British Journal of Oral and Maxillofacial Surgery

Editorial Board

2012-01-01

Reviewer thank you list

2011-12-12

Oral health and pathology: a macrophage account

2011-02-10

Abstract: Macrophages are present in healthy oral mucosa and their numbers increase dramatically during disease. They can exhibit a diverse range of phenotypes characterised as a functional spectrum from pro-inflammatory to anti-inflammatory (regulatory) subsets. This review illustrates the role of these subsets in the oral inflammatory disease lichen planus, and the immunosuppressive disease oral squamous cell carcinoma (SCC). We conclude that the role of macrophages in driving progression in oral disease identifies them as potential therapeutic targets for a range of oral pathologies.

Pathogenesis of post-traumatic ankylosis of the temporomandibular joint: a critical review

Gururaj Arakeri, Atul Kusanale, Graeme A. Zaki, Peter A. Brennan — 2010-10-22

Abstract: Many factors have been implicated in the development of bony ankylosis following trauma to the temporomandibular joint (TMJ) or ankylosis that recurs after surgical treatment for the condition. Although many reports have been published, to our knowledge very little has been written about the pathogenesis of the process and there are few scientific studies. Over the last 70 years various treatments have been described. Different methods have been used with perceived favourable outcomes although recurrence remains a problem in many cases, and ankylosis presents a major therapeutic challenge. We present a critical review of published papers and discuss the various hypotheses regarding the pathogenesis of the condition.

Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992–2009)

2010-12-20

Abstract: Reconstruction of surgical defects in the head and neck using microvascular free tissue transfer is reliable with success rates in excess of 95%. Our previous audit (1992–1998) showed that 16% of patients required an early return to theatre, and the overall free flap salvage rate was 73%. The medical records of 37 patients who had required early return to theatre (within 7 days) after free tissue transfer were analysed to ascertain the indication for reoperation, and whether surgical intervention had been successful, taking into account the timing and cause of compromise. The results of a retrospective re-audit (1999–2004 and 2005–2009) showed that the return to theatre rate had reduced to 4% overall because of a reduction in the number of cases: those that required evacuation of a neck haematoma, and venous compromise of fasciocutaneous or perforator free flaps. Salvage of flaps was most successful when done within the first 24h, and in cases of venous compromise. Three percent of free flaps failed without attempted salvage; most were late failures. Overall survival (1992–2009) for composite free flaps (93%) was lower than for fasciocutaneous or perforator free flaps (96%). Between 2005 and 2009 our overall free flap survival rate was 98%.

Outcomes following pharyngolaryngectomy reconstruction with the anterolateral thigh (ALT) free flap

2010-11-08

Abstract: We retrospectively reviewed 15 cases of pharyngolaryngectomy for advanced laryngeal carcinoma reconstructed with the anterolateral thigh (ALT) free flap. Thirteen patients had primary surgery and adjuvant treatment (radiotherapy or chemoradiotherapy), and two had salvage surgery. Thirteen had stage III or IV disease, and eight had cervical nodal extracapsular spread. In this series all the flaps survived, and at median follow-up of 14.5 months (range 3.7–31.2), 12 of the 15 patients were alive. One patient developed a chronic pharyngocutaneous fistula, and five required repeat balloon dilatations for late pharyngeal strictures. Six patients enjoyed restoration of full oral intake, seven were able to take a soft diet, and two were dependent on feeding by percutaneous endoscopic gastrostomy. Four patients developed adequate tracheo-oesophageal speech, and one successfully developed oesophageal speech. In this series many of the surgical problems associated with pharyngolaryngectomy reconstruction were addressed successfully by the ALT, but late dysphagia remained troublesome in an appreciable minority. While adjuvant radiotherapy could have contributed to this, future innovations will focus on the reduction of late strictures.

