Three changes to reduce the loss of dual degree trainees from OMFS national specialty selection in the UK: evidence based proposals.

The training pathway for oral and maxillofacial surgery (OMFS) has remained relatively stable for around 30 years. Circumstances surrounding the training pathway have changed including the priorities of individuals considering entering OMFS training. Run-through Specialty Training (ST1) OMFS posts (which include core surgical training) are oversubscribed while direct entry to Specialty Training (ST3) OMFS specialty recruitment rounds have unfilled posts, including places declined by appointable candidates. As part of a project to refine and improve OMFS recruitment and retention, data drawn from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and the OMFS National Selection administering Deanery, Health Education England South West were scrutinised. Numbers of students starting second undergraduate degrees (medicine or dentistry) to pursue an OMFS career are increasing. Of a total of 43 candidates deemed appointable at OMFS ST1 selection but not offered an available post, 16 did not subsequently apply for ST3 selection. In the period studied (2015-20), of a total of 116 unfilled ST3 posts, 39 remained vacant because appointable candidates declined the available posts (33%). Appropriate changes to the current national selection processes could help address the perceived OMFS ST recruitment problems. By increasing the number of available ST1 posts, widening the window during which appointable candidates can continue into training and increasing prior experience recognition (including creating benchmarking processes prior to ST). These three clear, fair and transparent changes could reduce the current levels of attrition.

The UK Mentoring and Support Programme (MSP) for those considering a career in Oral and Maxillofacial Surgery (OMFS). A review of a 'Register Interest in OMFS' website and the MSP as two key resources created by the British Association of Oral and Maxillofacial Surgeons to promote recruitment and retention (2008-2020).

In 2008, to create a rapid route for information transfer in relation training and recruitment for OMFS trainees, the British Association of Oral and Maxillofacial Surgeons (BAOMS) created a website to "Register Your Interest in OMFS" (RYIO). From 2011 a Mentoring and Support Programme (MSP) was created to provide focussed guidance for trainees aiming for specialty training. This paper reviews the effectiveness and cost of these programmes. Between 2008 and 2020, 1744 individuals used RYIO on 2715 occasions. Of these registrations, 1772 were by dentists, 193 dental students, 589 doctors and 161 medical students. 2354 were from UK and Ireland and 351 from the rest of the world. 188 registrants subsequently became UK OMFS trainees or specialists. All registrants valued the information provided. In response to RYIO trainee feedback the new 'Taste of OMFS 2020' programme was created. The MSP was originally called the Junior Trainee Programme (JTP). The MSP scheme provides a layer of mentorship/support which runs parallel to the medical/dental training post or period of study. Of 180 members of MSP, 72 have obtained specialty training posts in OMFS. There are 88 current members. Full information is available on the BAOMS website www.baoms.org.uk. Reviewing both programmes, participant feedback is excellent with tangible results whilst cost effectiveness is high.

Management of oral and maxillofacial trauma during the first wave of the COVID-19 pandemic in the United Kingdom.

We assess the effect of coronavirus disease 2019 (COVID-19) on UK oral and maxillofacial (OMF) trauma services and patient treatment during the first wave of the pandemic. From 1 April 2020 until 31 July 2020, OMF surgery units in the UK were invited to prospectively record all patients presenting with OMF trauma. Information included clinical presentation, mechanism of injury, how it was managed, and whether or not treatment included surgery. Participants were also asked to compare the patient's care with the treatment that would normally have been given before the crisis. Twenty-nine units across the UK contributed with 2,229 entries. The most common aetiology was mechanical fall (39%). The most common injuries were soft tissue wounds (52%) and, for hard tissues, mandibular fractures (13%). Of 876 facial fractures, 79 patients' treatment differed from what would have been normal pre-COVID, and 33 had their treatment deferred. Therefore the care of 112 (14%) patients was at variance with normal practice because of COVID restrictions. The pattern of OMFS injuries changed during the first COVID-19 lockdown. For the majority, best practice and delivery of quality trauma care continued despite the on-going operational challenges, and only a small proportion of patients had changes to their treatment. The lessons learnt from the first wave, combined with adequate resources and preoperative testing of patients, should allow those facial injuries in the second wave to receive best-practice care.

