bluuebunny/crossref_metadata_2025 huggingface dataset:
518 A Comparison of Outcomes After Analgesic and Anti-Inflammatory Injections into The TMJ After Arthroscopy and Arthrocentesis
Authors: Goel A , Tahim A , Komath D
Published: October 2021

Introduction

Temporomandibular joint dysfunction (TMJD) affects 12% of the population, with up to 5% seeking help for their symptoms. Minimally invasive TMJ surgery techniques have been harnessed by Oral and Maxillofacial surgeons to directly visualise joint pathology, facilitate joint arthrocentesis and enable safe injection of analgesic and anti-inflammatory agents into the joint space. This study compares outcomes after injection of either morphine or protein-rich plasma (PRP) after TMJ arthroscopy and arthrocentesis.

Method

Consecutive patients between 2017-2020 undergoing either morphine or PRP injections after TMJ arthroscopy and arthrocentesis were retrospectively reviewed. Basic demographics and Wilkes score were noted. All patients underwent a trial of conservative management prior to any surgical intervention. Pre- and post-operative mouth opening was measured objectively (mm), while pre- and post-operative pain scores were noted using standard subjective pain scores (1-10).

Results

31 patients underwent TMJ injections with morphine (n = 18) or PRP (n = 13) after TMJ arthroscopy and arthrocentesis. Both groups showed a significant reduction in subjective pain scores post-operative ( p < 0.05). Patients receiving PRP injections showed greater mouth opening scores (4.0mm change in MO for PRP vs 1.7mm change in MO for morphine) .

Conclusions

PRP shows to be as effective in pain management of patients with TMJD undergoing arthroscopy and arthrocentesis as morphine. The increase in mouth opening in patients receiving PRP injection could be attributed to the anti-inflammatory potential of PRP. These findings suggest that further evaluation of the benefits of PRP use in TMJD is warranted.
631 Designing an Oral and Maxillofacial Trauma Assessment Proforma for Dental Core Trainees in Northern Ireland
Authors: Harkness S M , Cullen A , McAuley D
Published: October 2021

Aim

The dental core training (DCT) scheme is an optional postgraduate training pathway for dental graduates who have completed their foundation training and wish to undergo further specialist training. The majority of posts available in Northern Ireland (NI) are within oral and maxillofacial surgery (OMFS) units and include on-call commitment. Dental core trainees (DCTs) are expected to examine and assess OMFS trauma patients and often have limited experience of this prior to post commencement. This project outlines the development of an OMFS trauma assessment proforma designed for DCTs working in NI.

Method

An initial OMFS trauma proforma was designed alongside senior staff. This was introduced to 6 DCTs and 2 trust SHOs within a tertiary OMFS unit. 34 proformas were recorded within month 1, following which a feedback survey was completed by the 8 trainees. A revised proforma was redistributed and 33 recorded over month 2, followed by a repeat feedback survey.

Results

The revised proforma was found to be successful amongst trainees within the unit to act as an aid memoir and provide systematic structure to trauma examination. 100% of trainees recorded the revised proforma as useful. As a result, the proforma was introduced as part of the national induction programme for new DCTs commencing training posts in NI.

Conclusions

Progressing from general practice dentistry to the role of an OMFS DCT can be a challenging transition for many trainees. The proforma aids to guide junior clinicians in how to structure and record oral and maxillofacial trauma whilst ensuring thorough and comprehensive examination.
748 Case Series: Experience of Using External Fixation as An Adjunct in The Management of MRONJ Affecting the Mandible
Authors: Shaw A , Pilkington R J J , Wilson A , Nugent M
Published: October 2021

Introduction

External fixation was first described by Malgaigne and Rigaud in 1870 for use on long bones, then adapted for OMFS in 1934 and used for treating comminuted fractures. In recent times, popularity of external fixators has decreased with the use of mini-plates, often only used in major trauma, for example gunshot wounds. This is a case series of patients who have been treated by external fixation for medication related osteonecrosis (MRONJ) of the jaw and could be a fairly simple alternative to major reconstructive surgery in such cases. This method of treatment has been particularly useful during the Covid-19 pandemic as a non-aerosol generating procedure.

Method

A single centre, retrospective study of 5 cases between December 2018 - December 2020. The MRONJ cases were graded using the AAOMS classification. All cases treated with external fixation of mandible were included. Pre-operative condition, medical history, treatment complications, pain management, length of treatment and follow-up results were recorded.

Results

Of the 5 cases treated for MRONJ, 4 of these had pathological fractures. All were AAOMS stage 3. The mean duration of treatment was 78 days, with regular clinical reviews monitoring progress. Of these cases, 4 cases healed well with significant improvement or closure of intraoral and extra-oral wounds.

Conclusions

In this small case series the technique has shown positive results; being well received by patients and allowing function while in situ. It allows treatment of pathological fractures as well as stabilising the mandible as a preventative measure whilst debriding severely atrophic mandibles.
782 Evaluation of Ketamine Sedation as An Alternative to General Anaesthetic for The Management of Paediatric Soft Tissue Facial Injuries During the Covid-19 Pandemic
Authors: Nijamudeen A , Cole-Healy Z , Clark Stuart
Published: October 2021

Introduction

Standard surgical practice of paediatric soft tissue facial injuries requires general anaesthetic (GA) if treatment with local anaesthetic is not tolerated. However, the Covid-19 pandemic has increased the risk of hospital admission for GA to patients and pre-operative Covid-19 testing can delay surgical treatment. In response, a service was established to facilitate short surgical procedures by the Oral and Maxillofacial surgical (OMFS) team with ketamine sedation (KS) at a tertiary level paediatric emergency department. Evaluation of this service demonstrates that KS is a suitable alternative to GA with reduced waiting times, low complications and equivalent surgical outcomes.

