British Journal of Oral and Maxillofacial Surgery

Our aim was to investigate the bone thickness at the site of titanium miniplates inserted to retain nasal prostheses. We studied 13 patients who had had titanium miniplates inserted for retention of nasal prostheses with a total of 60 titanium bone screws. A trajectory along each bone screw was segmented in fused computed tomographic (CT) data. Bone thickness was measured along this trajectory on the preoperative CT. The median bone thickness at the positions of the screws implanted on the frontal process of the maxillary bone was 1.4 (range 0.2–6.9) mm (mean 1.8).

We have investigated the effect of photobiomodulation on the recovery of neurosensory function of the lip and chin after bilateral sagittal split osteotomy (BSSO). Laser irradiation was applied with a GaAs diode laser (continuous wave 980nm wavelength, power 100mW, and energy density 12J/cm2). It was maintained within a 0.5cm2 area in a total of 12 points for 60seconds at each visit on each point. Unilateral extraoral contact photobiomodulation treatment was applied the day before operation and then on days 1, 3, 7, 14, 21, and 28 postoperatively.

This paper has been written to stimulate a debate in our specialty. A debate that we feel is long overdue. We are greatly concerned that recruitment into our specialty is in terminal decline. Recently only 30% of posts were appointed to at ST3 national selection. And it is not a blip. We would welcome a lively debate through the pages of the BJOMS and perhaps a dedicated day at the RCS hosted by BAOMS.

The recent article by Awal et al1 in this journal triggered me to share some information. In Germany, there is also huge variation in the aesthetic surgery curriculum among oral and maxillofacial surgery (OMFS), plastic surgery, and otorhinolaryngology (ORL). The recent study by Momeni and colleagues2 showed the lack of aesthetic surgery training in plastic surgery residency in Germany. This situation is similar for German OMFS training. Although OMFS trainees stay in their department for the entire training period, the Medical Council of every German State has no requirement for aesthetic surgery for the German Board of OMFS Examination (Table 1).

Henry Gray, an anatomist and surgeon at St George’s Hospital Medical School in London, first published his book on human anatomy in 1858. He died of smallpox 3 years later at the age of 34,1 but his legacy lives on over one and a half century later with the publication of the first edition of Gray’s Surgical Anatomy, written by a team of authors led by Professor Peter Brennan, an Oral & Maxillofacial Surgeon.

It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy.

Squamous cell carcinoma (SCC) of the tongue is the most common oral cancer. Because of the tongue’s frequent movement, abundant lymphatic drainage, and rich blood supply, the SCC is prone to regional lymph nodes and distant metastases, and its prognosis is worse than that of the other oral cancers.1 In addition, because of its special location, it and its secondary tissue defect postperatively may impair the patient’s pronunciation and swallowing. Reliable and stable therapeutic targets can improve the curative effect and reduce the toxic side effects caused by surgery, radiotherapy, and chemotherapy.

The aim of this retrospective cohort study was to evaluate the relative amount of cancellous bone in the mandibular ramus as a predictor of lingual fracture patterns after bilateral sagittal split osteotomy (BSSO). The study including 78 consecutive patients (156 osteotomy sites). In preoperative cone-beam computed tomographic (CT) scans, the volumes of cancellous and cortical bone in the BSSO surgical field were estimated. Patients were divided into two groups based on the cortico:cancellous bone ratio.

When I read the method of the above paper in detail it seemed likely that the ASIS would be included for <9cm and >9cm bone lengths as described by Taylor1 although this was not clearly stated. As a result I was not surprised that the pain score for longer defects was higher (6.71 v 4.64, p value not included, Table 1), the time to walking (6.64 v 4.72 weeks p value 0.002, Table 2) longer, as well as abnormality of the donor site (very abnormal >9cm 13/27(48%) v <9cm 6/35(17%), Table 5) greater.

Obstructive sleep apnoea syndrome (OSAS), which is characterised by repetitive episodes of pharyngeal collapse during sleep, is gaining much attention because of the important deleterious consequences it might have on the patient’s health. We therefore organised a retrospective longitudinal study to report the long-term follow-up of maxillomandibular advancement (MMA) as a treatment for OSAS. A total of 19 patients with severe OSAS was treated during the period 2007–2016. They were followed up six months postoperatively (T1) and after a mean follow up of 6.7 (range 4-10) years (T2, between November 2017 and February 2018) for the polysomnography variables, and the Epworth sleeping scale (ESS) and body mass index (BMI) were recorded.

