Maxillofacial Surgery Unit Research Articles

Prospective Evaluation of a Negative Pressure Dressing System in the Management of the Fibula Free Flap Donor Site

The fibula free flap donor site has been associated with short-term donor site morbidity, most commonly delayed healing. To evaluate the effectiveness of a negative pressure dressing (NPD) system in the management of fibula free flap donor sites that required skin graft closure. Cohort study comparing a prospective cohort whose donor sites were managed with the NPD system from June 2009 through March 2012 with a retrospective cohort whose donor sites were managed with a conventional pressure (bolster) dressing (CPD) from August 2006 through May 2009. Tertiary regional head and neck reconstructive and maxillofacial surgery unit. All patients who had a composite fibula free flap for maxillofacial reconstructive surgery and required donor site closure with split-thickness skin grafts from August 2006 through March 2012. Negative pressure dressing used to manage the skin-grafted fibula donor site. Primary: time until complete healing of the fibula donor site. Secondary: skin graft take rate, infection rate, returns to operating theater for donor site problems, delayed hospital discharge due to donor site problems, and community intervention required for donor site dressing. All healing outcome measures were similar for the 21 patients in the NPD group and the 19 patients in the CPD group, with no statistically significant difference. Two patients in the CPD group required surgical debridement of the fibula donor site, compared with none in the NPD group (P = .22). The NPD group had a higher skin graft take success rate (15 [71%] vs 11 [58%]; P = .51) and required less nursing intervention for donor site dressings (8 [38%] vs 9 [47%]; P = .75) but had a higher wound infection rate (6 [29%] vs 2 [11%]; P = .24). Our findings would, at best, suggest that NPD may decrease the rate of return to the operating theater for donor site problems. The fibula donor site healing remains problematic, and our results suggest that routine use of the NPD system in the management of the fibula free flap donor site is not justified from a health economic perspective.

Failures and complications of free flaps reconstruction. Experience of a maxillofacial surgery unit with start up free flap reconstruction in Nigeria

Objective: Microvascular free tissue reconstruction (MFTR) is an established technique in re-instating tissue following ablative head and neck surgery. It is widely practised in many European, American and Asian centres. Very few, if any centre in Africa performs routine MFTR and no head and neck MFTR (HN-MFTR) is routinely performed in Nigeria. The objective was to report our experience in a start-up HN-MFTR in a developing environment.

The genesis of an oral and maxillofacial surgery unit in the West of Ireland: a retrospective review

The genesis of an oral and maxillofacial surgery unit in the West of Ireland: a retrospective review

Transoral robotic surgery in a North American Oral & Maxillofacial Surgery Unit: early data outcomes assessment

Purpose: To evaluate the technical feasibility and patient outcomes with transoral robotic surgery (TORS) for the management of oral/oropharyngeal carcinomas within an academic Oral & Maxillofacial Surgery department.

Surgically-assisted rapid maxillary expansion of narrowed maxillae: a case-cohort study

Abstract Aims: The aim of this study was to investigate a consecutive cohort of surgically-assisted rapid maxillary expansion cases to determine the indications, results and relapse associated with the procedure. Methods: The records of 21 cases of SARME treated by the Oral and Maxillofacial Surgery and Orthodontic units at the University of Adelaide were examined. Overall expansion and subsequent relapse were compared on study models and postero-anterior cephalometric radiographs against the variables of age, gender, surgeon, surgical technique, final occlusion and the retention period. Statistical analysis was performed on paired variables. Results: Maximum expansion was gained across the intermolar width and the most relapse identified across the canines. Male patients showed statistically greater stability across the intercanine width. There were otherwise no significant relationships between the treatment variables, stability or relapse. Conclusions: SARME is a safe surgical technique for narrowed maxillae requiring intermolar expansion of 6 mm or more. Overexpansion of up to 60% is required to compensate for relapse.