Method

20 patients treated under KS from May- September 2020 were identified and compared to a control group of 20 patients treated under GA during the same time period. Data including patient demographics, surgical treatment and the KS/GA procedure was collected from the medical records and was analysed using Microsoft excel.

Results

The KS patients had shorter waits for treatment with 85% of patients waiting 1 day or less, compared with 55% for the GA group. Using the local KS protocol 1 or 2 doses of ketamine was sufficient in 79% of cases and adverse effects were minimal with 21% of KS patients suffering mild nausea and vomiting.

Conclusions

KS is an acceptable alternative to GA for the management of paediatric soft tissue injuries. KS reduces inpatient admission for GA which is of increased importance during the Covid-19 pandemic. Other OMFS units would benefit from access to a similar service.
803 Management of An Intra-Oral Resection with Integra® Dermal Regeneration Template – Worth A Bite?
Authors: McParland E , Dua R , Smith G
Published: October 2021

Introduction

There are a spectrum of treatment options available for reconstruction of oral mucosal defects including secondary healing, skin grafts, local flaps and microvascular free flaps. We present the use of an alternative intra-oral reconstruction with Integra® Dermal Regeneration Template.

Case Report

An 85-year-old patient with a severe gag reflex and history of oral cancer presented with biopsy proven severe dysplasia of the right palate extending to the hamular notch. She was treated with wide local excision, extraction of teeth, buccal fat pad advancement for closure of an oral-antral communication and placement of Integra® Dermal Regeneration Template. Discharge was possible the same day as the patient was able to eat and had minimal pain.

Discussion

Integra® Dermal Regeneration Template is a bilayer wound matrix consisting of silicone in the outer layer with bovine collagen and glycosaminoglycan from shark cartilage in the inner layer. Oral cancer predominantly affects the older population, and this method can reduce surgical time, remove donor site pain, reduce post-operative pain and avoid use of a cover plate where a strong gag reflex was present. The area heals quickly and aids quick restoration of oral function.

Conclusion

Integra® Dermal Regeneration Template has been used for head and neck defects with good outcomes. It is being increasingly used intra-orally with good outcomes, suggesting a further application of the material with advantages over traditional techniques in specific patient groups.
1119 Readdressing Consent in Head & Neck Free Flap Surgery: The Nottingham Experience
Authors: Jivraj A , Evans K , Aga H , Al-Qamachi L
Published: October 2021

Aim

The Montgomery vs NHS Lanarkshire case in 2015 led to a paradigm shift in the consent process within surgery. It became incumbent upon clinicians to outline all “material risks” prior to a procedure. Within head and neck surgery, the Enhanced Recovery After Surgery (ERAS) pathway addresses this obligation through a multi-disciplinary approach. The aim of this audit was to assess the effect of the existing ERAS pathway on the consent process.

Method

35 head and neck oncology cases involving free flap reconstruction were identified across two audit cycles. Cases pre- and post-introduction of the ERAS pathway were analysed to assess whether the existing pathway led to improvement in consent quality.

8 key consent elements were identified based on a review of current literature and guidelines. This was our gold standard. A tick-box system was devised, and each case assigned a percentage score based on compliance with these criteria. A consent checklist was introduced within the ERAS pathway file alongside multi-disciplinary documentation which would follow the patient from the pre-operative environment through to discharge.

Results

Prior to the introduction of the ERAS pathway, there was a 58% compliance with the gold standard. Upon implementation of the ERAS protocol, compliance rose to 65%. Following introduction of the checklist, compliance rose further to 85%. This resulted in an overall increase in compliance of 27%.

Conclusions

We recommend the introduction of a focused consent checklist within any unit providing major head and neck reconstruction procedures in order to ensure informed consent, mitigating medico-legal risks post-operatively.
1173 Airway and Breathing Problems in Pierre Robin Sequence: A Systematic Review Protocol
Authors: Ramjeeawon A , van der Plas P , van de Lande L , Ong J , Wyatt M , Abel F , Kangesu L , Sommerlad B , Navaratnarajah J , Wolvius E , Laverty A , Bulstrode N
Published: October 2021

Aim

The primary aim is to systematically review the specific airway and/or breathing problems which have been reported in Pierre Robin Sequence (PRS). Secondary aims are to understand the prevalence and severity of these airway and breathing problems, and options for screening, assessment, and monitoring.

Method

A search strategy will be designed to search the following databases: MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials(CENTRAL) including a grey literature search, to identify publications on airway and/or breathing problems in Pierre Robin Sequence patients. Airway or breathing problems to be included are defined upper airway conditions (e.g., sleep apnoea) or clinically or objectively defined airway/breathing problems (e.g., increased respiratory rate, polysomnography). Screening will exclude non-English articles, abstracts, letters, editorials, expert opinions and breathing problems not anatomically related to craniofacial underdevelopment.

