Oral And Maxillofacial Surgical Research Articles

United Kingdom oral and maxillofacial surgeons support changes to current specialty recruitment process, which could include ‘Walport’ style local selection and national benchmarking

Recruitment to oral and maxillofacial Surgical (OMFS) specialty training was centralised in 2010. The ‘flexibility’ for OMFS to respond to specialty specific recruitment issues is reducing and many Specialty Trainees’ (ST) posts are left unfilled. The National Institute for Health and Care Research (NIHR) appointment process designed to address the problem of recruiting and appointing academic surgeons with local selection with national benchmarking has worked. Using a database of all UK OMFS consultants/trainees, an electronic questionnaire was shared by e-mail, WhatsApp, and other social media. Of 306 replies, 125 (41%) were Consultants/post-certificate of completion training (CCT) individuals, 66 (22%) ST, 61 (20%) second degree students, 27 (9%) pre-second degree, 26 (9%) dual degree pre-ST trainees, and one did not indicate their status. A total of 249 (76%) studied dentistry first and 230 (75%) were male. Of those replying, 147 (48%) had no direct experience of national selection. 120 (39%) had experience as a candidate, 20 (7%) as a selector only, 17 (6%) as a candidate and selector, and two did not record their experience. Of 250 expressing an opinion, 156 (62%) supported local selection with 140 (56%) supporting local selection and national benchmarking, which is a process used for research training posts by the NIHR. Geographical continuity was most important for 78% of pre-second-degree trainees, 45% of STs, and 54% of second-degree students. A total of 57 respondents completed free text comments. There is support for changes in OMFS ST selection including creating OMFS posts which include Foundation and second-degree training in NIHR style locally recruited nationally benchmarked posts.

Pleomorphic dermal sarcoma: a case report

A pleomorphic dermal sarcoma (PDS) is considered a rare and poorly understood neoplasm of the skin.1 This has features similar to atypical fibroxanthoma (AFX).1 As well as the baseline similar characteristics to an AFX, a PDS also exhibits features of an infiltrative growth pattern which allows invasion of the subcutis, tumour necrosis and the possibility of lymphovascular invasion.2 These are more aggressive features than the more extensively reported AFX. There is a degree of metastatic potential associated with a PDS and hence early diagnosis and management with the appropriate multi-disciplinary team (MDT) is important to optimise the clinical prognosis. This case report will discuss a relatively rare diagnosis of a patient presenting with a PDS on the scalp and his management within the Oral and Maxillofacial Surgical (OMFS) Department, including consideration of his overall palliative care. Here, we will discuss the social, medical and physical implications of this diagnosis as well as considering the overall determinants of his quality of life (QoL).

Oral and maxillofacial injuries associated with e-scooter use at Broomfield Hospital: a cohort study of 24 months of data since e-scooter legalisation in the UK.

Introduction Rental electronic scooters (e-scooters) were legalised in July 2020 in the UK for use on public roads. This has led to higher numbers of emergency department (ED) attendances for head and neck injuries managed by the oral and maxillofacial surgical (OMFS) department.Aim The aim of this research is to assess the increase in e-scooter injuries requiring OMFS input and analyse factors and management associated.Method Data were collected over a 24-month period. A total of 212 e-scooter-related ED presentations were recorded, with 34 patients requiring input from the OMFS department. For the patients referred to OMFS, numerical and categorical factors used independent T-tests and one-way Analysis of Variance tests, respectively, to determine statistical significance at the 5% confidence level (p <0.05).Results The mean age was 32.8 years (SD = 15.9) in a predominately male cohort (79.4%). Alcohol intoxication was observed in 55.8% of accidents. Injuries were most common on Saturdays (41.2%). Soft tissue injuries were present in 64.7% of patients, bony injuries in 38.2% of patients and dental injuries in 11.8% of patients. Imaging was required for 76.5% of patients. In total, 44% of patients required surgical treatment, 5.9% required major surgery and 38.2% required minor surgery.Conclusion This research supports the literature suggesting significant growth in e-scooter-related injuries and their associated burden of conditions managed by the OMFS department.

