Anuj Jain

Myxoid Chondrosarcoma of Maxilla in a Pediatric Patient: A Rare Case Report

Myxoid variant of chondrosarcoma is an uncommon potentially lethal malignant tumor which is even rare in pediatric age group. In the present paper, we report one such case of intermediate grade myxoid chondrosarcoma of left side of maxilla in a 12-year-old girl. The present case had a firm, painless, and lobulated growth in premolar-molar region which was associated with bicortical expansion. Maxillofacial imaging showed ill-defined radiolucency with displaced maxillary molars. Osteolytic changes were evident with the alveolus and walls of maxillary sinus. Owing to the age of the patient, surgical excision was selected as the modality of management followed by postoperative radiotherapy. This report encompasses the entire gamut of clinicopathological, radiological, and treatment modalities employed for chondrosarcoma.

Use of Kerrison Rongeur for safe and effective removal of bone in temporomandibular joint ankylosis

Temporomandibular joint ankylosis (TMJA) is the formation of fibrous, bony, or fibro-osseous tissue between the glenoid fossa and the mandibular condyle. TMJA is characterized by limitation of jaw movements leading to inability to open mouth. It is associated with functional impairments with mastication, speech, breathing, swallowing, and nutrition. It also results in esthetic deformity with disturbance in mandibular growth [1]. The most frequently implied surgical procedures for the management of TMJA are gap arthroplasty, interpositional gap arthroplasty, and total joint reconstruction arthroplasty. However, irrespective of the technique being used, the basic procedures essential for management of TMJA are resection of the ankylotic lesion, ipsilateral/bilateral coronoidectomy, and early mobilization with aggressive postoperative physiotherapy [2, 3]. In order to carry out the resection of the ankylotic mass surgical drills and burs, surgical saws, chisels, and osteotomes are being used traditionally. The biggest disadvantage of using these modalities is the inherent risk of damaging soft tissue structures underlying the ankylotic mass including major vessels. To overcome this complication, we propose the use of Kerrison Bone Rongeur (KBR) for safe and effective removal of bone in TMJA. Use of KBR prevents the vital blood vessels mainly the internal maxillary artery and the ascending pharyngeal artery from getting injured during resection of the ankylotic mass. We have effectively used KBR in the management of 32 TMJA cases, with no incidence of any injury to underlying soft tissue structure. The initial resection of ankylotic mass is carried out with traditional bur till a thin bone is left to be removed. This bone is then removed using KBR without injuring the underlying structures (Fig. 1). KBR is an instrument (Fig. 2) with 4′′ long shaft facilitating its use in smaller areas. It has a blade which holds the bone and cuts it, with a guard saving the underlying structures. The handle of the instrument can be held comfortably and a controlled force can be delivered for osteotomy. This instrument is being used effectively in pediatric surgeries, neurosurgeries, and cardiac surgeries. It was Dr. Robert Masters Kerrison, an English physiologist and physician who first designed this instrument, and it took more than 100 years to modify the original design of the instrument to bring it to its current form with a purpose to make it more effective and operator friendly. Use of piezoelectric device for resection of ankylotic mass has also been emphasized upon in the literature [4]. It works effectively without injuring adjacent and underlying soft tissue. The only disadvantage of using

Comparison of single versus two non-compression miniplates in the management of unfavourable angle fracture of the mandible: a prospective randomized clinical study

PurposeThe purpose of this study was to compare the efficacy of single versus two non-compression miniplates in the management of unfavourable angle fracture of mandible.Materials and methodsA total of 28 patients who required open reduction of mandibular angle fracture were included in the study. The patients were randomly divided into two groups. Group I comprised of patients treated with two miniplates and those in group II were treated with single non-compression miniplate. The parameters of assessment were malocclusion, surgical site infection, need for implant removal, duration of surgery, inter-incisal mouth opening and cost of implants used, in both the groups. Statistical analysis was carried out to compare all the parameters.ResultsOut of 14 patients in group II, inadequate reduction was noticed in three patients, whereas screw loosening hadxa0occurred in two cases. Screw loosening was always associated with chronic infection. In these cases, hardware removal was deemed necessary. Plate bending was observed in two cases resulting in malocclusion and difficulty in eating. Non-union of fracture occurred in one patient treated in group II. In group I, no plate bending, screw loosening, surgical site infection, non-union or malocclusion was observed. No patient had to undergo implant removal in group I.ConclusionIn the management of unfavourable mandibular angle fracture, two miniplates must be preferred over the use of single miniplate as using two miniplates results in better results with minimal complications.

Accidental displacement of Mandibular first molar root into buccal space: A unique case

A few cases of accidental displacement of mandibular molar or fragment of tooth into adjacent anatomical spaces, during surgical interventions have been reported. This report describes a unique case of swelling with extra oral skin fistula in mandibular body region caused by unrecognized displacement of a lower first molar root into buccal space. The possible causes for such incident along with the complications which may occur, and the techniques used to prevent the risk of accidental displacement of tooth and roots, during extraction are discussed. The importance of recognizing this complication and actions to be taken after recognizing it are highlighted.

