RSS 1.0Maxillofacial Surgery
Recent Submissions
-
Can socioeconomic and psychosocial factors predict the duration of orthodontic treatment?Introduction and objectives: Very little is known about the role of socioeconomic and psychosocial factors in predicting orthodontic treatment duration. Thus, this study aimed to test whether socioeconomic position (SEP) and psychosocial factors, namely, family environment and resiliency can predict orthodontic treatment duration. Methods: Data were analysed from a hospital-based, prospective, longitudinal study that recruited 145 consecutively selected 12- to 16-year-old male and female adolescents. Baseline SEP and psychosocial data were collected by a validated child self-completed questionnaire before the placement of fixed appliances. Linear regression analysis was used. Results: The response rate was 98.6 per cent and the dropout was 8.2 per cent. Maternal emotional support was an important predictor of orthodontic treatment duration. Adolescents with high levels of maternal emotional support were more likely to have a shorter orthodontic treatment duration (by nearly four months) than those with low levels of maternal emotional support (P = 0.02). Parental SEP, paternal emotional support, maternal and paternal control, as well as resiliency were not significantly associated with orthodontic treatment duration (P > 0.05). The multivariable regression analysis (including age, gender, and malocclusion severity) confirmed the significance of maternal emotional support as a predictor of orthodontic treatment duration. Conclusions: Maternal emotional support is an important predictor of orthodontic treatment duration. This may be explained by a higher maternal involvement in the orthodontic treatment, which may have facilitated achieving the required orthodontic treatment outcome in a shorter treatment duration.
-
Bony cystic lesion with associated submandibular lymphadenopathy on a background of breast carcinoma: an unexpected case of cervicofacial actinomycosisActinomycosis is an uncommon, chronic suppurative granulomatous infection and needs to be considered as a differential diagnosis. A 56-year-old woman with a background of type 2 diabetes mellitus and breast carcinoma was referred to the Oral and Maxillofacial Surgery 2-week wait clinic, regarding a tender sublingual mass and firm erythematous swelling in the right submandibular and submental region. This was slowly progressive and had not responded to oral co-amoxiclav. An orthopantomogram showed a well-defined radiolucency and smaller radiolucent lesions throughout the edentulous right body of the mandible. A contrast-enhanced CT confirmed a right submandibular abscess communicating with cavitating lesions. The differentials included osteomyelitis, bony metastases, multiple myeloma or other cystic lesions. The patient underwent incision and drainage of the abscess, alongside biopsies, and intravenous co-amoxiclav was given. Microbiology cultures confirmed the presence of Actinomyces israelii and a diagnosis of cervicofacial actinomycosis with mandibular osteomyelitis. The patient was successfully treated with prolonged antibiotics.
-
Birmingham mandible and midface rules: determining variables for inclusion in a clinical predictor ruleStaff in emergency departments often rely on heuristics and algorithms to make clinical decisions on a wide range of problems. Clinical predictor rules such as the Ottawa ankle rules serve to reduce the need for unnecessary radiographs and help to give frontline staff the confidence to make a diagnosis. The current study aimed to achieve consensus on the variables to test for inclusion in a set of predictor rules for suspected fractures of the mandible and midface. A three-stage modified Delphi study was conducted of members and fellows of the British Association of Oral and Maxillofacial Surgeons (BAOMS). At the third stage, there was agreement of more than 51% to retain 11/35 of the suggested predictors for mandibular fractures and 14/28 of the midface predictors. To develop and validate clinical predictor rules for use by frontline staff, these variables will now form part of a prospective data gathering exercise at a major trauma centre.
-
Outcomes of non-surgical management of non-condylar mandibular fractures: a systematic review and meta-analysisSurgical intervention utilising open and (less commonly) closed reduction, are the main methods for the management of fractures of the mandible that do not involve the condyle or coronoid. Non-surgical management of these fracture patterns is rare. This systematic review aimed to collate current evidence surrounding this topic. A systematic review was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were adults with mandibular fractures. Exclusion criteria included any form of surgical intervention including open or closed reduction, and fractures of the condyle or coronoid. Four studies satisfied the eligibility criteria and comprised 80 patients. A total of 69 patients (86%) who were managed non-surgically produced satisfactory clinical outcomes with no surgical intervention required. The evidence suggests that non-surgical management can successfully avoid surgery in most cases when certain criteria are applied. This has huge health economic implications as it reduces morbidity and requirements for theatre and inpatient stay. Further research is required to establish which fracture patterns are most amenable to this approach, the most effective non-surgical instructions, and the recommended follow-up period.
