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   Table of Contents - Current issue
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January-June 2021
Volume 11 | Issue 1
Page Nos. 1-214

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EDITORIAL  

Treatment algorithm for orofacial mucormycosis p. 1
SM Balaji
DOI:10.4103/ams.ams_98_21  
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OBITUARY Top

In memory and tribute to Prof. Kenneth E. Salyer – Surgeon par excellence: 1936-2020 Highly accessed article p. 3
SM Balaji
DOI:10.4103/2231-0746.322266  
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ORIGINAL ARTICLES - COMPARATIVE STUDY Top

Prevalence of Human Papillomavirus (HPV) 16 and 18 in oral malignant and potentially malignant disorders: A polymerase chain reaction analysis – A comparative study p. 6
Sathya Sri, Pratibha Ramani, Priya Premkumar, Vijayalakshmi Ramshankar, Abilasha Ramasubramanian, Reshma Poothakulath Krishnan
DOI:10.4103/ams.ams_376_20  
Introduction: Human papillomavirus (HPV) are now being increasingly associated as a cause of oral squamous cell carcinomas (OSCC). This study was designed to evaluate the prevalence of HPV in Pelizaeus-Merzbacher disease (PMD) and OSCC using polymerase chain reaction that might help in better understanding of the role played by this virus in the oncogenic process even from its evolution stage. Materials and Methods: Formalin-fixed paraffin-embedded tissue samples (n = 40) of OSCC and mild, moderate, and severe dysplasia were used for this study. DNA was quantified and checked for purity spectrophotometrically. Statistical analysis was performed using SPSS software and statistical significance was assessed using Fischer's exact test (p < 0.05 was considered significant). Results: High-risk (HR)-HPV-16 was found to be positive in 35% of OSCC cases which showed a statistically significant association of HPV 16 with OSCC. Verrucous carcinoma had predominant HPV 16 infection (60%), followed by SCC with 40%. However, this association was not statistically significant. None of the OSCC samples were infected with HPV 18. Among the PMD, we found only 5% showing HR-HPV 16 infection which was not significant. Discussion: Although OSCC is attributed to tobacco and alcohol consumption, a significant proportion of OSCC cases have been demonstrated to contain HPV types. The high-risk HPV type 16 tends to be the most predominant type detected in cases of OSCC.
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Comparison of vestibular depth relapse and wound healing after reconstructive preprosthetic surgery using cryopreserved amniotic membrane and acellular dermal matrix - A comparative study p. 12
Danial Babaki, Masoumeh Khoshsimaybargard, Sanam Yaghoubi, Mahdi Gholami
DOI:10.4103/ams.ams_322_20  
Introduction: The significance of membranes as wound dressing in oral surgeries has been reported by previous studies. The aim of the present split-mouth randomized clinical study was to assess and compare the wound dressing properties of acellular dermal matrix (ADM) and cryopreserved human amniotic membrane (AM) after reconstructive preprosthetic oral surgery. Materials and Methods: Twenty-eight patients with complete mandibular edentulism and resorbed alveolar bone were included. After taking mandibular impression, a clear acrylic splint with increased labial flange height was created. In each participant, labial vestibular depth was elevated using the Clark's technique. Subsequently, half of the exposed periosteum was covered with ADM while the other half was covered with cryopreserved human AM. Vestibule depth and relapse in the two sides were measured immediately after vestibuloplasty and at the end of the 1st week, 2nd week, 1st month, and 3rd months with graduations of 0.1 mm. Furthermore, after 3 and 7 days, samples were collected from graft material, and the macrophage population was analyzed by flow cytometry. Results: There was no significant difference in the relapse of vestibule depth between the two grafts at different time intervals. However, the frequency of wound-infiltrating macrophages (CD68+ cells) was significantly higher in areas covered by ADM after 3 and 7 days. Discussion: ADM is as effective as cryopreserved AM in terms of maintaining the postoperative vestibular depth. On the other hand, our results suggested that the onset of healing phase in ADM-covered areas occurs faster compared to the periosteum covered with cryopreserved human AM. This clinical trial showed significantly faster postoperative healing onset when ADM was used than when cryopreserved human AM was applied on the periosteum.
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Does P16 protein expression affect treatment prognosis in oral squamous cell carcinoma - A comparative study p. 17
Mitra Rezaei, Hassan Mohajerani, Hamidreza Moslemi, Shervin Shafiei, Mohammad Amir Alizadeh Tabrizi, Reza Tabrizi
DOI:10.4103/ams.ams_321_20  
Introduction: P16 is an independent and reliable surrogate for the detection of human papillomavirus (HPV) in oral squamous cell carcinoma (OSCC). The aim of this study was to assess the P16 expression as a marker for HPV infection in OSCC and its impact on the treatment outcome. Methods and Materials: A cross-sectional study was conducted on patients with a definite diagnosis of OSCC. Patients were assigned into two groups with and without recurrence or metastasis. Tumour resection was performed in the same manner for all patients. P16 expression was evaluated by immunohistochemical staining. Independent t-test and Chi-square tests were used to find significant differences in age, gender, stage of the disease, tumour size, lymph node involvement, and P16 expression between the two groups. Results: Of 50 patients, 37 did not show any recurrence or metastasis (group 1), while 13 had a relapse (group 2). There was no significant difference for age, gender distribution, stage of the disease, or lymph node involvement between the two groups (P > 0.05). A significant difference in tumour size was noted between the two groups (P = 0.001). The mean expression of P16 was 38.92 ± 24.36 in group 1 and 51.54 ± 33.63 in group 2. No significant difference was found between the two groups for the mean expression of P16 (P = 0.23). Discussion: A review of the recent literature revealed that the HPV role in OSCC treatment is controversial. According to the results of this study, there was no significant difference in terms of P16 expression between OSCC patients with and without recurrence or metastasis.
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ORIGINAL ARTICLES - EVALUATIVE STUDY Top