The recent paper by Elledge et al1 provides an overview of the plethora of total temporomandibular joint (TMJ) replacement systems that are currently available on the market. The paper emphasises the importance of design factors, such as sufficient lateral fixation of the ramal component to the mandible, and the correct use of biomaterials. The discussion focuses on potential flaws in the biomaterials of some recent systems and mentions concern regarding the use of a totally ultra-high-molecular-weight polyethylene fossa.

Good aftercare of traumatic wounds reduces the risk of infection and improves functional and aesthetic outcomes. Inconsistencies in the instructions given by oral and maxillofacial (OMF) surgeons to patients with facial lacerations have previously been noted. We therefore sent anonymous online surveys to OMF clinicians in the United Kingdom to investigate the extent of the variation in aftercare advice given to patients who have had traumatic lacerations of the skin of the head and neck. Respondents were asked about their current practice, including instructions on how to clean wounds, the provision of cleaning materials, use of topical dressings, and advice regarding dry time; also the number of days before the removal of sutures, and specialist review of facial wounds.

The cumulative risk factors for osteoporosis are also common among patients with cancer of the head and neck and, in this aging population, this means that many patients with osteoporosis are operated on.1

We would like to congratulate Rajappa et al1 on publishing their work regarding perineural invasion in early oral cancer. We concur with their conclusions that perineural invasion is a risk factor for recurrence of oral cancer. As quoted by the authors themselves, the systematic review by Bur et al also concluded that adjuvant radiation in early oral cavity cancer in the presence of perineural invasion as the only risk factor cannot be recommended in view of considerable limitations in existing publications.

The importance of patient safety in medicine and dentistry cannot be understated. Wrong tooth extractions account for approximately 25% of wrong-site surgery, and the implications for the patient, the team, and the institution can be profound. The development of national safety standards for invasive procedures (NatSSIPs) has led to the introduction of specialty-specific local safety standards for invasive procedures (LocSSIPs), with the aim of improving safety further. The implementation of outpatient LocSSIPs is recommended in clinical dentistry when surgical interventions regularly take place.

We read with interest the article “Protocol for the management of ankylosis of the temporomandibular joint”by Khanna and Ramaswami1 about their stages for managing ankylosis of the temporomandibular joint (TMJ) in patients who are still growing and in those who are not. We would like to add some technical points based on our experience in managing this condition.

Reduction is one of the most difficult steps in condylar fracture surgery, and a key factor governing the postoperative outcome. In this study we evaluated quantitatively the effects of a digitised condylar retractor on the duration and rate of reduction. In a prospective, randomised, controlled clinical trial, 48 patients with unilateral condylar fractures who were listed for surgical treatment were randomised to an experimental and a control group (n=24 in each). The experimental group was treated with a digitised condylar retractor, and the control group with traditional surgical instruments only.

Vascular anomalies are common in the head and neck, and oral lesions are most commonly found on the lips, tongue, mucosa, and palate. Monoethanolamine oleate sclerotherapy (MOS) is an option for treatment, although we know of no established protocols yet. We report the prevalence and characteristics of intraoral vascular anomalies (IVA) and the results achieved with the use of 5% MOS, and suggest a clinical guideline. Data from the medical records of patients with IVA were collected (age, sex, ethnicity, site, size, duration, and treatment).

We read with great interest the article by Bennet et al on barriers in the United Kingdom to recruitment in oral and maxillofacial surgery (OMFS) and potential solutions.1

We wanted to find out whether ultrasound (US) can be used to assess the deep resection margins after excision of squamous cell carcinoma (SCC) of the tongue, as intraoperative feedback on their condition might help to prevent them being too close. Resected specimens of cancers of the tongue from 31 patients with SCC of the tongue were suspended in US gel and scanned with a small 5-10MHz US probe. The tumour was readily visible and US could differentiate it from muscle tissue. The margin of normal tongue musculature surrounding the tumour was measured on the US images, and the minimal resection margin was noted and compared with that reported by the histopathologist.