Assessment of Factors Associated With Surgical Difficulty During Removal of Impacted Maxillary Third Molars

Estimating the difficulty of removing third molars is a common dilemma. However, the estimation of the difficulty associated with maxillary third molar surgery has not yet been defined. The aim of the present study was to determine the degree of difficulty and identify predictor variables associated with the occurrence of difficulty in the removal of impacted maxillary third molars. A prospective cohort study was carried out involving patients who underwent at least 1 surgical removal of an impacted maxillary third molar at the Oral and Maxillofacial Surgery Unit, University of Pernambuco (Pernambuco, Brazil). Predictor variables indicative of surgical difficulty were classified by their demographic, clinical, and radiographic aspects. Degree of surgical difficulty was categorized as low, moderate, or high based on the surgical technique used. Descriptive and bivariate statistics were computed. In total, 106 patients fulfilled the eligibility criteria and 204 surgeries were performed. Patients' mean age was 22.8 ± 2.2 years and the proportion of women to men was 3:1. Approximately 20% of patients were overweight. Surgical difficulty was generally low and 5 variables were significantly associated with the occurrence of a high degree of surgical difficulty. Surgical difficulty during the removal of impacted maxillary third molars is generally low. However, for cases with a high degree of difficulty, identification of predictor variables may be useful for students and inexperienced clinicians to consider the decision not to execute the procedure, thus avoiding complications that often require complex management.

Prevention of Alcohol-Related Crime and Trauma (PACT): brief interventions in routine care pathway – a study protocol

BackgroundGlobally, alcohol-related injuries cause millions of deaths and huge economic loss each year . The incidence of facial (jawbone) fractures in the Northern Territory of Australia is second only to Greenland, due to a strong involvement of alcohol in its aetiology, and high levels of alcohol consumption. The highest incidences of alcohol-related trauma in the Territory are observed amongst patients in the Maxillofacial Surgery Unit of the Royal Darwin Hospital. Accordingly, this project aims to introduce screening and brief interventions into this unit, with the aims of changing health service provider practice, improving access to care, and improving patient outcomes.MethodsEstablishment of Project Governance: The project governance team includes a project manager, project leader, an Indigenous Reference Group (IRG) and an Expert Reference Group (ERG).Development of a best practice pathway: PACT project researchers collaborate with clinical staff to develop a best practice pathway suited to the setting of the surgical unit. The pathway provides clear guidelines for screening, assessment, intervention and referral.Implementation: The developed pathway is introduced to the unit through staff training workshops and associate resources and adapted in response to staff feedback.Evaluation: File audits, post workshop questionnaires and semi-structured interviews are administered.DiscussionThis project allows direct transfer of research findings into clinical practice and can inform future hospital-based injury prevention strategies.

Removal of a Maxillary Third Molar Displaced into Pterygopalatine Fossa via Intraoral Approach

The removal of impacted maxillary third molars is one of the most common procedures performed in oral and maxillofacial surgery units with low rates of complications and morbidity. A few cases of accidental displacement of third molars into adjacent anatomical spaces, such as the infratemporal fossa, the pterygomandibular space, the maxillary sinus, buccal space, or the lateral pharyngeal space, during surgical interventions have been reported. In this paper, a case of a maxillary third molar accidentally displaced into the pterygopalatine fossa is presented, and the removal of the tooth via intraoral approach is described.

Tumours of salivary glands in the stomatology and maxillo-facial surgery unit at the university hospital centre —Yalgado Ouédraogo

The aim of this study was to contribute to strengthening the efficiency in the treatment of the salivary gland tumours in the Stomatology and Maxillo-facial surgery service at the University Hospital Centre/Yalgado OUEDRAOGO of Ouagadougou. It has been a retrospective and descriptive study covering seven (7) years [January 2006-December 2012] on epidemiology and the treatment of 54 cases of the salivary glands tumours histologically confirmed. Benign tumours (non-malignant tumours were prevalent (61.11% of cases). The annual incidences were 4.71 cases for non malignant tumours and 3 cases for malignant tumours. The average age was 34-45 years for non malignant tumours and 44-33 years for malignant ones. In both groups, the tumour was discovered lately with an average 32-48 months before consulting in case of non malignant tumours and 18-29 months for malignant tumours. The location of non malignant tumours was very often the parotid (42.42%), under mandible gland (27.28%). Malignant tumours very often concerned the parotid (76.18%) and the under mandible gland (14.29%). The histology has revealed that pleomorphic adenoma was the leading type of non-malignant tumours (93.94% of cases) whereas carcinoma was predominant in malignant tumours (80.95% of cases). Long term track keeping was difficult and it has been complicated by the loss of contact with some patients. The low living standard, the time wasted before consulting, limited human resources and therapeutic means constitute handicaps to the treatment in our African context.

