Certification by the American Board of Oral and Maxillofacial Surgery: Residency to Retirement.

The American Board of Oral and Maxillofacial Surgery (ABOMS) has been serving the specialty since 1946. The ABOMS frequently reviews its strategic plan, mission, and vision. The board administers 4 examinations (the Oral and Maxillofacial Surgery In-service Training Examination, the Qualifying Examination, the Oral Certifying Examination, and Certificates of Added Qualifications in Head and Neck Oncologic and Reconstructive Surgery and Pediatric Craniomaxillofacial Surgery) and also oversees the Certification Maintenance process for diplomates. The members of the Examination Committee and directors are volunteers who create, validate, and deliver examination content for the various examinations by the ABOMS.

Maxillofacial Trauma Patterns in Bare-Knuckle Fighting.

PURPOSE: The purpose of this study is to analyze patterns and trends of maxillofacial injuries in bare-knuckle fighting. Results comparisons with other combat sports are provided in the Discussion section. MATERIALS AND METHODS: The study design is a retrospective cohort study. Data were collected by a single ringside physician who participated in all bouts. Predictor variables were number of rounds and final fight result (ie, knockout, technical knockout, and decision). The primary outcome variable was the frequency of maxillofacial injury, and secondary outcome variables were type of injury (laceration/fracture) and traumatic brain injury. The chi-square test was used to determine if there was any statistical significance between the predictor variables. RESULTS: Study sample consisted in fighters who suffered maxillofacial injuries during the matches from June 2018 to March 2022 (n = 177). A total of 177 fighters sustained maxillofacial trauma in 301 matches, and a total of 211 maxillofacial injuries were identified. Of the 211 injuries, 184 were lacerations and 27 were fractures. Proportionally more injuries occurred in matches that lasted 5 rounds (33%), and a significant association was found between the number of rounds fought and the frequency of injury (P < .00001). From a total of 107 technical knockouts, 74% of them caused at least 1 injury; from 96 knockouts, 60% caused at least 1 injury; and from 89 fights that ended in decision, 83% of them caused at least 1 injury. A statistically significant association was found between final fight result and frequency of injury (P < .00001). P value less than 0.05 (95% confidence interval) was considered statistically significant. CONCLUSIONS: Maxillofacial injuries were predominantly associated with longer fights and fights which result were knockout/technical knockout. Traumatic brain injury was associated with knockout results, which mostly occurred in the first and second rounds.

Historical evolution of surgical approaches to the face-part III: lower face.

Surgical approaches to the head and maxillofacial area have been described and modified by many authors throughout history. It was, however, during the nineteenth and twentieth centuries when most of the techniques were described, mainly thanks to the advent of anesthesia and antibiotic therapy. Currently, a myriad of surgical techniques are employed to access the maxillofacial complex, with each of them having advantages and disadvantages. Although the approaches are the subject of textbooks and articles, most do not describe the circumstances or the historical context under which they were designed. In a series of three articles, we will provide a historical perspective of the most common surgical approaches to the head and face employed today. Descriptions contain advantages and disadvantages and modifications are provided. The purpose of the present article (3/3) is to review the approaches to the lower face.

Historical evolution of surgical approaches to the face-part I: head and upper face.

Surgical approaches to the head and maxillofacial area have been described and modified by many authors throughout history. It was, however, during the nineteenth and twentieth centuries due in large part to improvements in the delivery of anesthesia and antibiotic therapy when most of the techniques were described. Currently, a myriad of surgical techniques are employed to access the maxillofacial complex with advantages and disadvantages for each one. Although each approach is described in many text and articles, few describe the circumstances or the historical context under which they were designed. In a series of three articles, a historical perspective will be provided on the evolution of some of the most commonly employed today. Descriptions will enumerate the advantages and disadvantages of as well as later modifications. The purpose of the present article (1/3) is to review the approaches to the head and upper face.

Historical evolution of surgical approaches to the face-part II: midface.

