Priya Jeyaraj

Importance of Early Cranioplasty in Reversing the “Syndrome of the Trephine/Motor Trephine Syndrome/Sinking Skin Flap Syndrome”

IntroductionThe “Motor Trephine Syndrome (MTS)” also known as the “Sunken brain and Scalp Flap Syndrome” or the “Sinking Skin Flap Syndrome (SSFS)” or the “Syndrome of the trephined” is an unusual syndrome in which neurological deterioration occurs following removal of a large skull bone flap. This syndrome is associated with sensorimotor deficit and neurological deterioration following decompressive craniectomy which is performed for various neurosurgical conditions involving cerebral swelling causing mass effect. The neurological deterioration can be exacerbated or precipitated by CSF diversion procedures like a Ventriculo-Peritoneal shunt.ObjectiveIt was the objective of this study to observe if any improvement in the patient’s condition, or if any beneficial effects in his sensorimotor deficit could be gained by performing an early cranioplasty as against after the usual delay of one to two years normally allowed for post-craniectomy cases.MethodsA 52 year old male suffered severe head injury in a road traffic accident and underwent a craniectomy and contusectomy of the left Fronto-Temporo-Parietal (FTP) region for treatment of Acute Subdural hematoma (SDH) as well as hemorrhagic and non-hemorrhagic contusions of the brain with severe mass effect. On recovery from this acute event he was bed bound, on tracheostomy, his GCS was E4VTrM4 with residual right sided hemiparesis. Three months later, he developed Hydrocephalus for which a Right Ventriculo-Peritoneal (V-P) shunt was performed. Following this procedure, severe depression of the skin/scalp flap occurred and the neurological recovery was not as expected. He was diagnosed as a case of “Syndrome of the trephined”. An immediate Cranioplasty was performed, on the third month following the craniectomy procedure, in an attempt to resolve the rapidly deteriorating neurological status of the patient.ResultsIn the case presented, following the early Cranioplasty which was performed within three months of the initial craniectomy, the patient’s neurological condition and cognitive functions showed a remarkable, immediate and dramatic improvement. The early Cranioplastic repair led to a remarkable clinical recovery of the patient, with improvement in the cognitive behavior and motor deficit with a rapid reversal of the sensorimotor paresis, reflecting an improvement in brain perfusion.Conclusion Patients with the classical “Motor trephine syndrome/ Sinking skin flap syndrome” following large craniectomy defects, may hugely benefit from an early cranioplasty procedure, with a reversal of features of this syndrome and early recovery of their neurological and cognitive functions. Hence, an early cranioplasty can serve as a therapeutic procedure, rather than merely a cosmetic one.

Mid Versus Late Secondary Alveolar Cleft Grafting Using Iliac Crest Corticocancellous Bone Graft

BackgroundMid-secondary alveolar cleft repair performed at ages 9–12, in the mixed dentition stage, prior to eruption of the permanent canine, is generally accepted as the ideal time for residual alveolar cleft closure in cleft lip and palate cases with a cleft alveolus.MethodsIn our study, four cases of mid-secondary and five cases of late–secondary alveolar cleft grafting were carried out using iliac crest corticocancellous bone graft. Clinical defect closure and radiographic bone fill were compared.ResultsAll the nine cases performed in the two different age groups showed excellent results, clinically, with complete closure of the cleft defect and achievement of continuity of the dental arches. One case was planned for a two-stage procedure owing to the large bilateral maxillary defects. Good bone fill was visualized radiographically in all nine cases.ConclusionPrecise timing for undertaking alveolar cleft repair may not be all that crucial for a successful alveolar cleft grafting procedure.

Coronoid hyperplasia in chronic progressive trismus.

Hyperplasia of the coronoid process of the mandible has been observed in conditions like Oral submucous fibrosis, TMJ ankylosis, etc. The etiopathogenesis of this coronoid overgrowth has not been clearly sequenced or adequately hypothesized, and no definite mechanism has so far been advocated to explain this elongation of the coronoid process in the above mentioned conditions. Coronoid hyperplasia is seen in both these conditions despite being completely unrelated etiologically. However, progressive hypomobility of the mandible seems to be the common underlying condition in both the cases. We attempt to hypothesize a mechanism of coronoid hyperplasia, which appears to be independent of the underlying etiological factor causing trismus in these conditions.