Evaluation of postoperative sensory and motor deficit following craniomaxillofacial reconstruction using bicoronal flap: An evaluative study p. 21
BC Sikkerimath, Aditya Anshu, Anu Jose, Saurabh Jain
DOI:10.4103/ams.ams_426_20  
Introduction: The ideal surgical approach to treat craniomaxillofacial skeleton should provide maximum exposure of the facial skeleton, ensure less potential for injury to facial structures and allow for good cosmetic result. Several designs have been described such as hemicoronal, preauricular, lateral eyebrow, and bicoronal approach. Although the bicoronal flap gives superior long-term cosmetic results, it has a few disadvantages. We conducted this study to assess neurosensory disturbances and motor deficit following craniomaxillofacial reconstruction using bicoronal flap. Materials and Methods: A prospective study was carried out in the Department of Oral and Maxillofacial Surgery, North Karnataka, India. Forty patients with craniomaxillofacial trauma requiring fixation of fracture or reconstruction were included in the study. Postoperative neurosensory evaluation is carried out at intervals of 1 week, 1 month, 3 months, and 6 months clinically using mechanoreceptive and nociceptive testing. Results: Among 40 cases, 11 (27.5%) had postoperative paraesthesia affecting the supraorbital region; 9 (22.5%) of them had return of normal sensation within 6 months and 2 (5%) patients became normal after one year. Four patients had unilateral frontalis weakness on the right side for a period of 6 months. Discussion: The bicoronal flap is a preferred approach for access to the craniofacial skeleton and orbit with minimal sensory and motor complications. However, before choosing the same, the advantage of raising such a wide flap should be weighted comparing the benefits and complications.
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Feasibility of use of the 8th edition of the American Joint Committee on Cancer staging for head and neck cancers in Indian scenario: An evaluative study p. 27
Kalpa Pandya, Sivakumar Pradeep, Naveen Kumar Jayakumar, Sivakumar Vidhyadharan, Naveen Hedne
DOI:10.4103/ams.ams_125_20  
Introduction: Inclusion of depth of invasion (DOI) and a separate classification for human papillomavirus (HPV)-associated Oropharyngeal Cancers (OPCs) are two of the many major changes in the 8th edition of the American Joint Committee on Cancer staging system. After more than 2 years of implementation, the authors found the need to evaluate if the Indian clinicians found it feasible to apply the system in their practice and if the same has influenced their decision-making. Methods: The survey was done in the form of a questionnaire which was distributed personally and via the internet to 100 clinicians. Seventy-two clinicians responded to the questionnaire. The results were analyzed and frequency distribution was computed. Results: Eighty-three percent of the clinicians experienced that palpation of the tumour was not a reliable method to determine the DOI. The common issues stated by the clinicians were difficulty in assessing DOI in certain subsites of the oral cavity (most commonly retromolar trigone–83%), inability to determine DOI in patients with trismus, and inability to correlate pathological and clinical DOI. Thirteen percent of the clinicians did not rely on radiological tools for measuring the DOI. Seventy percent of the clinicians did not perform a P16 assay for patients with oropharyngeal cancers. Fifty percent of the clinicians preferred chemoradiotherapy for early HPV positive oropharyngeal cancers. Discussion: Based on the results of the survey, the authors recommend a need for more interpretative guidelines and methods for determining the DOI. The authors also emphasize the need for determining HPV status for all oropharyngeal carcinomas.
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Prediction of soft-tissue changes following single and bi-jaw surgery: An evaluative study p. 32
Pooja Narendra Mandrekar, Vikas Dhupar, Francis Akkara
DOI:10.4103/ams.ams_138_20  
Introduction: Orthognathic surgery is carried out in the hard tissues; however, the patient perceives change in the soft tissue. It is important to accurately predict postoperative facial changes associated with each surgical procedure. This study aims to evaluate the changes in the soft tissues resulting from the movement of the hard tissue following single and bi-jaw surgeries. Materials and Methods: An evaluative clinical study was carried out on a total of 34 subjects which consisted of 52 jaw surgeries. Maxilla and mandible were considered as a separate entity even in bi-jaw cases for evaluation. Surgical procedures performed were either bilateral sagittal split osteotomy, Le Fort I osteotomy or both. Pre- and post-surgical lateral cephalograms were compared to assess the soft-tissue change at various soft-tissue points and were labeled T1 and T2, respectively. The points on maxilla were Point A and PrS on upper lip. The points on mandible were PrI and Point B on lower lip and Pog and Gn on chin. Results: All the points on the maxilla and mandible had a strong correlation between the hard and soft-tissue points except point PrS on upper lip. Discussion: Facial appearance is an important parameter in the present times which influences the social and psychological development of an individual. What patient sees is the external soft-tissue drape whereas orthognathic surgery is carried out on bony components of the face. Thus prediction of soft-tissue changes following surgery is an important part of treatment planning.
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Unilateral condylar fracture with review of treatment modalities in 30 cases - An evaluative study p. 37
Hirakben Bhagyendrakumar Patel, Nimisha N Desai, Ridhi G Matariya, Kalpesh G Makwana, Pratap N Movaniya
DOI:10.4103/ams.ams_312_20  
Introduction: The treatment of subcondylar mandible fractures is a topic of debate and can be variable even though these fractures are commonly seen. The present study aimed at evaluation of various treatment modalities for unilateral condylar fracture in adults. Materials and Methods: Thirty patients with unilateral condylar fractures between the age of 18 and 60 years were evaluated. Treatment protocol included closed reduction for 15 patients and open reduction for 15 patients. Results: Assessment was done functionally for maximum interincisal mouth opening, deviation on maximum interincisal mouth opening, occlusion and facial nerve function, and radiologically for ramus height shortening. In general, there were no statistically significant differences between closed and open methods. Discussion: Both the treatment options for condylar fractures of the mandible yielded acceptable results. Closed treatment appears to be a safe and appropriate modality for most unilateral condylar fractures. Although the open group, in general, showed similar outcomes, this treatment should be reserved for limited indications. The present study has confirmed that both treatment options can yield acceptable results. On clinical examination, there was no significant difference in mouth opening measures, the incidence of occlusal disturbances or in the degree of pain perception.
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Efficacy of collagen membrane graft in intraoral surgery - An evaluative study p. 42
Pratap N Movaniya, Tushar R Makwana, Nimisha N Desai, Kalpesh G Makwana, Hirakben B Patel
DOI:10.4103/ams.ams_192_20  
Introduction: Bovine-derived collagen membrane is usually and regularly used as a temporary cover or dressing for extraoral wounds and burns. It has wide applications because of its usefulness and biocompatibility. This has provoked us to do a study with the use of collagen membrane even for minor intraoral surgical defects. The aim of this evaluative study was to evaluate the clinical efficacy of collagen membrane in intraoral wounds created by removal of various soft tissue lesions. Materials and Methods: A total of 25 healthy patients (16 males and 9 females) were taken for this study. This study was confined to secondary defects of the oral mucosa, which occur after excision of premalignant lesions and other conditions, such as benign lesions, reactive proliferations, and incisional biopsy wounds. Only those lesions that were sufficiently large and could not be closed primarily were included in the study. Results: The results were evaluated on the day of surgery and in the postoperative period. The usefulness of collagen membrane as an intraoral temporary wound dressing material to promote haemostasis, relieve pain, induce granulation, and assist in rapid epithelialization at the wound site and prevent infection, contracture, scarring, and donor-site morbidity was evaluated, and finally, the efficacy of collagen membrane was tested by the use of Chi-square test and P < 0.001, which is a statistically and clinically significant value. Discussion: Collagen membrane was observed as both biological dressing material and drug carrier. It was found to be a suitable alternative to other graft materials mentioned for the repair of defects in the mucous membrane created by surgical excision of lesions. Therefore, when used judiciously in a controlled clinical situation, collagen membrane is biologically acceptable in nature. It is an alternative to autologous grafts rather than a replacement of other grafts used in the oral cavity.
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Accuracy of virtually planned maxillary distraction in cleft patients - An evaluative study Highly accessed article p. 49
Josep Rubio-Palau, Marta Ayats-Soler, Asteria Albert-Cazalla, Irene Martìnez-Padilla, Alejandra Prieto-Gundin, Natalia Prieto-Peronnet, Marìa Piedad Ramìrez-Fernandez, Javier Mareque-Bueno
DOI:10.4103/ams.ams_331_20  
Introduction: Maxillary distraction may be used to treat severe maxillary hypoplasia in cleft lip and palate (CLP) patients. Three-dimensional (3D) planning has been shown to increase the accuracy of distraction and reduce operative time and complications. The aim of the study was to measure the accuracy of internal maxillary distraction after 3D planning in CLP patients, to add evidence to validate the virtual osteotomy and distraction procedure. Materials and Methods: Eleven CLP patients with severe maxillary hypoplasia underwent maxillary distraction using internal distractors. Virtual planning was used to design the osteotomies, the distractor position, and the distraction vector. Cutting and positioning guides transferred this information to the surgical procedure. Four to six month postoperative computed tomography-scan was done before distractor removal; anatomical reference points were compared to the virtual planning to determine accuracy. Results: A high accuracy (point dislocation <1.5 mm) was found in 90% of the points of the surface of the maxilla; the majority of the zygomatic screws were placed within a distance of 0.8–1 mm from their planned position. Discussion: The high accuracy achieved through virtual planning promotes optimal distractor placement; a customized distraction vector has a direct effect on the final position of the maxilla.
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ORIGINAL ARTICLES - PROSPECTIVE STUDY Top