Management of odontogenic cervicofacial infections presenting to oral and maxillofacial units during the first wave of the COVID-19 pandemic in the United Kingdom.

On 25 March 2020, the Chief Dental Officer issued national guidance restricting the provision of all routine, non-urgent dental services in response to the spread of COVID-19. We analysed odontogenic cervicofacial infections (CFI) presenting to oral and maxillofacial surgery (OMFS) departments during the first wave of COVID-19 in the United Kingdom. From 1 April 2020 until 31 July 2020 a database was used to prospectively collect records for all patients with CFI who presented to oral and maxillofacial teams. Information gathered included clinical presentation, location/origin of infection, and how this was managed. The OMFS units were asked to compare the patient's care with the treatment that would usually have been given prior to the crisis. A total of 32 OMFS units recorded 1381 cases of CFI in the UK. Most of the infections were referred via the emergency department (74%). Lower first or second molars were the most common origin, contributing 40% of CFI. Collaborators reported that patients' treatments were modified as a response to COVID in 20% of cases, the most frequently cited reason being the application of COVID-19 hospital policy (85%). The impact of the first wave of COVID modified the management of a significant number of patients presenting with CFI, and there was a proactive move to avoid general anaesthetics where possible. Some patients who presented to secondary care were given no treatment, suggesting they could have been managed in primary dental care if this had been available. We recommend that OMFS units and urgent dental care centres (UDCCs) build strong communication links not only to provide the best possible patient care, but to minimise COVID exposure and the strain on emergency departments during the pandemic.

Workforce intelligence: what data do we need to collect to understand trends in substantive oral and maxillofacial surgery consultant posts? A retrospective review and plan for the future.

Understanding workforce pressures within surgery is an inexact science. This paper assembles evidence regarding oral and maxillofacial surgery (OMFS) consultant appointments in the UK and plans for prospective data collection in the future. Information about the number of OMFS specialists joining the UK specialist list was obtained from the General Medical Council and compared to a database of substantive OMFS consultant posts. OMFS consultants were asked to contribute information about their training programmes and consultant appointments (date, interview experience, and sub-specialty interest). This information was collated on Excel© and analysed using WinStat©. Data on OMFS consultant posts advertised in 'NHS Jobs' and the British Medical Journal were collected. The mean (SD) number of specialists joining the specialist list per year is 24.1 (5.2) with a median of 24 and a range of 15 - 36. The number of trainees completing training and numbers joining the OMFS specialist list are in balance at present. The median delay between OMFS specialist listing and appointment as a consultant was 72 days and mean of 169 with the 25th centile of five days, standard deviation of 239 days and maximum of 5.2 years. Of those returning data, 135 (47%) candidates were the sole interviewee and 83 (29%) had one other candidate at their successful interview. The mean application ratio for each post was 1.9 and the median number of candidates was one, mean 1.6 and maximum candidates seven. About half of the posts were filled by trainees from their regional training rotation. Prospective data collection on advertised posts, interviews held, expected retirements/new posts, combined with a route for trainees approaching CCT to highlight their availability may streamline recruitment and allow a more rapid recognition of recruitment problems.

Duration of specialty training in Oral and Maxillofacial Surgery in the United Kingdom for trainees joining the OMFS specialist list between 2002 and 2019.