Surgical approaches to the head and maxillofacial area have been described and modified by multiple authors throughout history. It was during nineteenth and twentieth century when most of the techniques evolved due to advances in anesthesia and antibiotic therapy. Currently, a myriad of surgical approaches are employed to gain access to the maxillofacial complex, with each of them having advantages and disadvantages. Although the approaches are presented in numerous textbooks and articles, few texts describe the circumstances or historical context under which they were developed. In a series of three articles, we will provide a historical perspective of the evolution of the most common surgical approaches to the head and face employed today. Descriptions contain advantages and disadvantages of the approaches and modifications are also provided. The purpose of the present article (2/3) is to review the approaches to the midface.

Dental Trauma and Alveolar Fractures.

A dentoalveolar fracture requires thorough clinical and radiographic examination for an accurate diagnosis to guide appropriate treatment. Dentoalveolar fractures can be classified into the following 4 groups: (1) crown/root fractures, (2) luxation/displacement of teeth, (3) avulsion, and (4) alveolar fractures. Treatment can be divided into nonrigid fixation (splinting with wires and composite) and/or rigid fixation (Erich arch bars, Risdon cable wires) depending on the extent of dentoalveolar fractures. Special considerations must be made for primary teeth and mixed dentition to avoid injuring tooth buds and arising permanent dentition.

Third molar surgery: Past, present, and the future.

Third molar surgery is the most common ambulatory procedure done by oral and maxillofacial surgeons. Surgical approaches for the removal of third molars have been published since the 20th century. This article reviews the history and development of extraction techniques through a literature review. The literature was selected through a search of an electronic database. Key words for the Medline search were "mandibular/maxillary third molar," "impacted mandibular/maxillary third molar," "mandibular/maxillary third molar flap design," and "mandibular/maxillary third molar incision." The search was restricted to English-language articles. Additionally, a manual search in the major oral surgery journals and books was performed. The aim of this article is to examine the evolution of third molar surgery, recognize pioneering techniques, and compare these techniques to current approaches. Common approaches employed today are discussed and treatment philosophies with thoughts for future therapies are provided.

Oculocardiac reflex in an adult with a trapdoor orbital floor fracture: case report, literature review, and differential diagnosis.

Orbital floor blowout fractures can result in a variety of signs and symptoms depending on the severity of the bone defect. Large defects often result in enophthalmos and restriction of ocular movement; yet the timing of surgery can be delayed up to two weeks with good functional outcomes. In contrast, an orbital trapdoor defect with entrapment of the inferior rectus muscle usually elicits pain with marked restriction of the upward gaze and activation of the oculocardiac reflex without significant dystopia or enophthalmos. When autonomic cardiac derangement is diagnosed along with an orbital floor fracture, it has been suggested that the fracture should be treated immediately. Otherwise, it will result in continued hemodynamic instability and muscular injury and may require a second surgery. This article reports the management of an unusual presentation of a trapdoor blowout orbital floor fracture surgery with oculocardiac response in an adult, with emphasis on its pathophysiology, management, and differential diagnosis.

Biodegradable polymerized simvastatin stimulates bone formation.

Previous research from our labs demonstrated the synthesis of polymerized simvastatin by ring-opening polymerization and slow degradation with controlled release of simvastatin in vitro. The objective of the present study was to evaluate the degradation and intramembranous bone-forming potential of simvastatin-containing polyprodrugs in vivo using a rat calvarial onlay model. Poly(ethylene glycol)-block-poly(simvastatin) and poly(ethylene glycol)-block-poly(simvastatin)-ran-poly(glycolide) were compared with simvastatin conventionally encapsulated in poly(lactic-co-glycolic acid) (PLGA) and pure PLGA. The rate of degradation was higher for PLGA with and without simvastatin relative to the simvastatin polyprodrugs. Significant new bone growth at the circumference of poly(ethylene glycol)-block-poly(simvastatin) disks was observed beginning at 4 weeks, whereas severe bone resorption (4 weeks) and bone loss (8 weeks) were observed for PLGA loaded with simvastatin. No significant systemic effects were observed for serum total cholesterol and body weight. Increased expression of osteogenic (BMP-2, Runx2, and ALP), angiogenic (VEGF), and inflammatory cytokines (IL-6 and NF-ĸB) genes was seen with all polymers at the end of 8 weeks. Poly(ethylene glycol)-block-poly(simvastatin), with slow degradation and drug release, controlled inflammation, and significant osteogenic effect, is a candidate for use in bone regeneration applications. STATEMENT OF SIGNIFICANCE: Traditional drug delivery systems, e.g., drug encapsulated in poly(lactic-co-glycolic acid) (PLGA), are typically passive and have limited drug payload. As an alternative, we polymerized the drug simvastatin, which has multiple physiological effects, into macromolecules ("polysimvastatin") via ring-opening polymerization. We previously demonstrated that the rate of degradation and drug (simvastatin) release can be adjusted by copolymerizing it with other monomers. The present results demonstrate significant new bone growth around polysimvastatin, whereas severe bone loss occurred for PLGA loaded with simvastatin. This degradable biomaterial with biofunctionality integrated into the polymeric backbone is a useful candidate for bone regeneration applications.