Results

This systematic review has been successfully registered on the PROSPERO International Prospective Register of Systematic Reviews (CRD42020210572)

Conclusions

PRS is a rare craniofacial condition which presents at birth, consisting of micrognathia, glossoptosis and airway problems, and is usually, but not always, associated with a cleft palate. There is no consensus on the type of airway problems that affect patients with PRS. The findings of this systematic review will help to develop a consensus on the airway and breathing problems in PRS and options for assessment and monitoring of the airway and breathing problem. This data may also contribute to development of a standardized guideline for management of airway and breathing problems in PRS.
1196 Sonographic Assessment Versus Direct Clinical Measurement of Sialolith Size and Its Influence on Modality of Endoscopic Removal
Authors: Pepper T , Karia R , Ryba F
Published: October 2021

Aim

The aim of this retrospective case series was to investigate the influence of sialolith size on the potential for endoscopic stone removal.

Method

The records of 52 patients who underwent salivary endoscopy between September 2018 and February 2020 were reviewed. Included cases presented with at least one symptomatic major salivary gland, and sonographic or radiographic evidence of stone disease.

Results

A total of 25 patients (48%) and 27 stones were identified. These patients had a mean age of 45.2 years (range 16–72); 52% were female. Most cases (19/25) involved the submandibular gland, with a virtually even division between left and right sides. The overall success rate of sialendoscopic retrieval was 23/27 (85%), with 17/27 stones removed intact and 6/27 undergoing fragmentation with an intraoral salivary pneumatic lithotripter (Cook Medical). Median (sonographic) stone size in the largest dimension for those stones removed intact was 4mm (range 3-12mm), while for those undergoing fragmentation it was 7mm (range 3-11mm). Ultrasound provided an accurate assessment of stone size in most cases, but underestimated diameter by an average of 1mm in 6/27 cases, and overestimated size by 1mm in a single case.

Conclusions

Sialendoscopic stone retrieval is a minimally invasive and effective treatment for sialolithiasis. It is possible to remove most stones using a basket, with intraoral lithotripsy employed for larger stones. Ultrasound is a reliable diagnostic tool for predicting stone size but may underestimate size in a small proportion of cases.
1239 Postoperative Complication Rate of Facial Injury Repairs Treated by Maxillofacial On-Call Team: Surgical Audit
Authors: Dhanjal G. , Ghouri M. , Crank S. , Philip J.
Published: October 2021

Introduction

A significant aspect of Oral and Maxillofacial Surgery workload relates to trauma, particularly soft-tissue injuries. Contingent on the aetiology of injury, facial wounds require debridement and rapid closure to reduce risk of infection and degree of scarring. The aim was to identify possible risks and frequency of postoperative complications, including problems identified by patients following treatment of facial injuries by the Maxillofacial on-call team.

Method

Data was retrospectively collected from patients who sustained soft-tissue facial injuries treated by the Maxillofacial team and provided with follow-up appointments from January to August 2020. Computerised clinical notes were accessed to determine patient demographics, mechanism and site of injury, location and time of repair, operator grade and postoperative complications (if any).

Results

153 patients required debridement and suturing of a facial injury under local or general anaesthetic. Among these, the male to female ratio was 65:35. 47% of facial injuries resulted from mechanical fall. Lips were found to be the most common site (31%) of injury. Postoperative complication rate was 8% within the 8-month period, with reports of infection, wound dehiscence and haematoma requiring further treatment. 58% of complications resulted from treatment carried out between 5pm-5am with a sole operator (DCT/SHO). 83% of complications followed treatment carried out within the Emergency Department rather than Maxillofacial clinical setting.

Conclusion

Following facial injury repair, just less than 8% of patients experienced complications, which required corrective treatment. Although facial injuries require immediate care, careful planning and performing treatment in a specialised setup may improve perioperative care, thus clinical outcomes.
1249 A 3D Morphable Model of the Apert Mandible
Authors: Ramjeeawon A , van de Lande L , O'Sullivan E , Bloch K , Khonsari R , Schievano S , Dunaway D , Bulstrode N
Published: October 2021

Aim

Assess the three-dimensional Morphable Model (3DMM) of the Apert mandible, investigate differences between sex and age, and characterise growth by age. Additionally, compare with a healthy mandible 3DMM.

Method

High-quality CT scans of children with Apert’s Syndrome (without previous mandibular surgery) between November1987-January2020 were sourced from Great Ormond Street (GOSH) and Necker Hospitals. DICOM files were constructed to 3D meshes through isolation of mandibles and artifact removal (MeshMixer, Mimics) and annotation using standardized landmarks (Wrapped). A 3DMM was constructed using an existing pipeline, and experiments performed to compare with the healthy mandible 3DMM, investigating differences between sex and age, and to characterise growth by age. A healthy mandible 3DMM has been created by our team using healthy mandible CT scans sourced from a GOSH database.

Results

A 3DMM of the unoperated Apert mandible was successfully constructed from 276 Apert CT scans, male=137 (aged0-20), female=139 (aged0-23), and the first components of the morphable model identified.