INTRODUCTION: OMFS Specialty Training in the UK is usually 5 years and 'starts' at Specialty Training Year 3 (ST3). In 2007 a pilot of 'run-through' training started with Core Training (CT) posts linked to specialty training (ST1 posts). ST1 posts are usually 12 months but may be up to 24 months. METHOD: UK OMFS consultants joining the OMFS specialist list between 2002 and 2019 were contacted regarding their training. If their training was extended beyond the expected date of completion, they were asked to give a primary and secondary reason from a simplified list. Results were analysed with Winstat©. RESULTS: A total of 382 consultants were contacted, 325 responding (86%) and of these 290 were appointed at ST3 and their mean extension of training time was 0.63 years. For those 35 who were appointed to ST1, their training was on average 0.77 years longer than planned. Undertaking a Fellowship (33%) was the commonest reason for extension, followed by administrative delay (24%), unsuccessful attempts at the FRCS exam (12%) and training reasons (10%). Female trainees (n=37) spent on average 1.28 years longer than planned in training compared to male trainees (288 - 0.67 years). Gender differences were also present in the main reasons for extension with 12% of female respondents giving family reasons as the main cause, whereas only 2% of males gave this reason. Problems with training was the main cause for extension for 19% of females compared to 8% of males. CONCLUSIONS: Understanding factors which extend training and the length of these extensions could have the twin benefits of openness for new trainees and directing support to existing trainees. Differential attainment and Equality Diversity & Inclusion (EDI) are domains whose monitoring is required by the General Medical Council and undertaken by training authorities. The small numbers of trainees in OMFS programmes may not always allow training variance to be recognised.

First degree hotspots for OMFS recruitment 1967-2010: dental and medical schools where OMFS specialists and trainees were more likely to start their careers.

Evidence around careers shows that many surgeons were inspired early in their career and this was often based on their undergraduate experience. In this context we have reviewed the location of the first degrees of oral and maxillofacial surgery (OMFS) consultants and specialty trainees to look for any patterns or trends. It has been shown that there is variation across medical schools when core surgical trainee recruitment is analysed. To our knowledge no previous paper has undertaken a similar analysis of medical and dental schools in the context of OMFS. The first-degree universities of OMFS specialists and trainees were compiled from the Medical and Dental Register, tabulated and analysed. There were 680 entries in total with dates of graduation ranging from 1967 - 2010. The relative frequency of first-degree locations based on the number of current places for medical and dental students was calculated to aid comparison. There are 'hot-spots' from where many OMFS specialists originate and also universities that rarely or never produce OMF surgeons. Reviewing these figures in the context of the number of places available to students and against time, points to areas where OMFS appears to be promoted, and others were the specialty has a low impact. The University of London leads the way for both medicine and dentistry-first trainees by a considerable margin. Glasgow is the next most productive for dentistry and Nottingham for medicine. The 13 current medical schools from which no OMFS specialists or trainees have originated are Brighton, Cambridge, Anglia Ruskin, Exeter, Hull, Keele, Lancaster, Norwich, Plymouth, Swansea, University of Central Lancashire (UCLan), and Warwick. Other new medical schools are opening this year. There are opportunities for all OMFS units and training rotations to look at 'best practice' for OMFS recruitment and apply as many inspiring interventions as they can in their local medical and dental schools, and in foundation and core training programmes.

Changes in United Kingdom oral and maxillofacial surgical specialty trainees since 1995 - numbers, gender, first degrees, and nations of origin.

Training in UK surgery has changed dramatically since 1995, from a relative lack of structure to time-limited and highly documented programmes. Training in oral and maxillofacial surgery (OMFS) has shared these changes and included some significant changes of its own. Minutes from the OMFS Specialty Advisory Committee (SAC) were reviewed over the last 25 years to record the number and location of newly approved posts. The General Medicine Council's (GMC) OMFS specialist list in 2019 was combined with the records of OMFS specialists' dental qualifications held by the General Dental Council (GDC) and augmented from a database of OMFS trainees and consultants in the UK. Data on demographics, location, and nature of the first medical or dental degree were noted for analysis. A total of 691 OMFS specialists and trainees were identified from GMC, OMFS SAC and consultant databases. Of these, 12 consultants held only dental qualification/registration. First degree data could not be obtained for 12 specialists (all male). A further 20 OMFS specialists, whose training was outside the UK, were also excluded from further analysis. In 1995 there were 95 national training posts, by 2013 there were 150. Over the last quarter of a century, there has been an increase in medicine first trainees, an increase in female trainees and specialists, and a relative decrease in OMFS trainees from the Indian subcontinent. The varied origins of the OMFS workforce has contributed to greater diversity and inclusion within the specialty. In the UK, OMFS appears to have produced the correct number of specialists whilst maintaining a high standard of training. The next change in OMFS training programmes is to deliver The Postgraduate Medical Education and Training Board's (PMETB) recommendations. As we move to achieve this it is imperative that as new doors open, we do not close others.