-
Potentially modifiable patient factors in mandible fracture complications: a systematic review and meta-analysisThe mandible is the most common bone to develop complications following treatment of facial fractures. This is due to a complex interaction of both fracture specific and patient factors. Our aim was to identify those patient factors, with a specific focus on those that may be potentially modifiable to reduce the incidence of complications. A systematic review of the literature was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology to identify patient factors ascribed to an increased risk of complications following the treatment of mandibular fracture. These were divided into non- modifiable and potentially modifiable factors. A meta-analysis was performed to weight those factors for which statistical analysis had been performed. Twenty-two pertinent papers were identified, of which eight described non-modifiable and seven potentially modifiable factors. The most common potentially modifiable factor identified was smoking. Meta-analysis established that tobacco smoking demonstrated an increased risk of complications in three studies (Odds Ratio: 4.04 - 8.09). Division of patient factors into those that are potentially modifiable and those that are not will enable clinicians to focus on those in which change within the immediate postoperative period can be instigated. This includes smoking cessation assistance, education as to the need for a soft diet, and facilitating postoperative clinic attendance. It also enables stratification of risk in terms of consent, and choice of treatment. Further research should use standardised terminology, particularly in stopping the use of generalisable terms such as patient compliance and instead describing its individual components.
-
Validation of an extended total joint replacement (eTJR) classification system for the temporomandibular joint (TMJ).The aim of this paper was to validate a previously described classification system for extended total joint replacements (eTJRs) of the temporomandibular joint (TMJ). We engaged an expert panel to review 60 TMJ eTJR devices and classify them using the system, examining their responses for inter-rater agreement and concordance with the correct response as determined by the authors. Conger's kappa was 0.34 for the fossa (F) component sub-classification and 0.67 for the mandibular (M) component. A posthoc analysis showed improvements in inter-rater agreement for a modified three-tiered F sub-classification system which is suggested in a revised version of the TMJ eTJR classification system
-
Osteosclerotic metaphyseal dysplasia, dysosteosclerosis or osteomyelitis? Paediatric case presentation with associated mandibular swelling and a review of the literature.Osteosclerotic metaphyseal dysplasia (OMD) is an extremely rare form of osteopetrosis, which bears significant clinical similarities to dysosteosclerosis (DSS). We aim to present a rare case of OMD with mandibular swelling and osteomyelitis infection including diagnosis journey as well as management in 7-year-old patient. Literature review completed for OMD cases. Case report investigative methods include genetic testing, CT facial bones and MRI scan, orthopantogram and bone biopsies. An initial suspected diagnosis of DSS with chronic osteomyelitis was made. However, following genetic testing, a diagnosis of OMD was confirmed. Our patient underwent a surgical debulking procedure and antibiotic treatment. Less than 10 patients with this condition have been reported within the international literature. There is a wide range of presentation. OMD, DSS and osteomyelitis are all within a similar spectrum of bone conditions. Our understanding, regarding OMD, remains limited and, hence, further research is required to elucidate a thorough clinical picture.
-
Oral ulceration in Stüve-Wiedemann syndrome: a new presentation.Stüve-Wiedemann syndrome (SWS) is a rare, autosomal recessive disorder, causing dysautonomia and multisystem failure. Symptoms include skeletal malformations, restricted joint mobility and desensitisation to pain. Patients with SWS presenting with intraoral lesions are extremely rare and this is probably due to their shortened lifespan. We present a case of a 9-month-old patient who presented to our Oral and Maxillofacial Surgery (OMFS)Unit with a chronic inflamed ulcer affecting the tongue, secondary to trauma from erupting central incisors. We believe that depapillation in conjunction with an increased pain threshold contributed to its development. The patient was successfully treated by extraction of the lower central incisors and intralesional steroid injections under general anaesthetic. This case highlights that patients with SWS can present to the OMFS clinician with oral lesions and that they can be safely managed under general anaesthesia.