Conclusions

Apert’s Syndrome is a rare genetic condition, with characteristic extremity (syndactyly) and craniofacial features (craniosynostosis), however breathing problems, sleep apnoea, relative prognathism and Angle class III malocclusion have been reported. Few studies have analysed the potential role of the Apert mandible. 3DMMs are statistical tools used to represent 3D shapes and have been used to create shape and texture parameters for anatomical areas. The 3DMM of the unoperated Apert mandible has potential applications for further understanding of Apert’s Syndrome, diagnostic purposes and may be used to develop further management of these patients, such as surgical planning.
1264 A Cross-Sectional Study of Psychological Expectations of Orthognathic Surgery Patients Based on Their Typology
Authors: Falinda D , Tahim A , Cronin A , Komath D , Pabla R , Mistry P , Lee S
Published: October 2021

Aim

Orthognathic surgery corrects craniofacial deformity which compromises breathing or masticatory function. Patients typology influences their expectations for physical and psychological transformation before and after surgery and is an emerging area of research. This study aims to evaluate: 1) subjective expectations and/or perceived outcomes and 2) whether orthognathic surgery meets patients’ expectations.

Method

A questionnaire-based cross-sectional survey was administered pre- and post-operatively. Patients were classified according to typology, namely metamorphosizers - patients with high expectation of psychological and physical changes, evolvers - opposite of metamorphosizers, pragmatists - low expectation of psychological and high expectation of physical changes, and shedders - opposite of pragmatists. A chi-square test was used to examine whether orthognathic surgery met patients’ expectations.

Results

A total of 27 patients consisting of 19 pre-operative and 8 post-operative completed the survey over an 11-month study period (females = 11; males = 16; mean age= 22.5 years; range = 17-52). Typologically, metamorphosizers dominated, 48%, followed by shedders, 30%, evolvers, 13% and pragmatists, 9%. This indicates that most patients, 78% (metamorphosizers and shedders) had high expectations of psychological change pre-operatively [X2 (2, N = 90) = 43.9, p < .0001)] and perceptions of psychological change post-operatively [X2 (2, N = 90) = 48.8, p < .0001)].

Conclusions

Most patients in this study anticipated and perceived psychological changes after orthognathic surgery. Understanding patient typology may help the orthognathic surgeon understand, address and improve post-operative psychological outcomes in their patients.
1307 Linking Pre-ST Trainees into The Surgical Profession - An Example from OMFS Of A Structured Introduction to The Speciality
Authors: McLean A , Rapaport B
Published: October 2021

Introduction

Inspiration and support are two of the key principles that enthuse junior trainees to pursue a career in surgery. Exposure to Oral and Maxillofacial Surgery (OMFS) is minimal at undergraduate level and can present a challenge for those postgraduate individuals who wish to gain more experience before applying to further training. This has prompted the formation of a support programme comprised of two stages: Taste of OMFS and Mentoring and Support Programme (MSP).

Method

Feedback was captured from OMFS junior trainees and educational supervisors on the existing junior trainee programme. It was concluded that a new programme was required to create a more structured system to help support trainees achieve their goals within OMFS. Taste in OMFS aims to provoke intrigue in the specialty. Individuals who are inspired to experience more can advance on to the MSP which consists of checklists, carefully designed to help the trainee obtain adequate exposure and achieve the recommended requirements for second-degree and specialty training applications.

Results

The new programme was trialed by existing junior trainee programme members over a six-month period. The results were encouraging with positive feedback on the structure of both sections. This, in combination with ideas generated from a focus group has helped create the final version, now published and accessible on the British Association of Oral and Maxillofacial Surgeons website.

Conclusions

We hope to raise awareness of this dynamic programme which can be tailored to each individual, in the hope that more junior trainees pursue a career within OMFS.
1318 Peri and Post-operative Fluid Management in Relation to Outcomes in Free Flap Reconstructive Surgery - A Systematic Review
Authors: Shah K S V , Fernando S , Preena D , Jigajinni S , Ahmed A
Published: October 2021

Aim

Free tissue transfer is one of the options available in the armamentarium of the reconstructive surgeon. Being a highly demanding and skilled procedure, success is dependent not only on the technical aspect of the anastomosis, but also on other variables including a patient’s fluid status. In order to address the controversy surrounding optimal fluid balance in free flap reconstruction, a systematic review of studies investigating the influence of peri and post- operative fluid balance on free flap reconstruction outcomes was carried out.

Method

We searched the Medline database from 1970 to 2020 and manually searched the bibliographies of relevant studies. The articles were graded according to the level of evidence set out by the Centre for Evidenced-Based Medicine and followed the PRISMA guidelines.

Results

Of the 62 abstracts screened, we identified 14 studies that met the inclusion criteria. Of the 14 studies, 12 studies concluded that excessive fluid therapy led to either medical or surgical complications (including free flap complications) or increased length of hospital stay. One study concluded that restricted fluid therapy led to a higher complication rate of delayed thrombotic events. One study reported no difference between volume of fluid administered with respect to pulmonary complications.