A historical perspective with current opinion on the management of atrophic mandibular fractures.

The management of atrophic mandibular fractures has been a challenge for maxillofacial surgeons for decades. During the past 70 years, various techniques for treating edentulous mandibular fractures have been advocated. These techniques have been praised, criticized, abandoned, improved, and used in combination with other methods. Although some of the principles of management outlined before the end of World War II are still valid in today's technological era, other concepts did not survive the test of time. The aim of this paper is to examine the evolution of treatment modalities for the management of atrophic mandibular fractures that have been employed over the years. Debates and discussions generated by this topic are included. Current techniques and treatment philosophies with thoughts for future therapies are provided.

Atrophic Mandible Fractures: Are Bone Grafts Necessary? An Update.

PURPOSE: The management of atrophic mandibular fractures poses a challenge because of anatomic variations and medical comorbidities associated with elderly patients. The purpose of this article is to review and update the literature regarding the management of atrophic mandible fractures using load-bearing reconstruction plates placed without bone grafts. MATERIALS AND METHODS: We performed a review of the English-language literature looking for atrophic mandibular fractures with or without continuity defects and reconstruction without bone grafts. Included are 2 new patients from our institution who presented with fractures of their atrophic mandibles and had continuity defects and infections. Both patients underwent reconstruction with a combination of a reconstruction plate, recombinant human bone morphogenetic protein 2, and tricalcium phosphate. This study was approved as an "exempt study" by the Institutional Review Board at the University of Kentucky. This investigation observed the Declaration of Helsinki on medical protocol and ethics. RESULTS: Currently, the standard of care to manage atrophic mandibular fractures with or without a continuity defect is a combination of a reconstruction plate plus autogenous bone graft. However, there is a need for an alternative option for patients with substantial comorbidities. Bone morphogenetic proteins, with or without additional substances, appear to be a choice. In our experience, successful healing occurred in patients with a combination of a reconstruction plate, recombinant human bone morphogenetic protein 2, and tricalcium phosphate. CONCLUSIONS: Whereas primary reconstruction of atrophic mandibular fractures with reconstruction plates supplemented with autogenous bone graft is the standard of care, in selected cases in which multiple comorbidities may influence local and/or systemic outcomes, bone morphogenetic proteins and tricalcium phosphate can be used as a predictable alternative to autogenous grafts.

Simultaneous removal of third molars and completion of a sagittal split osteotomy: effects of age and presence of third molars.

OBJETIVES: The risk of removal of third molars (M3) during a sagittal split osteotomy (SSO) is controversial. The purpose of this study was to review our experience with removal of mandibular M3 during versus before SSO. STUDY DESIGN: A chart and radiographic review was completed in all patients who underwent an SSO from April 2010 until September 2014. The presence or absence of M3, degree of impaction, age, sex, and occurrence of bad splits were noted. The variables were analyzed using the Pearson χ(2), ANOVA, and Fisher's exact tests set to a significance of 5%. RESULTS: For the 215 patients, the mean age was 23.28 years with an increase in the incidence of bad splits in older patients (P = .013). Sixty-six (30.70%) of them had at least 1 M3 present at the time of surgery. There were 6 (2.79%) bad splits. Paradoxically, looking at the occurrence of bad splits and presence of third molar, when the data were analyzed by the number of patients undergoing the procedure, there was slight evidence of a difference (P = .073), but when the data were analyzed by the surgical site, there was a statistically significant association (P = .05). CONCLUSION: The discrepancy between the 2 ways of analyzing the data may be related to there being double the number of observations when analyzed by surgical site and thus the analysis being more powerful.