The concept of external fixation applied to the mandible was first developed by Ginestet in 1936 (cited by Mukerji et al).1 It describes a technique in which long screws are passed through the skin into either side of a fractured segment and secured in place using an external fixator. This approach is indicated in cases where there is significant loss of bone, in heavily comminuted fractures, and in fractures that are pathological or grossly infected.2

Signet-ring cell (histocytoid) carcinoma is a rare and aggressive skin neoplasm that most commonly affects elderly men. It typically originates from the upper or lower eyelid, with bilateral involvement only in rare cases, and results in a diffuse and infiltrative appearance clinically, radiologically, and histologically (the “monocle” sign). It is essential to carry out a full investigation to rule out metastasis from an internal origin.

Treating chronic diffuse sclerosing osteomyelitis (DSO) is challenging and many treatments have been reported. However, we know of no standard protocol or guidelines. In this systematic review of relevant publications we provide an overview of the different treatments used. We made an electronic search of PubMed, Medline, Embase, Web of Science, and the Cochrane Library databases, for papers that described the treatment of DSO of the mandible. The search yielded 48 papers that applied to all inclusion criteria, resulting in 16 case reports, 13 case series, 18 retrospective clinical cohort studies, and one randomised controlled trial.

This retrospective study included eight patients with chronic and habitual dislocations of the temporomandibular joint (TMJ), who were admitted to our institution, between 2006 and 2018. Radiographic examination involved three-dimensional computed tomography to ascertain the height of the articular eminence. Preoperative assessment included a thorough recording of history, physical examination, and assessment of the type of dislocation; we also recorded the patients’ age, sex, and frequency of the recurrences of the dislocations.

We report on an additional innervation to the sternothyroid that, to our knowledge, has not been previously described. During a cadaveric neck dissection, we found an aberrant nerve to the sternothyroid in addition to the normal innervation. The classical innervation to the sternothyroid is through the ansa cervicalis (C1-C3), and the sternothyroid muscle is important for depression of the thyroid cartilage that is involved with swallowing and speech. The cervical plexus is difficult and time consuming to elucidate in fixed cadavers, which limits knowledge of variations from this source.

This paper describes the heroic efforts of Graeme Warrack, an oral surgeon, to save as many lives as possible during the battles around Arnhem in 1944. As the chief medical officer (CMO) of the medical section of the 1st British Airborne Division, he and his staff took care of many casualties, both on the battlefield and at the emergency hospital in Apeldoorn, north of Arnhem. He escaped from the hospital when all the patients were to be transported to prisoner of war (POW) camps in Germany, and was hidden by a Dutch family.

Oral and maxillofacial surgery (OMFS) has its origins in dentistry, yet is now firmly established as one of the 10 UK surgical specialties, with similar requirements to complete training. These include the successful completion of (CST) and passing the Membership of the Royal College of Surgeons (MRCS) examination. Core surgical training CST is followed by a five-year full time (or equivalent less than full time, LTFT) approved training programme in OMFS including sitting the exit Fellowship (FRCS) examination.

We read with great interest the recent paper by Cavalcante et al, “Association between facial measurements and polymorphisms in human epidermal growth factor and transforming growth factor β1”.1 They noted that “Genetic polymorphisms in EGF and TGF-β1 are associated with facial measurements in a Brazilian population of patients with dentofacial deformities.”1 In fact, the molecular change attributed to EGF and TGF-β1 can result in altered phenotypic expression. Nevertheless, there are also other genetic polymorphisms that are associated with facial measurements2 such as ENPP1 and FGFR1.

We present three patients with botryoid odontogenic cysts that were managed by enucleation and treatment with Carnoy’s solution, to highlight this promising treatment that warrants further investigation.

The aim of this study was to compare the impact that the orthodontics-first approach and the surgery-first approach have on quality of life, anxiety, and depression in patients treated for dentofacial deformities. Data were collected on 32 patients (aged 17–47 years) who were all treated at a single multidisciplinary orthognathic clinic. They completed a 22-item Orthognathic Quality of Life Questionnaire (OQLQ), a seven-item Generalised Anxiety Disorder (GAD-7) questionnaire, and a nine-item Patient Health Questionnaire (PHQ-9), at one week preoperatively (T1), and at six weeks (T2) and six months (T3) postoperatively.

