Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK).

Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.

Carvable calcium phosphate bone substitute material.

This study investigated the use of partially set hydroxyapatite forming calcium phosphate cement as a carvable and mechanically stable bone substitute material. Hydroxyapatite-forming cements were made of either mechanically activated alpha-tricalcium phosphate or a mixture of tetracalcium phosphate and dicalcium phosphate anhydrous and setting was arrested up to 4 h post setting. The study showed that these partially set rigid samples of defined geometry could be carved into a desired shape when the degree of reaction was 30-40% and the relative porosity between 40 and 50%; samples are then expected to set completely after implantation in the presence of water or serum, having the same compressive strength as a continuously set calcium phosphate cement (up to 36 MPa). The development of compressive strength, phase composition, and crystallinity when varying production parameters of these partially "preset" bone substitute materials are presented for both cement systems.

Contemporary surgical management of hypodontia.

Hypodontia is the term most commonly applied to the condition in which teeth congenitally fail to develop. Such cases differ from teeth that have been lost early or that have failed to erupt, although their initial presentation may be similar and therefore not recognised. The range of missing teeth and their physical and psychological results is large, and the difference in complexity in the management of a patient with isolated hypodontia compared with one with oligodontia or anodontia together with skeletal and orthognathic discrepancies should not be underestimated. Surgical interventions primarily involve augmentation of bone before placement of an implant, but may include techniques such as distraction osteogenesis and orthognathic surgery. These patients are best managed by a multidisciplinary team, and in this review our aim has been to describe the role of oral and maxillofacial surgeons within it.

Success rates and complications of autologous onlay bone grafts and sinus lifts in patients with congenital hypodontia and after trauma.

Autogenous bone remains the gold standard for augmentation of the alveolar ridge in congenital hypodontia and appreciable post-traumatic deformity. This generally reflects the volume of material required for such defects and the osteogenic potential of the grafts. Morbidity at the donor site and success rates may lead to autogenous grafts being superseded by xenografts or alloplastic materials in the future, but we know of little evidence to confirm this. All patients having augmentation of the alveolar ridge or sinus lift to enable subsequent placement of implants between 01 January 2009 and 31 December 2016 were identified from a prospectively-gathered database held at the Queen Elizabeth Hospital, Birmingham. Morbidity was recorded, with overall success defined as a graft that enabled subsequent placement of an implant. During this period the following grafts: calvarial (n=4), iliac crest (n=4), and ramus (n=149) were recorded, as well as 53 sinus lifts. Sinus lift augmentation with BioOss® had the highest success rate (51/53). Calvarial and iliac crest grafts had higher failure rates (2/4 and 3/4, respectively) than those from the mandibular ramus (6/149, 4%). Fifteen of 149 (10%) ramus grafts resulted in transient anaesthesia of the inferior alveolar nerve but no patients developed any permanent morbidity at the donor or recipient sites. Ramus grafts are a predictable method of bone augmentation with only transient morbidity at the donor site. Higher failure rates for extraoral grafts probably reflect their use in more challenging cases when more bone is required. Bilateral ramus grafts are an alternative to extraoral grafts and may be supplemented by bovine-derived particulate grafts with no appreciable increase in complications.

Cortical bone screw fixation in ionically modified apatite cements.

Hydroxyapatite cements are used in reconstruction of the face; usually in well-defined cavities where the cement can be stabilized without the need for internal fixation. A hydroxyapatite cement that could enable screw fixation and some loading therefore has considerable potential in maxillofacial reconstruction. It has been demonstrated recently that water demand of calcium phosphate cements can be reduced by ionically modifying the liquid component. This study investigated the capacity of an ionically modified precompacted apatite cement to retain self-tapping cortical bone screws. Screw pullout forces were determined in the direction of the screw long axis and perpendicular to it, using cortical bone and polymethylmethacrylate cement as a control. In bending pullout tests, measured forces to remove screws from ionically modified precompacted cement were insignificantly different from cortical bone. However, pullout forces of bone screws from hydroxyapatite cement decreased with aging time in vitro.

Anchoring the detached temporalis muscle in craniofacial surgery.

The temporalis muscle is often detached to enable craniofacial tumour and trauma access surgery. Failure to carefully handle and reattach the muscle often leads to a cosmetic and functional deformity. The authors discuss the principles of elevation of the whole temporal muscle within its surrounding fascia to reduce atrophy. The temporalis muscle is then reattached to its point of origin, using suspensory absorbable sutures attached to 3 mm titanium microscrews placed inferior to the limits of the muscle, to make them non-palpable. The aim is to reduce the postoperative temporal hollowing often seen when these principles are not observed. A series of cases using this technique are reported.

