Predictive risk factors for facial nerve injury in temporomandibular joint replacement surgery.

The objective of this study was to determine the prevalence of temporary and permanent facial nerve injury in total temporomandibular joint (TMJ) replacement surgery and to identify potential predictive risk factors. We made a retrospective review of case notes and opportunistic review of patients treated in a single tertiary referral unit by a single surgeon. For each patient a number of potential risk factors were determined, and the presence or absence of nerve injury recorded at 2 week follow up and a minimum of 12 months follow up. At 2-week review, facial nerve weakness was noted in 38/133 cases (28%) and at last follow up there were 4/133 cases (3%) with continuing (permanent) facial nerve weakness. Bilateral surgery, revision TMJ replacement, primary diagnosis, the number of previous surgeries and a history of recovered facial nerve injury all significantly increased the likelihood of temporary facial nerve injury, but not the likelihood of permanent facial nerve injury. Factors which increase the risk of temporary facial nerve injury are relatively predictable and include bilateral surgery, revision TMJ replacement, and multiple open TMJ surgeries. Risk factors associated with permanent injury are less predictable but are likely to be similar. The identification of such factors allows for the risk stratification of patients and improve informed consent. We also recommend that patients with a single, previously failed open TMJ surgery should be considered for early TMJ replacement and in multiply operated patients a subfascial plane of dissection is adopted.

Management of patients at risk of bisphosphonate osteonecrosis in maxillofacial surgery units in the UK.

AIM: To establish how oral and maxillofacial surgery units in the UK manage patients requiring dental extractions who are currently taking, or have previously taken, bisphosphonates and to review current guidelines for management of these patients. METHODS: Postal questionnaire sent to 117 oral and maxillofacial surgery units in the UK. RESULTS: 63 replies were received (54% response rate). Only 8% of the units who responded have a protocol for managing these patients. The current strategies for the prevention of bisphosphonate osteonecrosis include chlorhexidene mouthwash and pre- and post-operative antibiotics. DISCUSSION: Bisphosphonate osteonecrosis (BON) is likely to become and increasing problem due to the large number of patients being prescribed drugs of this class. The aetiology and pathogenesis is BON is not clear but more similarities exist to 'phossy jaw' and osteopetrosis than to osteoradionecrosis. Where oral surgery is required, the use of mouthwash and antibiotics should be considered. The surgical technique should be atraumatic and where possible each sextant of the mouth should be treated in a staged manner.

Use of ultrasound-activated resorbable sheets and pins in the management of fractures of the condylar neck of the mandible: a case series.

The need to treat fractures of the mandibular condyle remains controversial, but when the decision to operate has been made, then multiple forms of fixation are advocated. Traditionally, metal plates and screws have been used, but this is thought to have several disadvantages, particularly in the growing skeleton. Resorbable fixation for maxillofacial fractures has not gained widespread acceptance because of technical difficulties with the materials and concern about inflammatory reactions during their resorption. Because not all patients have typical fracture patterns that fit the size and shape of metal plates, mouldable resorbable fixation materials can be useful, and ultrasound-activated resorbable sheets and pins have the necessary stability to fix fractures of the condylar neck. We present a series of patients in whom ultrasound-activated resorbable sheets and pins were used to fix condylar fractures in which the fracture pattern did not permit the use of stable metal fixation, or the age of the patient in our opinion precluded the use of metal fixation. There were no perioperative complications and no problems related to the stability of the fixation. Minor swelling relating to the resorption of the material in one case did not require any management.

Use of patient-reported outcome measures in oral and maxillofacial trauma surgery: a review.

