Surgical Glove Perforation and Percutaneous Injury during Intermaxillary Fixation with 0.5 Mm Stainless Steel Wire.

INTRODUCTION: The risk of exposure of either the patient or the surgeon to pathogens when the surgical glove is perforated is significant. This is particularly so in jaw fractures when intermaxillary fixation is done with the stainless-steel wire as many perforations also result in percutaneous injury. MATERIAL AND METHOD: This study was carried out in two tertiary Hospitals in Abuja, Nigeria. Adult patients for intermaxillary fixation as a result of jaw fractures were consecutively recruited into the study. Similarly, surgeons and their trainees (assistants) were also recruited. Factors investigated included the method of gloving used by surgeons and trainees (single versus double gloving), glove perforations and percutaneous injury rates, years of operator's experience, among others. During surgical operations, percutaneous injuries were recorded and obviously perforated or torn gloves were labelled and changed. At the end of every surgical procedure, gloves used were investigated for perforation. RESULTS: A total of 564 gloves were investigated (Surgeons-337; Trainees-227) after use for wire intermaxillary fixation procedures. The frequency of glove perforations for the surgeons was 72 (21.4%). Forefinger perforations were most frequent; 40 (55.6%) cases. Assistants, had 35 (15.4%) cases of glove perforations. Percutaneous injury occurred in 9.7% (7/72) and 5.7% (2/35 cases) of cases for surgeons and assistants, respectively. CONCLUSION: The study revealed high risk for wire-based IMF procedures. Single gloving was more frequently associated with percutaneous injuries although double gloving was more associated with perforations with higher surgeon infection risk. Double gloving reduces the risk of percutaneous injuries and, therefore, the likelihood of exposure to blood-borne pathogens.

INTRODUCTION: Le risque d'exposition du patient ou du chirurgien à des agents pathogènes lorsque le gant chirurgical est perforé est important. Cela est particulièrement le cas dans les fractures de la mâchoire lorsque la fixation intermaxillaire est effectuée avec le fil en acier inoxydable, car de nombreuses perforations entraînent également des lésions percutanées. MATÉRIEL ET MÉTHODE: Cette étude a été réalisée dans deux hôpitaux tertiaires à Abuja, au Nigeria. Des patients adultes pour une fixation intermaxillaire à la suite de fractures de la mâchoire ont été recrutés consécutivement dans l'étude. De même, des chirurgiens et leurs stagiaires (assistants) ont également été recrutés. Les facteurs étudiés comprenaient la méthode de gloving utilisée par les chirurgiens et les stagiaires (simple versus double gloving), les perforations de gants et les taux de blessures percutanées, les années d'expérience de l'opérateur, entre autres. Au cours des opérations chirurgicales, des blessures percutanées ont été enregistrées et des gants manifestement perforés ou déchirés ont été étiquetés et changés. À la fin de chaque intervention chirurgicale, les gants utilisés ont été étudiés pour la perforation. RÉSULTATS: Au total, 895 gants ont fait l'objet d'une enquête (Surgeons-337; Stagiaires-227) après utilisation pour les procédures de fixation intermaxillaire du fil. La fréquence des perforations de gants chez les chirurgiens était de 72 (21,4 %). Les perforations de l'index étaient les plus fréquentes, 40 (55,6 %) cas. Assistant, avait 35 (15,4%) cas de perforations de gants. Des lésions percutanées sont survenues dans 9,7 % (7/72) et 5,7 % (2/35 cas) des cas chez les chirurgiens et les assistants respectivement. CONCLUSION: L'étude a révélé un risque élevé pour les procédures filaires du FMI. Le gloving simple était plus fréquemment associé à des blessures percutanées, bien que le double gloving soit plus associé à des perforations avec un risque d'infection plus élevé chez le chirurgien. Le double gloving réduit le risque de blessures percutanées et, par conséquent, la probabilité d'exposition à des agents pathogènes transmissibles par le sang. MOTS CLÉS: Fixation intermaxillaire, gants, Chirurgien, Lésion percutanée.