A Modified Approach to Surgical Correction of Anterior Plagiocephaly

The gold standard for surgical correction of both uni- and bilateral coronal synostosis remains to this day, the “standardised bilateral fronoto-orbital advancement and reshaping” based on the “tongue in groove” technique developed by Tessier. It consists of bilateral frontal craniotomy for suture release and decompression, combined with creation of a “supraorbital bar” as a bilateral orbital complex by osteotomising the orbital roof (anterior cranial base), supraorbital ridge and upper lateral orbital rims bilaterally. This is followed by a bilateral advancement and remodelling of the frontal region as well as the orbital region bilaterally which is then rigidly fixed in position, the supraorbital bar to the face (at the fronto-zygomatic region and the fronto-nasal region) and the reconstructed forehead to the supraorbital bar. In this study, a slightly modified procedure was employed for correction of the right sided unilateral coronal synostosis, using a bifrontal craniotomy combined with unilateral orbital osteotomy (creating a unilateral supraorbital bar/bandeau), followed by radial osteotomies/kerfing, reshaping and advancement of the bifrontal calvarial segment. This was followed by the “tongue in groove” advancement of the right orbital segment (unilaterally). We preferred to spare osteotomising the contralateral (that is, the left) orbital region as it was not involved by compensatory growth deformity, and the frontal bossing/bulging was restricted to the upper forehead region alone. A gratifying aesthetic outcome and perfect symmetry was achieved using this technique. There were also no complications like wound infection or dehiscence, CSF leak, bone loss from resorption, damage to orbital contents or brain, recurrence of the dysmorphology or residual deformities or asymmetrics of the orbital region or forehead. Gratifying cosmetic results were seen using this modified technique and it was found that bilateral frontal reshaping and unilateral orbital advancement together with kerfing the frontal segment followed by fixation using resorbable implants is an effective strategy to not only permit remodelling of the skull and face thus correcting the cosmetic deformity, but also to increase the intracranial volume within the anterior cranial vault, without the need for any graft placement.

Solitary Extramedullary Plasmacytoma of the Maxillary Sinus, Progressing to Smoldering Multiple Myeloma with Multifocal Skeletal Involvement, which Resolved Completely Following Chemotherapy Alone

Plasmacytoma is an uncommon malignant tumor originating either from plasma cells located in the bone marrow also known as the solitary bone plasmacytoma, or from plasma cells located outside the bone, for e.g. in mucosal surfaces, referred to as the extramedullary plasmacytoma also called the solitary extramedullary plasmacytoma. Both, solitary as well as extramedullary bone plasmacytomas may, particularly in later stages, be accompanied by other osteolytic bone lesions (multifocal bone involvement) and features such as anemia, hypercalcemia, or renal impairment attributable to and indicative of progression to multiple myeloma. These three distinct disorders together comprise the plasma cell neoplasms and essentially represent a continuum of related disease processes. Extramedullary and solitary bone plasmacytomas of the head and neck region are extremely uncommon, and amongst them plasmacytoma of the maxilla is extremely rare. Such a case is being reported here for its rarity. Also, it was associated with multifocal skeletal involvement, making a correct categorization difficult as well as imperative in order to institute the correct treatment. Radiotherapy is considered to be the treatment of choice of plasmacytoma, with adjuvant chemotherapy for multi focal involvement. Surgery is usually limited to biopsy and excision of any residual disease following radiotherapy. The case presented responded extremely well to chemotherapy alone, with a complete resolution of the maxillary tumor, obviating the need for radiotherapy.

A Conservative Surgical Approach in the Management of Longstanding Chronic Protracted Temporomandibular Joint Dislocation: A Case Report and Review of Literature.

Chronic protracted dislocation of the TMJ is a relatively uncommon but extremely unpleasant and distressing condition for a patient. It is also particularly challenging and difficult to treat as it worsens with time due to continuing spasm of the masticatory muscles and progressive fibrosis, adhesions and consolidation in and around the dislocated joint. No definite guidelines or treatment protocols have been laid down in literature till date, towards management of such dislocations. A range of extensive and invasive surgical procedures such as eminectomy, condylectomy, menisectomy, and various osteotomies of the mandibular ramus and body have been performed to reduce these dislocations. A chronic longstanding unilateral TMJ dislocation in a 64-year-old woman was managed successfully and effectively using a modified, rather conservative surgical technique. The aim was to reduce the dislocated condyle (without excessive manipulation of the intra-articular space or extra-articular joint components); and at the same time, to limit further excessive translation of the condyle and restore physiological TMJ biomechanical constraints, to prevent future recurrence. This was achieved by surgically exposing the dislocated joint and manipulating the anterosuperiorly positioned condyle back into the glenoid fossa, aided by a downward distraction of the mandible; followed by soft tissue tethering of the meniscus and fibrous capsule of the joint to the temporal fascia above. The procedure yielded excellent results without any functional limitations or recurrence, and can hence constitute a viable and effective treatment option which can be attempted prior to resorting to the more invasive surgical procedures as described in literature.

Value of immunohistochemistry in diagnosing a rare case of maxillofacial plasma cell granuloma masquerading as a gingival epulis.