In the UK, about one person/100/year sustains a facial injury, so trauma surgery accounts for a considerable part of the caseload in oral and maxillofacial surgery (OMFS). Patient-reported outcome measures (PROM) allow for patient-centred assessment of postoperative outcomes, but to our knowledge, most research in OMFS trauma does not currently include them. To investigate their use, we searched Medline to find relevant studies that reported outcomes from inception in January 1879 to August 2016. Those not in the English language and those that did not report operations were excluded. We retrieved 416 articles, of which 21 met the inclusion criteria (five randomised controlled trials and 16 cohort studies) yielding 16 outcome measures. Most of these had been devised by authors (eight studies), four studies reported use of the Geriatric Oral Health Assessment Index, and three the Nasal Obstruction Symptom Evaluation. Most were used in studies on mandibular surgery (n=13), followed by those on nasal and facial surgery (n=3 each). There is a great heterogeneity in the use of these assessments in OMF trauma. In view of their increasing importance compared with simpler objective measures that may not be relevant to the patients' own perception, more research is needed to establish which of them can be used to measure the QoL of patients treated for OMF trauma.

Ophthalmic outcomes of fractured zygomas.

In patients with fractures of the zygomatic complex, computed tomography (CT) often identifies extensive defects in the orbital floor. Some surgeons recommend routine exploration and repair of these defects during repair of the zygoma, while others advocate a more selective approach, but there is a paucity of evidence either way. We report a retrospective case series of 50 patients who had open reduction and internal fixation of zygomatic fractures by a single surgeon in the maxillofacial department at the John Radcliffe Hospital, Oxford, between 2011and 2014. The orbit was repaired only in those with severe diplopia, or restriction or malpositioning of the globe. Patients were evaluated by age, sex, aetiology, preoperative findings including diplopia and ocular malpositioning, fracture pattern, and morbidity. A total of 14 had preoperative ophthalmic signs. In five these were minimal so treatment was conservative. Nine (eight with diplopia and one with a malpositioned globe) had exploration and seven of them had the orbit repaired at the same time as the zygoma. This was not possible in the remaining two because of the complexity of the defect. There were no postoperative ophthalmic signs in the 41 who did not have orbit explored, or in the seven who had it repaired, and residual signs resolved after planned secondary reconstruction in the remaining two. We recommend that the orbit is explored only in patients with severe diplopia, or restriction or malpositioning of the globe.

Fixation of fractures of the condylar head of the mandible with a new magnesium-alloy biodegradable cannulated headless bone screw.

It is difficult to fix fractures of the condylar head of the mandible. Several techniques have been described which show satisfactory outcomes, but stability can be questionable, and some can cause irritation of the soft tissues. We describe a technique and first results of treating such fractures with resorbable magnesium-based headless bone screws (Magnezix® 2.7mm CS; Syntellix AG, Hanover, Germany).

Nerve injury associated with orthognathic surgery. Part 2: inferior alveolar nerve.

The inferior alveolar nerve (IAN) is the most commonly injured structure during mandibular osteotomies. The prevalence of temporary injury has been reported as 70/100 patients (95% CI 67 to 73/100) or 56/100 nerves (95% CI 46 to 65/100), and the prevalence of permanent alteration in sensation was 33/100 patients (95% CI 30 to 35/100) or 20/100 nerves (95% CI 18 to 21/100) when assessed subjectively. The prevalence varied significantly between different operations (p<0.0001). It was significantly higher for sagittal split osteotomy (SSO) combined with genioplasty than for SSO alone (p<0.0001) or vertical ramus osteotomy (VRO) (p<0.0001). Injury may result from traction during stripping or manipulation of the distal fragment, incorrect placement of the cuts, or misjudged placement of fixation in ramus ostotomy. During SSO, they can occur during retraction to make cuts in the medial ramus, when the bone is cut or split, and on fixation. The impact of injury is generally said to be low as it does not seem to affect patients' opinions about the operation.

Nerve injury associated with orthognathic surgery. Part 3: lingual, infraorbital, and optic nerves.

In the final paper of this 3-part series we review the incidence of injuries to the lingual, infraorbital, and optic nerves during orthognathic operations. We know of few published studies on the incidence of injuries to the lingual or infraorbital nerves, but in most cases they are thought to result from traction and are predominantly temporary. The incidence of permanent injury to the lingual nerve was 2/100 patients (95% CI 1 to 3/100) or 0/100 nerves (95% CI 0 to 1/100). The methods used to assess injury to the infraorbital nerve differed so it was not possible to calculate the incidence. Injuries to the optic nerve, although rare, have a considerable impact on the patients affected.