Retrospective evaluation of necrotizing fasciitis in University College Hospital, Ibadan.

CONTEXT: Cervicofacial necrotizing fasciitis (CNF), although a potentially fatal fulminant infection has been largely under-reported in the dental literature. AIMS: To report our experience with cases seen and treated at the University College Hospital, Ibadan, Nigeria. SETTINGS AND DESIGN: A descriptive retrospective clinical study. MATERIALS AND METHODS: A retrospective survey of cases treated between January 2002 and January 2007 was done. Diagnosis of CNF was established by fascia necrosis found on surgical exploration. Patients' age, sex, medical status, etiology of infection, bacteriology, and treatment received and complications were reviewed. STATISTICAL ANALYSIS USED: SPSS version 15. RESULTS: Of the 48 cases of cervicofacial infection admitted during the study period, only 12 cases of CNF were found. Male:Female ratio was 4:8. The mean age of patients was 58.83 ± 11.91 years while the age range was 42-83 years. Those that had immunocompromised medical conditions included three cases each of diabetes mellitus and chronic nutritional anaemia and one case of retroviral infection. Mixed bacterial isolates of anaerobes and enterobacteriaceae were found in 10 cases while beta hemolytic streptococci were the sole isolate in two cases. All patients had serial debridement combined with intravenous antibiotic medications. Complications included anterior chest wall infection in three patients and one case of pleural effusion. The only mortality occurred in the patient with retroviral infection. CONCLUSIONS: We advocate early recognition, surgical debridement and intensive medical care for treatment of CNF in order to reduce morbidity and mortality from this condition.

Mandibular defect reconstruction with nonvascularized iliac crest bone graft.

CONTEXT: Reconstruction of mandibular defect is a challenge to the head and neck surgeon because of associated functional and esthetic problems. Our experience with the use of nonvascularized iliac crest bone graft is hereby reported. AIM: The aim was to report our experience with the use of nonvascularized iliac crest bone for mandibular defect reconstruction at University College Hospital, Ibadan. Nigeria. SETTINGS AND DESIGN: A retrospective descriptive study was performed. MATERIALS AND METHODS: Cases of mandibular reconstruction with iliac crest bone graft between January 2001 and December 2007 were included in this study. Grafts were secured with either a stainless steel wire or a titanium plate. Preoperative diagnosis, postoperative follow-up records including investigations, diagnosis of graft infection and subsequent treatment modalities were extracted from the available records. STATISTICAL ANALYSIS USED: Descriptive variables were analyzed with SPSS version 14. RESULTS: A total of 47 patients had mandibular defect reconstruction with nonvascularized iliac crest block bone during the study period. Thirty-eight patients had graft secured with transosseous wire [NVIBw] while 9 had a titanium plate [NVIBp]. The male:female ratio was 26:21 while the mean age of the patients was 24.6±4.25 years. Ten patients (21.3%) developed persistent graft infection during the postoperative period. All cases of infection occurred in patients who had transosseous wiring and analysis showed that 60% of the infected grafts revealed mixed microbial isolates containing Klebsiela spp, Pseudomonas Aeurogenosa, and E coli. Six (60%) of the infected grafts were removed as a result of unabated infection while 4 (40%) were successfully treated by exploration and pus drainage. CONCLUSIONS: Nonvascularized iliac crest bone graft provides an affordable and less technical choice for mandibular reconstruction with minimal complications in a resource-limited economy.

An audit of mandibular defect reconstruction methods in a Nigerian Tertiary Hospital.