United Kingdom immigration and emigration of oral and maxillofacial Surgery (OMFS) specialists 2000-2020: how might Brexit impact on OMFS?

The United Kingdom left the European Union (EU) in January 2020. As it is unclear how many of the rights of OMFS surgeons to travel and work will remain after the transition period, we have reviewed how these rights have been used in the past. The OMFS specialist list from the GMC was compared with a database of current OMFS colleagues. Data were analysed using WinStat® (R. Fitch Software). Of 494 active surgeons on the OMFS specialist list, 23 (5%) completed their OMFS training outside the UK. Of these, 22 were specialists from Europe of whom 12 were substantive NHS consultants with others working as Fellows or visiting the UK occasionally. Two per cent of UK OMFS consultants are -specialists from Europe, the majority from Greece. Of the OMFS specialists who completed training in the UK since 1995, 24 are currently working outside the UK, and of them, 16 left the UK to return to their nation of origin (all 11 of those working in the European Economic Area [EEA] were born there). Of the seven UK-born specialists working overseas, none was working in the EEA. Twenty per cent of UK trainees whose primary degree was known (n = 117) received their primary qualification outside the UK, 38 in from the EU, and 79 from further afield. The majority of these UK trained specialists with non-UK first degrees (n = 101) stayed in the UK to work after training. The most significant impact of Brexit on OMFS could be a restriction on the opportunity for non-UK doctors and dentists to come to the UK to train and stay to work.

European OMFS in the time of Brexit - where did the UK fit and how might the future look?

INTRODUCTION: The specialty of OMFS in the UK is a dual degree specialty which was recognised in Europe within Annex V of Directive 2005/36/EU. Currently UK law matches that of the EU. Brexit may change this. DIRECTIVE 2005/36/EU: Defines two specialties within European nations, Dental, Oro-Maxillo-Facial Training DOMFS (Basic dental & medical training) and Maxillofacial Surgery (basic medical training). The UK sat within DOMFS and so specialists from DOMFS nations could travel and work in the UK. Specialists from all other nations were required to use the Certificate of Eligibility for Specialist Registration (CESR) route. DIRECTIVE 2013/55/EU: This directive updated 2005/36/EU regarding Mutually Recognised Professional Qualifications (MRPQ) including creating an international alert system for doctors in difficult Entry onto the UK OMFS Specialist List by CESR Route CESR application is a large and complex portfolio of evidence to demonstrate knowledge, skills and experience are equivalent to a Certificate of Completion of Training (CCT) holder. To date, no EU applicants have successfully completed a CESR application. UNION OF EUROPEAN MEDICAL SPECIALISTS (UEMS): Even after Brexit, the UK will remain a full member of UEMS. The OMFS Section of UEMS is a source of information and support for specialists wishing to work in other nations and for nations wishing to develop an OMFS specialty in their nation. ACCESS TO UK OMFS TRAINING FOR NON-UK TRAINEES: Applicants meeting the person specifications for approved OMFS specialty training (ST) posts in the UK are welcome to apply to the national selection process for OMFS specialty training in the UK. Many have done so successfully. Fixed term appointments and Fellowships are advertised and represent a useful route to gain support for application for training or through the CESR Route. CONCLUSIONS: The UK remains part of the diverse OMFS community in Europe. There is support from within the UK and from UEMS for trainees and specialists interested in coming to the UK to train or to work.

2012 - The year when BAOMS and its officers prevented closure of all UK shortened medical and dental courses.