Peroneal perforator flap for intraoral reconstruction

2010-12-29

Abstract: Thin and pliable flaps with long, high calibre pedicles are ideally suited to lining the inside of the mouth. The radial forearm free flap has been our flap of choice until now, but we are unhappy with its potential for complications at the donor site. As an alternative, 30 patients have been treated in our unit with peroneal perforator flaps. Magnetic resonance (MR) angiography is necessary preoperatively to identify major perforating vessels. Flaps were raised using a lateral approach after the position of the most suitable perforator had been marked on the skin. The skin flaps were outlined in the proximal half of the lower leg with a maximum width of 5cm to allow for direct closure of the wound. Five patients (of the original 35) were excluded after the results of MR angiography were known. All perforators identified on MR angiography could be exposed in the proximal half of the lower leg and most had a septocutaneous course. Reconstructions were in the floor of the mouth (n=16), tongue (n=11), and buccal mucosa (n=3). All but one flap survived with satisfactory functional results. The donor site morbidity was low. With the aid of MR angiography the peroneal perforator flap is a safe option for intraoral reconstruction. For small and medium sized defects we think that this flap is a good alternative to others, particularly if direct closure at an inconspicuous donor site is desired.

Computed tomography-guided implant surgery for dental rehabilitation in mandible reconstructed with a fibular free flap: description of the technique

2011-01-03

Abstract: The fibular free flap, with or without a cutaneous component, is the gold standard for reconstructing mandibular defects. Dental prosthetic rehabilitation is possible this way, even if the prosthesis-based implant is still a challenge because of the many anatomical and prosthetic problems. We think that complications can be overcome or reduced by adopting the new methods of computed tomography (CT)-assisted implant surgery (NobelGuide®, Nobel Biocare AB, Goteborg, Sweden). Here we describe the possibility of using CT-guided implant surgery with a flapless approach and immediate loading in mandibles reconstructed with fibular free flaps.

Alcohol and interpersonal violence may increase the severity of facial fracture

Connor O’Meara, Robert Witherspoon, Narada Hapangama, Dylan M Hyam — 2010-12-10

Abstract: The association between alcohol and interpersonal violence has been established in studies from a number of countries. We aimed to determine whether alcohol was a contributing factor in the incidence or severity of facial trauma. For 15 months we prospectively studied patients with facial fractures who presented for oral and maxillofacial review. Severity of injury was assessed using the maxillofacial injury severity score (MFISS). Of the 255 patients with facial trauma who presented to our tertiary referral centre, 202 had fractures of the facial skeleton. Most presentations were secondary to interpersonal violence (n=105, 52%), and 91 (87%) of these involved alcohol. Overall, alcohol was involved in 53% of cases (n=107). The relative risk of requiring surgical intervention when alcohol was involved was 1.61 (CI=1.12–2.32). Alcohol significantly increased the severity of facial fracture for both MFISS: alcohol (n=107) mean (SD) 11.43 (7.63); no alcohol (n=95) mean (SD) 6.87 (6.22) (p<0.05). Interpersonal violence also increased the severity of facial fracture: interpersonal violence (n=105) mean (SD) 11.06 (6.68), no interpersonal violence (n=97) mean (SD) 7.37 (7.59) (p<0.05). Patients whose facial fractures are the result of interpersonal violence have more severe injuries and are more likely to require surgery if alcohol is involved. This results in a heavier surgical workload, and is an economic and social burden to the community. Primary prevention strategies will have an important role in reducing such injuries.

Pentoxifylline and tocopherol in the management of patients with osteoradionecrosis, the Portsmouth experience

N.M.H. Mcleod, C.A. Pratt, T.K. Mellor, P.A. Brennan — 2011-01-20

Abstract: Osteoradionecrosis of the jaw remains the most problematic consequence of radiotherapy for the management of head and neck cancer. Treatment is often complex and multimodal. New theories on its pathophysiology have allowed the development of potential treatment modalities, including the use of pentoxifylline and tocopherol. In this retrospective case series we examined the outcomes of patients with ORN prescribed pentoxifylline and tocopherol.