Odontogenic infections can become life-threatening if not managed in a timely manner, and they increase the physical cost of treatment to the patient and the financial cost to the public health system. We investigated the number of admissions to a Queensland tertiary hospital within a decade, and differences in the patients’ characteristics, severity at presentation, and clinical outcomes. We compared patients with odontogenic infections who were taken to theatre at the Royal Brisbane & Women’s Hospital (RBWH) between January 2003 and December 2004 with those treated between January 2013 and December 2014, a total of 292.

Prognostic stratification in cancer has always been a largely misunderstood and poorly conducted field of research.1 Research into prognosis is dominated by poor quality studies, which are often opportunistic and badly designed, riddled with under-reporting, selective reporting, or no reporting of important findings at all.2 Therefore, the majority of prognosis research studies in cancer achieve nothing but introducing “noise” to medical publications. There is no surprise, therefore, as to why cancer clinicians and surgeons rely heavily on nested prognosis analysis within randomised controlled trials, which may have been designed for other purposes – and this is far from ideal.

We describe the different categories of systems and systems thinking, and illustrate why almost all clinical interactions constitute simultaneously complex and complicated systems, so-called “wicked systems”. We also discuss why they are not amenable to quantitative analysis. With the use of comparisons and illustrations we show some of the problems that reductionist metrics create, and support concerns regarding quantitative fallacy. The systematic correlation of data in medicine was one of the earliest achievements of the discipline.

Human error is as old as humanity itself and occurs on a daily basis, whatever we are doing. Recognising our fallibility is the first step to understanding error and ways to reduce it. The term “never event” is, therefore, a misnomer as these serious adverse incidents can never be eliminated completely. Up to 1 in 20 hospital admissions includes some form of error, and while many have little detrimental effect on patients’ care (such as forgetting to write a discharge summary), 6% are serious. Many medical errors could have been prevented through the understanding and application of human factors (HF) including (but not exclusively) better team working, situational awareness, and the lowering of authority gradients.

Rehabilitation of gunshot injuries that require combined reconstruction of bone and soft tissue poses a considerable challenge. We describe three cases of rehabilitation for mandibular defects and deformities caused by gunshot injuries. After debridement, three kinds of internal distractors were used. The bony transport discs were distracted about 10-22mm, and the new bone formed well in the distracted gaps. There was no evidence of infection during the consolidation period or follow up. Aesthetic appearance was also pleasing after treatment.

Transoral endoscopic thyroid surgery (TOET) is a new, minimally-invasive approach that does not result in a scar in the anterior neck. To prevent infection of the surgical site from oral cavity flora into the thyroidectomy area, postoperative antibiotics are generally given orally for 3–7 days. However, there is no clinical evidence to support this approach. This study was an open-label, randomised, controlled trial to evaluate the clinical usefulness of postoperative antibiotics given orally to patients having TOET.

The aim of this single-institution, observational study was to detect and explain any potential changes in the incidence of pleomorphic adenoma and cystadenolymphoma over a period of 19 years. The records of all patients who were treated for benign parotid tumours between 2000 and 2018 were evaluated and the data analysed to detect any potential changes in the incidence over time. A total of 2988 patients were studied, 1150 of whom had cystadenolymphomas (39%), and 1047 pleomorphic adenomas (35%).

Foreign bodies in the orbit are uncommon, and dental intraconal displacement is even more rare. We aim to present and discuss what is to our knowledge the first case and its management. A 55-year-old woman had a dental implant placed in the upper right maxilla, but during the procedure it was displaced into the orbit. It was removed reliably and safely through an enlarged endoscopic medial maxillectomy.

The use of cold atmospheric pressure plasma (CAPP) as a bacterial decontaminant for chronic wounds has shown good results. The purpose of this in vitro study was to evaluate the bactericidal effects of CAPP on the cancellous area of the bone. Sterile glass slides and processed sterile human bone allografts 1, 2, 3, and 4mm thick were used for initial contamination and further CAPP treatment. Each block was contaminated with Staphylococcus aureus suspension on one side. Each slide was turned 180° and treated on the reverse side.

It is increasingly common in OMFS to treat patients who are taking therapeutic doses of anticoagulant or antiplatelet drugs, or both. These patients have a high risk of postoperative bleeding ranging from minor oozing that can be managed using local measures, to a major haemorrhage necessitating transfusion. The risk of bleeding associated with tyrosine kinase inhibitors (TKI) taken orally is not well-known in the specialty. We report a case series of two patients treated with them and discuss this group of drugs.

