British Journal of Oral and Maxillofacial Surgery

Temporomandibular Joint (TMJ) ankylosis is a condition in which the bony or fibrous adhesion of the anatomic joint components results in loss of function of the joint. This is particularly distressing and debilitating for affected patients, who struggle to maintain good oral hygiene, resulting in additional pain, oral disease and ultimately, a poor aesthetic profile.A retrospective chart review was carried out documenting the cases of three patients who attended a single centre for management of ankylosis of the TMJ.

On behalf of the authors, I would like to appreciate the interest in our article, which details the preoperative digital planning and the surgical execution of predetermined gap arthroplasties. The authors have carefully read the letter to the Editor concerning our latest publication at BJOMS entitled "Computer-guided gap arthroplasty: a new approach to the execution of preplanned osteotomies for the treatment of bony ankylosis of the temporomandibular joint.",1 and this is the detailed reply:

Lateral posterior segmental mandibular defects present a reconstructive challenge and an osseous flap would be the gold standard to reconstruct such a defect. However, combining a mandibular reconstruction plate (MRP) with a soft-tissue free flap (to restore mucosal integrity and provide durable coverage of the plate itself) offers an alternative option for posterior segmental mandibular defects in patients who are not suitable for osseous reconstruction, or do not choose it. We retrospectively reviewed 30 consecutive patients (19 male and 11 female) who underwent reconstruction of a segmental mandibulectomy defect using a bridging MRP and anterolateral thigh (ALT) free flap.

Tracheostomies are commonly carried out in a critical care or head and neck surgery setting for prolonged intubation or airway protection in case of postoperative swelling. However, they have a well-recognised incidence of morbidity and mortality. Significant complications occurring post insertion have been identified by the National Confidential Enquiry into Patient Outcome and Death in 2014. A principal recommendation was that bedside staff involved in the care of tracheostomy patients should be competent in recognising and managing airway complications.

A recent position paper published by the EACMFS1 on the management of the clinically N0 neck in early oral squamous cell carcinoma has come as a reminder that this 30-year-old plus debate is far from over. The authors of this paper eloquently describe the evolution of the neck management, from the early Weiss2 mathematic network modelling, to the landmark D’Cruz RCT3 and the UK SEND trial4 (and the other randomised trials combined in a meta-analysis4) and the establishment of the sentinel node biopsy (SNB) as a diagnostic staging procedure as part of NICE recommendations5.

This systematic review aims to examine whether the incidence of osteonecrosis differs between patients who have dental extractions performed prior to or following radiotherapy.

The eighth edition of the Union for International Cancer Control (UICC) staging manual was recently introduced. The staging of oral cavity squamous cell carcinoma saw changes in relation to depth of invasion and extra-nodal extension. We aimed to evaluate this system and its prognostic ability in a UK cohort. A retrospective review was undertaken of patients diagnosed with squamous cell carcinoma (SCC) of the oral cavity between January 2009 and December 2013. Data were collected on demographics, histology, and recurrence-free (RFS) and five-year overall survival (OS).

I commend the recent Editorial by Brennan and colleagues in allegiance with the Black Lives Matter movement towards ensuring global health equity. I wish to elaborate on the authors’ candid remark, “racism remains a public health emergency”, by highlighting the inequalities that disproportionately affect Black, Asian and minority ethnic people presenting with oral cancer and encourage advocacy for tackling socio-economic inequalities rooted in ethnicity and race as a priority for the oncological and wider global health agenda.

This study was undertaken with the aim to compare the T stages in a series of cutaneous squamous cell carcinoma (cSCC) patients using both the eighth edition of the Union for International Cancer Control (UICC) TNM Classification of Malignant Tumours (TNM8) and Brigham and Women’s Hospital (BWH) staging systems. This would allow comparison of the two to determine suitability with regards to T stage and the effect on local recurrence and nodal disease. This was a six-year retrospective cohort study of patients with primary invasive cSCC of the head and neck who were diagnosed and treated at Western Sussex Hospitals Trust in the United Kingdom between 2007 and 2012.

A 13-year boy presented to our tertiary care hospital with a history of progressive nasal obstruction and epistaxis. On further evaluation, he was found to have juvenile nasopharyngeal angiofibroma (JNA) extending into the infratemporal fossa (ITF) and adjacent soft tissue of the cheek. He was managed surgically by a maxillary swing approach. The purpose of this letter is to revisit one of the classic, but rarely appreciated, radiological signs that we encountered in this patient.

Patient-reported outcomes (PRO) are an important component of treatment evaluation. Typically they are completed by patients on paper, but through advances in technology such as mobile phone apps and websites, there is a great opportunity for electronic completion. It can be challenging, particularly at a regional or national level, to maintain accurate core clinical records on head and neck cancer (HNC) (baseline, recurrence, second primary, and further treatment), and these will influence PROs and the reporting of outcomes.