Correlation between the expression of matrix metalloproteinase-9, matrix metalloproteinase-13, tissue inhibitor of metalloproteinases-1, p16 and differentiation of head and neck squamous cell carcinoma: A prospective observational study p. 58
Kapil Soni, Poonam Elhence, Darwin Kaushal, Nikhil Rajan, Amit Goyal, Bikram Choudhury, Vidhu Sharma
DOI:10.4103/ams.ams_249_20  
Introduction: The expression of matrix metalloproteinase-9 (MMP-9), MMP-13, and tissue inhibitor of metalloproteinases (TIMP-1) in head and neck squamous cell carcinoma (HNSCC) could be a useful predictor of tumour differentiation, nodal metastasis, and invasiveness. We conducted this study to ascertain the correlation between the expression of these markers and differentiation of tumour cells. Materials and Methods: A prospective observational study was conducted in a tertiary care center. Forty-three cases of proven HNSCC were recruited after obtaining informed consent. Using the surgically excised specimen, tumour differentiation and invasiveness were assessed and correlated with rates of expression of the markers. Chi-square test was done to correlate immunohistochemical (IHC) marker positivity and the degree of differentiation of the tumour, lymph node metastasis, and invasiveness. Results: MMP-9, MMP-13, and TIMP-1 were expressed in 72%, 34%, and 18% of cases, respectively. p16 expression was not found in any of the cases. MMP-13 expression correlated with poorer differentiation of the tumour (p = 0.03), and relatively younger age at diagnosis (p = 0.01). However, there was no correlation with lymphovascular or perineural invasion or lymph node metastasis. Discussion: In our study, MMP-13 expression correlated with poorer tumour differentiation and younger age at diagnosis, giving indirect evidence of tumour aggressiveness. IHC markers can provide additional information to prognosticate HNSCC. Identifying potential targets for newer biological therapy is essential in the Indian population as there are biological differences in cancer behavior. Increased expression of the proteolytic MMP-13 correlated with poorer differentiation of HNSCC.
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Basal implants: An asset for rehabilitation of atrophied resorbed maxillary and mandibular jaw – A prospective study p. 64
Kiran Patel, Sonal Madan, Deval Mehta, Setu P Shah, Vaibhav Trivedi, Hemant Seta
DOI:10.4103/ams.ams_446_20  
Introduction: Conventional implants have great limitations in case of atrophic maxillary and mandibular ridges. Ultimately, patients who have severely atrophied jawbones paradoxically receive little or no treatment, as long as conventional implants are considered the device of first choice. Basal implants were developed with the goal to overcome the limitations of conventional implantology, primarily for atrophied ridges or inadequate bone with the protocol of immediate loading. However, studies regarding the rehabilitation followed by placement of screwable basal implants in atrophied ridges are limited. The purpose of the study was to conduct a prospective evaluation for the feasibility of placing strategic basal implants in clinical practice along with its merits and demerits. Materials and Methods: A prospective study was designed to evaluate the protocol of immediate functional loading using the technology of strategic basal implants® for fixed complete arch prostheses and segmental teeth prostheses. A minimal of 10 patients selected in the age group of 20–80 years were restored with strategic basal implants irrespective of the quality and quantity of cancellous/alveolar bone following immediate functional loading protocols. Results: About 157 various designs of basal implants were placed in 10 patients, out of which four failed with the survival rate of 97.5% of basal implants. Discussion: The new concepts laid by basal implantology eliminate all drawbacks of conventional implantology and should be used as an adjunct to improve the quality of life of our patients. The concept of strategic implantology is innovative but reliable technique for patients in need of permanent rehabilitation.
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Gummy smile management using diode laser gingivectomy versus botulinum toxin injection - A prospective study p. 70
Aida M Mossaad, Mostapha A Abdelrahman, Amr M Kotb, Albraa B Alolayan, Shadia Abdel-Hameed Elsayed
DOI:10.4103/ams.ams_458_20  
Introduction: Gummy smile (GS) is a nonesthetic condition that affects the confidence of many young people. The present study aimed to compare the results of two approaches used in the management of GS in a group of Egyptian females. Materials and Methods: This comparative cohort study included 24 female patients aged 25–35 years, divided into two groups. Group A included patients treated with diode dental laser gingivectomy, while Group B included patients who were treated with Botox injection. The clinical assessment of the pre-and post-operative measurements of exposed gums in millimetres on an active full smile was analyzed and compared for both groups. The paired t-test was used to compare pre and post measurements in each group, and the mean difference between the groups was compared using the independent t-test. Results: Group A showed instant improvement, while Group B results appeared 1 week later. The variation between preoperative and postoperative GS measurements in both groups was statistically significant. The preoperative and postoperative mean ± standard deviation was (5.17 ± 0.9 and 1.89 ± 0.5) in Group A and (4.27 ± 1.0 and 1.79 ± 1.0) in Group B. Comparison between the two groups revealed a highly significant greater mean difference of 3.27 ± 0.5 mm in Group A than Group B (P < 0.001). The findings were satisfactory in all cases of both approaches, and there were no complications. Discussion: Using a diode laser to treat gummy smiles for oro-dental genetics case with gingival hypertrophy saves time and effort compared to conventional surgical techniques. Diode dental laser is a safe fast and effective method of treatment giving more superior results than Botox injection which showed a less invasive alternative temporary GS therapy that is easily guaranteed and more patient-favored.
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Assessment of postoperative bleeding after dental extractions in patients who are on antiplatelet therapy: A prospective study p. 75
Md. Mahbubul Hoda, Romir Navaneetham, ME Sham, Suresh Menon, Veerendra Kumar, S Archana
DOI:10.4103/ams.ams_406_20  
Introduction: Patients with ischemic heart disease are placed on antiplatelet therapy (APT). This study allows a definite protocol to be set which will allow us the make the right judgment when it comes to extractions in patients on APT. Materials and Methods: For this study, 100 patients were taken up for dental extraction after obtaining a thorough case history. Bleeding time was assessed preoperatively for all the patients and patients with normal bleeding time were taken up for surgery under local anesthesia. Local haemostatic measures were employed after the extraction. Patients were monitored for first 30 minutes at the clinic and a telephonic review of all the patients was done at 24 h–48 h interval after the procedure. If there was an active ooze from the surgical site at any point, haemostatic measures with local haemostatic agents were carried out. Results: In patients with mono antiplatelet therapy, bleeding was noted in 16 patients after the 1 h time interval and was absent after 24h–48 h time intervals. The q = 32 and the P < 0.001, making it statistically significant. Regarding patients on dual APT, bleeding was noted in ten patients after 1 h, and in one patient after 24 h with no patients presenting with bleeding at the 48 h time interval. The q = 16.545 and P < 0.001, making it statistically significant. Discussion: The benefits of continuing APT for patients who require dental extraction outweighs the risks of postoperative bleeding. Conclusion: Antiplatelets are used for the prevention of myocardial infarction, ischemic stroke, and vascular death among patients who are at high risk of these events. Antiplatelets have minimal impact on the amount and duration of bleeding following routine dental extractions.
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ORIGINAL ARTICLES - RETROSPECTIVE STUDIES Top