Local bupivacaine infusion following bone graft harvest from the iliac crest.

A method of local analgesic delivery to the donor site after the harvest of autogenous corticocancellous bone from the iliac crest is described. The technique reduces the need for postoperative systemic analgesia and facilitates early patient mobilization.

Links between anaesthetic modality and nerve damage during lower third molar surgery.

OBJECTIVE: To investigate the relationships between eruption status, gender, social class, grade of operator, anaesthetic modality and nerve damage during third molar surgery. DESIGN: Two centre prospective longitudinal study. SETTING: The department of oral and maxillofacial surgery, University Hospital Birmingham NHS Trust and oral surgery outpatient clinics at Birmingham Dental Hospital. SUBJECTS: A total of 391 patients had surgical removal of lower third molars. Sensory disturbance was recorded at one week post operatively. Patients with altered sensation were followed up at one month, three months and six months following surgery. RESULTS: 614 lower third molars in 391 patients were removed. Forty-six procedures (7.5%) were associated with altered sensation at one week with three procedures (0.49%) showing persistent symptoms at six months. Of these 46 nerve injuries, 26 (4.23%) involved the lingual nerve and 20 (3.25%) the inferior dental nerve (IDN). All three persistent sensations were IDN related. A logistic regression model found that the use ofa lingual retractor chi2 = 11.559, p = 0.003 was more significant than eruption status chi2 = 12.935, p = 0.007. There was no significant relationship between anaesthetic modality, age, social class, sex and seniority of operator. CONCLUSIONS: There was no link between the choices of local or general anaesthesia and nerve damage during lower third molar removal when difficulty of surgery was taken into account.

A method of skeletal anchorage for maxillary distraction.

A simple method of providing skeletal anchorage in maxillary distraction is described. The method utilizes cheap and readily available miniplates and provides rigid fixation to the fragment. It can be utilized at multiple levels in high-level osteotomies and situations with an inadequate dentition for anchorage.

Role of parental risk factors in the aetiology of isolated non-syndromic metopic craniosynostosis.

To try and identify potential parental risk factors for isolated non-syndromic metopic craniosynostosis, we did a telephone survey of parents of children who attended the craniofacial centre at Birmingham Children's Hospital (BCH), UK, from 1995 to 2004. We calculated the prevalence of a number of potential risk factors and compared them with those of the general population. A total of 103 children with syndromic or non-syndromic isolated metopic craniosynostosis were seen, of which 81 (79%) had non-syndromic, isolated metopic craniosynostosis (M:F ratio 3:1). The response rate to the telephone survey was 72%. The prevalences of maternal epilepsy and the use of valproate, antenatal maternal complications (hypertension or pre-eclampsia, haemorrhage, and urinary tract infection), and fertility treatment in our sample were significantly higher than among the general population (p=0.01 or less in all cases). The likely roles of maternal epilepsy and taking valproate in the aetiology of isolated non-syndromic metopic craniosynostosis are further consolidated by our study. The finding that antenatal complications are possible risk factors for craniosynostosis has not to our knowledge been published previously.

Changing referral patterns to a designated craniofacial centre over a four-year period.

Craniofacial conditions are mainly treated within England by four supra-regional centres. Due to a continuous increase in the number of cases referred to our service we audited the source and nature of these referrals. Data was prospectively collected over a four-year period from April 2004 to March 2008. The speciality of the referring clinicians was recorded, along with the diagnosis. A year-by-year increase in the number of referrals from 138 in 2004-2005 to 253 in 2007-2008 was seen. There was a 214% increase in the number of patients referred with single suture craniosynostosis, a 520% increase in patients with benign hyperplastic conditions such as fibrous dysplasia, neurofibromatosis and vascular anomalies and a 220% increase in patients treated elsewhere but now needing revision surgery. A 407% increase in referrals for positional plagiocephaly was recorded. Our referral pattern reflects the internationally accepted increase in the incidence of metopic synostosis and positional plagiocephaly. Due to the skill mix and experience present in a designated craniofacial service other benign hyperplastic and hypoplastic conditions are increasingly being referred. Additional referrals have come from a change in the referral pathway. To manage the increased workload we have established separate clinics to manage vascular anomalies and have adopted a policy of not reviewing patients with positional plagiocephaly.

Removal of miniplates in maxillofacial surgery: a follow-up study.