The COVID-19 outbreak has rapidly progressed into a worldwide pandemic, and the need for social distancing has changed the way we learn and work. Our monthly OMFS journal club has been no different, and is currently meeting on the video conferencing application Microsoft Teams. The use of a virtual setting for training in medicine and dentistry is not new and, as in the case of our recent move to a virtual medium, it may be that COVID-19 has fast-tracked this digital transformation. There are of course disadvantages to online teaching that traditional face-to-face teaching overcomes.

As a result of COVID-19, there has been an exponential increase in the use of remote technology for many local, regional and national meetings that would previously have been held on a face-to-face basis. Remote meetings have ensured that essential clinical, educational and strategic work can continue but it is not ‘business as usual’, although colleagues accept this form of communication as the new norm.In medical education and assessment, the Annual Review of Competence Progression (ARCP) meetings and other formative educational meetings are being conducted remotely.

Altered orbital morphology of patients with Crouzon syndrome, could impact treatment planning for diverse populations, in spite of confounding influences of different cranial suture synostosis. This study attempts to explore the differences between Asian and Caucasian orbital characteristics of Crouzon syndrome in association with pansynostosis.

Appropriate patient information is essential to improving patient experience.This prospective audit looked at compliance with QVH Orthognathic information patient protocol and patient opinion regarding information provision.77 patients participated, with 75 reporting that they received sufficient information to make an informed decision.Prior to attending the MDT, 69 patients had read the information leaflet, although only 37 patients had accessed the British Orthodontic Society (BOS) online resource.

We read with great interest the technical note entitled ‘Aerosol prevention in osteosynthesis for maxillofacial trauma’ and published in British Journal of Oral and Maxillofacial Surgery1.

Resorbable materials are used for sagittal split ramus osteotomy (SSRO) bone fragment fixation. However, there is no clear regimen for antibiotic prophylaxis in SSRO with absorbable materials. The purpose of this study was to compare inpatient single-agent and extend dual-agent antibiotic prophylaxis for the prevention of surgical site infection (SSI) in patients after sagittal split ramus osteotomy. This prospective study included a total of 100 patients who were diagnosed with jaw deformity and underwent SSRO.

COVID-19 is a global pandemic of unprecedented proportions. It has resulted in changes to all aspects of our lives. The impact on medicine has been significant. Clear and effective communication during these times is vital. We present an evaluation of the use of video conferencing (VC) and offer a simple format to structure meetings for their effectiveness and promotion of team communication and wellbeing.

This review paper summarises articles regarding orthognathic surgical planning and computerised technology, which were published in two leading national journals in both oral and maxillofacial surgery and orthodontics. This article aims to keep readers up to date with the literature published in this rapidly progressing field.

The purpose was to benchmark the unscheduled postoperative return to theatre rate for patients (URTT) undergoing head and neck surgery with free tissue transfer in a UK setting and identify opportunities for quality improvement.

We are describing our transcutaneous approach using a nerve stimulator to guide needle insertion and injection to the Lateral Pterygoid muscle (LPM) with Botulinum Toxin. This technique increases significantly the safety and efficacy of the treatment. No additional clinical skills or resources are required for the Maxillofacial Theatre team.

Submental artery perforator flap (SAPF) is a novel option for the intraoral reconstruction of oral squamous cell carcinoma (OSCC) patients in recent years, but its surgical outcomes have not been well assessed. Herein we compared the surgical outcomes and oncological safety of SAPF reconstruction for median-sized soft-tissue defects after the ablation of primary oral cancer with traditional submental island flaps (SIF) and anterolateral thigh perforator flaps (ALTPF). Fifty-one SAPFs, thirty SIF, and seventy-four ALTPF were reviewed for the intraoral median-sized reconstructions after the ablation of oral cancer from our institutional clinical oncologic databases.

Many guidelines and studies describe haemostatic management protocols for haemophilia patients, but few have evaluated risk factors for post-extraction bleeding. This retrospective cohort study was performed to investigate risk factors for post-extraction bleeding among haemophilia patients.

Most surgical specialities have attempted to address the concern of unfair comparison of outcomes by ‘risk-adjusting’ data in order to benchmark speciality specific outcomes indicative of quality of care. We explore the ability to predict for positive margin status in order that effective benchmarking that accounts for complexity of case-mix is possible.

The main objective of this study was to evaluate whether the 2016 Brexit referendum has contributed to an increase in maxillofacial injuries specifically targeted against ethnic minority groups in the district of North London. The secondary objectives were to identify the most common types of injuries following the assaults and the number of patients admitted to hospital. A total of 1,391 people was assaulted between 1 January 2014 and 31 December 2018. They were classified into the following categories: White (62.4%), Asian (13.6%), Black/African-Caribbean (11.9%), Other (Arab) (9%) and Mixed Ethnic Group (3.2%).