Assessment of relationship of ABO blood groups in oral cancer patients - A retrospective study p. 80
Pradhuman Verma, Avinash Kumar, Shantanu Dixit, Kratika Mohan, Nidhi Gupta, Gourab Mandal
DOI:10.4103/ams.ams_265_20  
Introduction: India is a high-risk region for oropharyngeal cancer (OC) due to high prevalence of tobacco, betel nut, and alcohol and accounts for 30% of all new cases of oral cancer annually. Materials and Methods: Records of all 73 diagnosed cases of different types of OC and oropharynx patients were analyzed who reported in “Tobacco cessation center”' of the Institute between January 2017 and December 2019.The patients' demographic details, blood groups, oral habits, and clinicohistological records were obtained from the medical records available in the hospital. Results: OC incidence was 3.75 cases/year with male-to-female ratio 3.29:1. Mean age was 51.25 ± 13.6 years. The most common site of tumour presentation was mandibular alveolar ridge. Combined use of tobacco/betal nut/alcohol constituted the major cause for the development of oral squamous cell carcinoma (OSCC). Majority patients were presented in Stage II (43.8%). Histopathological reports were suggestive of maximally well-differentiated (52.1%) OSCC. People with blood group A+ve had 3.22 times higher risk of developing OSCC compared to people of other blood groups. Discussion: Male: female ratio was reported higher than in most of other studies. Mandibular alveolus was the most frequent site because most of the patients tend to keep the tobacco quid in the buccal vestibule with close proximity to alveolus. The relative downregulation of glycosyl transferase that is involved in the biosynthesis of A and B antigens as seen in association with tumour development could be the reason for increased OC reported in blood group A subjects.
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Cancer chemotherapy-induced oral adverse events: Oral dysesthesia and toothache - A retrospective study p. 86
Shunsuke Hino, Miki Yamada, Yosuke Iijima, Yuki Fujita, Motohiko Sano, Takahiro Kaneko, Norio Horie
DOI:10.4103/ams.ams_136_20  
Introduction: Due to the development of newly developed anticancer drugs, oral dysesthesia and toothache other than conventional oral mucositis, dry mouth, and dysgeusia are increasing among oral adverse events. The objective of this study was to assess the characteristics of chemotherapy-induced oral dysesthesia and toothache. Materials and Methods: Subjects were patients referred to the oral surgery clinic for oral adverse events related to cancer chemotherapy and with an observation period of more than 1 month after the last course of chemotherapy. Oral adverse events were divided according to the categories of the National Cancer Institute Common Terminology Criteria for Adverse Events, v5.0. Statistical comparison was made using the binomial test. Results: A total of 180 patients were referred to the oral surgery clinic. Oral dysesthesia and/or toothache was found in 15 cases, which included 13 with oral dysesthesia, 4 with toothache, and 2 with both oral dysesthesia and toothache. Of these 15 cases, 13 had concomitant occurrence of peripheral neuropathy (PN) (86.7%, P = 0.0037) and 12 cases had dysgeusia (80.0%, P = 0.0176). Symptoms of oral dysesthesia and/or toothache continued after chemotherapy in 10 of 15 cases with the continuation of accompanied PN (66.7%) and/or dysgeusia and persisted for more than 6 months in 5 cases (33.3%). Discussion: Although oral dysesthesia and toothache are low-grade chemotherapy-induced adverse events, it is suggested that they may be nervous system disorders rather than gastrointestinal disorders. Clinicians should understand that they potentially persist for a long period after the end of chemotherapy.
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Application of patient-specific implants as alternative approach to zygoma defect management - A retrospective study p. 91
Yurii Chepurnyi, Tatiana Kustro, Denis Chernogorskyi, Olena Zhukovtseva, Oleksandr Kanura, Andrii Kopchak
DOI:10.4103/ams.ams_294_20  
Introduction: Zygoma defects are a challenging clinical problem and are frequently connected with the alteration of facial harmony, horizontal asymmetry of the face, and significant functional deficit. The application of patient-specific implants (PSIs) has the potential to improve the effectiveness of zygoma defect management. The aim of this study was to evaluate the anatomic, esthetic, and functional outcomes of PSI application for zygoma reconstruction. Materials and Methods: A retrospective study was conducted on data from 11 patients with zygoma defects who underwent a reconstruction procedure in which a PSI was applied and was followed for >1 year after surgery with the evaluation of esthetic and functional outcomes. Precision of PSI position and anatomy reconstruction was estimated by superimposition of the models with automatic point-to-point measurement and determination of the existing deviations between models. Results: The mean follow-up period in our study was 21.6 ± 6.2 months (range 14–39 months). No major complications occurred in the postoperative period: There were no clinical or computed tomography symptoms of maxillary sinusitis, implant-related infection, or implant exposure. The mean deviation between the planned and real positions of PSIs in our series was 0.72 ± 0.41 mm. The mean deviation between the reconstructed zygomatic complex and the mirrored intact side in our series was 1.45 ± 0.7 mm. The mean volume difference between the intact and damaged orbits was 1.7 ± 0.8 mm3. Discussion: The results of the present study support the wider clinical application of PSIs in orbital and zygoma reconstructions, as it is an effective option to achieve precise reconstruction of the complex zygoma anatomy.
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Evaluation of panfacial fractures in a german supraregional trauma center between 2015 and 2017 – A retrospective study p. 97
Akos Bicsak, Abel Dietmar, Yannic Wruck, Stefan Hassfeld, Lars Bonitz
DOI:10.4103/ams.ams_418_20  