Temporomandibular Joint Ankylosis In Children

Temporomandibular joint (TMJ) ankylosis is defined as osseous or fibrous fusion of the condyle of the mandible and the mandibular fossa of temporal bone (Nitzan et. al. 1998).It is a debilitating disease that renders the afflicted person unable to use their oral cavity well. Clinical presentation depends on the age at which ankylosis occurs and whether ankylosis is unilateral or bilateral. Surgery and postoperative physiotherapy are regarded as the mainstay treatment for TMJ ankylosis. The study reviews surgical outcomes of 13 children treated for temporomandibular joint (TMJ) ankylosis in the maxillofacial and oral surgery unit at Red Cross Children's Hospital. Nine patients were treated by gap arthroplasty, while four patients had previous reconstruction with costochondral graft. One patient treated by gap arthroplasty reankylosed. The study showed a positive correlation between intraoperative MIO and the outcome, and between age and the outcome. Mouth opening was improved by 15mm, with postoperative change of -4mm.

Orofacial Clefts: Our Experience in Two Suburban Health Facilities

Background: There may be gross under-reporting of clefts in developing nations due to late and non-presentation. The aim of this study was to highlight the descriptive epidemiology of the cleft lip and palate cases managed at the Oral and Maxillofacial Surgery units of two secondary health facilities in southwestern Nigeria and the factors accounting for late presentation. Methodology: A prospective, cross-sectional study with consecutive recruitment of consenting cleft patients on presentation at the facilities between July 2010 and February 2012. A questionnaire was used to collect patients’ data. The data was analyzed using SPSS version 17.0 (SPSS, Chicago, IL, USA) to present descriptive statistics. Results: Sixty three patients participated: 27 males (42.9%), 36 females (57.1%). The median age was 8 years (age range 1 day to 41 years). In addition the age distribution was multimodal (modal ages: 1 year and 4 years). The male to female ratio was 1: 1.3. The most common type of cleft seen was unilateral cleft lip with or without palate (50.8%) while median cleft was the least common (1.6%). About 9.5% 0f the cleft cases were associated with congenital anomalies. Consanguinity was not found in any of the patients. Over 70% of the patients presented late for treatment with financial constraints being the most common reason for late presentation. Only 6.3% of the patients gave a family history of clefts. Only a third of those who had surgery were present at the third follow up visit. Conclusions: Late presentation, poor compliance to follow up and poverty remain the great challenges to OFC repair services in developing countries. It is believed that increasing availability of OFC repair services, together with an increase in awareness campaigns, may help to resolve these issues. There is a need for well designed prospective studies in the developing world to assess the true burden of the entity.

Prevalence and Distribution of Odontogenic Cyst in Indian Population: A 10 Year Retrospective Study

The purpose of this study is to determine the prevalence of odontogenic cyst in an Indian population and compare it with various reports from the other geographic areas of the world. The files on odontogenic jaw cysts treated between 2001 and 2011 at the oral and maxillofacial surgery unit were retrieved retrospectively. Patient's demographic information mainly age, sex and location of the lesion was recorded and analyzed using descriptive statistics. The diagnosis of odontogenic cyst accounted in 150 cases and accounted for 15.31% of all lesions biopsied throughout the period. Mean age of the patient was 32.2years, and 58% were males. The overall male to female ratio was 1.38:1. Radicular cyst was most prevalent histological type (48.67%) followed by dentigerous cyst, odontogenic keratocyst, lateral periodontal cyst, paradental cyst, residual cyst, adult gingival cyst, glandular odontogenic cyst, calcifying odontogenic cyst. The most common locations of the odontogenic cysts were the mandibular (49.33%) and posterior region (33.33%). The distribution pattern of odontogenic cyst in this study is relatively similar to that in other parts of the world but there are some geographic differences with regard to the relative frequency, sex, and anatomic distribution of the odontogenic cyst.