AIMS AND OBJECTIVES: To audit methods of mandibular defect reconstruction used in our institution. MATERIALS AND METHODS: A retrospective study of mandibular bone reconstruction at the University College Hospital Ibadan between January 2001 and December 2007. Relevant records were retrieved from patients' case notes and operation register. Comparative analysis of various methods of reconstruction was done by assessing treatment outcomes such as restoration of continuity and stability, graft infection, extrusion and fractures. RESULTS: Only 65 of the 82 patients that had mandibular continuity defect during the study period had reconstruction. Ameloblastoma accounted for 67% [n=55] of pathologies that required mandibular resection. Methods of reconstruction included non vascularised iliac bone anchored with either stainless steel wire (NVIBw) [n=38] or titanium plate (NVIBp) [n=9], titanium reconstruction plate [n=4] Steinman pin [n=12], rib graft [1] and acrylic plate temporisation [n=1]. The findings showed that titanium plate and NVIBp had the least complications in terms of infection, graft extrusion, fracture and wound dehiscence. NVIBw and Steinman pin had the highest infection rates. CONCLUSION: We recommend the use of NVIBp and titanium reconstruction plate as they have the least complication rate. We also advocate future prospective study.

Comparative effect of tube drain on post operative inflammatory complications of impacted mandibular third molar surgery College Hospital, Ibadan, Nigeria.

BACKGROUND AND OBJECTIVES: Swelling, pain and trismus are acute reversible inflammatory complications of impacted mandibular third molar (M3) surgery. They contribute to the deterioration of quality of life and loss of several useful working hours. This study aimed to investigate whether the use of a surgical drain following M3 surgery can minimise these inflammatory complications. PATIENTS AND METHODS: Eighty consecutive patients who gave consent were enrolled into the study. Patients were assigned into two groups (drain and no drain) by systematic sampling method which was modified to ensure matching of patients by age, sex and spatial relationship of the impacted mandibular third molar. The patients in the drain group (n=40) had a Foley's catheter drain inserted into the wound after the surgical procedure while the patients in the no drain group (n=40) had their wound closed without the use of drain. All patients had primary wound closure with 3.0 black silk sutures after the procedure. Demographic data, cheek dimension and maximal mouth opening were recorded before the procedure. Pain, swelling and trismus were evaluated in the two groups at 24 hours, 48 hours and 7th day after surgery. RESULTS: Post operative swelling and visual analogue scale score for pain were comparatively lesser in the drain group patients. The maximal interincisal distance was also more in the drain group patients. CONCLUSION: The findings from this study indicated that there is a significant benefit of using a surgical drain in minimising postoperative oedema, pain and trismus following surgical removal of impacted mandibular third molar.

Incidence and risk factors for nerve injuries in mandibular third molar surgery.

BACKGROUND: The inferioralveolar (IAN), lingual (LN) and long buccal nerves (LBN)are the three terminal branches of the trigeminal nerve which are susceptible to injury during surgical extraction of impacted mandibular third molars. While it is not always possible to accurately predict the patients that will be affected with these complications, understanding and identifying the risk factors may allow the adoption of appropriate technique and expertise for specific cases. We embarked on this study to document the incidence and duration of injury to the inferior alveolar nerve (IAN), lingual nerve (LN) and long buccal nerve (LBN) following the operative removal of impacted mandibular third molars and to identify the associated radiographic and operative risk factors. METHOD: Pre- and postoperative neurosensory tests were performed for seventy nine patients who had surgical extraction of unilateral impacted mandibular third molars to determine the incidence and duration of complicating nerve injuries. The risk factors for nerve injury were determined among the radiographic variables and documented operative events. RESULTS: The incidence reported were 6.6% for IAN, 2.6% for LN and 4.0% for LBN; all but one of the nerve injuries resolved within 2 weeks. Depth of impaction (Pell & Gregory Level C) and linguo-version were the significant risk factors for IAN and LN injuries respectively while no risk factors was detected for LBN injury. Some significant operative events were associated with nerve injuries. CONCLUSION: Nerve injury in third molar surgery can be predicted based on some radiographic risk factors and some unforeseen intraoperative events. Most of the injuries are transitory in nature.

Evaluation of Pederson index as an instrument for predicting difficulty of third molar surgical extraction.