Introduction: Panfacial fractures represent the most severe injuries to the face. The combination of these fractures determines the treatment strategy. This study aims to retrospectively review the data of adult patients treated for complex facial skull fractures in a hospital in Dortmund, Germany from 2015-2017. Materials and Methods: We extracted related patient data from the hospital electronic repository and reviewed the patient files and radiological images. The fractures were classified based on the AO-Classification. The statistical analysis was performed by descriptive statistical methods. The main goal was to determine the most common fracture combinations. Results: A total of 188 patients with panfacial fractures were identified (181 adults, 7 children and adolescents). The gender and age distribution corresponded to the international literature (male-to-female ratio: 3.1:1, most common injuries among young men). 2–9 fracture sites were identified per patient, resulting in a fracture frequency of 3.13 per patient. 69 different fracture combinations have been identified. The most common ones were combinations of lateral and central mid-face fractures, and combinations of nasal bone fractures with lateral midface fractures or nasal bone fractures combined with mandibular fractures. Between 1 and 13 osteosynthesis implants per patient were used for osteosynthesis; the most commonly used plates were 2.0 mm and 1.5 mm straight plates. The average inpatient stay was 3 days (standard deviation [SD] = 3.0 days), and the average operation time (incision to suture) was 39.5 min (SD = 53.5 min). Discussion: Panfacial fractures are the most complex maxillofacial injuries. The complication rate in this study (4.5%) is below the international data. The treatment of panfacial fractures requires designated centers with experienced teams and good interdisciplinary cooperation.
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Head and face injuries in Brazilian homicide victims – A retrospective study p. 103
Alessandro Leite Cavalcanti, Fernanda Júlia Cartaxo de Sousa, Isla Camilla Carvalho Laureano, Alidianne Fábia Cabral Cavalcanti
DOI:10.4103/ams.ams_158_20  
Introduction: Violence is a serious problem in view of its magnitude and impact on the health of the population in several countries. The aim of the study was to evaluate the occurrence of head and face injuries among homicide victims in a municipality in the Northeastern region of Brazil. Materials and Methods: A cross-sectional study carried out at the Police Station for Crimes against Persons of the Civil Police, which evaluated 168 police inquiries of homicide victims notified from January 2015 to December 2018. Variables analyzed were related to the Victim's sociodemographic profile, homicide characteristics and body region involved. Descriptive data analysis and Pearson's Chi-square test (P < 0.05) were performed. Results: There was greater involvement of men (92.9%) aged 20–29 years (36.3%), drug users (70.7%) and with a criminal record (65.9%). There was a predominance of simple homicides (92.3%), with greater occurrence on Sundays (16.7%), in the night shift (40.1%), revenge was the main reason for the crime (32%), and firearms as the main means used (89.2%). Regarding the number of body regions affected, victims were more frequently affected in 2 regions (36.5%). Head injuries were identified in 68.3% of victims, while face injuries represented 35.3%. There was an association between the presence of head injuries and number of injuries (P < 0.05). Discussion: The prevalence of head and face injuries resulting from homicide was high and victims are predominantly young men, drug users and those with a criminal record. The association was found between the presence of head injuries and number of injuries.
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Significance of morphometric and anatomic variations of nasopalatine canal on cone-beam computed tomography in anterior functional zone - A retrospective study p. 108
Shalu Rai, Deepankar Misra, Akansha Misra, Mansi Khatri, Sahil Kidwai, Suman Bisla, Prerna Jain
DOI:10.4103/ams.ams_283_20  
Introduction: Oral rehabilitation in maxillary anterior region has increased concerns in the dental fraternity to have detailed morphological examination in treatment planning. The nasopalatine canal (NPC) along with its contents plays an important role in determining the prognosis of implants and their associated surgeries. The present study was performed to evaluate morphometric anatomic variations of the NPC using focused small field of view on cone-beam computed tomography (CBCT). Materials and Methods: The study included 250 participants. CBCT examination was conducted using standard exposure and patient positioning protocols. Sagittal, coronal, and axial sections were reviewed to determine NPC morphology and dimensions. Results: Single, round, incisive foramen with mean mesiodistal diameter of 3.23 (±1.00) mm, and mean anteroposterior dimension of 3.03 (±0.96) mm was found. Single Stenson's foramen along with funnel shaped, slanted NPC with mean angulation of 81.97 (±42.19), and mean length of 12.67 (±2.69) mm was found. Mean mesiodistal diameter at nasal fossa of NPC was 3.27 (±1.75) mm, at mid-level was 2.23 (±1.02) mm, at palate was 3.46 (±1.12) mm. At least one additional foramen was found. Discussion: Anatomy of the NPC is highly variable. Age-wise and gender-wise correlations revealed statistically significant results for different parameters. The present study highlighted significance of NPC along with its variations. Therefore, a methodical three-dimensional presurgical assessment is mandatory before any surgical intervention in this region.
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Outcomes of management of sinonasal malignancies at a dedicated cancer institution: A retrospective study p. 115
Rahim Dhanani, Muhammad Faisal, Hamza Shahid, Kashif Iqbal Malik, Arif Jamshed, Raza Hussain
DOI:10.4103/ams.ams_16_21  
Introduction: Sinonasal malignancies (SNMs) are a rare and heterogeneous group of cancers with an incidence of 3%–5% of all head-and-neck tumours. The aim of the present study was to identify the characteristic features of SNMs and to analyze the treatment outcomes and the prognostic factors affecting it. Materials and Methods: A retrospective review of patients with SNM treated at a dedicated cancer center of Pakistan between 2004 and 2018 was carried out. All patients with histologically proven diagnosis of malignancy arising from nasal cavity or paranasal sinuses and being treated with curative intent were included. The medical records of 184 cases were utilized for final analysis. Chi-square test was applied to identify significant differences. Five-year disease-specific survival (DSS) was calculated using Kaplan–Meier curve via log-rank test and comparison was made between squamous and nonsquamous histologies. P ≤0.05 was considered statistically significant. Results: Squamous cell carcinoma was the most common histopathology (n = 62, 33.7%). 130 (70.7%) patients presented with stage IV disease. Nodal metastasis was seen in 24 (13%) patients. Treatment failure was seen in 96 (52.2%) patients and was significantly associated with tumour size and the overall stage. DSS of patients with squamous cell carcinoma was 29% as compared to 52% for patients with nonsquamous histologies (P = 0.001). Discussion: SNM is a diverse group of cancers presenting in late stages. A higher rate of treatment failure associated significantly with stage of the disease was identified in our study.
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SYSTEMATIC REVIEWS AND META-ANALYSIS Top