Study Protocol: Screening and Treatment of Alcohol-Related Trauma (START) – a randomised controlled trial

BackgroundThe incidence of mandibular fractures in the Northern Territory of Australia is very high, especially among Indigenous people. Alcohol intoxication is implicated in the majority of facial injuries, and substance use is therefore an important target for secondary prevention. The current study tests the efficacy of a brief therapy, Motivational Care Planning, in improving wellbeing and substance misuse in youth and adults hospitalised with alcohol-related facial trauma.Methods and designThe study is a randomised controlled trial with 6 months of follow-up, to examine the effectiveness of a brief and culturally adapted intervention in improving outcomes for trauma patients with at-risk drinking admitted to the Royal Darwin Hospital maxillofacial surgery unit. Potential participants are identified using AUDIT-C questionnaire. Eligible participants are randomised to either Motivational Care Planning (MCP) or Treatment as Usual (TAU). The outcome measures will include quantity and frequency of alcohol and other substance use by Timeline Followback. The recruitment target is 154 participants, which with 20% dropout, is hoped to provide 124 people receiving treatment and follow-up.DiscussionThis project introduces screening and brief interventions for high-risk drinkers admitted to the hospital with facial trauma. It introduces a practical approach to integrating brief interventions in the hospital setting, and has potential to demonstrate significant benefits for at-risk drinkers with facial trauma.Trial RegistrationThe trial has been registered in Australian New Zealand Clinical Trials Registry (ANZCTR) and Trial Registration: ACTRN12611000135910.

Osteonecrosis maxilar asociada a bisfosfonatos e infección por Actinomyces

Bisphosphonate related osteonecrosis of the jaw (BRONJ) has raised considerable interest since its recent description. Its pathogenesis is not yet clarified; formerly it has been considered a non-infectious complication, but recent studies seem to implicate bacteria of the genus Actinomyces. The objective of this study is to analyze the cases of BRONJ in our institution. Review of medical records of patients diagnosed of BRONJ in the Maxillofacial Surgery Unit of our hospital. We have found 11 cases of BRONJ in our hospital: 4 women taking oral alendronate or risendronate for osteoporosis and 7 cancer patients treated with intravenous zolendronic acid. All of them showed bone invasion by bacteria of the genus Actinomyces. Nine patients underwent prolonged treatment with amoxicillin with favourable clinical outcome in all of them, but 3 died of their malignancy. By contrast, one patient with beta-lactamic allergy and irregular treatment with erythromycin and tetracycline had a chronic evolution of the lesions. There was no information for other patient. Actinomyces play an important role in the development of BRONJ and specific antibiotic treatment improves the prognosis of this process.

Management of severe odontogenic infections in pregnancy

The objective of this study was to review the management of patients presenting with severe odontogenic infections and who are also pregnant. A retrospective clinical audit was conducted of all female patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant patients were identified and their age, medical history, previous obstetric and gynaecological history, stage of current pregnancy, presenting infection, diagnosis and management were recorded, as well as the outcome of the pregnancy. A total of 346 female patients were admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe odontogenic infection and five were pregnant. Besides surgical and anaesthetic assessment, mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, five with severe infection were successfully resolved and four proceeded to a normal delivery with a healthy child. The remaining patient had an already planned therapeutic abortion. Pregnant patients with severe odontogenic infections require urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate management of the complex requirements of mother and foetus.