It is an honour to give this citation in support of the award of the Down’s Surgical Prize, 2018 to Mr Michael Stephen Dover.

We write about an interesting article by Zaggut et al1, that was published in your journal. We wondered what the authors’ opinions are regarding the concept of the thin orbital floor and medial orbital wall being akin to a biological orbital “crumple zone.” The orbit has a pyramidal shape with a wide base and narrow apex.2 Ordinarily, forcing the globe into the orbit would increase orbital pressure as the globe moves posteriorly into a smaller space. Subsequently, the medial orbital wall or orbital floor would preferentially fracture before the intraocular pressure increased to levels that might cause the globe to rupture.

The treatment of craniomaxillofacial and cervical wounds in a disaster relief setting is done by clinicians from local medical treatment facilities, non-governmental organisations (NGO), or the military. Although each group and individual surgeon will need specific equipment, this will be restricted by weight, portability and interoperability. We systematically reviewed scientific and commercial publications according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

End-stage disease of the temporomandibular joint (TMJ) can be managed successfully with alloplastic total replacements, but these can fail because of allergy, infection, wear, fracture, and heterotopic development of bone. We prospectively reviewed the outcome data of all patients who required revision of previously placed replacement joints between 2004 and 2016. Data included pain and diet scores using 100mm visual analogue scales (VAS), and interincisal distance recorded before, and at six weeks, six months and 12 months after operation.

The “crumple zone” hypothesis suggests that the paranasal sinuses protect the brain as a zone to distribute and absorb energy after trauma to the head. We investigated the relation between the size of the frontal sinus and mortality in patients with cranial trauma. All patients with head trauma admitted to the ICU between 1 January 2016 and 20 December 2017 were reviewed retrospectively. They were divided into two groups (according to their outcome) : died and survived. The volumes of the frontal sinuses and other trauma-related variables were assessed on computed tomographs (CT) on admission.

Digitally-designed static surgical guides provide an acceptable level of accuracy and predictability for the placement of dental implants. However, to our knowledge, few published studies have compared the long-term survival of implants placed in this way with those placed using other methods. A systematic search of electronic databases using a population, intervention, comparison, and outcome (PICO) framework was conducted of Medline and EMBASE, as well as grey literature and hand searches, to obtain all relevant work pertaining to the survival of dental implants placed by guided surgery.

The feasibility of laser-assisted treatments of medication-related osteonecrosis of the jaw (MRONJ) remains poorly understood, so we have therefore systematically evaluated their effectiveness. We made a comprehensive search of MEDLINE, Pubmed, and Embase to find randomised controlled trials, case-control studies, and prospective cohort studies that assessed them. We assessed the eligible studies in duplicate, and if possible conducted a meta-analysis. Ten studies with a low to high risk of bias met the inclusion criteria.

The aim of the study was to evaluate the association between genetic polymorphisms in human epidermal growth factor (EGF) (rs4444903) and transforming growth factor β1 – (TGF-β1) (rs1800470) with facial measurements in patients with dentofacial deformities. A total of 144 adult patients with dentofacial deformities were included. Facial linear and angular measurements were traced in lateral cephalometric radiographs used Dolphin 2D software. Cells from oral mucosa were collected for DNA to be extracted.

The first edition of this new text provides an excellent resource for students, trainees, and experts alike. It is a comprehensive atlas – with excellent line diagrams and clinical photographs – that illustrate the embryological development of the human body. A large portion of the book is also dedicated to developing an understanding of congenital malformations. The atlas is not concerned with the management of these conditions, but does provide an excellent and detailed starting point to understanding the breadth of congenital malformation, the basic science, classification, and clinical presentation of these conditions.

In orthognathic surgery, an occlusal splint is used to position the maxilla and mandible correctly into the planned postoperative occlusion.1 An occlusion wafer is secured during orthognathic surgery, and in cases of intraoral vertical ramus osteotomy in the mandible, it must remain in place for weeks postoperatively. In general, the occlusion wafer is fixed on to the maxillary teeth, and a wire is used to hold it in place.2 The postoperative wafer is fixed on to multiple maxillary teeth to maintain the planned postoperative dental occlusion.