Conclusions

An important aspect of successful microvascular reconstruction involves determining a patient’s fluid status and targeted optimal resuscitation. This is best achieved with goal directed fluid therapy using tools such as an oesophageal doppler or other arterial waveform- based systems. Further good quality trials are required to determine which system is superior.
1322 Two Staged Skin Pedicle Reconstruction of Superior Helical Rim
Authors: Holden Adam , Doumas Stergios , Dhandar Jag
Published: October 2021

Introduction

Skin grafting onto the ear has its challenges, loss of the skin results in inadequate vascular bed for the graft leading to decreased uptake 1,2. As a result, advancement flaps or sacrifice of the underlying cartilage allows primary closure with compromised aesthetics. A two staged procedure however leads to acceptable scarring, can be performed under local anaesthetic, is quick and easy enabling transfer of skin to acutely exposed cartilage. The authors demonstrate a two staged reconstruction technique of the superior helix after traumatic degloving of the dermal tissues.

Method

Under local anaesthetic an incision in line with the most inferior extent of the skin loss is made. A subdermal plane is expanded superiorly, and the exposed auricular cartilage inserted, healing of the adjacent margins occurs and enables later skin transfer. The patient was discharged on oral antibiotics and returns at two weeks to have the pedicle divided in an outpatient setting. A further skin incision superior to the extent of the tip of the helix is performed. This skin flap is then thinned and folded to reconstruct the posterior aspect of the ear. The skin is sutured in place and the patient is sent home on oral antibiotics. A further reviewed in two weeks to check healing is advised and the patient was subsequently discharged.

Conclusions

In conclusion, this is demonstrated to be a useful technique to add to the Oral and Maxillofacial Surgeons armament for reconstruction of the superior helix when iatrogenic or traumatic loss of skin coverage occurs.
1341 Outcomes of Sialendoscopic Stone Retrieval Under Local Anaesthesia in The Outpatient Setting- A Single Surgeon’s Experience
Authors: Karia R , Pepper T , Ryba F
Published: October 2021

Aim

The aim of this retrospective case series was to investigate the success rate of sialendoscopic stone retrieval under local anaesthetic.

Method

The records of 52 patients who underwent salivary endoscopy between September 2018 and February 2020 were reviewed. Included cases presented with at least one symptomatic major salivary gland, and sonographic or radiographic evidence of stone disease.

Results

A total of 25 patients (48%) and 27 stones were identified. Most cases (19/25) involved the submandibular gland, with a virtually even division between left and right sides. 19/25 patients underwent stone retrieval under local anaesthetic (LA) in the first instance (two of these patients had two stones). 6/25 patients underwent stone retrieval under general anaesthetic (GA) in the first instance, and this was successful in 5/6 cases. The overall success rate of LA sialendoscopic stone retrieval was 18/21 (86%), with 14/21 stones (66%) being successfully removed at the first treatment session and a further four at the subsequent treatment session. Under LA, 13/18 stones were removed intact, while the remaining 5 underwent fragmentation with an intraoral salivary pneumatic lithotripter (Cook Medical).

Conclusions

Sialendoscopic stone retrieval is a minimally invasive and effective treatment for both submandibular and parotid duct stones. It is possible to remove most stones under local anaesthetic at the first treatment session, using intraoral lithotripsy as an adjunct when indicated. This treatment modality provides therapeutic benefit with 86% success of stone retrieval under local anaesthetic with gland preservation in the vast majority of patients.
1353 Accuracy of Surgical movements in the Le Fort I Osteotomy
Authors: Nandhra K , Flett A
Published: October 2021

Introduction

The Le Fort I osteotomy is a surgical procedure planned by a joint orthognathic team aiming to correct skeletal discrepancies of the maxilla, with subsequent soft tissue profile changes of the patient.

We undertook a retrospective case series analysis of patients receiving Le Fort I surgery at a UK teaching hospital over the last four years to assess the accuracy of Le Fort I surgical movements, by comparing the actual maxillary movement with planned surgical movements.

Method

A retrospective analysis of patients receiving Le Fort I surgery over a 4-year period, 2016-2020, was completed. Pre- and post-surgical lateral cephalograms were traced to determine postoperative anterior maxillary movements, and these were compared to the original orthognathic plan. Based on a literature review, we created a locally established standard of surgical movement to be within 2mm of planned movement on the lateral cephalogram trace for a satisfactory outcome.

Results

91% of patients undergoing Le Fort I surgery (n = 11) had postoperative maxillary movement within 2mm of the surgical plan, and the mean difference between planned and surgical movements was 1.13mm.

Conclusions

Our retrospective analysis shows there is good surgical accuracy demonstrated of Le Fort I maxillary advancement movements compared to their original plan. Following this, we will continue to monitor and maintain this high standard for optimal patient outcome.
1370 Classifying Morbidity and Error in Oral and Maxillofacial Trauma Using the Clavien-Dindo Classification: A Prospective Pilot Study
Authors: Wu E , Luo J , Parmar S , Breeze J
Published: October 2021

Introduction

The collection of morbidity outcomes following surgery was recommended by the Royal College of Surgeons of England in 2014. They suggest a structure to stratify complications into groupings but do not include a classification this limits comparison. Our unit, a regionalised maxillofacial trauma service, introduced a standardised morbidity and error classification to be applied at M&M meetings.

Method

Prospective collection of data from March 2019 to February 2020. All patients discussed at our M&M meeting were then classified according to the Clavien-Dindo Classification (2004), assigned an error type and recommended action determined through a panel of between 5-10 consultants.

