Oral surgery II: Part 6. Oral and maxillofacial trauma.

Oral and maxillofacial trauma can range from an avulsed tooth as a result of a simple fall, to pan-facial injuries in the context of a polytraumatised patient involved in a road traffic accident. Regardless of aetiology, similar principles apply to all oral and maxillofacial injuries, and this chapter broadly outlines the more common forms of oral and maxillofacial trauma and the options available for their management. Throughout the chapter all references and values are for adult patients unless indicated.

The efficacy of locally applied aspirin and acetaminophen in postoperative pain after third molar surgery.

This study evaluated the efficacy of and investigated the site of action of aspirin and acetaminophen placed directly into tooth sockets after bilateral third molar surgery under local anaesthesia. On completion of surgery, 12 patients received in random, blind order either a suspension of aspirin in a methyl cellulose gel (100 mg/ml) in their tooth sockets and an oral placebo or the methyl cellulose alone in their sockets and an oral dose of aspirin (50 mg). The remaining 12 patients were treated in the same fashion with use acetaminophen. Patients were asked to record their pain, at intervals, over an 8-hour period on a 10 cm visual analog scale. Significantly less pain (p less than 0.05) was recorded throughout the 8-hour investigation period after both locally placed drugs than after placebo. There was no adverse effect on healing. The peripheral activity of aspirin is confirmed, and our findings suggest that acetaminophen has a significant peripheral effect in mediating its analgesic properties in postoperative pain after third molar surgery.

The use of a metal detector for localisation of a metallic foreign body in the floor of the mouth.

The case illustrates the valuable assistance provided by a metal detector in localising an elusive broken instrument which was hidden in a recess on the medial side of the mandibular angle and encapsulated in fibrous tissue. A relative degree of sophistication built into the detector aided early localisation.

Angiomyoma of the temporal region.

A case of angiomyoma of the temporal region is presented. Judging from the number of reported cases this is an uncommon site for the tumour to occur. The clinical and histopathological features of smooth muscle tumours of the superficial tissues of the head and neck are reviewed.

Assessing competency in dentoalveolar surgery: a 3-year study of cumulative experience in the undergraduate curriculum.

AIM: To assess and observe the development of competence in oral surgical skills during a 3-year undergraduate programme. METHOD: Over a 3-year period 75 students were followed through from the beginning of their clinical course to their Bachelor of Dental Surgery graduation and their surgical experience monitored by the use of logbooks. Their development of competence was assessed objectively through structured assessments and subjectively by a single tutor responsible for each year. Assessments were made of their ability in exodontia, pre-surgical assessment and the surgical extraction of teeth/roots. RESULTS: Seventy-three students completed the course (97%). Successful completion rates for the objective testing were 100% for both exodontia and pre-surgical assessment. The surgical assessment, (surgical extraction of a tooth or root) had a successful completion rate of only 23% and the caseload for students was low with a mean of four teeth removed surgically upon graduation. Relationships were examined between total numbers of teeth extracted, total number of minor oral surgical procedures completed and the successful completion of the surgical competence assessment, but no significant relationships were found. CONCLUSIONS: This study demonstrates that it is possible to achieve objectively measurable levels of competence in undergraduates undertaking oral surgery procedures. It is however, a labour and time intensive process and appropriate clinical and teaching resources are required. National co-operation towards agreed standardised competencies should be encouraged to allow data to be pooled and more powerful analyses to occur.

A modification of sub-mental intubation.

In patients who have sustained base of skull fractures, the mode of intubation is controversial, with many anaesthetists arguing against nasal intubation. In several maxillofacial procedures temporary intermaxillary fixation (IMF) in the intraoperative period may be essential to achieve optimal results in fixation. For patients with combined facial and base of skull injury, tracheotomy may have to be performed. The submental approach to intubation allows IMF to be used without resort to nasal intubation or tracheotomy. We describe a modification of the original technique which is applicable to any reinforced tracheal tube and which does not compromise the airway.

The efficacy of locally applied morphine in post-operative pain after bilateral third molar surgery.

1. Recent evidence has hinted at a peripheral site of action of morphine analgesic efficacy. 2. Previous studies by the same authors have developed a model for testing local analgesic efficacy by placing drugs into tooth sockets after third molar surgery. 3. The present studies test the hypothesis of local morphine activity at two dosage concentrations, 100 ng ml-1 and 100 micrograms ml-1 after third molar surgery. 4. No significant analgesic efficacy was found at either dose when compared with placebo.

Effects of peripherally and centrally acting analgesics on somato-sensory evoked potentials.

1. The effects of aspirin 1000 mg, paracetamol 1000 mg, codeine 60 mg on somatosensory evoked potentials (SEPs) were measured in a four-way cross-over study. 2. SEPs were elicited by electrical stimulation of the skin overlying the digital nerve at intensities close to pain threshold. 3. Amplitudes and latencies of both early and late SEPs were recorded, as well as first sensory threshold and subjective pain threshold. 4. None of the study medications affected the amplitude or latency of the late SEP components (100-250 ms post-stimulus). The amplitude of early components (15-30 ms post-stimulus) was also unaffected, but aspirin shortened the latency 30 min after ingestion. 5. Sensory detection and pain threshold to electrical skin stimulation were also unaffected by any of the study medications despite subjective central effects with codeine.