AIM: This study was intended to assess the clinical reliability of the Pederson index as an instrument for preoperative determination of surgical difficulty in third molar surgery. METHODS: Pederson index was used to predict the difficulty of 79 cases of impacted mandibular third molar extractions. The predictions were compared with actual surgical difficulty determined by operation time. The reproducibility as well as the reliability of the index was determined. RESULTS: The index was found to be highly reproducible (P=0.00). The sensitivity and specificity were 94.9% and 45% respectively. The Positive predictive value (PPV) was 67.2% and the negative predictive value was 90% while the accuracy was 69.6%. CONCLUSION: The Pederson index though reproducible is not a reliable instrument for predicting surgical difficulty of third molar surgery when compared with actual surgical difficulty as determined by the operation time. There is a definite need to derive an index that could be used for preoperative prediction of difficulty; however it is much more important that any index so employed should provide accurate information as the consequence of wrong judgments could be quite deleterious to the patients and embarrassing to the surgeon. While it is not completely unimportant, the Pederson index should not be employed as a sole instrument for preoperative assessment of difficulty in third molar surgery.

Indications for the removal of impacted mandible third molars at Ibadan--any compliance with established guidelines?

The removal of impacted lower third molars has been a subject of controversy among dental practitioners since the turn of the twentieth century. A yet unresolved aspect of the controversy is the definition of appropriate indications for surgical extraction. Clinical guidelines have long been established but the effectiveness of adoption of the guidelines is still to be proved in our environment. A retrospective observational study of the indications for extractions in oral surgery clinic of the University College Hospital (UCH), Ibadan was conducted with the aim of identifying the common indications and to verify the level of compliance with established guidelines. There were 294 extractions out of which the indications for 268 cases were recorded. We found that pericoronitis constituted the most frequent indication 190 (33.6%) recurrent, 36 (13.4%) acute cases] while apical periodontitis 70, (26.1%) was next most frequent. Prophylactic extractions were performed in 34 (12.7%) cases. Other indications such as pulpitis 19, (7.1%), dental caries 13, (4.9%), dentoalveolar abscess (4, 1.5%), orthodontic reason (1, 0.3%) and tooth fracture (1, 0.37%) were also recorded. Compliance rate with NIH criteria and NICE guidelines were 87.3% and 73.9% respectively. We recommend that prophylactic extractions be discouraged while guidelines should be adequately emphasized for effective clinical practice.

Multiple malignant lesions involving the orofacial region: a case report.

We describe a rare finding in a 38 year old patient with previously undiagnosed prostate cancer who presented with multiple facial swellings, mental nerve neuropathy and paraplegia. While the co-existence of paraplegia and mental nerve neuropathy is a possible feature of metastatic prostate cancer involving the spine and mandible, the concomitant occurrence of multiple facial swellings involving the anterior mandible with its related gingival and lip mucosa, frontal bone and parotid glands is a rare finding. This raised a suspicion of two histologically different malignancies co-existing in this patient. Fine needle aspiration cytology (FNAC) of the parotid lesion and incisional biopsy of the gingival lesion were reported as Lymphoblastic lymphoma and Non Hodgkin's Lymphoma respectively. A Transrectal biopsy of the prostate gland confirmed adenocarcinoma of the prostate gland. The patient however died due to a number of intercurrent illnesses and rapid deterioration consequent on his disease condition. Unfortunately, all efforts to carry out an autopsy were unsuccessful due to strong objection of the relatives on religious grounds. Problem associated with the diagnosis and management of such a rare case in a developing economy was highlighted.

Incidence and pattern of maxillofacial fractures in the elderly.

The results of an audit analysing patients above 60 years and above treated for maxillofacial fractures over a 15-year period at the University College Hospital, lbadan are presented. Of the total number of 1689 patients of all ages treated for facial fractures, 53 (3.1%) were within the age range of the study. The male to female ratio was 1.1:1 and 41 (77.4%) patients were younger than 70 years. Road traffic accidents were the most common cause of facial fractures (58.5%) and the mandible was involved in 91% of cases. Complications were noted in 2 (3.8%) patients. Attention should be paid to update driving courses and home safety instructions in order to reduce the incidence of maxillofacial fractures in the elderly.