In Spring 2011 the Department of Health (DH) received a request to review European Union Directive 2005/36 EU – the directive relating to the recognition of professional qualifications. The Department of Health lawyer raised concerns that the existing shortened dental courses may be in breach of EU law. There were three shortened dental courses in the UK: 4year graduate entry courses in Liverpool/Peninsula and 3-year Dental Programme for Medical Graduates (DPMG) in Kings, London. During the summer the General Dental Council (GDC) was made aware of these concerns.

Evidence around careers show that many surgeons are inspired early in their career, often based on their undergraduate experience. In this context we reviewed the location of the first degrees of Oral and Maxillofacial Surgery (OMFS) consultants and specialty trainees to look for any patterns or trends. It has been shown that there is variation across medical schools when core surgical trainee recruitment is analysed. No previous paper has undertaken a similar analysis of medical and dental schools in the context of OMFS surgery.

The objective of this study was to assess the resorption index of calvarial particulate graft in maxillary sinuses with residual alveolar bone less than or equal to 3 mm-thick, in patients undergoing total atrophic maxilla reconstruction.

Recent studies have indicated that the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) is a viable adjunctive to alveolar cleft reconstruction owing to its osteoinductive capacity. This study aimed to evaluate the efficacy of rhBMP-2 in the treatment of alveolar cleft with autologous bone graft by precise volumetric analysis. Twenty-six patients (ages 8 to 14) with unilateral alveolar clefts were enrolled in this comparative study. Patients were divided into two groups: the iliac crest bone graft (ICBG) was placed at the side of the cleft in the control group (ICBG group), and rhBMP-2 was mixed with the ICBG in the rhBMP-2 group (BMP group).

Complete tumor resection (R0 margin) is an axiom of surgical oncology. Oral cancer ablation is challenging, due to anatomical, functional and aesthetic considerations. R0 margin is strongly linked to better survival outcomes with great variation in the R0 % across units. This is commonly attributed to disease biology. Without disputing the importance of biological characteristics, we contend that image-based anatomical surgical planning has an important role to play in achieving complete resection.

Our aim was to evaluate the functional outcomes and complications of mandibular condylar fractures managed surgically and non-surgically. Patients were identified retrospectively from audit data and clinical records from 2005-2018, and functional outcomes were evaluated based on the development of complications at clinical follow up. Patients were categorised into three treatment groups: conservative (management with soft diet, analgesia, and monitoring), closed (management with intermaxillary fixation), and open reduction and internal fixation (ORIF).

The United Kingdom left the European Union (EU) in January 2020. As it is unclear how many of the rights of OMFS surgeons to travel and work will remain after the transition period we have reviewed how these rights have been used in the past.

Training in UK surgery has changed dramatically since 1995, from relative lack of structure to time-limited and highly documented programmes. Training in Oral and Maxillofacial Surgery has shared these changes and included some significant changes of its own.

Rigid external distractor (RED) is used for midface advancement in craniofacial synostosis (Al-Namnam et al., 2018). Placement of halo frame is challenging especially in the patients with multiple skull defects due to previous cranioplasty procedures. Multiple skull defects remain even after successful healing of bone. RED fixation after Le Fort III osteotomy through skin itself is relatively a blind procedure and skull defects adds further complexity (Aizenbud et al., 2008). Safe pin placement is imperative as inner table perforation or positioning in areas of skull defect might lead to untoward consequences.

Up to June 2020, 232 patients were admitted to Intensive Care Units (ICU) at King’s College Hospital (KCH), London due to COVID-19. Our Oral and Maxillofacial Surgery Unit received 51 referrals for surgical tracheostomies. With 96231 admissions to ICU nationally, there was a shortage of the commonly used Tracoe® twist tracheostomy tubes (Tracoe Medical, GmbH) with inner and outer cannulas and a subglottic suctioning port.

We have read with great interest the article entitled, “Do state-trait anxiety and previous unpleasant dental experiences predict the need for sedation in women having third molar surgery?” by Sirin et al1 in a recent issue of the journal. We appreciate that the authors provided us with worthy clinical results, especially in consideration of past dental experiences during initial examination, to help us provide comfortable treatment. In this communication, we would like to propose some opinions to the authors.

In the United Kingdom (UK) the estimated prevalence of dental infection involving the supporting bone is 2%, and from 2014–2015 there were 2281 admissions in England alone due to dental abscess. We undertook an analysis of 184 dental abscesses that required surgical drainage, as there is surprisingly little in the literature on the subject.This was a retrospective study of 184 consecutive patients with dental abscesses who were admitted between January 2016 and September 2019. On admission, all patients had orthopantomograms (OPG) and baseline blood tests.