The evidence base for oral and maxillofacial surgery: 10-year analysis of two journals

Amandip Sandhu — 2010-12-14

Abstract: All articles published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) and the International Journal of Oral and Maxillofacial Surgery (IJOMS) between January 1999 and December 2009 were classified by study design and evaluated to find the evidence base in oral and maxillofacial surgery (OMFS). Those in related specialties, and the impact factor of related dental journals were also compared. From a total of 3294 articles (1715 (52%) BJOMS; and 1579 (48%) IJOMS) most of the studies were observational or descriptive (36% BJOMS; and 31% IJOMS). Review articles constituted 5% in the British Journal and 6% in the International Journal. Analytical (non-controlled) studies made up 6% and 7% of the studies in the British Journal and the International Journal, respectively. There were 28 randomised controlled trials (RCT) (2%) in the British Journal and 40 (3%) in the International Journal. One meta-analysis was recorded in the International Journal, and one closed loop audit was recorded in the British Journal. Forty percent of the papers in both journals were non-clinical, scientific, or animal studies. The number of RCTs published in OMFS is low and is comparable with the related specialties of ear, nose, and throat (ENT) (1%) and plastic surgery (4%). Greater effort is required to carry out quality research if we are to provide the best possible evidence to patients for our interventions.

Validation of a new method for building a three-dimensional physical model of the skull and dentition

M. O’Neil, B. Khambay, K.F. Moos, J. Barbenel, F. Walker, A. Ayoub — 2011-01-03

Abstract: We present a new method for replicating the skull and occlusal surface with an accurate physical model that could be used for planning orthognathic surgery. The investigation was made on 6 human skulls, and a polyvinyl splint was fabricated on the dental cast of the maxillary dentition in each case. A cone beam computed tomogram (CBCT) was taken of each skull and a three-dimensional replica produced. The distorted dentition (as a result of magnification errors and streak artefacts) was removed from the three-dimensional model and replaced by new plaster dentition that was fabricated using the polyvinyl splint and a transfer jig replication technique. To verify the accuracy of the method the human skulls and the three dimensional replica model, with the new plaster dentition in situ, were scanned using a laser scanner. The three-dimensional images produced were superimposed to identify the errors associated with the replacement of the distorted occlusal surface with the new plaster dentition. The overall mean error was 0.72 and SD was (0.26)mm. The accuracy of the method encouraged us to use it clinically in a case of pronounced facial asymmetry.

Orthognathic patients with nasal deformities: case for simultaneous orthognathic surgery and rhinoplasty

Tian Ee Seah, Hugh Bellis, Velupillai Ilankovan — 2011-05-19

Abstract: Orthognathic surgery is a recognised way of correcting dentofacial deformities and it is common practice to treat problems that affect the chin simultaneously, while deferring or not treating nasal deformities. There is inadequate published information about the prevalence of nasal deformities in such patients, and our aim was to remedy this. We retrospectively studied 75 patients with dentofacial deformities to find out if there was an association between nasal and dentofacial abnormalities. Forty-six of the 75 patients (61%) had mild to prominent cosmetic nasal problems, of whom 27 had deformities of the nasal bridge, 22 of the lobule of the nasal tip, 20 of nasal width, 14 in the width of the alar base, and 11 of the columella; 8 presented with deviation of the nose, and 6 with abnormal nasal length. Skeletal classes II and III had only slightly varied emphasis on nasal deformities. In comparison 14 patients (19%) had problems with the chin that required, or had already had, genioplasty. We also studied 9 patients who had had corrective bimaxillary surgery with simultaneous rhinoplasty. We set no formal questionnaire, but all patients expressed satisfaction with the postoperative results.

Liposomal delivery system for topical anaesthesia of the palatal mucosa

M. Franz-Montan, E. de Paula, F.C. Groppo, A.L.R. Silva, J. Ranali, M.C. Volpato — 2010-11-24

Abstract: An effective topical agent to reduce pain during local anaesthesia of the palate is not yet available. The aim of the present study was to evaluate the efficiency of liposome-encapsulated ropivacaine in different concentrations for topical anaesthesia of the palatal mucosa. In this single-blinded, placebo-controlled, crossover study 40 (20 male) healthy volunteers were randomised to be given: liposome-encapsulated 2% ropivacaine, liposome-encapsulated 1% ropivacaine, a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA), and liposomal placebo gel, topically on to the palatal mucosa of the right canine region for 5min each, at four different sessions. Pain associated with insertion of a 30G needle, and with injection of a local anaesthetic, was rated on a visual analogue scale (VAS). The effect of liposomal ropivacaine 1% and 2% did not differ from that of placebo (p=0.3 and p=0.1, respectively) in reducing pain during insertion of the needle. Lower VAS were obtained with EMLA. In this group VAS were lower in women than men (p=0.007). There was no difference in VAS among groups (p=0.3) as far as injection of the local anaesthetic was concerned. In conclusion, liposomal-encapsulated ropivacaine formulations did not reduce the pain of insertion of a needle into the palatal mucosa. None of the anaesthetic formulations tested, including the positive control (EMLA), were effective in reducing the pain of an injection of local anaesthetic compared with placebo.