The association of travel distance and severity of odontogenic infections.

Odontogenic infections (OI) are a preventable disease commonly managed in a tertiary hospital setting. Prevention of severe infections and hospitalisation relies on timely access to primary dental care. This study outlines the pre-hospital treatment of patients presenting to hospital with OIs and the association between travel distance from thepatients' residence to a tertiary hospital oral and maxillofacial surgical (OMS) unit. This study analysed patients who initially presented hospital with an OI. Patient demographics, pre-hospital treatment, and clinical markers of severity were recorded. The travel distance from the patient's residence to the hospital was recorded in kilometers, along with any inter-hospital transfer via road/air ambulance. Two hundred twenty-seven patients were included in this study, 17.2% required an inter-hospital transfer. Of these patients, 70.3% had prior treatment before hospitalisation, and antibiotics without source control was the most frequent treatment (83.1%). The mean travel distance for patients with more severe markers of infection significantly greater than patients with minor infections (p = < .001). Patients who required an inter-hospital transfer accounted for most cases with airway compromise requiring ICU admission. This study found that most patients presenting to hospital with an OI had received antibiotics alone as treatment before hospitalisation. The travel distance from a tertiary hospital with OMS services had a significant correlation to more severe infections. This has important public health implications for the allocation of preventative dental services, and patient access to OMS services.

Radiological analysis of maxillary artery relationships to key bony landmarks in maxillofacial surgery

The maxillary artery (MA) is a key structure at risk of injury in numerous oral and maxillofacial surgical (OMS) procedures. Knowledge of safe distances from this vessel to surgically familiar bony landmarks could improve patient safety and prevent catastrophic haemorrhage. Distances between the MA and bony landmarks on the maxilla and mandible were measured using CT angiograms on 100 patients (200 facial halves). The vertical height of the pterygomaxillary junction (PMJ) was mean (SD) measurement of 16 (3) mm. The MA enters the pterygomaxillary fissure (PMF) a mean (SD) distance of 29 (3) mm from the most inferior point of the PMJ. The mean (SD) shortest distance between the MA and medial surface of the mandible was 2 (2) mm (with the vessel directly contacting the mandible in 17% of cases). The branchpoint (bifurcation of the superficial temporal artery (STA) and MA) was directly in contact with the mandible in 5% of cases. The mean (SD) distances between this bifurcation point and the medial pole of the condyle were 20 (5) mm and 22 (5) mm, respectively. A horizontal plane through the sigmoid notch perpendicular to the posterior border of the mandible is a good approximation of the trajectory of the MA. The branchpoint is usually within 5 mm of this line and inferior in 70% of cases. Surgeons should take note that both the branchpoint and the MA contact the surface of the mandible in a significant number of cases.

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

IntroductionStandard 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.Method20 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.ResultsThe 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.ConclusionsKS 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.

Oral and maxillofacial surgery patient satisfaction with telephone consultations during the COVID-19 pandemic

Due to the COVID-19 pandemic most oral and maxillofacial surgical (OMFS) units have moved to conducting patient consultations over the telephone. The aim of this study was to assess patients' satisfaction with telephone consultations during the COVID-19 pandemic. A retrospective survey was conducted of OMFS patients at our hospital who had telephone consultations between 1 April - 8 June 2020. The survey was conducted by independent interviewers and used the Generic Medical Interview Satisfaction Scale (G-MISS) along with a previously published additional questionnaire. Variables recorded included age, gender, theme of consultation, grade of clinician, and type of consultation. Statistical analysis was performed to assess for any differences between patient groups. The records of 150 consecutive patients were reviewed and 135 met inclusion criteria. A total of 109 patients completed the survey giving a response rate of 80.74%. The total G-MISS score for satisfaction was high, which indicates a high level of satisfaction among all patients. We found no statistical difference in satisfaction when comparing patients in terms of gender, age, theme of consultation, or level of clinician. A significant difference was found in compliance levels between review and new patients, with review patients demonstrating higher compliance levels (p=0.004). Overall, 83.48% of patients said they would be willing to have a telephone consultation in future. The majority of patients in this study reported high levels of satisfaction with telephone consultations. New patients reported lower levels of compliance which may suggest this type of consultation is less suited to telephone consultation.