Results

301 surgical procedures were carried out with a 7% complication rate. 26 cases were discussed at M&M. The commonest error type was ‘nature of the disease’ (48%) followed by ‘error in judgement’ (37%). Clavien-Dindo Classification IIIb (intervention under GA) was the most frequent morbidity (74%)

Conclusions

Standardised national data collection of morbidity and error can be used to analyse a single institution or between institutions to improve patient care. To our knowledge, this is the first standardised classification of morbidity in maxillofacial trauma and was of educational and service benefit. However, there was discussion of the appropriateness of the classification systems to facial fractures. We would therefore recommend further development of both a morbidity classification and an error type classification specific to treatment of facial fractures so that it can be used to improve outcomes for our patients in the future.
1435 A Review of Literature Reviews: What Is the Quality of Publications That Dictates Best Practice for Managing Plunging Ranulas?
Authors: Taha A , McIntosh C , Mizen K , Crank S , Philip J
Published: October 2021

Introduction

We present a case of an extensive plunging ranula in a 10-year-old boy with a review of literature reviews with a focus on pathophysiology, diagnosis, and the best treatment options.

Method

PubMed was used as the search engine and the phrase “plunging ranula” was used. The search dates were between 2000-2020. 124 articles were found by the search. Systematic review and review articles in English were then selected and duplicates removed, which narrowed the search down to 10. The abstracts were then reviewed by two data extractors as per PRISMA review guidelines and full articles were then scrutinised for quality control as per AMSTAR2 tool.

Results

Using the AMSTAR2 tool the overall quality of the reviews was low as most did not fulfil multiple sections in the evaluation tool. Based on case series and meta-analysis of observational studies, opinions varied on the use of diagnostic tools with 80% of the literature reviewed using CT over Ultrasound (60%) and MRI (60%) scans. In all review articles, expert opinion suggested surgery as the best treatment and 50% discussed the benefits of Sclerotherapy as an alternative. 60% discussed the use of aspiration as an intermediate tool in diagnosis and treatment.

Conclusion

For plunging ranulas, CT scan was most commonly used in the reviews. However, the best evidence for diagnosis and treatment was MRI, US scans and surgery. Temporary symptomatic relief has been achieved with aspiration and enabled the fluid to be analysed for amylase content to aid diagnosis. Evidence is mainly from retrospective observational studies.
1537 Squamous Cell Carcinoma Arising in A Maxillary Odontogenic Keratocyst in Gorlin Goltz Syndrome - A Rare Case Report
Authors: Sarai R , Raj S , Parmar S , Martin T , Idle M , Praveen P , Anstey H , Hussain K
Published: October 2021

Introduction

Gorlin Goltz syndrome (GGS) is a rare, hereditary, AD condition with multiple BCCs, odontogenic keratocysts (Jaw cysts), calcification of falx cerebri, skeletal anomalies & a predisposition to neoplasms like medulloblastomas, fibromas and rhabdomyosarcomas.

Aim

We present a rare case of a Squamous cell carcinoma (SCC) developing in a Maxillary odontogenic keratocyst in a 32-year male with GGS.

Discussion

This patient was referred to the OMFS unit with a non-healing UL3 extraction socket and exophytic growth. Initial biopsies suggested an atypical squamo-proliferative lesion, however a repeat biopsy demonstrated an invasive SCC arising from a background odontogenic keratocyst of the maxilla. He was initially reluctant to undergo a staging CT scan to avoid risks of developing further BCCs due to IR exposure. This was eventually performed as per H&N MDT recommendation & showed a T4aN0M0 SCC of the left maxilla and bilateral multiple mandibular odontogenic keratocysts. He underwent a left maxillectomy, left neck dissection & reconstruction with a DCIA free flap, but did not want his mandibular keratocysts treated at the same time. Complete tumour clearance was achieved with no involved neck nodes & he remains disease-free at 4 months postoperatively. Although for a T4 tumour he would have needed postoperative radiotherapy, in view of the GGS, no adjuvant treatment was indicated.

Conclusions

SCC developing in a maxillary OKC is exceedingly rare with only two previous cases reported in GG syndrome. This is the first reported case of a GGS patient with oral SCC undergoing a complex free flap reconstruction.
1599 Review of Telephone Consultations for Suspected Head and Neck Cancer Referrals During The COVID-19 Pandemic
Authors: Suresh A , Goel A , Khan N , Promod P , Pabla R , Cymerman J
Published: October 2021

Introduction

Pandemic COVID-19 necessitated a transformation in the delivery of healthcare. Telephone consultations were introduced to protect and progressively manage patients with minimal delay. This is a review of the effectiveness of these remote consultations for suspected 2-week wait (2ww) head and neck cancer referrals to a north London NHS teaching hospital Oral and Maxillofacial unit during the first official UK government lockdown from March - July 2020.

Method

Prospective electronic records of 176 consecutive 2ww referrals between March – July 2020 was assessed. Data analysed included initial telephone consultations, subsequent face-to-face (F2F) appointments, if required, the interval from telephone to F2F appointments and histopathological diagnoses.

Results

157 patients (n = 176) received an initial telephone call, of which 127 (80.9%) required a F2F consultation. The number of days between the initial telephone consultation and subsequent F2F assessment ranged from 0 to 141, with a mean of 11 and a median of 1. Notably, 31 patients (24.4%) were seen in person on the same day as their telephone consultation. Biopsies were indicated for 69 patients (54.3%) of which 9 (13.0%) were diagnosed as malignancies.

