Development of a patient-reported outcomes and experience measure for Orthognathic surgery: validation of the Northwick Park Orthognathic Questionnaire (NOQ).

Orthognathic surgery aims to correct dentoskeletal and facial discrepancies. The expected benefits are functional, cosmetic, and psychological. In a previous publication, this group assessed the determinants of patient satisfaction to formulate the Northwick Park Orthognathic Questionnaire (NOQ). The aim of the present study was to validate this questionnaire. A total of 118 postoperative patients prospectively completed the NOQ, 30 of whom completed the questionnaire a second time. The mean completion rate was 87.6 ± 10%. Response reproducibility was high: 92% of patients gave identical responses (range 81-100%). The intra-class correlation coefficient (ICC) was 0.96 (0.96 ± 0.072). Average test-retest scores for each domain were as follows (range in parenthesis): reasons for treatment 93% (60-100%), preoperative experience 96% (81-100%), preparation for surgery 95% (81-100%), inpatient experience 89% (55-100%), post-discharge experience 83% (55-100%), benefits of treatment 92% (71-100%), overall patient education 91% (62-100%). Internal validity using Cronbach's alpha was 0.72 (standard deviation 0.23, range 0.5-1). The results confirm the consistency of responses and the reliability of the information collected with the NOQ. The NOQ is a novel questionnaire and a valid metric to quantify a patient's perception of their experience. Its adoption may aid in making targeted improvements to patient care.

Condylectomy: treatment of recurrent unilateral dislocation of the temporomandibular joint in a patient with Ehlers-Danlos syndrome.

We report the use of unilateral condylectomy to treat the recurrent dislocation of the temporomandibular joint (TMJ) in a 21-year-old woman with Ehlers-Danlos syndrome. Eighteen months after operation the patient had no further dislocation on full mouth opening, and no surgical complications.

Patient expectations and satisfaction following orthognathic surgery.

Orthognathic surgery aims to correct dentoskeletal and facial discrepancies. Treatment usually requires a minimum of 18 months, necessitating that patients are adequately satisfied with the treatment provided. This study aimed to assess the determinants of patient satisfaction following treatment. One hundred and eighteen patients who had undergone orthognathic surgery were included prospectively. All participants completed a questionnaire regarding their reasons for undergoing treatment, treatment logistics, treatment outcomes, and satisfaction throughout their journey. Most patients were 'very satisfied' (71.2%) or 'satisfied' (19.5%) with the overall treatment. The majority wished to improve their smile (78.0%); post-treatment, 89.0% of patients reported an improved smile. Almost half of the patients (46.6%) stayed in hospital for only one night, and 41.5% took over 4 weeks off work or school post-surgery. People with postoperative breathing difficulties spent more days in hospital (P=0.021), but importantly, the duration of hospital stay did not differ between maxillary advancement, bilateral sagittal split osteotomy, and bimaxillary surgery (P=0.78). In conclusion, patient satisfaction was high following orthognathic treatment. The results highlight areas for improvement, such as information delivery to the patient throughout the treatment journey, and show that the presence of ongoing problems is an important predictor of patient satisfaction.

New technique for endoscopically-assisted particulate graft reconstruction of the mandible.

The reconstruction of mandibular defects using particulate grafts is a proven technique that restores the osseous anatomy effectively. Secondary osseous reconstruction can be accomplished with endoscopic assistance and reduced-access incisions if an intermediate spacer is placed during resection. Two patients required reconstruction after resection of mandibular ameloblastomas. We used a modified protocol that involved the implantation of a graft of particulate corticocancellous bone after removal of the spacer, and prepared the recipient site under endoscopic guidance with small extraoral incisions. The grafts healed uneventfully and matured into ossicles suitable for the placement of osseointegrated implants.

Comparing disciplines: outcomes of non melanoma cutaneous malignant lesions in oral and maxillofacial surgery and dermatology.