Safety of local anaesthesia in dental patients taking oral anticoagulants: is it still controversial?

Branislav V. Bajkin, Ljubomir M. Todorovic — 2010-12-06

Abstract: The aim of this study was to investigate the safety of local infiltration techniques and the inferior alveolar nerve block (IANB) in dental patients taking oral anticoagulants. A total of 352 patients were given a total of 560 injections of local anaesthetic (119 IANB and 441 others). The study group comprised 279 patients with therapeutic international normalised ratios (INRs), and the control group 73 patients who were taking oral anticoagulants but had subtherapeutic INR on the day of operation. Blood was aspirated 7 times (7.3%) during the IANB in the study group. However, there were no clinical signs of prolonged haemorrhage into the medial pterygoid muscle or pterygomandibular space after 96 IANB, including those from whom blood had been aspirated. Only two minor haematomas developed after multiple infiltrations in the lingual sulci. The results suggest that bleeding as a result of the use of local anaesthesia in patients with therapeutic INR is unlikely, provided that the IANB is done correctly.

Guided bone regeneration using collagen membranes for sinus augmentation

Xiang Li, Song-ling Chen, Shuang-xi Zhu, Guo-qing Zha — 2011-01-13

Abstract: We investigated the effect of guided bony regeneration using collagen membranes for sinus augmentation in the first maxillary molars of 18 adult female beagle dogs. The teeth were extracted bilaterally and the sinus floors were lifted with simultaneous implantation. The grafted material composed of a combination of autografts and Bio-oss™ in a 2:1 ratio. On the experimental side in each dog, collagen membrane was folded at the lateral osteotomy window, at the apex of the implants, and at a certain part of the palatal bone. On the opposite (control) side, the collagen membrane covered the osteotomy window. Six animals were killed at each of 4, 12, and 24 weeks postoperatively. Gross observation, biomechanical testing, and histological examinations were made. On the experimental side, grafted materials showed no obvious resorption or subsidence, and a new bone had formed at the apex of the implants. On the control side, the grafted materials had been shifted and absorbed. Histological examination showed increased formation of a new bone in the experimental group, which matured over time. At 4 weeks, inflammatory cells were present in the control group, which showed less maturation of the new bone. The pull-out force increased with time and, at week 24, there was a significant difference in pull-out force between the two groups (p<0.01). Guided bony regeneration with the enfolded coverage of membrane can effectively reduce resorption of grafted bone on the apical surface of implants and stimulate formation of the new bone in sinus augmentation.

Biomechanical evaluation of a titanium implant surface conditioned by a hydroxide ion solution

2010-12-22

Abstract: Two groups of titanium dental implants, identical in geometry but different in the treatment of their surfaces, were tested in an in vivo minipig model of the mandible. The surfaces that were tested were, first, sandblasted and acid-etched; and secondly, sandblasted, acid-etched, and conditioned. The removal torque was assessed at 2, 4, and 8 weeks after implantation (n=6 animals in each healing period). The interfacial stiffness was also evaluated. All dental implants were well-integrated at the time of death. Removal torque values increased significantly over the course of 8 weeks. Removal torque and interfacial stiffness were increased for conditioned surfaces after 2 weeks, but there were no significant differences between the two surfaces. The sandblasted and acid-etched implants are the standard, and conditioning of the surface showed a tendency to increase early peri-implant formation of bone.