A Simple and Effective Scalp Tourniquet for Controlling Scalp Hemorrhage

The scalp is supplied abundantly with blood with a peculiar arrangement of vessels running in the dense connective tissue layer. The amount of blood scalp receives is larger than any other potion of the skin of equal area [1]. The main source of blood is from supraorbital, supratroclear arteries and branches of external carotid artery, viz., superficial temporal artery, posterior auricular artery and occipital artery. Such high volume of hemorrhage during scalp surgeries is highly disturbing to the operating surgeons and also puts the patient at risk. A bloodless operative field facilitates the surgical procedure hence shortening operating time subsequently reducing the anesthetic risk to the patient, furthermore the necessity for blood transfusion. Various devices have been tried in the past which includes use of rubber bands [2], soft rubber tubing and various inflatable cuffs, including bicycle tire inner tubes [3] not only to control hemorrhage but also to prevent hair loss by diminishing the contact of chemotherapy drugs in the scalp hair [4]. All these measures require preoperative preparations and are time-consuming. We suggest use of sterile surgical glove as a scalp tourniquet which is a simple, less time-consuming technique and provides adequate control of hemorrhage intraoperatively. A sterile glove is cut from its wrist portion (Fig. 1) and is stretched and tied over scalp just above eyebrows, external auricle and just below the external

A technique for intraoperative maxillomandibular fixation

Nowadays, open reduction and internal fixation (ORIF) is preferred technique for the management of most of the maxillofacial fractures. However, meticulous ORIF is not possible without achieving proper intraoperative maxillomandibular fixation (MMF). There are varieties of techniques highlighted in the literature for achieving intraoperative MMF, unfortunately, most of them requires use of wires or screws which are harmful to the patients as well as the surgeon since they are associated with a high risk of glove puncture and needlestick injury [1]. We recommend zip tie (Novoflex Marketing Pvt. Ltd. Kolkata, India) for intraoperative MMF to eliminate all the drawbacks of wires and screws (Fig. 1). The zip tie is a beltlike plastic self locking device which has a flexible tape sectionwith teeth which gets engaged with the pawl in the head to form a ratchet. Once the free end of the tape section is pulled through the head, the tie-wrap tightens and does not allow loosening (Fig. 2). It cannot be removed without cutting using a blade.

Modified spreader for facilitating controlled osteotomy in orthognathic surgery: RAI and JAIN Modification

During sagittal split osteotomy, in approximately 2.3% cases per site, the osteotomy propagates in a malapropos direction, known as bad split [1]. There are various risk factors influencing the occurrence of bad splits including incomplete corticotomy cuts, the presence of third molars, age of the patient, mandibular morphology, design of osteotomy, and the experience of the surgeon [1]. Bad splits usually eventuate when a corticotomy is remodeled into a complete osteotomy. In accomplishing desired results during orthognathic surgeries, avoiding such bad splits is a preeminent concern. In order to prevent this complication, various instruments have been designed which control the direction of osteotomy. Visualization and control of lower border is of paramount importance for an appropriate split. This can be achieved by instruments like a modified osteotome [2] or a modified channel retractor [3]. Another instrument which can be used to cut cortices more accurately is Withington osteotome [4]. All these instruments aid in corticotomy but according to Precious et al. [5], to convert this corticotomy into complete osteotomy, spreaders must be preferred over chisel and mallet. Smith spreader is a commonly used instrument for this purpose. Another spreader which has been introduced is a T-shaped spreader [6]. The biggest disadvantage that we have encountered while using smith spreader in our practice is the uncontrolled force which is delivered to the bone due to its uneven beaks. This increases the risk of bad splits as well as chipping of cortical bone at the points where beaks rest over thin cortices, especially when performed by trainees or residents [7]. To overcome these problems, we have modified the existing smith spreader (RAI and JAIN Modification) wherein we have fixed two stainless steel plates, both equal in all dimensions, over the beaks [Fig. 1]. This delivers equal and controlled force over both the cortices overcoming the risk of bad split and chipping of cortical bone. Another advantage of this modification is that the beaks are calibrated at 1 mm [Fig. 2] which provides an idea to the operator regarding the depth of instrument insertion in the osteotomy cut. Beginners in this marvelous field of oral and maxillofacial surgery can also achieve great results by performing osteotomies without bad splits using this modified spreader delivering controlled and equal force on both the bone fragments. We have effectively used this modified spreader in 20 cases without any bad splits or chipping of cortices. The

Use of two miniplates to achieve intraoperative maxillomandibular fixation

Various modalities are being used to achieve intraoperative maxillomandibular fixation. All these techniques have their own merits and demerits. This paper intends to propose a new technique to achieve intraoperative maxillomandibular fixation using two titanium miniplates. The technique proposed is simple, effective, less time consuming.

Posterior belly of digastric muscle flap for contour deformity correction after superficial parotidectomy

The correction of the contour deformity after parotidectomy has become an essential procedure in the recent times for the betterment of patients quality of life. Various modalities have been highlighted in the literature for the same. We recommend the use of posterior belly of digastric muscle flap for correction of contour deformity post excision of parotid gland tumors, subsequently ameliorating the aesthetics of the face.

Use of cable guide while performing segmental mandibulectomy using Gigli saw

Segmental mandibulectomies are performed commonly in patients having benign or malignant pathologies of mandible. For this purpose, Gigli saw is used frequently by most of the maxillofacial surgeons. The two main challenging tasks while using Gigli saw includes passage of the device around the bone which is to be cut and the preservation of the underlying soft tissue from getting damaged by the saw during its movement. Hence, we propose the use of a Cable guide with hook which not only helps in easy passage of Gigli saw around the mandible but also prevents injury to the underlying soft tissue while performing mandibulectomy.