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis p. 121
Rathindra Nath Bera, Preeti Tiwari
DOI:10.4103/ams.ams_339_20  
Background: There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck. Objectives: “Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?” Data Sources: PubMed, Cochrane Library, clinicaltrials.gov and hand searches. Participants and Interventions: Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap. Study Appraisal and Synthesis Methods: Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05. Results: There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412–0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5–7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech. Limitations: Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility. Conclusions and Implications of Key Findings: Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.
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CASE REPORTS - CRANIOMAXILLOFACIAL SURGERY Top

Minimally invasive endoscopic approach towards management of frontoethmoidal mucocoele with lateral displacement of eyeball and proptosis - A case report p. 129
Tanzeem Ahmed, Samsuddin Ahmed, Nikhil Kaushal
DOI:10.4103/ams.ams_420_20  
Rationale: Mucocoeles of paranasal sinuses are expansile and destructive lesions which can present with a variety of symptoms. If not treated early, they may lead to various complications. Patient Concerns: This report presents a case of a 26-year-old male patient with complaints of swelling of the left eye and double vision for 18 months. Diagnosis: Diagnosis of frontoethmoidal mucocoele with an unusual presentation of lateral displacement of the eyeball and proptosis was made based on patient history, clinical examination, and computed tomography. Treatment: The case was managed conservatively with marsupialization of the mucocoele using the transnasal endoscopic approach. Outcome: Complete resolution of the Mucocoele and its associated symptoms was observed, and frontal sinus ostium was found to be patent and completely epithelialized in 12-month follow-up. Take-away Lessons: The endoscopic approach toward the management of frontoethmoidal mucocoele is an effective alternative to conventional surgery with less patient morbidity and mortality.
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Surgical technique and review of management of frontoethmoidal encephalocoele - A case report p. 132
Hasna Abdourafiq, Farid Zahrou, Lamia Benantar, Khalid Aniba
DOI:10.4103/ams.ams_274_20  
The Rationale: Encephalocoele is a herniation of the brain formed during embryonic development, because of the incomplete closure of Neural Tube. It is a rare skull defect and most cases are located in the occipital bone. Frontal encephalocoeles are very rare and they may involve the ethmoid bone, nasal bones and/or the orbits. Surgical repair is complex and usually requires a multidisciplinary approach. Patient Concerns: We present a case of a 6-month-old baby girl with a congenital frontoethmoidal encephalocoele. Diagnosis: The diagnosis was made by computed tomography scan that showed a defect on the frontoethmoidal zone. Treatment: Cranial approach was employed using standard bicoronal access. The malformation was removed and the defect was repaired by using an autologous parietal bone graft, without any complication in the follow-up. Outcomes and Take-away Lessons: The goal of the surgery is to reconstruct the normal anatomy, to achieve a good cosmetic repair, and to avoid a cerebrospinal fluid leak. A description of the case and the surgical technique is presented with a review of literature.
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Management of large dural defect with CSF leak in hypertelorism correction p. 136
SM Balaji, C. V. Shankar Ganesh, Preetha Balaji
DOI:10.4103/ams.ams_43_21  
The Rationale: Dural tear is a serious complication during hypertelorism corrective surgeries. Identifying the tear and managing requires considerable expertise. Managing large dural tears correctly is necessary to prevent cerebrospinal fluid (CSF)-related complications in craniofacial surgery. Patient Concerns: The patient presented with hypertelorism as a part of the Tessier Cleft 0 and sought to correct the widely placed eyes. Diagnosis: Large critical-sized dural tear during modified box osteotomy surgery. Treatment: Besides successful modified box osteotomy surgery, the critical-sized dural tear was managed with fascia lata and fibrin glue. Outcomes: There was no CSF leak or related complication postsurgically indicating successful sealing and healing of the dural tear. Take-Away Lessons: The synergistic mechanism by which fascia lata graft and fibrin glue help to hermetically seal the critical-sized defect, especially when there are variable amounts of hydrostatic-hydrodynamic forces of CSF exerting pressure on the patched area, is discussed.
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CASE REPORTS - CYST AND TUMORS Top

Chondrosarcoma of maxilla - A rare case report p. 140
Hitesh Dewan, Hiren Patel, Haren Pandya, Bijal Bhavsar, Urvi Shah, Parth Suthar
DOI:10.4103/ams.ams_429_20  
Rationale: Chondrosarcoma, although being a rare entity in jaws, may turn fatal if left untreated or inadequately excised. Prognosis in terms of 5-year survival rate ranges from 90% for Grade I, 81% for Grade II and 43% for Grade III respectively. Patient Concerns: A 35-year-old male patient reported with a gradually progressive hard painless growth over right maxillary molar region. His main concern was removal of pathology without long-term morbidity. Diagnosis: Computed tomography revealed ill-defined mass with internal calcification involving posterior half of upper right alveolus. Treatment and Outcomes: Mandatory biopsy suggested benign chondroma, however wide excision and infrastructural maxillectomy revealed Grade II chondrosarcoma. Take-away Lessons: Complex anatomy of maxilla renders surgical excision of chondrosarcomas with histological clear margins, a daunting task. Due to misdiagnosis of preoperative biopsy, suboptimal excision of malignant mass may lead to local recurrence and occasional distant metastasis. This necessitates further therapy and long term follow up, with occasional poor patient compliance.
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A huge carotid space schwannoma arising from the cervical sympathetic chain - A case report p. 144
Malek A Elsayed, Ahmed M Ibrahim, Mustafa A El Darawany, Mohamed A Ellabban
DOI:10.4103/ams.ams_230_19  
The Rationale: Although 25%–45% of schwannomas are originating from the neck, carotid space schwannomas are extremely rare. Patient Concerns: We report a rare case of huge-sized schwannoma in a 20-year-old student who presented with a symptomless large carotid space mass. Diagnosis: Cervical magnetic resonance imaging (MRI) with contrast revealed a huge, well-defined mass measuring 13.7 cm × 6.4 cm × 4.1 cm. Cervical MRI along with brain MRI were consistent with neurofibromatosis type II. Treatment and Outcomes: Preoperative tracheostomy and wide local excision of schwannoma via a transcervical approach were performed with nerve preservation. Takeaway Lessons: The scarceness of cervical sympathetic chain schwannoma made this case of our patient very interesting to report. Moreover, our patient's huge tumour size is extremely rare, and we could not find any similar cases in the literature.
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Intramuscular hemangioma of masseter muscle: Case report of rare clinical entity p. 148
Ramanpal Singh Makkad, Gunjan Agarwal, Santosh Gupta, Ravleen Nagi, Akshay Ragit, Farhin Jamal
DOI:10.4103/ams.ams_100_20  
Rationale: Intramuscular hemangiomas are unique benign vascular tumours of skeletal muscles; involving masseter and trapezius muscles in the majority of cases. The rationale was to emphasize that the diagnosis of asymptomatic swelling in the masseteric region is important as due to their deep anatomic location and unfamiliar presentation, they are often misdiagnosed as a parotid swelling or other muscular pathologies. Patient Concern: This report describes a rare case of a 25-year-old healthy male patient who presented with an asymptomatic swelling in the right masseteric region. The patient had cosmetic concerns due to the large size. Diagnosis: Colour Doppler ultrasonography was done to assess the vascularity within the lesion. Treatment: Complete excision was successfully achieved using combined Risdon's and preauricular approach. Outcome: No signs of recurrence were observed after 6 months Take-away Lessons: Appropriate selection of diagnostic modalities enables the clinician in making an accurate preoperative diagnosis of progressive swelling in the masseteric region.
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Hematological paraneoplastic syndrome and heparin-induced thrombocytopenia in untreated parotid acinic cell carcinoma - A case report p. 152
Suthaharan Ragulan, Tom Walker, Prince Modayil, Babatunde Odutoye, Michael Lee
DOI:10.4103/ams.ams_121_13  
Rationale: Acinic cell carcinoma (ACC) is a rare and indolent malignancy commonly found in the parotid gland. This can give rise to paraneoplastic syndromes, which represent the clinical manifestations of indirect and remote events produced by tumour metabolites. Patient Concerns: A 38-year-old Afro-Caribbean female suffered an indolent parotid mass. She only presented to our tertiary center when it started to ulcerate and bleed. Diagnosis: She was diagnosed with advanced parotid ACC. She also went on to develop an hematological paraneoplastic syndrome resulting in venous thrombi. This was complicated by her developing heparin-induced thrombocytopenia (HIT). Treatment: A difficult multidisciplinary decision was made to proceed with surgery despite her extremely poor condition. Outcomes: After the surgery, the patient made a full recovery. Take-away Lessons: ACC is a relatively uncommon and indolent malignancy that is usually found in the parotid gland. It can be associated with a hematological paraneoplastic syndrome and further complicated by iatrogenic HIT.
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A rare entity of undifferentiated pleomorphic sarcoma of the mandible - A case report p. 156
TS Archana, Akshay Shetty, Mohammed Imran, Nida Ahmed, Praveen Kumar, TM Shruthi
DOI:10.4103/ams.ams_334_20  
The Rationale: Undifferentiated pleomorphic sarcoma originally known as malignant fibrous histiocytoma was declassified by the World Health Organization in 2002 as a formal diagnostic entity and renamed as an undifferentiated pleomorphic sarcoma. It accounts for <1% of malignant tumours of the long bone. Patient Concerns: A 33-year-old male patient reported with swelling and pain in the lower left posterior jaw region for 3 months with a history of fall on the floor 3 months back. Diagnosis: On examination, diffuse solitary swelling was present on the left lower third of the face and was diagnosed radiographically and histopathologically as undifferentiated pleomorphic sarcoma of the mandible. Treatment and Outcomes: Selective neck dissection, followed by reconstruction with fibula osteomyocutaneous flap and then referred for adjuvant radiotherapy. Take-away Lessons: Vimentin staining plays a substantial role in the diagnosis of undifferentiated pleomorphic sarcoma. A long-term follow-up after treatment is required to increase the chances of disease-free survival for the patients.
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Giant multilobular lipoma of neck - A case report p. 160
Jasmine , Ankush Chavan, Snehal N Ingole, Mohan D Deshpande, Dipak S Burungale, Kejal Jain
DOI:10.4103/ams.ams_4_21  
Rationale: Presenting a rare case report of a giant multilobular lipoma in submandibular and submental spaces of anterior and lateral aspect of neck. Patient's Concerns: The patient's main concern was persistent diffuse swelling in right lower face and neck region for 5–6 years. Diagnosis: The lesion was diagnosed as multiple septate lipoma measuring 11.5 cm × 10.5 cm × 6.5 cm involving submandibular region and anterior triangle of the right neck following fine-needle aspiration cytology and radiological imaging. Treatment: Extraorally complete surgical excision was carried out through submandibular approach under general anesthesia. Outcomes: The patient's postoperative recovery was uneventful. The patient was followed up on a monthly basis for 6 months. No recurrence was observed. The patient was satisfied with the treatment. Lessons: Lipomas should be considered as a rare differential diagnosis for anterior neck swelling. Biopsy is not necessary to confirm the diagnosis. Surgical excision remains the mainstay of treatment following final diagnosis through imaging modalities.
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CASE REPORTS IMPLANTOLOGY Top