Aetiology and presentation of ankylosis of the temporomandibular joint: report of 23 cases from Abuja, Nigeria

Seidu Adebayo Bello, Bayo Aluko Olokun, Abayomi Ademola Olaitan, Sunday O. Ajike — 2011-01-21

Abstract: Several studies have reviewed the management of ankylosis of the temporomandibular joint (TMJ), but only a few focused on the aetiology and clinical features. We retrospectively studied the aetiology and clinical features of patients with ankylosis of the TMJ who presented to the Maxillofacial Unit, National Hospital, Abuja, Nigeria, between 2004 and 2009. There were 13 male and 10 female patients, M:F ratio 1.3:1, age range 6–62, mean (SD) 20 (13) years. The aetiological factors were trauma (n=11) that comprised falls (n=6), untreated fractures of the zygomatic arch (n=4) and myositis ossificans (n=1); infection (n=9), that comprised cancrum oris (n=3) and ear infection (n=6); congenital or unknown (n=2), and coronoid hyperplasia (n=1). The maximum interincisal distance at presentation ranged from 0 to 25mm (mean (SD) 6.7 (7.2) mm). Seventeen had facial deformities. The diagnoses recorded were as follows: left extracapsular ankylosis, (n=8); right intracapsular bony ankylosis, (n=6); left intracapsular bony ankylosis, (n=4); bilateral intracapsular bony ankylosis, (n=4), and bilateral intracapsular fibrous ankylosis (n=1). Extreme poverty was the main predisposing factor. There is a need for a concerted effort among healthcare providers, policy makers, and the world in general to eradicate poverty and improve healthcare to limit the incidence of ankylosis of the TMJ.

Impact of coding errors on departmental income: an audit of coding of microvascular free tissue transfer cases using OPCS-4 in UK

Kanwalraj K. Moar, Simon N. Rogers — 2011-03-08

Abstract: Since the introduction of “Payment by Results”, departmental income has been linked to clinical activity, and the coding of theatre activity (Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision), OPCS-4) must be accurate and timely. We assess the accuracy of OPCS-4 coding for patients having microvascular free tissue transfer for head and neck cancer, and evaluate the impact it has on departmental income. Codes for a consecutive cohort of patients were checked to identify inaccuracies and the tariffs were recalculated. Incorrect coding in 11/21 cases resulted in a financial loss of £77449.00 because reconstruction had not been recorded as F39.1, which would automatically place it in the maximum income group, CZ04. If funding is to be optimised surgeons must be cognisant of the importance to code procedures accurately with respect to financial reimbursement. Regular monitoring of coding is suggested, including that of coexisting morbidities.

Vacuum-assisted dressing for promoting granulation over the dura: technical note

R.I. Mohammed-Ali, S.A. Khurram, V. Nahabedian, A.T. Smith — 2010-12-10

We report the use of a vacuum-assisted dressing to promote wound healing in a large defect in the scalp with exposed meninges, which was a result of multiple deeply invasive recurrences of cutaneous squamous cell carcinoma (SCC) after both local and free flap reconstruction of the scalp.

Re: Pathogenesis of post-traumatic ankylosis of the temporomandibular joint: a critical review

A.N. Kanatas, S.F. Worrall — 2010-12-09

We read with interest the paper by Arakeri et al. on the pathogenesis of post-traumatic ankylosis of the temporomandibular joint. In this critical review the authors outlined the management and recognised the difficulties in the management of patients with post-traumatic ankylosis. A variety of techniques have been described including gap and interpositional arthroplasty, osteotomy and excision of the ankylotic mass within the TMJ. As far as the reconstruction is concerned again a variety of techniques that utilise bone or alloplastic materials have been described with variable outcomes. In our experience post-traumatic ankylosis is a challenging problem to correct. We recently examined all our patients with ankylosis and have reported our outcomes. Pain was seen to decrease over time and maximal mouth opening improved for females, males and the overall group only over the entirety of the study period. We do advocate a two stage technique with excision of the ankylotic material and with a second stage reconstruction with Custom joints that allows for changes in antero-posterior and vertical dimensions enabling changes in the occlusion to be made (). It is clear from the paper from Arakeri et al. that in the literature there are several studies that advocate a different and maybe equally successful management of such patients. The patient numbers are small for higher level studies and in the era of evidence based medicine it is time to think about a multicenter randomised trial that if well design will give us answer that can only be of benefit to our patients.

Diclofenac sodium intramuscularly, or paracetamol intravenously? Question not answered

Lasse A. Skoglund, Ellen C. Vigen, Per Skjelbred — 2011-08-08

Öncül et al. referred to Precious et al. as stating that a 30% difference in visual analogue scores (VAS) “would be considered as clinically important”, and continues with “so 15 (patients) in each group were needed to ensure a type 1 error of 0.05 and type 2 error of 0.20”. Precious et al. presented no data that allowed a specific sample size of 15 to be inferred when comparing 2 active analgesic drugs. They categorised mean pain scores (on a 10cm VAS) of <3cm as comfort days and ≥3cm as discomfort days.