During the COVID pandemic five Oral and Maxillofacial Surgery (OMFS) Dental Core Trainees (DCT) in our hospital were redeployed to the Department of Critical Care (DCC). Following redeployment, a structured evaluation was conducted with assistance from the University of Gloucestershire, to explore the impact of this redeployment on their professional development. Respondents completed an online survey consisting of 14 open-ended questions, and data were analysed using a thematic approach. (Braun et al., 2006) All redeployed DCTs completed the survey.

Understanding workforce pressures within surgery is an inexact science. This paper assembles evidence regarding OMFS consultant appointments in the UK and plans for prospective data collection in the future.

The number of patients with COVID-19 is exhibiting a constant increase.1,2 This pandemic has resulted in new challenges for clinical teams. There is emerging evidence that the current crisis is affecting the management of head and neck cancer (HNC) patients. Clinicians worldwide face this new severe infectious lung disease with limited therapies. In some units the service of head and neck cancer-related surgery has been cancelled or at least delayed. The demand for maintaining intensive care unit (ICU) availability has affected surgeries with reconstruction when free tissue transfer is required.

Disc repositioning to re-establish the relationship of the condylar head with the fossa is a common step in several temporomandibular joint (TMJ) surgical procedures. Discopexy has been described both as part of an open procedure, and endoscopically.1 Multiple techniques and systems such as the Mitek system2 (mini anchor, Mitex Products Inc) and Arthrex system3 (Arthrex Corkscrew® mini anchor system) have been described. These devices have limitations in the requirement for specialised equipment and associated cost.

Fibrous dysplasia (FD) can be surgically managed by bone shaving, however it is best done using navigational surgery to achieve symmetry and adequate removal of FD bone.1 Unfortunately, in certain centres, navigational surgery is still not available. A patient was referred for management of excess FD bone over the right frontal region extending laterally to the frontozygomatic suture region causing facial asymmetry (Fig. 1). We have successfully used a hybrid technique to ensure three dimensional bone reduction in our FD patient.

Oral squamous cell carcinoma (OSCC) remains the most common cancer among males in Sri Lanka. Metastasis to neck is a crucial prognostic factor. A modified radical/ radical neck dissection including levels I –V, is performed in patients with OSCC who has a clinically positive neck (cN+). Currently, evidence suggest sparing level V in a cN + may be justified due to less chance of metastasis in early stages of the disease. The incidence of metastasis to level V in patients with cN + s have not been previously investigated in a Sri Lankan context.

Whilst there have been great improvements in the management of injuries in elite and professional athletes with the formalisation of the clinical specialty of sports and exercise medicine, the management of facial injuries has perhaps lagged in this group. Professional athletic careers can be put in jeopardy by unnecessarily long absences from training and competition after facial injuries. Professional and elite sports athletes can benefit from different approaches to the management of their facial injuries that reduce time away from competing but maximise their safety.

Much has already been written about the harmful effects of COVID-19 on maxillofacial surgery, however we have found that there have also been enormous opportunities to be experienced in sick patient management during this period, and this has been to the benefit of our maxillofacial patients on return to normal duties.

In this paper we describe the effects of peripheral cryoneurotomy on a consecutive series of patients with intractable trigeminal neuralgia (TN) who had been treated by a single surgeon over a ten-year period. The results of 55 patients who underwent a total of 102 cryoneurotomies were documented. The age at first cryofreeze was 64 (30-92) years with 24 males and 31 females. Thirty-five had primary TN and 20 secondary TN. The first cryofreeze resulted in 28.2 (5-144) pain free months. Twenty-nine had a second freeze which lasted 34 (2-100) pain-free months and 13 had a third cryofreeze which lasted 26 (1-108) pain free months.

Oral mucosal defects after ablative surgery may be reconstructed utilising various techniques. The options can range from secondary healing to traditional complex reconstruction with a microvascular free flap. There is a surge in the adaptation of newer techniques, which are simple, effective, and representative of the tissue being replaced with negligible morbidity to the affected population (who are mainly elderly with associated comorbidities). We present a novel approach to restore an oral cancer defect, which was complicated by a communication with the nasal cavity.

Discussion about recruitment and length of training in oral and maxillofacial surgery (OMFS) is a welcome initiative.1,2 It is important, however, to acknowledge that these issues and concerns go beyond any single specialty, and Rimmer has published detailed concerns regarding the crisis in the appointment of consultants and trainee physicians.3 Despite the large number of vacancies, which is around 43% in England and Wales, 56% remain vacant due to the lack of applicants, and in 34% of cases the trainees are not suitable.