate of removal of staple and suture; scar evaluation by the clinician, patient, and two-blind observers on 15th day, 1 month, 3 months, and 6 months. Results: The rate of closure was significantly faster in staple group than in suture group. There was no significant difference in the postoperative pain, pain on removal and rate of removal between the two methods of closure. However, within the groups, more postoperative pain was observed in wound with incision length of >5 cm. Initially, on 10th postoperative day, the appearance of scar was significantly better in suture group but after 6 months, scar was better in staple group. Conclusion: The staple method of wound closure appears to be better than conventional suture in terms of rate of closure and scar appearance.
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A retrospective study on factors affecting the dropout rate among temporomandibular joint internal disc derangement patients in India - A single-institution experience p. 457
Shallu Bansal, Saurabh Bansal, Vikrampal Aggarwal, Dinesh Kumar Verma, Kaushal Charan Pahari, Huzefa S Talib
DOI:10.4103/njms.njms_314_21  
Introduction: Patients suffering temporomandibular joint internal disc derangement (IDD) ignore appointments after the first examination or after the first or second sessions of initial treatment. The dropout rate for these patients varies from 36% to 78% as per literature. Unfortunately, very few studies have investigated the dropout rate of these patients. Hence, the present study was undertaken to find out the dropout rate among these kinds of patients. Material and Methods: A retrospective study was done from June 2008 to December 2017 by collecting the records of the patients who were diagnosed to have IDD. Outcome variables included were age, sex, distance traveled, occupation, and education. Results: Out of 1021 patients 766 patients were included in the study after fulfilling the inclusion and exclusion criteria. The data were analyzed using Chi-square test. The level of significance was set at <0.05. In this study, there is slight male predominance (52.8%) and 63.1% (21–40 years) were among young adults and the patients in the age group of 21–30 years had shown good compliance, Postgraduate has shown the highest follow-up rate when compared with graduates and school level and the difference was found to be statistically significant. People in the job had shown good compliance when compared with business class and retired people and the patients within 50 km had shown the maximum follow-up with a statistically significant difference (P < 0.01). Conclusion: This study has shown that the dropout rate of treatment in temporomandibular joint disorder is affected by age, sex, distance traveled, occupation, and education.
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Evaluation of knowledge and attitude of dental students regarding COVID-19: A multicentric study p. 462
Pragya Pandey, Saumya Johri
DOI:10.4103/njms.njms_472_21  
Background: Despite the life-threatening risk that corona virus disease (COVID-19) poses to dentists, their role in suppressing its transmission and the need to deliver dental care to the patients is inevitable. In this regard, it is essential to determine the awareness and knowledge among Indian dental students regarding COVID-19 and to assess their preparedness to handle the current situation. Methods: This cross-sectional study enrolled 408 dental undergraduate (UG) and postgraduate (PG) students from private and government dental teaching hospitals. A closed-ended online questionnaire containing crucial elements of COVID management during dental procedures was given to the participants assessing their knowledge and perception pertaining to COVID-19 regarding dental practice. Chi-square, Mann–Whitney U, and Kruskal–Wallis tests were employed for statistical analysis. P ≤ 0.05 was considered statistically significant. Results: The study consisted of 64.71% UG and 35.29% PG dental students, with a mean age of 25.75 ± 3.69 years and M: F ratio of 0.5:1. COVID-19 knowledge increased significantly with age (P = 0.0055) and educational level (P < 0.01). Awareness was also significantly greater in students from government institutions in comparison with private colleges (P < 0.001), with 91.67% of participants being aware of the transmission routes. However, familiarity with survival of virus in aerosols, considerations regarding the use of masks, and strategies for confirmed/suspected COVID-19 health-care workers to return to work after recovery were seen in only 35%, 53.9%, and 38.9% of the students, respectively. Conclusion: COVID-19 awareness among Indian dental students is significantly related to their education level. The lacunae in this knowledge need to be filled by adequate training by incorporating it as a part of their education.
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CASE SERIES Top

Mysterious alarming mucormycosis: Anesthetic challenges in a series of four cases p. 471
JF Neville, Abhinay Jayanthi, Reena , Amrita Rath
DOI:10.4103/njms.njms_465_21  
The sudden epidemic of mucormycosis amid COVID-19 pandemic has significantly challenged our understanding of the disease while affecting the whole medical and surgical management. Overzealous use of steroids in the management of covid-19 and uncontrolled diabetes mellitus has resulted in a tremendous rise in mucormycosis cases further burdening the already strained health care infrastructure and health care workers, especially the anesthesiologists. While working in a tertiary care institute of the country, we have been facing multiple challenges in its anesthetic management on a daily basis. This article is a case series involving four different patients who were operated for rhino-orbito-cerebral mucormycosis with a brief discussion on various aspects of this multisystem epidemic.
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CLINICOPATHOLOGIC CASE REPORT Top

Two sides of a coin: A report of two contrasting cases of adenomatoid odontogenic tumor with unusual presentations p. 475
Imran Khan, Anshul Singhal, Uqba Raza, Shubhangi Premchandani
DOI:10.4103/njms.njms_494_21  
This study aims to report two distinct cases of adenomatoid odontogenic tumor (AOT) with contrasting presentations. The first case involved a 12-year-old female patient with the presence of AOT in the posterior mandible extending into the mandibular ramus up till the coronoid process which is a rare reported site for AOT and the second case is of a 19-year-old male patient with the tumor in the anterior maxilla with an impacted central incisor. Both cases were successfully managed via surgical enucleation and are under regular follow-ups without any complication. The contrasting nature of the two clinical presentations with the same pathologic entity is reported here. Though AOT has been rarely reported extending into the mandibular ramus, a maxillofacial surgeon should be more circumspect of this pathology while dealing with benign swellings of the mandibular posterior region.
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CASE REPORTS Top