The influence of 2020 coronavirus lockdown on presentation of oral and maxillofacial trauma to a central London hospital

The novel coronavirus COVID-19 was first identified in China in December 2019. Its spread resulted in a pandemic, with the United Kingdom entering a period of national lockdown on 23 March 2020 to reduce disease burden on the National Health Service (NHS). King’s College Hospital is a Major Trauma Centre serving an inner-city population of 700,000 with 120,000 patients attending the emergency department (ED) annually. We aimed to determine the effect of lockdown on OMFS trauma presentations and lessons learned from emergency service provision during a pandemic. All referrals to the oral and maxillofacial surgical (OMFS) team from ED during the first six weeks of the lockdown period – 23 March 2020 - 3 May 2020 – were compared with the same six-week period in 2019. A total of 111 referrals were made to OMFS during the first six weeks of the lockdown period in 2020 compared with 380 referrals in 2019. Of these, 50.5%, (n=192) were related to facial trauma in 2019 vs (63.1%, n=70) in 2020. Fewer patients were admitted under OMFS: 17.4% (n=35) in 2019 vs 2.9% (n=2) in 2020, and a greater number of patients were discharged from OMFS care directly from the ED: 63.2% (n=127) in 2019 vs 82.9% (n=58) in 2020. There was profound effect of the lockdown on referrals to OMFS from the ED, in number and type of diagnosis. This is potentially reflective of the increased availability of acute/emergency dental services in South-East London during the lockdown period. This gives us valuable insight for service planning in the event of further restrictions.

Maxillofacial injuries associated with domestic violence: experience at a major trauma centre.

Domestic violence continues to be a global public health issue, and facial injuries in these cases are common with a reported incidence of up to 94%. Our aims were to identify patients with facial injuries caused by domestic violence, and to find out how confident members of the oral and maxillofacial surgical (OMFS) team were at assessing them. In this 18-month retrospective study of patients seen at King's College Hospital we identified 18 and obtained details on sex, age, nature of maxillofacial injury, mechanism of injury, time to presentation, and alleged assailant, from their electronic records. Most of the patients were female and the mean (range) age was 28 (16-44) years. In 10 cases, the alleged assailant was the patient's current partner. A total of 15 patients presented on the same day as their injury, and only 3 the following day. Punching was the most common mechanism (n=13) followed by use of a weapon. We also circulated a questionnaire among the OMFS team to gain an insight into their attitudes regarding screening for domestic violence. Most OMFS clinicians were only "somewhat confident" at recognising and asking about domestic violence, and few were "very" or "extremely confident". Targeted training for frontline staff in OMFS teams is likely to increase their confidence to identify and manage these patients, and to refer them appropriately.

Use of a chalazion clamp for intraoral biopsies: a technical note.

Oral biopsies are common diagnostic and therapeutic procedures in oral and maxillofacial surgical (OMFS) outpatient departments. The chalazion clamp is similar to a pair of forceps. One extension has a flat, solid, oval plate, the other, a ring-like structure that is used to clamp and retract soft tissues. We highlight the benefits of using this simple, widely-available tool during oral biopsies. We find that the clamp increases effectiveness and efficiency for the clinician and assistant. We recommend its use in daily OMFS practice.

Our experience of a nurse-led oral and maxillofacial surgical clinic in a tertiary centre: two years on.

We describe our two-year experience of a nurse led clinic (NLC) in a tertiary centre oral and maxillofacial surgical (OMFS) department. The clinic is run by a specialist nurse, in parallel with a consultant's clinic and focuses on the management and review of non-malignant lesions. Increased clinical flexibility, reduced waiting times, and tailored educational resources have contributed to an improved experience for the patients.