Rehabilitation with endosseous implants in fibula free-flap mandibular reconstruction: A case series of up to 10 years

PurposeTo evaluate the clinical outcome and the aesthetic and functional results of implant rehabilitation of fibula free-flap reconstructed mandibles. Materials and methodsThe charts of patients who underwent mandibular reconstruction with fibula free flap and implant prosthodontic rehabilitation between 1998 and 2008 at the Operative Unit of Maxillofacial Surgery of Parma, Italy, were reviewed. In the study the estimated survival rates of implants placed in reconstructed mandibles we identified the prognostic factors and evaluated the functional outcomes. ResultsFourteen patients with a mean age of 50 years (range 15–63 years), were included in the study. A total of 62 implants were positioned. Complications occurred in 7 cases, an improvement in function and aesthetics was reported by the majority of patients. ConclusionsA high survival rate for implants placed in fibula free-flap reconstructed mandibles was observed. Although different factors were believed to be associated with a poorer prognosis (radiotherapy, composite defects, etc.) no statistically significance was found, showing no absolute contraindications to implant placement.

Free flaps in elderly patients: Outcomes and complications in head and neck reconstruction after oncological resection

IntroductionFree flaps represent the first reconstructive option for many head and neck defects. The increasing life expectancy of the population results in increasing numbers of ageing patients facing complex reconstructive surgery. In this study we evaluated our experience with free-flap transfers in older patients, analysing the post-operative reconstructive and systemic complications. Materials and methodsBetween 2000 and 2009, 360 patients underwent free flap reconstruction of defects resulting from the treatment of head and neck tumours at the Operative Unit of Maxillofacial Surgery, University – Hospital of Parma, Italy. Fifty-five patients (15.3%) were more than 75 years old at the time of treatment. ResultsAt the end of the follow-up successful free-flap transfer was achieved in 360 of the 373 flaps harvested (96.5%). The overall reconstructive complication rate was 31.4%, (31.8% in the younger group and 29.1% in the remaining patients). Medical complications were observed in 29.2% of cases (less than 75 years: 28.8%; more than 75 years: 30.9%). The ASA status was associated with a statistically significantly higher incidence of complications within patients less than 75 years old (p < 0.0001). Discussion and conclusionsThe results of this study, in agreement with previous studies, provide evidence that free-tissue transfer may be performed in ageing patients with a high degree of technical success. The chronologic age cannot be considered an sappropriate criterion in the reconstructive decision. On the contrary, a careful selection of the patients based on comorbidities and general conditions (ASA status) is of primary importance in reducing post-operative complications and to improving the results of surgery.