Surgical management of maxillary trauma in pediatric special needs patient using modified cap splint Highly accessed article p. 479
Shivangi Gaur, Rubin S John, Asha S Hariharan
DOI:10.4103/njms.njms_479_21  
Pediatric maxillofacial trauma is a rare entity, which is primarily the reason for an individual surgeon's inexperience in managing such injuries. More so, maxillary injuries are infrequent. Pediatric maxillofacial injuries are usually a result of blunt force trauma such as falls, motor vehicle accidents, bicycle injuries, sports-related injuries, assault, and child abuse. The atypical pattern of facial injuries in the pediatric population necessitates each surgeon to approach individual cases with a unique and innovative technique of management, while still following the basic principles of surgical management of maxillofacial injuries. Since facial trauma and surgical interventions both have the potential to lead to disturbance in growth and development, management should be as conservative as possible. The foundation of any surgical intervention must be developed keeping in perspective, the future growth, and development of dentofacial structures. Pediatric facial trauma management is in itself a disconcerting situation for a maxillofacial surgeon, but when a special needs child is involved it becomes an even more perplex decision. We present a case of maxillary trauma in a pediatric patient with global developmental delay, the treatment dilemma, and a review of current literature.
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Frontal sinus stenting: A feasible option for post-traumatic recurrent giant mucocele compromising vision p. 484
Smile Kajal, Hitesh Verma
DOI:10.4103/njms.njms_476_21  
Giant mucocele of frontal sinus following facial trauma is not uncommon. It can lead to the gradual erosion of anterior and posterior bony walls and may extend to the orbital and intracranial structures leading to visual compromise or intracranial complications. A 52-year-old man presented with a history of swelling above the right eye, right eye proptosis, and decreased vision. He had a history of a road traffic accident 30 years ago following which he had lost vision in his left eye and had undergone surgery twice earlier for right frontal mucocele. Computed tomography showed cranialization of the right frontal sinus and a well-defined mass lesion in the region of frontal sinus compressing on the right eye globe. Naso-orbital meningoencephalocele was considered as a differential but magnetic imaging resonance confirmed the lesion as a mucocele. As this was the second recurrence and there was an endangered vision in the only functional eye, he underwent emergency excision of mucocele and recreation of the frontal sinus outflow tract (FSOT) with silastic stenting to maintain its patency. Post-operatively, the patient's vision returned to normal at a 1-week interval. There was a reduction in swelling and proptosis in a 6-month period and the stent was removed after 1 year. Treatment of recurrent frontal sinus mucocele can be challenging. Frontal sinus stenting can be considered in such cases to maintain the patency of FSOT for a prolonged period. Regular follow-up, inspection, and cleaning of the nasal cavity and the stented area are important to prevent any stent-related complications.
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Frozen section detected perineural spread in a grossly normal nerve away from tumor changes the surgical plan in parotid cancer p. 488
TV Murali, S Deepa, A Afzal, Amal V Antony
DOI:10.4103/njms.njms_303_21  
Perineural spread (PNS) through the facial nerve is a well-recognized pathway of spread in parotid cancers. Negative margins in the facial nerve are important in the total extirpation of cancer. We report a case of mucoepidermoid carcinoma of the parotid which was involving only the upper temporofacial division of the facial nerve at the periphery clinically and per-operatively. The upper trunk was divided at about 3cm away from the tumor at its junction with the lower trunk and the nerve was grossly normal. To our surprise disease was extending at this distance as a PNS in the frozen section analysis. This unexpected finding made the resection margin positive and we had to sacrifice the main trunk of the facial nerve as back as possible in the parotidectomy field for a negative margin in the nerve which was confirmed with frozen section again. The case emphasizes the importance of microscopic margin assessment of facial nerve in parotid cancers with the involvement of nerve at branches, even if imaging is negative or gross disease is not seen at the cut end or distant from the tumor-involved area.
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Is extracorporeal plating ideal for condylar fracture? A case report with a two-year follow-up study p. 491
Nathiya Balasubramaniyan, Ganesan Suresh Kumar, M James Antony Bhagat, Veeramuthu Muthulingam
DOI:10.4103/njms.njms_499_21  
Management of condylar fractures includes the closed and open methods. The closed method, although is conservative, has disadvantages such as inadequate reduction, disturbances in occlusion, and a decrease in ramal height. To overcome these disadvantages, surgeons prefer open reduction and internal fixation. One of the methods used is extracorpeal fixation of condyle fractures. This method has a limiting factor of excessive condylar resorption and avascular necrosis. We report a two-year follow-up of a patient with condylar head resorption and fractured implant.
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ORTHOGNATHIC SURGERY Top

Technical note: “Shoe-heel design” for custom-made miniplates. A new design for an easier screwing on the proximal segments in guided bilateral sagittal split osteotomies p. 495
Benoit Philippe
DOI:10.4103/njms.njms_37_22  
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ERRATA Top

Erratum: Antero-medially displaced condylar head leading to pseudoankylosis: A case report p. 498

DOI:10.4103/njms.njms_195_22  
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Erratum: Perioperative trigeminocardiac reflex in patients undergoing surgical treatment of temporomandibular joint ankylosis: A study p. 499

DOI:10.4103/njms.njms_196_22  
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