300 cases of non-melanoma cutaneous lesion procedures carried out by the Oral and Maxillofacial Surgery and Dermatology departments in a North West London hospital over a 6 month period between September 2011 and February 2012 were included in a retrospective case control study. The results from each speciality were compared. The mean age of the OMFS group was 75.8 years compared to 69.9 years in the dermatology group. There was no statistically significant difference in gender between the 2 groups. The OMFS group treated a higher proportion of atypical (17%) and malignant (64.9%) cases compared to the dermatology group (11.3% and 50.5% respectively). This could also account for the fact that the OMFS group carried out a higher number of full excisions compared to dermatology. Both groups had a similar number of false positives (a benign lesion initially diagnosed as malignant) and a similar proportion of false negatives (a malignant lesion initially diagnosed as benign). Overall, the results show that both specialities had similar outcomes when managing non-melanoma cutaneous lesions. Both groups adhere to the guidelines set out by the British Association of Dermatologists and the National Institute of Clinical Excellence when managing such lesions.

A survey of self-assessed surgical competencies with respect to qualifications, training and working patterns of members on the oral surgery register.

AIMS: This study surveyed members of the Oral Surgery (OS) register and requested a self assessment of their surgical competencies with regard to both core and extended procedures, as defined by the OS curriculum. Details of education, training backgrounds and working patterns were also requested. METHODS: Members of the OS register were identified on the General Dental Council website and mailed a questionnaire. Replies were anonymous. RESULTS: Three hundred and seventy-three valid replies were received. Seventy-five percent of respondents were on the OS specialist list only (single registrants) and 25% of respondents were on both the OS and oral and maxillofacial surgery (OMFS) specialist lists (dual-registrants). Sixty-two percent of single registrants did not feel comfortable performing all core procedures compared to 13% of dual-registrants. Fifty-one percent of OS single registrants felt comfortable performing some extended procedures, as did 99% of dual-registrants. Fifty percent of single registrants and 100% of dual-registrants had a higher qualification. Thirty-seven percent of single registrants had undergone some formally-approved registrar-level training; 98% of dual-registrants had done likewise. Twenty-one percent of single registrants practised exclusively in the private sector compared to 8% of dual-registrants. CONCLUSION: Extended competencies are being practised by members of the OS register with wide-ranging educational and training backgrounds.

Soluble and insoluble signals and the induction of bone formation: molecular therapeutics recapitulating development.

The osteogenic molecular signals of the transforming growth factor-beta (TGF-beta) superfamily, the bone morphogenetic/osteogenic proteins (BMPs/OPs) and uniquely in primates the TGF-beta isoforms per se, pleiotropic members of the TGF-beta supergene family, induce de novo endochondral bone formation as a recapitulation of embryonic development. Naturally derived BMPs/OPs and gamma-irradiated human recombinant osteogenic protein-1 (hOP-1) delivered by allogeneic and xenogeneic insoluble collagenous matrices initiate de novo bone induction in heterotopic and orthotopic sites of the primate Papio ursinus, culminating in complete calvarial regeneration by day 90 and maintaining the regenerated structures by day 365. The induction of bone by hOP-1 in P. ursinus develops as a mosaic structure with distinct spatial and temporal patterns of gene expression of members of the TGF-beta superfamily that singly, synergistically and synchronously initiate and maintain tissue induction and morphogenesis. The temporal and spatial expressions of TGF-beta1 mRNA indicate a specific temporal transcriptional window during which expression of TGF-beta1 is mandatory for successful and optimal osteogenesis. Highly purified naturally derived bovine BMPs/OPs and hOP-1 delivered by human collagenous bone matrices and porous hydroxyapatite, respectively, induce bone formation in mandibular defects of human patients. By using healthy body sites as bioreactors it is possible to recapitulate embryonic developments by inducing selected biomaterials combined with recombinant proteins to transform into custom-made prefabricated bone grafts for human reconstruction. The osteogenic proteins of the TGF-beta superfamily, BMPs/OPs and TGF-betas, the last endowed with the striking prerogative of inducing endochondral bone formation in primates only, are helping to engineer skeletal reconstruction in molecular terms.