Ethics and the Limits of Science

Sir:FigureScience, however, cannot create ends and, even less, instill them in human beings; science, at most, can supply the means by which to attain certain ends. But the ends themselves are conceived by personalities with lofty ethical ideals and—if these ends are not stillborn, but vital and vigorous—are adopted and carried forward by those many human beings who, half-unconsciously, determine the slow evolution of society. —Albert Einstein We read with great interest the article by Chuang and Chen1 entitled “The Possibility and Potential Feasibility of Putting an Extra Functioning Free Muscle Transplant onto a Normal Limb: Experimental Rat Study.” We would like to discuss the ethical implications of their scientific outcomes, and we are sincerely surprised that no one has published any comment yet. In their investigation, the authors revealed that the extra muscle transfer resulted in significant increases in size and function of the operative limb without interfering with the original biceps function and demonstrated that the transfer is safe and feasible for functional and aesthetic augmentation purposes in a normal rat limb with no functional deficit.1 That is contrary to what reconstructive surgery has been developed for: surgery to restore the form and function of the body becomes surgery to selectively improve subject physical qualities and features. Although Chuang and Chen1 suggested how an extra functioning free muscle transplant may correct cosmetic defects in particular cases such as asymmetric limbs, they concluded too easily that their outcomes should be the first step to potentially enhance the performance of athletes or heavy laborers as a form of functional augmentation. From the scientific point of view, we indeed have to congratulate the authors1 for their brilliant idea and exhaustive extraction and analysis of data. From the ethical point of view, it seems necessary to open a debate regarding the future implications of these experiments. Scientific progress should certainly be seen as a blessing more than it could represent a curse. Advancements in technology in every field represent the way through which humans satisfy their desire for discovering what is still unknown and apply it to daily life to allow it to become known and useful, and it is an admirable purpose. It is the highest purpose of science. However, are we ready to create the perfect human (either athlete or heavy laborer or soldier or whatever)? History is full of myths and legends in which the pursuit of enhancement of human phenotypic characteristics is emphasized (the Prussian king even forced tall women to marry tall soldiers so they could breed more tall boys!2). Since Mendel's discoveries on genetics, a robust number of scientists have spent their lives attempting to improve the gene pool of the entire species through genetic engineering with the questionable aim of propagating selective “positive” characteristics in humans. Although we are still very far from this achieving this in humans, and regardless of what this would be used for, the question that should be asked is, “even if we could, should we?” The work of Chuang and Chen1 testifies that we could (at least in animals); however, are we so sure that potential enhancement and/or augmentation of healthy human functions would appear more enriching than destructive? In any event, less than 500 years ago, Galileo Galilei was already convinced that it would be a great mistake not to support science and research (“I do not feel obliged to believe that the same God who has endowed us with sense, reason, and intellect has intended us to forgo their use”3), and we all have inherited his philosophy, being sons of his scientific method. However, maybe we would do better to focus on improving patients' lives than on manipulating human functions. Davide Lazzeri, M.D. Operative Unit of Plastic and Reconstructive Surgery, Hospital of Pisa, Pisa, Italy Lorenz Larcher, M.D. Section of Plastic, Aesthetic, and Reconstructive Surgery, General Hospital Linz, Linz, Austria Fabio Nicoli, M.D. Department of Plastic and Reconstructive Surgery, University of Tor Vergata, Rome, Italy Corrado Campisi, M.D. Unit of Plastic and Reconstructive Surgery and, Unit of Lymphatic Surgery and Microsurgery, RCCS University Hospital “San Martino”, Genoa, Italy Tommaso Agostini, M.D. Maxillofacial Surgery Unit, Hospital of Florence, Florence, Italy DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this communication.

Dental foundation year 2 training in oral and maxillofacial surgery units – the trainees’ perspective

Most dental foundation year 2 (DF2) training takes place in oral and maxillofacial surgery (OMFS) units. We did a survey of DF2 trainees in these units by telephone interviews and an online questionnaire to find out about their experience of training and their career aspirations. A total of 123 responded, which is roughly 41% of the total estimated number of trainees. Trainees applied for these posts mainly to improve their dentoalveolar skills (50%), and this was cited as the best aspect of the training. Most (81%) were on-call at night and this was generally thought to be a valuable training experience (77%), but 20% thought that it was the worst aspect of the job. Most did not regret taking up the post although the experience had caused 75% to alter their intentions about their future career; general dental practice was the commonest choice. In conclusion, trainees are generally satisfied with their training and these positions have guided their choices about future careers.

Elderly patients with maxillofacial trauma: the effect of an ageing population on a maxillofacial unit's workload

The purpose of this study was to identify the aetiology and management of facial fractures in patients over 60years old and to identify potential trends in caseload to assist with planning of resources for maxillofacial services in the coming decades. We made a prospective study over 2years (2009–2010), during which all injured patients referred to the oral and maxillofacial surgery unit at The Canberra Hospital, Australia were recruited. The patients were classified into two groups: less than 60years old (younger group); or 60years old or more (older group). Factors studied included sex, age, aetiology, site of fractures, severity scored using the Maxillofacial Injury Severity Score (MFISS), and management. Based on current trends, the expected workload was extrapolated. A total of 470 patients were recruited (younger: n=430 and older: n=40). Falls were the most common cause of fracture in the older group (85%) and the zygoma (40%) was the bone most commonly fractured. The mean (SD) MFISS for the older group was 3.8 (2.2) (17% of these maxillofacial injuries were operated on) and 6.0 (5.0) for the younger group (72% of these were operated on). In Australia, population trends suggest that older people as a proportion of the total population will rise from about 20% of 22 million to 26% of 30 million by 2034. As the older group increases there will be a corresponding increase in the number of older people who present with trauma to maxillofacial units. The overall maxillofacial surgical workload will probably not increase much because the injuries tend to be less severe and are less likely to require operation.