Are Office-Based Oral and Maxillofacial Surgical Procedures Profitable? A Benefit–Cost Analysis

Although many oral and maxillofacial surgical (OMS) procedures might seem to be profitable, no current data have analyzed the costs versus benefits of performing office-based OMS procedures. The purpose of the present study was to analyze the costs of performing 6 common office-based OMS procedures compared with the reimbursement rates for those same procedures. The present study was a cross-sectional, microcosting survey analyzing the costs of materials used in the outpatient Oral-Maxillofacial Surgery clinic at the University of Texas Health Science Center at San Antonio. The costs incurred were based on dental procedure coding and national statistical databases and not on actual patient interactions. The primary predictor variable was the procedure costs for 6 commonly performed outpatient OMS procedures using 3 types of trays: a simple tray, a surgical tray, and an implant tray. The ancillary materials were listed for as-needed use for each tray. The primary outcome variable was the revenue after expenses per procedure. Descriptive statistics were computed. The net profit or net loss of performing 6 commonly performed outpatient OMS procedures was analyzed by subtracting the cost of performing the procedure from the insurance reimbursement for those procedures. Without the addition of sedation to the procedures, routine extractions had a net loss of $230 to $261, surgical extractions had a net loss of $153 to $242, and incision and drainage procedures had a net loss of $212 to $311. Furthermore, preprosthetic procedures had a net loss to net profit of -$269 to+$140, and pathologic procedures had a net loss to net profit of -$269 to+$326. Only implant procedures yielded a net profit of $847. The results of the present study have demonstrated that not all routine OMS procedures are profitable when performed alone without the inclusion of additional procedures or sedation.

Relation between facial fractures and socioeconomic deprivation in the north east of England

Patients with a low socioeconomic status suffer disproportionately from trauma, and have a high incidence of mandibular fractures. To explore how deprivation affects the incidence of facial fractures in the north east of England, we reviewed 1096 patients who were admitted to the oral and maxillofacial surgical (OMFS) unit at Sunderland Royal Hospital for treatment of a facial fracture between December 2013 and December 2017. Levels of socioeconomic deprivation, which were obtained from postcodes and the UK Government Open Data Communities database, were compared with a random sample of deprivation data from the catchment area of our hospital. Patients with nasal and mandibular fractures were more likely to be socioeconomically deprived than those in the catchment area of our hospital (p = 0.006 and p < 0.001, respectively), but this was not the case in those with malar/maxillary or orbital floor fractures (p = 0.184 and p = 0.641, respectively). The incidence of fractures that were caused by assault was not associated with increased socioeconomic deprivation (p = 0.241). Patients of low socioeconomic status were more likely to have been under the influence of a substance when the injury occurred (p = 0.014). There is a strong association between socioeconomic deprivation and facial fractures. OMFS departments should therefore be as accessible as possible to patients from more disadvantaged backgrounds, given their greater risk of injury.

The Safety and Effectiveness of Superficial Cervical Plexus Block in Oral and Maxillofacial Surgery as an Alternative to General Anesthesia in Selective Cases: A Clinical Study.

To assess the safety and effectiveness of superficial cervical plexus (SCP) block in oral and maxillofacial surgical (OMFS) practice as an alternative to general anesthesia in selective cases. The total number of patients was 10, out of which 6 were male and 4 were female patients. Five patients had incision and drainage of perimandibular space infections, two patients had enucleation of cyst in the body of mandible, one patient had open reduction and internal fixation isolated angle fracture, and two patients had submandibular lymph node biopsies. Informed& written consent were obtained from the patients after they had the procedure explained to them. Medically compromised patients and those who were excessively anxious and apprehensive, patient who did not want the procedure to be done under regional anesthesia, and patients with a history of allergy to local anesthetic were excluded. All patients had their surgical procedures under regional anesthesia (SCP block with supplemental nerve blocks) performed by the same surgeon under the supervision of anesthesiologist with continuous monitoring. SCP block with concomitant mandibular nerve and long buccal nerve block has a high success rate, low complication rate, and high patient acceptability as shown in the study. Superficial cervical plexus block anesthesia is a safe and useful anesthetic technique with the low risk of accidents and complications, thus a good alternative for regional anesthesia in selected cases in oral and maxillofacial surgery.