Conclusions

Whilst protecting patients from a pandemic is utmost, continuing care for non-pandemic conditions must be considered. It is even more important to manage 2ww referrals efficiently. These results indicate the majority of suspected cancer referrals warrant F2F assessment for a confident outcome. Despite reinstated, ongoing social restrictions, 2ww referrals are now being seen exclusively F2F, subject to patient choice. This information is useful for planning and strategizing services in a head and neck OMFS unit.
1619 Evaluation of Referrals to The Maxillofacial on Call Service Over A Seven-Year Period in A Busy Tertiary Trauma Centre and Teaching Hospital
Authors: Musa A , Lin Y , Collard B
Published: October 2021

Aim

University Hospitals Plymouth is the only designated adult major trauma centre for the south west of England, also serving secondary care to a catchment of 450,000 patients. The on call maxillofacial service receives numerous referrals daily, which began to be recorded in a trauma database populated on a daily basis. Our study aims to evaluate these referrals with a view to classifying them and identifying service provision needs; improve support and training of the junior team; and understand patient demographics.

Method

There were 3717 referrals recorded between 7th January 2014 and 7th January 2021. All referrals were taken into account; from the emergency department; from primary care providers; from other hospital departments; and directly from patients themselves. Both adult and paediatric cases were included.

Results

Of these 3717 referrals, 2122 (57%) were pertaining to male patients. Adult patients accounted for 85% of the referrals and 1200 (32%) of all patients were referred for soft tissue injury. Around 20% of patients attended with facial swellings. 1090 (29%) patients were able to have treatment under a local anaesthetic, whilst 959 (26%) required admission. Most common fractures were nasal (8%), followed by orbital wall (6%) and mandibular fractures (4%).

Conclusions

Evaluation of the database shows a slight prevalence of male attenders, particularly in cases involving trauma. Management of soft tissue injuries under local anaesthetic is an important topic during the induction of new junior trainees to the department, in accordance with the expected service provision. Furthermore, the large sample has allowed for epidemiologic analysis and interventions.
1633 Developing Confidence in Dental Core Trainees; A National Review of The Trainee Experience
Authors: Karia R , Miskry S , Fan K
Published: October 2021

Aim

In the U.K, Dental Core Training (DCT) is an elective postgraduate training programme. There are over 700 DCT jobs with the majority in Oral and Maxillofacial Surgery (OMFS). Our focus was to measure the confidence and skills of 103 DCTs, as they mature during a year in OMFS.

Method

OMFS DCTs answered questionnaires in month 1, 3 and 6 of their training post, regarding confidence and proficiency in assessment of dental infections, facial fractures, swellings, pathology, airway risk, imaging and performing suturing.

Results

In month 1, 55% of DCTs were ‘somewhat confident’ in performing intra-oral suturing and assessing dento-facial infection out of the skills assessed. Only 22% of DCTs were ‘extremely confident’ in any competencies. Specifically, DCTs felt ‘not at all confident’ with interpretation of scans (78%) and assessment of facial fractures (35%). Between month 1 and month 6 there has been an increase in confidence across all competencies. Notably, a 42% confidence increase in extra-oral suturing and 61% increase in assessing mandibular fractures.

Conclusions

We demonstrate that an OMFS training year improves confidence in clinical skills and that an adequate time in a post is required to attain that. Our results highlight areas where DCTs lack confidence early in their posts. These could be targeted at dental school, during the hospital induction process or through guided support and training in the initial phase of their jobs. This study adds clarity to both dentists and doctors contemplating a training year in OMFS and gives insight into how to support and train them.
1662 Closure of Oro-Antral Fistulae in Conjunction with Functional Endoscopic Sinus Surgery: A Retrospective Analysis + Systematic Review
Authors: Aruede G , Smart K , Mustafa S
Published: October 2021

Aim

The aim of this study was to evaluate the surgical closure of OAFs created following dental extractions in conjunction with FESS in adult patients within a hospital in South Wales, UK, during a 5-year period, from 1st January 2014 to 31st December 2018, with a systematic review of the literature to investigate success rates.

Method

A manual search in the hospital’s theatre system for surgery between 2014 and 2018 containing codes for FESS, OAC or OAF was completed. These were screened for joint cases, and the patient’s hospital numbers entered into a Microsoft Excel spreadsheet. A retrospective analysis of their clinical records was performed. Success was measured as total closure and relief of sinusitis after 1 month. The PRISMA format was used to complete the systematic review.

Results

13 patients (mean age 51 ± 12.44, 7:6 male to female) met the inclusion criteria. The most common cause was extraction of the maxillary first molar. A 100% success rate was achieved, with no patients requiring revision surgery. The systematic review highlighted an average success rate of 98.7%. A protocol for the management of OACs was designed in both English and Welsh and distributed to Primary Care Dentists within South Wales.