Journal Oracle

2011-12-14

Notices

2012-01-01

Case of tuberculosis of the temporomandibular joint

Meera Patel, Neil Scott, Carrie Newlands — 2011-06-15

Abstract: Tuberculosis (TB) of the temporomandibular joint (TMJ) is rare and misdiagnosis is common. We describe an unusual case of the disease in a 27-year-old Zimbabwean woman.

Pulsed radiofrequency modulation for lingual neuralgia

S.U. Rehman, M.Z. Khan, R. Hussain, A. Jamshed — 2011-07-08

Abstract: Pulsed radiofrequency modulation (PRM) is a minimally invasive procedure that has been used successfully to treat neuropathic pain. Its use to treat lingual neuralgia has not to our knowledge been described previously, and we report a case.

The nasolabial approach: a potential alternative to the lip-splitting incision for maxillectomy

Karen A. Eley, Stephen R. Watt-Smith — 2011-07-27

Abstract: First described by Weber and later modified by Fergusson, the Weber–Fergusson incision has undergone numerous modifications, but the fundamental approach to maxillectomy has largely remained the same. We report the potential benefit of a nasolabial incision for partial maxillectomy. The incision is hidden within the nasolabial fold and obviates the need for division of the upper lip, which may undergo atrophy and shortening after radiotherapy.

Giant cell arteritis—an incidental finding

Gillian A. Greenhill, D.W.G. Kennedy, A. Evans — 2011-07-26

Abstract: Giant cell arteritis is a systemic, inflammatory, and vascular syndrome that requires early diagnosis and immediate management because of the risk of loss of vision. Local symptoms include headache, scalp tenderness, jaw claudication, visual disturbances, and scalp necrosis. Systemic symptoms include weight loss, fever, malaise, fatigue, and polymyalgia rheumatica. We describe a case that was identified histologically as an incidental finding after excision of a basal cell carcinoma from the parietal area of the scalp. A search of PubMed and Medline using the keywords “giant cell arteritis”, and “incidental histopathological diagnosis” returned no similar previously published cases in the head and neck. We present this as an unusual and interesting case.

Simple technique to minimise facial scarring during extraoral mandibular distraction

S. Basa, A. Varol, G. Göçmen, B. Karataş — 2011-06-23

External mandibular distraction devices produce considerable distress for patients until they are removed, and can cause appreciable facial scarring. Extraoral distractor pins tear the skin and subcutaneous planes while moving through the skin during the active stretching period. This movement causes unpleasant scars, which are accepted as the main disadvantage of extraoral distraction. Scars are even getting larger now some brands of distractor use double pins to stabilise each osteotomy or stump.

Low-cost suturing training model for use in developing nations

Nakul Uppal, Sharon Saldanha — 2011-08-01

Residency in oral and maxillofacial surgery requires competence in suturing. Texts that explain suturing techniques and videos that illustrate them are available. However, manual dexterity is achieved by practice, for which commercial models are available for a resident to train on before working on patients. It is also desirable to minimise the incidence of needle-stick injuries. In some units, acquiring commercially available models to train on may be hindered by cost. Foam also has a finite life, and ultimately needs replacement. Animal skin and waste meat from butchers are a useful option, but their procurement and storage in tropical climates may be difficult. We have therefore developed a suturing model with affordability as the priority.

Supernumerary teeth and gemination

Ge Yang — 2011-08-22

We describe a rare case of a patient with geminated supernumerary teeth. A 21-year-old man presented to our department complaining of a hard lump in his oral mucosa. On clinical examination there was a tooth cusp in the palatal mucosal area between the right first and second premolars. At first we assumed that it might be the cusp of a supernumerary tooth. However, to our surprise, panoramic radiographic examination showed that there were two supernumerary teeth crowns and only one root. Cone beam computed tomography (CBCT) clearly showed a single pulp canal that joined two crowns of the teeth, giving the appearance of gemination (). The two extracted supernumerary teeth had one root.