Fractures of the mandible in children.

OBJECTIVE: To determine the pattern of occurrence of mandibular fractures in a paediatric population. DESIGN: A retrospective study. SETTING: University College Hospital, Ibadan, Nigeria. SUBJECTS: Seventy two paediatric patients seen and managed between 1989 and 1998. RESULTS: Road traffic accidents were the most common (52.8%) cause of mandibular fractures. The majority of the patients (57.0%) were within the age group (12-16 years). The body of the mandible was involved in 43.4% of the fractures. Eyelet wires with intermaxillary fixation was used in 41.7% of the cases. CONCLUSION: There is a need to enforce legislation aimed at preventing road traffic accidents to reduce maxillofacial injuries among children.

Necrotizing fasciitis of odontogenic origin in Ibadan, Nigeria.

We reviewed eight patients with necrotizing fasciitis of odontogenic origin. There were three women and five men, mean age 58 (range 46-72), and none had any associated medical condition such as diabetes. All cases had symptoms of toothache for a mean duration of 34 days (range 26-42) before they sought treatment. Infection originated in the molar teeth region, and initially presented as an odontogenic or periodontal abscess. The clinical features of necrotizing fasciitis became apparent only after the superficial fascia had been invaded. The transient unusually reddish hue for a dark skin might be explained by the fact the deep fascia and muscles were affected before the superficial fascia and skin. Necrosis of the skin began in the submandibular region and progressed downwards. The necrotic area was less than the extent of infection. Antimicrobial treatment, debridement, and fasciotomy improved healing. Delay before appropriate treatment had an adverse affect on outcome, and one patient died.

Ankylosis of the temporomandibular joint as a complication of forceps delivery: report of a case.

A two and half years old girl presented with severe limitation of mouth opening, facial asymmetry, inability to masticate, and proclination of the anterior maxillary and mandibular teeth. There was no history of facial trauma, infection or neonatal fevers. A diagnosis of bony ankylosis of the TMJ was made following a confirmation of delivery by means of obstetrics forceps during a difficult labour. The causes of TMJ ankylosis and the sequaele are highlighted.

Mandibular segmental reconstruction with iliac crest.

Twenty patients consisting of 14 males and 6 females with benign destructive lesions of the mandible were reconstructed using free nonvascularised iliac crest. Harvested bone was contoured and secured with 0.5 mm stainless steel wire and reinforced with maxillo-mandibular fixation. Five patients has hemimandibulectomy with immediate reconstruction. The other 15 patients had 1 to 3 segments of the mandible reconstructed. There was only one failure. Mouth opening and closure were centric except in the patients that had hemimandibulectomy without condylar reconstruction. Mastication and facial appearance were satisfactory. In conclusion, the iliac crest is recommended for reconstruction of hemimandible as well as long contiguous segments of the mandible.

Dentofacial findings in Down's syndrome: report of case.

Provision of dental services to the mentally subnormal in our society is relatively neglected. A patient with Down's syndrome who sought dental treatment is reported. Following the assessment of the patient, he needed orthodontic-surgical treatment and scaling and polishing. The former was not given due to the cost, complications and stress of such an involving procedure vis-a-vis the benefit to such a patient. However, patient received thorough scaling and polishing with emphasis on routine 6-monthly dental check-ups given. Handicapped individuals are beginning to seek dental services and the percentage of them doing so is likely to increase as more of such individuals are now staying in the normal home setting. Early preventive treatments for such patients are encouraged. Therefore, the dentists and the rest of the therapy team should be sensitized to face the challenge of providing services to them.

Dental emergencies in children seen at University College Hospital (UCH), Ibadan, Nigeria--5 year review.

A five year review of 106 children aged less than 17 years who presented at the accident and emergency unit of UCH, Ibadan for an after hour dental emergency services is presented. More than 50% of the children were males. The dominant age group was 0-4 years and the most common aetiology was road traffic accident. Jaw fractures and soft tissue lacerations were the commonest presentation and fractured limbs were the most common concomitant injuries. The need to abolish street trading among children is emphasised as this has been recognised to expose children to hazards of the road since most of the children were pedestrians.