PURPOSE: We sought to follow-up a cohort of patients who had miniplates (plates) inserted in the oral and maxillofacial region during a 13-month period over 4 years to study the incidence and factors associated with plate removal. PATIENTS AND METHODS: One hundred fifty-three patients had plates inserted in the oral and maxillofacial region in the Department of Oral & Maxillofacial Surgery, University Hospital Birmingham, UK, between November 1, 1998, and November 30, 1999. All 153 patients' records were revisited on or after October 31, 2002, giving a minimum follow-up of 3 years and a maximum of 4 years. RESULTS: During a period of 13 months (November 1, 1998 through November 30, 1999), 308 plates were inserted into 153 patients. A total of 32 plates were removed from 21 patients by October 31, 2002, (10.4%) over 4 years; 27 plates were removed from 16 patients for purely plate-related symptoms, with infection being the most common cause accounting for 16 plates (50%) in 9 patients. Symptoms necessitating plate removal occurred within 52 weeks after insertion in 16 patients, accounting for 23 of the plates removed (72%). The age of the patient at plate insertion may have some influence on plate removal but this was not significant. Seniority of the operator did not affect plate removal. CONCLUSION: Our experience with the removal of miniplates compares with previously published reports. Longitudinal follow-up at 4 years indicates that plate-related problems leading to removal are likely to occur in the first year after insertion.

Cranioplasty in children.

OBJECTIVE: The objective was to assess the outcome and complications associated with different cranioplasty implant materials in children. MATERIALS AND METHODS: A retrospective review was conducted of 28 consecutive cranioplasties carried out on 24 children between 1994 and 2001 (age range, 9 months to 15 years; minimum follow-up 18 months). The indications were: defect from previous craniectomy for trauma, tumour, infection or evacuation of haematoma (n=21), intradiploic dermoid cysts (n=2), growing fractures (n=4) and residual bony defect following craniofacial reconstruction (n=1). The materials used were: patient's craniectomised bone flap (n=16), split calvarial graft (n=8), acrylic (n=3) and titanium (n=1). All patients were assessed for bony fixation, cosmesis, wound healing and flap infection. RESULTS: There was no mortality and 18% morbidity (n=5: 3 infected flaps, 1 sterile wound dehiscence and 1 sterile wound discharge; overall infection rate 10%). Out of the 14 patients who had their own craniectomised bone flaps implanted initially, 3 became infected (2 in patients with bilateral defects) necessitating flap removal. Two of these were successfully re-implanted. No donor or recipient bone flap complications were seen in the 8 split calvarial grafts, wound discharge was seen in 1, requiring wound toilet. No complications were seen with acrylic or titanium cranioplasties. CONCLUSION: In this series, the use of the patients' own craniectomised flap had a low infection rate, and was mainly seen in patients who had bilateral flaps re-implanted soon after removal. There were no complications arising from the use of split calvarial and allograft material. Use of autologous implant material should be preferred whenever possible due to obvious resource and biological advantages, and can even be re-implanted if infected.

The effect of collagen and indomethacin on inflamed dental pulp wounds of baboon teeth.

Following the induction of experimental pulpitis in baboon teeth, calf skin collagen, indomethacin, or zinc oxide-eugenol was used to dress exposed dental pulp wounds in selected teeth. The teeth were extracted after 7, 35, and 90 days fixed in formalin, and processed, for histopathologic examination. The inflammatory response to zinc oxide-eugenol remained moderate throughout the experiment, whereas the inflammatory response to indomethacin and collagen was present from the outset and became progressively more severe, especially with collagen. The amount of irritation dentin production, however, was greater in those dental pulps dressed with collagen and indomethacin.

Breast abscesses and cigarette smoking.

An 11-year retrospective review of women with breast abscesses presenting to a district general hospital was performed. A total of 122 women were identified with a breast abscess: 85 (70 per cent) with non-lactational abscesses and 37 (30 per cent) with an abscess in the puerperium. Six of 37 lactational and 24 of 85 non-lactational abscesses recurred. Sixteen mammillary fistulae developed, all following incision and drainage of non-lactational breast abscesses. Women with non-lactational breast abscesses were more likely to smoke cigarettes (P less than 0.005). Breast abscesses containing anaerobic bacteria were significantly more likely to occur in current cigarette smokers (P less than 0.05). Women with non-lactational breast abscesses who were heavy cigarette smokers were more likely to suffer recurrent abscesses (P less than 0.01). There was histological evidence of duct ectasia on biopsy in 25 women with non-lactational abscesses and 21 of 25 were current smokers. Mammillary fistulae developed more frequently in current smokers (P less than 0.03). Cigarette smoking is important in the natural history of non-lactational breast abscesses and may predispose to anaerobic breast infections and the development of mammillary fistulae.