Conclusions

OAF closure with FESS can be considered as a highly effective approach, leaving patients symptom free. It is important that protocols are in place for dentists suspecting an OAC in order to expedite patient management.
58 Should Single Group and Save (G&S) Sampling be Implemented in Spinal Cord Stimulation Surgery (SCSS)?
Authors: McKenna M , Ye T , Nannapaneni R , Patel C
Published: October 2021

Aim

SCSS is offered to patients who have persistent chronic neuropathic pain after trials of conservative management. Although severe bleeding complications are rare, it is common practice to take two G&S samples from patients pre-operatively. Unnecessary testing can induce patient anxiety and is a financial burden to the NHS. We aim to determine if a single G&S sample before SCSS would be beneficial, and to assess the association between number of risk factors for bleeding and blood loss in SCSS.

Method

Retrospective analysis of 100 patients in one centre who had SCSS over a 3-year period. Bleeding risk factors, haemoglobin levels and complications were recorded for each patient. A review of current literature along with a cost analysis was subsequently performed.

Results

An average drop in haemoglobin levels of 9g/L post-operatively was seen. No patients required blood transfusions. There was no statistically significant difference (P = 0.364) between number of risk factors and blood loss.

Conclusions

The results obtained suggest that SCSS carries a low risk of adverse bleeding requiring blood transfusions. With the lack of guidelines for preoperative G&S samples it is difficult to make decisions on the amount of samples needed before SCSS. Single G&S sampling in patients without bleeding risk factors can reduce patient burden, save costs, and reduce environmental footprints left by laboratory tests. Those with risk factors may still benefit from two pre-operative G&S samples to ensure patient safety.
126 Neurosurgical Clipping Versus Endovascular Coiling for Unruptured and Ruptured Distal Anterior Cerebral Artery Aneurysms: A Systematic Review and Meta-Analysis
Authors: Lee K S , Zhang J , Teo M
Published: October 2021

Aim

To assess outcomes after clipping or coiling of distal anterior cerebral artery (DACA) aneurysms via a meta-analysis.

Method

Systematic searches of Medline, Embase and Cochrane Central were undertaken from 1st January 1973 until 1st May 2020 for published studies reporting microsurgical clipping and endovascular coiling of DACA aneurysms. Primary outcome measure was independent functional outcome (modified Rankin scale (mRS) 0–2, or Glasgow Outcome Scale (GOS) 4–5). Secondary outcomes were poor clinical outcome and mortality, perioperative complications, aneurysm occlusion rates, rebleeding and recurrence.

Results

938 and 223 patients with ruptured and unruptured DACA aneurysms, respectively, were reported across 28 studies. Pooled rate of procedure-related morbidity was 6.8% (95%CI: 3.2 – 11.2) and 1.3% (95%CI: 0.0 – 9.1) for clipped and coiling ruptured DACA aneurysms respectively. Pooled rate of intraoperative rupture for clipped and coiled ruptured DACA aneurysms was 10.0% (95%CI: 2.5 – 20.6) and 5.7% (95%CI: 1.1 – 12.5) respectively. Pooled rate of acute hydrocephalus for clipped and coiled ruptured DACA aneurysms was 7.8% (95%CI: 0.5 – 19.7) and 1.4% (95% CI: 0.0 – 11.3) respectively. Pooled rate of perioperative mortality was 0.002% (95% CI: 0.0 – 0.7) ruptured DACA aneurysms treated by clipping. For clipped unruptured DACA aneurysms, pooled rates of procedure-related morbidity, intraoperative rupture, acute hydrocephalus were 2.5% (95%CI: 0.0 – 7.5), 0.002% (95%CI: 0.0 – 3.1) and 0.5% (95%CI: 0.0 – 5.1) respectively.

Conclusions

Clipping results in poorer short-term outcomes when compared to coiling. However, the final decision-making should be shared with the patient and be performed on a selective, case-by-case basis in order to maximize patient benefits.
339 The Glasgow Lumbar Spinal Stenosis Scale: An Individualised Measurement Formula for the Radiological Assessment of Lumbar Spinal Stenosis
Authors: Bradley R , Kumar A , Barrett C
Published: October 2021

Background

Lumbar spinal stenosis (LSS) is a common spinal problem. Currently there is no universally accepted quantitative approach to the radiological measurement of LSS. Quantitative descriptions do exist, but these are unidimensional and do not consider normal variation in anatomy. We propose a universal and individualised measurement system for the quantitative radiological assessment of lumbar spinal stenosis.

Method

A retrospective case series of patients who had undergone surgery for symptomatic lumbar spinal stenosis over a 3-year period. Pre-operative T2 weighted lumbar spine MRI were analysed. Each patient had the degree of lumbar canal stenosis quantified using our approach.

Results

Our novel formula for the quantitative radiological assessment of LSS is two dimensional, repeatable, and presented as a percentage, to correct for the individual patient. The surface area of the canal at the level of stenosis is measured (mm2). The adjacent 2 levels are then measured and averaged. The calculation becomes (A-S/A) x 100 = R, where S is the canal surface area at the stenosed level, A is the average canal surface area of the two levels adjacent to the level of interest and R is the relative degree of lumbar spinal canal stenosis expressed as a percentage.

Conclusions

This novel quantitative measurement formula for the radiological assessment of lumbar canal spinal stenosis is quick and simple to calculate and most importantly adjusts for the individual patient’s normal or degenerative anatomy. This new measurement tool will need validation against specific clinical and operative criteria in the future.