Rehabilitation of auricular defect with implant-retained auricular prosthesis - A case report p. 164
Dushyant Chauhan, ID Roy, M Viswamnara, Ashish Thakur, Ravi Athwale
DOI:10.4103/ams.ams_343_20  
Rationale: Maxillofacial defect is of great concern physically, emotionally, and psychologically for a patient. However, it is an even bigger challenge for a team attempting rehabilitation, as a crucial decision has to be made between surgical approach and/or prosthetic rehabilitation. However, if both are combined, it will result in best of esthetics and function with ease of maintainance, resulting in a sucessful rehabilitation. This case report represents a case of auricular defect rehabilitated with a combination of implants and bar-retained silicone prosthesis. Patient Concern: A 38-year-old male patient with right auricular defect reported with the main concern of esthetic rehabilitation of a lost part of the external ear. Diagnosis: With through evaluation and examination, a diagnosis of acquired partial auricular defect of the right side secondary to trauma was established. Treatment: An implant-retained auricular prosthesis was planned for this case. Surgically, three intraoral implants were placed in the mastoid bone, and after healing, bar framework was fabricated and attached. Finally, silicone prosthesis was fabricated and delivered to the patient. Outcome: A successful rehabilitation was carried out in this case using implants and bar attachment for retention of the silicone prosthesis. This prosthesis provided excellent retention and restored the appearance and confidence of the patient. Take-away Lessons: Rehabilitation of the auricular defect can be carried out with surgical approach, which involves multiple surgeries, and still, the results may not be esthetically favorable. Prosthetic rehabilitation is an option, but retention is generally a hindrance. However, implant-retained prosthesis has really paved a way for rehabilitation of the maxillofacial defect esthetically and more reliably. Cone-beam computerized tomography (CT) can be used for planning and evaluation instead of CT, which will save the patient from a lot of radiation exposure. Hence, in the maxillofacial defect, attempts should be made to explore the option of implant-retained prosthesis.
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Life-threatening sublingual hematoma after mandibular implant placement - A case report p. 169
F Javier Barrientos-Lezcano, Guadalupe Corchero-Martín, Ana Belén González-Núñez, Francisco Soler-Presas
DOI:10.4103/ams.ams_365_20  
Rationale: Sublingual hematoma is a potentially lethal complication following mandibular implant placement. Due to the scarce cases reported, the management is controversial. In this article, a case is discussed focusing on the different treatment options to establish an orientative guideline. Patient Concerns: A patient with sublingual hematoma following implant surgery was urgently referred. Despite no active bleeding, breathing difficulty due to oropharyngeal obstruction and oxygen saturation decrease were present. Diagnosis: Stable sublingual hematoma with respiratory distress, based on clinical findings and observation. Treatment: Under local anaesthesia, percutaneous tracheostomy without previous intubation was performed for airway preservation. No surgical approach for the hematoma was made. Outcomes: Uneventful recovery with spontaneous resolution of the hematoma in few days. Takeaway Lessons: Anatomic knowledge of this area and proper surgical planning are required to avoid this complication. Regarding management, airway preservation is mandatory. Surgical approach for the bleeding source will depend on hematoma progression.
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CASE REPORTS - MINOR ORAL SURGERY Top

Postanaesthetic aseptic palatal necrosis - A case report p. 173
Archana Chaurasia, Meenal Airan, Sunil Mall, Sakshi Gupta, Himanshu Sharma, Anila Mohini
DOI:10.4103/ams.ams_289_20  
Rationale: In dentistry, the most common procedure to be applied is administration of a local anaesthetic agent. It is impossible to practice dentistry without local anaesthesia. In the oral cavity, the palatal mucosa is tightly adherent to the palatal bone and there is little space for anaesthetic solution to be deposited. If local anaesthetic is forcefully injected by the syringe, it creates pressure on blood vessels and causes palatal necrosis. Patient Concern: Here, we present a case report of a 25-year-old male patient who reported to us with chief complaint of an ulcer on the palate. Diagnosis: Patient was diagnosed with postanaesthetic aseptic palatal necrosis. Intervention: The patient was managed conservatively using copious irrigation and a palatal acrylic splint. Outcome: On the 6th month follow-up, the lesion was completely replaced by healthy mucosa. Take-away Lessons: We should avoid forceful injection of local anaesthetic agent to prevent further postoperative complications.
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Feasibility of navigation-assisted bone lid surgery for deeply impacted maxillary tooth - A case report p. 176
Shintaro Sukegawa, Ai Fujimura-Sato, Keisuke Nakano, Hitoshi Nagatsuka, Yoshihiko Furuki
DOI:10.4103/ams.ams_370_20  
Rationale: Bone lid surgery (BLS) is minimally invasive surgery that removes the cortical bone and returns it to original position after removing lesions. However, jawbone lesions are completely covered with cortical bone, and it can be difficult to accurately determine the lesion position from the outside. Patient Concerns: A 24-year-old Japanese woman, identified as having an impacted maxillary canine, was referred to our department. Periapical radiolucent lesion, with lateral incisor root absorption by canine compression, was confirmed. Diagnosis: The diagnosis was incisor root absorption due to an impacted canine. Treatment: As a potential solution, we performed navigation-assisted BLS. Outcomes: Using navigation, we could confirm the state of impacted tooth under the covered bone. We could establish reliable bone cutting and the removed cortical bone was successfully returned to the presurgical position. Take-away Lessons: Navigation-assisted BLS for the removal of impacted teeth may increase surgical accuracy and minimize invasion.
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CASE REPORTS - SALIVARY GLAND PATHOLOGIES Top