Nerve injury associated with orthognathic surgery. Part 1: UK practice and motor nerve injuries.

The head and neck is anatomically complex, and several nerves are at risk during orthognathic operations. Some injuries to nerves are reported more commonly than others. To find out what consultant surgeons tell their patients about the prevalence of common nerve injuries before orthognathic operations, we did a postal survey of fellows of the British Association of Oral and Maxillofacial Surgeons (BAOMS). We also reviewed published papers to find out the reported incidence of injuries to cranial motor nerves during orthognathic operations. Only injuries to the facial nerve were commonly reported, and we found only case reports about injuries to the oculomotor, abducens, and trochlear nerves. The risk of temporary facial nerve palsy reported was 0.30/100 nerves (95% CI 0.23 to 0.50) and permanent facial nerve palsy was 0.06/100 nerves (95% CI 0.02 to 0.15).

Oral cancer: delays in referral and diagnosis persist.

Oral cancer accounts for around 1% of all new cancers diagnosed in the United Kingdom every year. Mortality rates remain relatively high and prognosis is worst in cases of more advanced disease at time of diagnosis. Early identification of malignant lesions and speedy referral to a specialist for treatment are therefore important. The reasons and extent of the delays at the different stages between a patient first noticing an oral lesion and attending a health care professional and then being referred for specialist care have previously been studied and consistently found to be longer than desired. The National Oral Cancer Awareness Week (NOCAW), first run in 1995, aimed to increase the awareness of oral cancer amongst health care professionals and the public. It has since been repeated and is now an annual event. Alongside publications by the British Dental Association and guidelines circulated by the Department of Health on oral cancer diagnosis and referral, it is hoped this will lead to a decrease in the delay between the onset of oral cancer and patients receiving appropriate treatment. We looked at the previously published data on referral delay in oral cancer both in the United Kingdom and overseas and then identified delays in referral of oral cancer patients in a region that had been studied before NOCAW was introduced, to see if this was having any effect on referral delays. We found that despite the great publicity raised by NOCAW and the other publications and courses on oral cancer since the original audit, patient delay and referral delay have not improved. We conclude that more needs to be done to transfer guidelines to everyday practice.

Pentoxifylline and tocopherol in the management of patients with osteoradionecrosis, the Portsmouth experience.

Osteoradionecrosis of the jaw remains the most problematic consequence of radiotherapy for the management of head and neck cancer. Treatment is often complex and multimodal. New theories on its pathophysiology have allowed the development of potential treatment modalities, including the use of pentoxifylline and tocopherol. In this retrospective case series we examined the outcomes of patients with ORN prescribed pentoxifylline and tocopherol.

Bisphosphonate osteonecrosis of the jaws; an increasing problem for the dental practitioner.

Osteonecrosis of the jaws is an increasingly recognised complication of bisphosphonate therapy. Although this has generated a large amount of literature in the last few years, it is difficult to know how the complications associated with bisphosphonates are impacting on general dental practitioners (GDPs). Bisphosphonates are commonly prescribed in the management of osteoporosis, hypercalcemia and multiple myeloma. The risk of osteonecrosis in patients taking bisphosphonates is low but difficult to quantify. The risk associated with oral therapy is in the order of 0.01% although with parenteral therapy it may be as high as 10%. Associated factors in the development of osteonecrosis include poor dental health, odontogenic infection and invasive dental treatment. Guidelines on managing patients who are currently taking or have previously taken bisphosphonates have not yet been published in the UK. The management of patients relies on existing experience in managing patients with apparently similar conditions such as osteoradionecrosis. Most GDPs do not routinely make specific efforts to identify patients who have taken bisphosphonates, and as patients may be poor at providing such information voluntarily, it is likely that many patients are currently not identified when they attend general dental practice. The dental management of patients with a history of bisphosphonate treatment is based around prevention and minimally traumatic treatment. Failure to recognise these patients and manage them appropriately could contribute to the development of osteonecrosis, which can be very difficult to manage.