Barriers to Repair in Maxillofacial Trauma.

IMPORTANCE: Multiple factors can be associated with the delayed repair of maxillofacial injuries that may be associated with increased morbidity. OBJECTIVE: To assess factors affecting timing of repair and barriers which may exist in the management of maxillofacial trauma. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study at a tertiary care facility used the Current Procedural Terminology coding to identify adult patients undergoing operative repair of maxillofacial injuries between January 2010 and December 2013. Demographic information, presence and severity of concomitant injuries, as well as fracture-specific data including fracture type(s), mechanism of injury, and documented complications were recorded. Identifiable delays for medical, logistical, or other reasons were also documented. Multivariate regression modeling was used to determine factors associated with increased time to repair. A comparative analysis was used to identify association between complications and time to operative repair. MAIN OUTCOMES AND MEASURES: Time to operative repair from date of presentation; association of known operative delay and perioperative complications. RESULTS: Overall, 780 patients were included in the study. Of patients meeting inclusion criteria, mean (SD) age was 36.7 (14.2) years (range, 18-88 years), and 616 patients (79%) were male. Average time to repair was 6.5 days (range, 0-43 days), and 138 patients (17.7%) were observed to have a documented reason for delay for medical reasons (n = 62 [44.9%]), operating room logistical factors (n = 17 [12.3%]), or other reasons (n = 59 patients [42.8%]) either as a function of delayed patient presentation or failure of patients to make scheduled appointments or operations. Injury severity score (ρ = 0.45; P < .001), concurrent injuries (P < .001), decreased Glasgow Coma Scale (P < .001) and inpatient status at time of surgery (P < .001), were associated with increased time to repair. The observed complication rate was 13.6%. There was no statistically significant association between known operative delay and development of complications (χ21 = 2.92; P = .08). CONCLUSIONS AND RELEVANCE: Management of maxillofacial trauma appears to occur in a timely manner. Patient injury severity appears to have the greatest effect on timing of repair. While delays in operative repair may be unavoidable in certain circumstances, streamlining and managing causes of known delay may help improve and expedite patient care. LEVEL OF EVIDENCE: 3.

Decision making in third molar surgery: a survey of Brazilian oral and maxillofacial surgeons.

This study was designed to evaluate the variations in decision making among Brazilian oral and maxillofacial surgeons (OMFS) and trainees in relation to third molar surgery. A survey on 18 diverse clinical situations related to the assessment and treatment of the third molar surgeries was conducted during the 20th Brazilian National OMFS meeting. Participants were divided into three groups according to their level of training. Another variable studied was length of experience. Correlation between the question answers and the variables was analysed using the chi-square test and the f test. The mean age of participants was 32.68 years, and their mean length of experience was 5.24 years. There were no statistical differences between the level of training and number of years of experience and the responses to 15 of the 18 questions on clinical situations. However, differences were found in responses to prophylactic extraction of asymptomatic third molars, use of non-steriodal anti-inflammatory drugs (NSAIDs) during the preoperative surgical period and the use of additional imaging to plan extractions. The group with shorter time of experience (3.8 ± 3.94 years) tended to recommend extractions of asymptomatic third molars more frequently compared with the more experienced surgeons (P = 0.041). More experienced surgeons used NSAIDs in the preoperative surgical period, whereas the majority of the youngest surgeons (4.1 ± 5.96 years of experience) did not (P = 0.0042). The certificated trained and in practice group tended to treat deep lower third molar impactions based on the findings of a panoramic radiograph, without obtaining additional imaging [cone beam computed tomography (CBCT)] before treatment (P = 0.0132). Decision making regarding third molar treatment differs according to the level of training and is influenced by the number of years of experience. Therefore, further continuous education programmes in this area are warranted to make recommendations regarding third molars consistent with the current literature.

Effects of epidermal growth factor-loaded mucoadhesive films on wounded oral tissue rafts.