Abscess associated with sialolith in a parotid duct - A case report p. 180
Augusto Cesar Sette Dias, Halysson Fernandes de Souto, Jéssica de Freitas Tavares, Vladimir Reimar Augusto de Souza Noronha
DOI:10.4103/ams.ams_301_20  
Rationale: The aim of this work is to describe the case of a large abscess associated with a sialolith in the parotid duct. Patient Concerns: Patient's concern is evident in this pathology, because infection untreated or rapidly spreading infections can be potentially life-threatening secondary to airway compromise or septicemia. Diagnosis: Clinical examination, ultrasonography of the region, and cone beam computed tomography were requested to confirm the diagnosis of a sialolith associated with a large abscess. Treatment: Antibiotic therapy with extraoral drainage was performed. After remission of the infection, the stone was located, removed, and the edges sutured. Outcomes: The patient was followed for 6 months. There was a minimal scar without any other noteworthy change. Take-away Lessons: The pathological changes involving the salivary glands are extremely important for diagnosis and treatment plan.
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Mucoepidermoid carcinoma of sublingual salivary gland: A rare case report p. 183
K Sankar, G Vasupradha, N Jaipal
DOI:10.4103/ams.ams_252_20  
Rationale: Sublingual salivary gland tumours are very rare but are mostly malignant. As very limited literature is available, we present a rare case of mucoepidermoid carcinoma (MEC) of sublingual salivary gland. Patient Concerns: A56-year-old female presented with an asymptomatic swelling of 15-year duration in the floor of the mouth and chin region. Diagnosis: Mandibular occlusal view, computed tomography scan, and ultrasonogram revealed calcification and the tumour to be of salivary origin. Incisional biopsy showed clear cell changes. Treatment: The sublingual and submandibular salivary gland along with the associated nodes was excised through transoral approach with midline osteotomy. Outcomes: The histopathologic diagnosis of excised specimen was “Intermediate grade MEC” with clear cell changes, stromal hyalinization, and local invasion. The patient was followed up for 12 months, and there was no evidence of any recurrence. Takeaway Lessons: Sublingual salivary gland malignancies show early invasion and a higher rate of metastases, thus requiring a vigilant intervention.
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CASE REPORT TMJ PATHOLOGIES Top

Distraction osteogenesis and customized temporomandibular joint prosthesis in the reconstruction of a large mandibular defect - A case report p. 187
Weber Ceo Cavalcante, Paula Rizerio D'Andrea Espinheira, Sandra de Cássia Santana Sardinha, Daniel Barros Rodrigues, Luciana M Pedreira Ramalho
DOI:10.4103/ams.ams_266_18  
The Rationale: Mandibular resections involve esthetic and functional impairment and impose a challenge during the reconstruction. This case report is a successful reconstruction with distraction osteogenesis (DO) and customized temporomandibular joint (TMJ) prosthesis. Patient Concerns: A 51-year-old male patient presented with a complaint of facial asymmetry, mastication, and speech difficulties. Diagnosis: As the patient had undergone a hemimandibulectomy procedure 20 years ago, clinical examination showed facial asymmetry. Radiographic examination exhibited the defect and a radiopaque image representing Kirschner's wire. Treatment: DO by bone transport was performed, followed by dental implant and TMJ prosthesis placement. Outcomes: DO is a viable treatment option in resections, even when the defect was generated by an ancient injury. The follow-up is around 7 years after the osteogenic distraction, with no complaints and functional capacity. Take-away Lessons: The major challenge in mandibular reconstructions through DO is to reproduce the curve of the arch.
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CASE REPORTS - TRAUMA Top

Surgical dilemmas in multiple facial fractures – Coronal flap versus minimally invasive: Case report and literature review p. 191
Saleh Nseir, Fadi Abu Shqara, Andrei Krasovsky, Adi Rachmiel
DOI:10.4103/ams.ams_452_20  
rThe Rationale: Pan-facial fracture is a complex trauma that involves the upper, middle, and lower third of the facial bones. The surgical management of such complex cases is either by the posterior approach (coronal flap) or anterior approach through local incisions. Patient Concerns: This report describes the case of severe pan-facial trauma in a 52-year-old male who sustained a severe pan-facial trauma. Diagnosis: He suffered from multiple facial fractures that included: Frontal bone, skull base, Naso-orbitoethmoid (NOE), zygomatic and sub-condylar fractures. Treatment: He was managed by minimally local periorbital and lynch incisions. Outcomes: Fractures were properly reduced with resultant symmetrical facial dimensions. No postoperative complications were demonstrated including facial nerve function. Take-away Lessons: We should consider minimally invasive local incisions in pan-facial fractures when there is no need to restore the frontal sinus and the anterior-posterior dimensions of the zygomatic arch.
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Splitting and splaying apart of the craniomaxillofacial skeleton by medially directed disruptive forces of unusual etiologies- A case series Highly accessed article p. 195
Priya Jeyaraj
DOI:10.4103/ams.ams_275_20  
Introduction: Extreme forces directed towards the centre of the facial region can produce devastating injuries, with disruption of the mandible, maxilla and naso-orbito-ethmoid complex, with or without frontal bone involvement. The magnitude and trajectory of the force and nature of the impacting object, dictate the degree of displacement and comminution of the craniomaxillofacial skeletal components, as well as the extent of soft tissue loss sustained. Diagnosis & Challenges: To elucidate various challenges faced in the management of four cases of extreme craniomaxillofacial injuries, caused by centrally directed forces of rather unusual etiologies, namely, a traversing bullet, a bamboo rod, a heavy iron cattle tethering peg and a metal electrical pole. In each of the cases, the force of impact resulted in splitting and splaying apart of the facial skeleton, with a resultant increase in its transverse width, and an ensuing severe facial deformity and functional debility. Rationale & Interventions: A 'Bottom-up, Outside-in' surgical sequence was employed to carry out reduction, fixation and reconstruction of the deranged maxillofacial skeletal architecture and restoration of the soft tissue morphology. Outcomes & Lessons: The transverse dimensions of the flared out facial frames could be re-established and restored to their pre-trauma status successfully in all the cases, thereby achieving excellent esthetic and functional outcomes. Despite the extensive and serious nature of the injuries sustained, gross residual craniofacial defects, deformities and asymmetries, as well as debilitating functional deficits, could be effectively and successfully averted.
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LETTER TO EDITOR Top

A need to estimate the economic burden of oral cancer in India p. 214
Satvinder Singh Bakshi, Vinoth Kumar Kalidoss
DOI:10.4103/ams.ams_94_20  
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