Transformation of a prefabricated hydroxyapatite/osteogenic protein-1 implant into a vascularised pedicled bone flap in the human chest.

We describe the intramuscular transformation of a hydroxyapatite/osteogenic protein-1 (HA/OP-1) composite implant, into a vascularised pedicled bone flap useful for reconstruction of a hemi-mandible. Extraskeletal induction of a bone flap for transplantation was achieved without the addition of harvested bone, bone marrow, or stem cells. Five months after apparent clinical success, an MRSA infection of the graft led to its failure. The background to ectopically induced bone flaps is introduced, with our experience in a human case presented. The results from this emerging biotechnology are discussed in the light of limited human clinical experience.

Sagittal split osteotomy of a vascularised iliac crest free flap to correct residual asymmetry and malocclusion in the reconstructed mandible.

Reconstruction of the mandible with a vascularised bone graft from the iliac crest based on the deep circumflex iliac artery is an established and reliable technique. We report two cases in which mandibular asymmetry followed reconstruction with such grafts and was corrected by sagittal split osteotomies.

Fresh frozen bone in femoral impaction grafting: can developments in bone regeneration improve on this?

Major advances in the understanding of bone regeneration have led to revolutionary applications of bone conduction and induction. Revision hip surgery is on the increase with an active, ageing population demanding increased quality of life. The technically demanding instrumentation and materials necessary for revision prosthetic hip replacements have been rapidly incorporated into clinical practice. Unfortunately, advantage has not been taken of the basic and fundamental principles of bone induction and regeneration, available for many years now. In impaction grafting for revision hip replacements where fresh frozen bone is currently used as a standard, we argue and demonstrate from the literature why this technique is biologically inferior to the results which potentially can be gained by exploiting osteoinductive grafts such as demineralised bone matrix, hydroxyapetite, and inductive factors such as bone morphogenetic proteins.

Induction of cementogenesis by recombinant human osteogenic protein-1 (hop-1/bmp-7) in the baboon (Papio ursinus).

Recombinant human osteogenic protein-1 (hOP-1), a member of the bone morphogenetic protein family, was examined for its efficacy in periodontal regeneration. Twelve furcation defects, surgically prepared in the first and second mandibular molars, were treated with bovine insoluble collagenous matrix in conjunction with 0.0 (control), 100 and 500 mu g of recombinant hOP-1 per g of matrix. After 60 days of healing, histological and histometric analyses on serial, undemineralized sections cut at 7 mu m showed substantial cementogenesis on the exposed dentine of furcations treated with both doses of hOP-1 (p < 0.01 vs control). Foci of nascent mineralization were seen within the newly deposited cementoid along the coronal areas of hOP-1-treated defects. Within the furcations, there were substantial amounts of residual collagenous carrier, interspersed with a mineralized matrix having histological features of cementum. This mineralized cementum-like material was predominantly deposited around the carrier, and blended into newly formed cementum along the root surfaces. In the apical area, the cementum-like material and the remaining alveolar bony housing were not connected; indeed the two components were separated by a fibrovascular tissue that had numerous features of the periodontal ligament space. Formation and insertion of Sharpey's fibres into newly formed root cementum were also observed. It is likely that the expression of specific cell phenotypes by hOP-1 is regulated, in part, by the extracellular matrix microenvironment, including dentine. Thus, exposed dentine, in the presence of exogenous hOP-1 at the doses tested, may preferentially modulate the expression of the cementogenic phenotype. These findings in a non-human primate show that hOP-1, at the doses tested, induced cementogenesis on surgically denuded root surfaces, indicating a specific function during repair and regeneration of periodontal tissues.