Current treatments for traumatic oral mucosal wounds include the gold standard of autologous tissue and alternative tissue-engineered grafts. While use of autografts has disadvantages of minimal availability of oral keratinized tissue, second surgery, and donor site discomfort, tissue-engineered grafts are limited by their unavailability as off-the-shelf products owing to their fabrication time of 4-8 weeks. Hence, the current work aimed to develop a potentially cost-effective, readily available device capable of enhancing native mucosal regeneration. Considering the key role of epidermal growth factor (EGF) in promoting mucosal wound regeneration and the advantages of mucoadhesive delivery systems, mucoadhesive films composed of polyvinylpyrrolidone and carboxymethylcellulose were developed to provide sustained release of EGF for a minimum of 6 h. Bioactivity of released EGF supernatants was then confirmed by its ability to promote proliferation of BALB/3T3 fibroblasts. Efficacy of the developed system was then investigated in vitro using buccal tissues (ORL 300-FT) as a potential replacement for small animal studies. Although the mucoadhesive films achieved their desired role of delivering bioactive EGF in a sustained manner, treatment with EGF, irrespective of its release from the films or solubilized in medium, caused a hyperparakeratotic response from in vitro tissues with distinguishable histological features including thickening of the spinous layer, intra- and intercellular edema, and pyknotic nuclei. These significant morphological changes were associated with no improvements in wound closure. These observations raise questions about the potential of using in vitro tissues as a wound healing model and substitute for small animal studies. The mucoadhesive delivery system developed, however, with its potential for sustained release of bioactive growth factors and small molecules, may be loaded with other desired compounds, with or without EGF, to accelerate the process of wound healing.

Incidence of bracket failure during orthognathic surgery: a comparison of two techniques to establish interim maxillomandibular fixation.

PURPOSE: The purpose of this study is to review the frequency of bracket failure using two different techniques for establishing interim fixation during orthognathic surgery. METHODS AND MATERIAL: The first group (standard technique) had a maxillomandibular fixation (MMF) established during surgery by ligating splints to orthodontic appliances. The second group of patients had an interim fixation established using maxillomandibular screws (alternative technique). Preoperative and immediate postoperative panoramic radiographs were examined for loose and or missing brackets in both groups. Intraoperative observations were also recorded in the second group. The type of surgery (one- or two-jaw) and whether or not cemented bands on the molars were present were noted. A Pearson's chi-square analysis was done comparing the two groups. RESULTS: There were 210 patients in the first group and 104 in the second. The overall incidence of missing or loose brackets following surgery in the standard technique group was 16%; 172 of them had a cemented band on either the first or on the first and second molars. There was a higher incident of lost or loose bonded brackets when the patients had no cemented brackets or underwent a two-jaw surgery. In the second group of 104 patients, there was one loose or missing brackets caused by the application of MMF (Pearson's chi-square value = 15.84, p < 0.0001). CONCLUSIONS: When using orthodontic brackets to establish interim fixation, the incidence of missing or loose brackets during orthognathic surgery was dramatically higher in two-jaw cases and in cases where only bonded brackets were placed by the orthodontist. When using maxillomandibular screws to establish interim fixation, the problem has been greatly diminished.

Local delivery of imiquimod in hamsters using mucoadhesive films and their residence time in human patients.

OBJECTIVE: To investigate the ability of mucoadhesive films to locally deliver an immune response modifier (imiquimod) to oral mucosa. STUDY DESIGN: After determining the residence time of films in hamster cheek pouches, drug-loaded films and commercially available imiquimod cream were tested for localization of drug in mucosal tissue. The residence time of drug-free films at different locations was also tested in humans. RESULTS: Mucoadhesive films delivered imiquimod to the buccal mucosa with no measureable amounts in blood. In contrast, although the cream formulation resulted in higher tissue levels, it also led to significant systemic distribution of imiquimod. In humans, the films resided on tissue for up to 4 hours, increasing in the order of tongue < cheek < gingiva. CONCLUSION: Preclinical findings of localized imiquimod delivery in animals and residence in humans support future investigations of the mucoadhesive system in controlled clinical trials for treating oral precancerous lesions.