-
Interventions for promoting the eruption of palatally displaced permanent canine teeth, without the need for surgical exposure, in children aged 9 to 14 years.Background: A permanent upper (maxillary) canine tooth that grows into the roof of the mouth and frequently does not appear (erupt) is called a palatally displaced canine (PDC). The reported prevalence of PDC in the population varies between 1% and 3%. Management of the unerupted PDC can be lengthy, involving surgery to uncover the tooth and prolonged orthodontic (brace) treatment to straighten it; therefore, various procedures have been suggested to encourage a PDC to erupt without the need for surgical intervention. Objectives: To assess the efficacy, safety and cost-effectiveness of any interceptive procedure to promote the eruption of a PDC compared to no treatment or other interceptive procedures in young people aged 9 to 14 years old. Search methods: An information specialist searched four bibliographic databases up to 3 February 2021 and used additional search methods to identify published, unpublished and ongoing studies. Selection criteria: We included randomised controlled trials (RCT) involving at least 80% of children aged between 9 and 14 years, who were diagnosed with an upper PDC and undergoing an intervention to enable the successful eruption of the unerupted PDC, which was compared with an untreated control group or another intervention. Data collection and analysis: Two review authors, independently and in duplicate, examined titles, keywords, abstracts, full articles, extracted data and assessed risk of bias using the Cochrane Risk of Bias 1 tool (RoB1). The primary outcome was summarised with risk ratios (RR) and 95% confidence intervals (CI). We reported an intention-to-treat (ITT) analysis when data were available and a modified intention-to-treat (mITT) analysis if not. We also undertook several sensitivity analyses. We used summary of findings tables to present the main findings and our assessment of the certainty of the evidence. Main results: We included four studies, involving 199 randomised participants (164 analysed), 108 girls and 91 boys, 82 of whom were diagnosed with unilateral PDC and 117 with bilateral PDC. The participants were aged between 8 and 13 years at recruitment. The certainty of the evidence was very low and future research may change our conclusions. One study (randomised 67 participants, 89 teeth) found that extracting the primary canine may increase the proportion of PDCs that successfully erupt into the mouth at 12 months compared with no extraction (RR 2.87, 95% CI 0.90 to 9.23; 45 participants, 45 PDCs analysed; very low-certainty evidence), but the CI included the possibility of no difference; therefore the evidence was uncertain. There was no evidence that extraction of the primary canine reduced the number of young people with a PDC referred for surgery at 12 months (RR 0.61 (95% CI 0.29 to 1.28). Three studies (randomised 132 participants, 227 teeth) found no difference in the proportion of successfully erupted PDCs at 18 months with a double primary tooth extraction compared with extraction of a single primary canine (RR 0.68, 95% CI 0.35 to 1.31; 119 participants analysed, 203 PDCs; mITT; very low-certainty evidence). Two of these studies found no difference in the proportions referred for surgical exposure between the single and the double primary extraction groups data at 48 months (RR 0.31, 95% CI 0.06 to 1.45). There are some descriptive data suggesting that the more severe the displacement of the PDC towards the midline, the lower the proportion of successfully erupted PDCs with or without intervention. Authors' conclusions: The evidence that extraction of the primary canine in a young person aged between 9 and 14 years diagnosed with a PDC may increase the proportion of erupted PDCs, without surgical intervention, is very uncertain. There is no evidence that double extraction of primary teeth increases the proportion of erupted PDC compared with a single primary tooth extraction at 18 months or the proportion referred for surgery by 48 months. Because we have only low to very low certainty in these findings, future research is necessary to help us know for sure the best way to deal with upper permanent teeth that are not erupting as expected. Trial registration: ClinicalTrials.gov NCT02675036.
-
Classifying the causes of morbidity and error following treatment of facial fractures.Analysing morbidity and using this to improve the quality of patient care is an important component of clinical governance. Several methods of data collection and clinical analysis have been suggested, but to date none have been widely adopted. All adult patients sustaining facial fractures were prospectively identified between 01 March 2019 and 28 February 2020, and matched to those who required a return to theatre for surgical complications. Morbidity resulting in a return to theatre was determined using the Clavien-Dindo classification and the Northwestern University error ascribing method. During this period, return to theatre occurred for 33/285 (11.6%) procedures and 23/173 (13.3%) of patients being treated for facial fractures. According to the 27 procedures discussed, Clavien-Dindo Grade IIIb was most commonly found (20/27). Error in judgement (13/35) and nature of disease (12/35) were ascribed as the most common causes of error. Presence of a consultant was associated with increased odds of a return to theatre (p = 0.014). Standardised national data collection of morbidity and error is required for comparisons of outcomes within a single institution or between institutions. To the best of our knowledge, this is the first paper to utilise these widely used methods of morbidity analysis for facial fracture surgery. We would recommend further development of an error analysis method that is more specific to complications from facial fracture surgery.
-
E-scooter-related dental injuries: a two-year retrospective review.Introduction In June 2020, the United Kingdom (UK) published guidance on electric scooter (e-scooter) use to ease transport congestion and reduce pollution. This study aims to examine dental injuries sustained during the two years following initiation of the trial.Methods The research was conducted at a UK, Level 1, supra-regional major trauma centre. All eligible patient records were analysed to identify e-scooter-related dental injuries to the following regions: teeth, periodontium, alveolus, palate, tongue, floor of mouth, frenum, buccal mucosa and lips. To assess significant associations between recorded variables, a Pearson's chi-square test was utilised.Results Of the 32 patients who experienced a total of 71 dental injuries, 46.5% (n = 33) affected teeth, predominantly upper central incisors (n = 17). 'Lacerations' (n = 32) and 'lips' (n = 30) were the most common type and site of soft tissue injuries, respectively. Unprovoked falls by riders accounted for 53.1% (n = 17) of the injuries. There was an overall increase in e-scooter-related dental injuries throughout the two-year period.Conclusion E-scooters have introduced an additional source of dental trauma. It is imperative health care professionals can also identify signs of head and non-dental injuries when managing such patients. Further studies are warranted allowing for better informed and optimised dental public health interventions.