Sports related maxillofacial fractures in 77 Nigerian patients.

A ten-year review of seventy-seven maxillofacial fractures due to sports seen and treated at the Maxillofacial Unit, Ring Road State Hospital, Ibadan and University College Hospital, Ibadan is presented. Majority of the patients were in the 21-30 years age group. The male to female ratio was 4.1:1. Males were more involved than females. The mandible (54.5%) was more involved in sports injuries than the middle third region of the face. The most common sport implicated in maxillofacial fracture was soccer followed by boxing. A greater percentage of the patients (57.1%) had closed reduction and fixation. Though sports related maxillofacial fractures tend to be less grave than those due to road traffic accidents, they could be lessened by the use of mouth and face guards.

Facial bone fractures in Nigerian children.

A ten year review of ninety-three patients aged 16 years or less treated for facial bone fractures at the University College Hospital, Ibadan was studied. Of the total number of 1203 patients of all ages treated for facial fractures, 93 (7.7%) were within the age range of the study. The male to female ratio was 2.6:1 and majority of the patients (50, 53.8%) were within age group C (11-16 years). The mandible (106, 83.5%) was more involved than the middle third of the facial skeleton (21, 16.5%). Road traffic accidents (51.6%) were the most common cause of facial fractures while the most common concomitant injuries were soft tissue injuries (74.5%).

Prevalence of hepatitis B virus surface antigen (HBsAg) in patients undergoing extraction at the University College Hospital, Ibadan.

Hepatitis B Virus (HBV) infection and its sequelae (liver chirrhosis and hepatic carcinoma) are endemic in Africa. The risk of transmission of the infection during dental treatment is real. This study was carried out to determine the rate of Hepatits B Surface Antigen (HBsAg) as a marker of hepatitis B virus infection in patients undergoing dental extraction in order to highlight the potential risk of nosocomial transmission among the Dental Health Workers (DHW) and their patients. Three hundred (143 males and 157 females) consecutive patients requiring dental extraction who volunteered were enrolled into this study. Their ages ranged from 11 years to 95 years with a mean of 37.2 years (SD = 16.725) and a median of 36 years. The overall HBsAg infection rate was 18.3% (55/300). A higher infection rate (23.1%) occurred among the male patients compared with 14% in females (p = 0.0086). The high rate of HBV infection found among this study population suggests that Dental Surgeons in this environment have a high risk of exposure to hepatitis B virus and should be immunized at the beginning of their professional life. Universal biosafety measures should be observed strictly in all invasive procedures.

Human immuno-deficiency virus (HIV) infection among oral surgery patients at the University College Hospital, Ibadan, Nigeria.

The Human Immuno-deficiency Virus is a World-wide epidemic and evidence abound that the infection is spreading rapidly in sub-Saharan Africa with little or no control. Nosocomial transmission of HIV in the Dental Surgery has been documented. This study was undertaken to determine the prevalence of HIV among dental patients undergoing extraction at the University College Hospital, Ibadan. Three hundred patients requiring dental extraction at the dental clinic, UCH, Ibadan who consented were enrolled for the study. Blood samples from these individuals were tested for the presence of HIV antibodies using commercially available ELISA (Monolisa Sanofi, Pasteur, France). All initially reactive samples were confirmed by a commercial Western immunoblot assay (Bio-Rad Norapath HIV kit). A prevalence of 2.3% (7/300) was obtained among individuals tested for this study. Four (2.8%) of the 143 males and 3 (1.9%) of 157 females were positive for HIV antibodies. All the seropositive patients except one were within the age range 20-39 years and most of them (6 out of 7) do not use condom during intercourse. More than half (57%) of the patients had more than one sexual partner. This study shows that the risk of transmitting HIV to DHCW during treatment is also a potential hazard in this environment. Hence, adequate preventive measure should be observed always.