BackgroundPlasma cell granuloma is a non-neoplastic lesion rather uncommonly seen in the maxillofacial region. Its etiology, biological behavior, ideal treatment and prognosis are still unclear and rather controversial.StudyA detailed histopathological examination and immunohistochemical study of the excised specimen was carried out, both for making a confirmatory diagnosis as well as to determine the etiopathology, biological behavior and prognosis of the lesion.ResultsLight microscopy revealed a hyperplastic stratified squamous epithelial lining, overlying a densely fibrocellular granulation tissue containing a rich proliferation of mononuclear inflammatory cells, among which there was a predominance of plasma cells with their typical eccentric, cartwheel shaped, “clock-faced” nuclei. Strong immunohistochemical positivity was observed for CD-138 by numerous cells of the connective tissue of the lesion, thus confirming them to indeed be plasma cells. Further, immunohistochemistry (IH) analysis also demonstrated the expression of both, the lambda and kappa light chain immunoglobulins by the plasma cell population, thus confirming them to be polyclonal and of an inflammatory, non-neoplastic origin.Summary and ConclusionAs a plasma cell granuloma is rarely encountered in the oral and maxillofacial region, its diagnosis could have been very easily missed, had it not been for the detection of the large numbers of plasma cells by light microscopy, which was further confirmed by IH. IH also helped in establishing the likely etiopathology of the lesion and confirmed it to be of a non-neoplastic reactive/inflammatory origin.

Management of the frontoethmoidal encephalomeningocele

Introduction: The Frontoethmoidal encephalomeningocele (FEEM) is a congenital neural tube anomaly, with herniation of intracranial material such as the brain and leptomeninges through a defect of the dura and anterior skull base at the junction of the frontal and ethmoidal bones. It may result not only in neural defects, sensorimotor deficits, neurological morbidities, visual impairment, impaired nasal function, and a potential risk of intracranial infection, but also in significant craniofacial disfigurement with complex deformities in the frontal, orbital, and nasal regions. Materials and Method: The standard two-staged surgical protocol comprises of the first stage performed by a neurosurgeon, which aims at correcting the neural defect by a formal craniotomy; then the second stage performed by a craniomaxillofacial or plastic and reconstructive surgeon, to correct craniofacial hard and soft tissue deformities. The case discussed was managed using a modified intracranial-transcranial single stage approach, achieving both the desired objectives. Results and Conclusion: This protocol elucidates the importance and value of teamwork between the Neurosurgeon and Craniomaxillofacial surgeon, in comprehensively and efficiently managing small to moderately sized FEEMs, assuring their complete elimination, satisfactory defect closure, effective functional treatment as well as esthetic correction and reconstruction of the attendant craniofacial deformities by means of a single-stage definitive surgical approach.

Soft tissue healing and bony regeneration of impacted mandibular third molar extraction sockets, following postoperative incorporation of platelet-rich fibrin

Introduction: Surgical removal of impacted mandibular third molars is one of the most commonly performed dentoalveolar surgeries by dental surgeons around the globe. It is known to be associated with clinically significant postoperative morbidity including swelling, pain, trismus, fever, and infection. In addition, the residual bony defect takes 7 months to 1 year to gradually fill with bone and to reossify. Aims and Objective: (1) To carry out a prospective study to evaluate differences in soft tissue healing and bony regeneration of impacted mandibular third molar extraction sites, with and without the incorporation of autologous platelet-rich fibrin (PRF) within the surgical wounds. (2) To also compare the incidence of short- and long-term posttreatment complications in both cases. Materials and Methods: Sixty patients were randomly inducted into two groups, consisting of 30 patients each. The first group, which served as the study group, consisted of patients in whom fresh autologous PRF were placed within the extraction site immediately following the surgical removal of the impacted mandibular third molar, before suturing of the mucoperiosteal flap. The second group, which served as the control froup, included those patients in whom the mucoperiosteal flaps were closed without incorporation of PRF within site.Both groups were evaluated and compared for postoperative pain, swelling, trismus, soft tissue healing, as well as bone fill of the extraction socket. Results: It was found that the study group in which autologous PRF had been incorporated into the operative site exhibited quick and complication-free soft tissue healing as well as a much quicker reossification and bone fill of the extraction socket, as compared to the control group in which no PRF was used. Conclusion: Incorporation of PRF within extraction sockets of impacted third molars proved to be beneficial for patients, yielding a quicker postoperative recovery with fewer complications such as postoperative swelling and edema, pain, and trismus; better overall postoperative results in terms of faster soft tissue healing as well as an earlier bony regeneration.

Synovial Osteochondromatosis of the Temporomandibular Joint Manifesting as a Large Infratemporal Space Occupying Lesion

Synovial chondromatosis (SC) is a rare, benign monoarthritic arthropathy of unknown etiology characterized by chondroid metaplasia of the synovium usually affecting larger diarthroidal joints of the axial skeleton, typically the knee (35 %), elbow (22 %), wrist (11 %) and hip (4 %) [1, 2]. Highly cellular metaplastic, cartilaginous nodules develop in the synovial membrane of the affected joint, which slowly enlarge and then detach to form loose bodies within the joint, the ossification of which lead on to osteochondromatosis. TMJ involvement is rare, with approximately 120 cases having been reported so far [3]. Females are affected more frequently than males [2]. Various synonyms include chondrometaplasia, synovial chondrosis, osteochondromatosis, and periarticular tenosynovial chondrometaplasia [4]. SC may arise either as a primary form or may be secondary to pre-existing joint disease, such as arthritis [5]. Case Report