-
Clinical negligence claims in oral and maxillofacial surgery over the last 10 years.According to NHS Resolution, the cost of harm from clinical activity in the last year was £8.3 billion. The steady increase in litigation within the National Health Service (NHS) has led to concerns being raised regarding the sustainability of the NHS, the increasing practice of defensive medicine, and the psychological impact on healthcare professionals. To our knowledge, litigation within oral and maxillofacial surgery has not been investigated in the UK since 2010, therefore our aims were to identify the trends within our specialty and the common reasons for negligence claims over the last 10 years. A freedom of information request was made to NHS Resolution for all clinical negligence claims from 2010 to 2020. A total of 1,122 claims were registered and the total for damages paid was £32,631,131. The claims were categorised by the primary injury and further divided into groups of cause codes. Four types of primary injury comprised 65.4% (n = 734) of all negligence claims and were as follows: additional or unnecessary operations (n = 313, 27.9%), unnecessary pain (n = 156, 13.9%), nerve damage (n = 139, 12.4%), and dental damage (n = 126, 11.2%). The damages associated with nerve damage were the costliest, with a total of £8,033,737 being paid. The significant increase in the number and cost of clinical negligence claims is concerning. The lessons from these claims must be shared and implemented to reduce the burden on the NHS, and ensure that we are providing a high quality of care with improved patient outcomes.
-
Endoscopic transsphenoidal surgery reconstruction using the fibrin sealant patch Tachosil.The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach.
-
Experience of orbital floor fractures in a UK level one trauma centre: a focus on the surgical approach and lid-related complications.The two surgical approaches to access orbital fractures are transconjunctival and transcutaneous. The aim of this study was to assess the outcomes of orbital repairs with a focus on lid-related complications and their management. A retrospective analysis was carried out over a five-year period (January 2015 to January 2020) to assess all consecutive orbital repairs in our unit. Data were collected for variables including demographics, fracture pattern, surgical approach, and details of postoperative complications. A total of 111 patients were included in the study, 94 were male (85%), the majority being between 16 and 45 years of age. A total of 46 (41%) had isolated orbital floor fractures, 31 (28%) zygomaticomaxillary complex, and 18 (16%) Le Fort pattern fractures. Eighty per cent (n = 91) received a transconjunctival approach as first choice. In the transconjunctival group, six (6.6%) had entropion and increased scleral show, four (4.4%) had ectropion, and none had canthal malposition. In the transcutaneous group (n = 20) there was a higher rate of ectropion (25%, n = 5), a lower rate of entropion (n = 1, 5%) and higher rate of increased scleral show (n = 2, 10%). Factors associated with a higher rate of complications included complex fractures, use of conjunctival sutures, and increased length of time to surgery. Seventy-two per cent of patients who suffered entropion required further surgical treatment. The most common complication of the transconjunctival approach was entropion, and clinicians should have a low threshold for early surgical management. We feel that this should be part of the consenting process, especially in high-risk cases.
-
Accuracy and cost effectiveness of a waferless osteotomy approach, using patient specific guides and plates in orthognathic surgery: a systematic review.The aim of this systematic review is to evaluate the accuracy of waferless osteotomy procedures in orthognathic surgery with a secondary aim to determine the cost-effectiveness of the procedure. A literature search was conducted on the databases PubMed and Scopus, with PRISMA guidelines followed. An initial yield of 4149 articles were identified, ten of which met the desired inclusion criteria. The total sample of patients undergoing waferless osteotomies included in this review was 142 patients. Nine of the studies used surgical cutting guides along with customised surgical plates to eliminate the surgical wafer and one study used pre-bent locking plates instead of customised plates. The eligible articles determined their surgical accuracy by comparing the positions of bony or dental landmarks on the pre-operative and post-operative images. The articles all reported acceptable accuracy within previously established clinical parameters. The majority of authors concluded that it is an accurate surgical approach and can be cost effective which is often a barrier to novel techniques however there were studies that contrasted the view of the cost efficacy. Due to the lack of published randomised controlled trials, current evidence is not strong enough to recommend the use of surgical cutting guides and customised/pre-bent plates for orthognathic surgery.
-
Delivering a net zero NHS: Where does Otorhinolaryngology - Head and Neck Surgery stand?No abstract available