The use of superficial cervical plexus block in oral and maxillofacial surgical practice as an alternative to general anesthesia in selective cases

Aim:(1) To assess the feasibility, safety, and effectiveness of superficial cervical plexus (SCP) block in oral and maxillofacial surgical (OMFS) practice as an alternative to general anesthesia in selective cases. (2) To assess any associated complication specifically related to the procedure.Subjects and Methods:The total number of patients was 10, out of which 6 were male and 4 were female patients. Six patients had incision and drainage of perimandibular space infections, two patients had Level Ib cervical lymph node biopsies, one patient had enucleation of cyst in the body of mandible, one patient had open reduction and internal fixation isolated angle fracture. Informed written consent was obtained from the patients after they had the procedure explained to them. Exclusion criteria included patient's refusal to undergo the procedure under regional anesthesia, allergy to local anesthetic, excessively anxious, and apprehensive patients, significant upper airway compromise warranting an endotracheal intubation to secure airway. All patients had the procedure done by the same operating surgeon. All patients had their surgical procedures under regional anesthesia (SCP block with supplemental nerve blocks) performed by the same surgeon with satisfactory anesthesia and analgesia without any complication.Results:SCP block with concomitant mandibular nerve and long buccal nerve block has a high success rate, low complication rate, and high patient acceptability as shown in the study.Conclusion:The notable anesthetic effect and adequate working time, summed with the low risk of accidents and complications, make this technique a good alternative for sensitive blockage of part of the cranial and cervical regions and have positive outcomes in selective OMFS cases.

In reply

I applaud Ms Holland for her enthusiasm and work ethic and the dedicated oral and maxillofacial surgical (OMS) faculty at Temple University for the development of an honors OMS program (Honors Oral Surgery Training). There are other institutions across the country with similar programs. This is certainly a positive step forward for OMS education.

Results of the centralisation of adult emergency oral and maxillofacial surgical services at the University Hospital, Birmingham

In 2001, the oral and maxillofacial surgical (OMFS) services for adults in Birmingham were centralised at the Selly Oak site of the University Hospital and the OMFS department was given access to the emergency operating theatre every day. We examined the effects of this on the emergency workload during the 6 months after centralisation and compared it with the emergency workload at the University Hospital during the 6 months before centralisation. The number of adult patients who attended the University Hospital as emergencies increased from 242 in the 6 months before centralisation to 545 in the subsequent 6 months (an increase of 127%). Of the latter 164 (30%) were admitted and operated on, 138 (84%) within 24 h of admission. Despite the large increase in the number of patients, 102 (74%) were operated on during normal working hours. After centralisation, all operations were done on multidisciplinary emergency lists compared with only 55% before centralisation. Centralisation did not reduce the access of patients to the emergency service and conformed with the guidelines of the National Confidential Enquiry into Perioperative Deaths (NCEPOD).

The development of a telemedicine system for a centralized maxillofacial unit serving four towns.

Following the amalgamation on one site of inpatient oral and maxillofacial surgical (OMFS) services serving four towns, patients attending accident and emergency (A and E) departments in Bolton, Burnley and Bury who required specialist OMFS care were transferred to Blackburn. This sometimes led to inappropriate transfer, with inconvenience for patients, sub-standard care and wasted resources. To reduce these problems, a videoconferencing system was established, linking the A and E departments of three peripheral hospitals to the central site. This allowed realtime visualization of patients and their radiographs, discussion between clinicians and transfer of a summary data-sheet. The aim was to improve remote diagnosis and to deliver a cost-effective, high-quality specialist service. In the first 12 months, there were an average of 25 remote consultations per month, with favourable feedback from both patients and clinicians.