In Spring 2011 the Department of Health (DH) received a request to review European Union Directive 2005/36 EU - the directive relating to the recognition of professional qualifications. The Department of Health lawyer raised concerns that the existing shortened dental courses may be in breach of EU law. There were three shortened dental courses in the UK: 4year graduate entry courses in Liverpool/Peninsula and 3-year Dental Programme for Medical Graduates (DPMG) in Kings, London. During the summer the General Dental Council (GDC) was made aware of these concerns. In autumn 2011 the Chief Dental Officer for England with the GDC, told the Dental Deans' Council (DDC) that shortened dental courses were illegal. On 12th Jan 2012 students on the DPMG were told that they would have to complete a full 5-year dental degree. The GDC said that this interpretation of EU law would also impact on shortened medical courses. In view of the potentially enormous impact that this would have on OMFS training, BAOMS engaged all the resources it could and by assembling legal opinions including written contributions from Sir David Edward, whose opinion was being misinterpreted by the GDC and DH, and by sharing these resources with all the stakeholders, BAOMS was able to preserve shortened dental and medical courses. Now that the UK has left the European Union, negotiations around mutual recognition of qualifications may mean this issue will resurface. We should remain vigilant.

Legislation for Oral and Maxillofacial Surgery (OMFS) in the UK lags behind the patient care we provide: an illustrative timeline and recommendations for the future.

OMFS is the surgical specialty which bridges dentistry and medicine. As the specialty of OMFS emerged from the dental specialty of Oral Surgery during the 1980s the Dentists Act 1984, whose purpose included preventing medical practitioners providing unregulated general dental care, was published. In 2008 the Postgraduate Medical Education and Training Board (PMETB) review of training in OMFS concluded that dual qualification was essential and recommended that OMFS specialists should only be required to register with one regulator, the General Medical Council. For OMFS to continue to provide high quality patient care, and to help the GDC and GMC in their roles regulating our specialty, BAOMS has identified 5 areas for regulatory change: (1) All OMFS specialists should be able to practice the full curriculum of OMFS with only GMC registration if they wish to - this was recommendation 4 of the PMTEB Review of OMFS in 2008. (2) If an OMFS specialist or trainee is registered with both the GMC and GDC. (3) A Memorandum of Understanding between the GMC and GDC should prevent any fitness to practice concerns being processed by both regulators. (4) Dually registered OMFS specialists should be able to indicate that they have had "appraisal of the full scope of practice" to comply with GDC Continuing Professional Development (CPD) regulations. (5) Oral Surgery specialist list should retain Route 11 for OMFS specialists as the Oral Surgery Curriculum is entirely within the OMFS curriculum. Legislative changes may be the best route to deliver these recommendations. Until these changes happen, the GMC, GDC and BAOMS should work together in the best interests of patients.

UK Oral and Maxillofacial Surgery trainees join the specialist list at a similar age to other surgical specialists.

It is 11 years since Cameron and Westcott published 'Maxillofacial training is no longer than other surgical specialties'1. This showed that OMFS trainees completed training at ages comparable to their surgical peers. Much has changed in surgical training since then so an updated review was undertaken. Based on published training pathways specialty training in most surgical specialties should be ten years (two years foundation, two years core and six years specialty training). For OMFS specialty training in the UK from either medicine first or dentistry first is 18-21 years depending on the length of second degrees and participation in pre-Certificate of Competition of Training (CCT) fellowships. Information on the age of entry onto the surgical specialist lists between 1997 and 2018 was obtained from the General Medical Council (GMC). The 'age on entry' included the ages of specialists from other nations joining the list for the first time and doctors re-joining the lists after a break. The age on joining surgical specialist lists ranged from 27-83 years, with the median of 39 and mean of 41.4 years. In Oral and Maxillofacial Surgery (OMFS), age ranged from 32-67 years, with the median and mean of 41 and 42.7 years respectively. Looking in more detail at the small differences in median and mean, the surgical specialties of vascular and cardiothoracic had age distributions which were statistically similar to OMFS. For other surgical specialties the distribution was wider. The small number of OMFS specialists whose age at joining the OMFS specialist list in their early 30s had all trained overseas in nations where the second degree was incorporated into specialty training. These data show that there is a small difference between age on entry to the OMFS specialist list and those joining other surgical specialties. Combining integration of second-degree studies into UK specialty training as recommended by the 2008 PMETB Review of OMFS Training with the new competency based OMFS curriculum could reverse this age difference.

The future of OMFS lies in creating pathways to implement the PMETB recommendations and inspiring our trainees. Enough time has been spent debating, we need to deliver!: Re: Newman L, Brown J, Kerawala C, et al. Our specialty. The future. Is the writing on the wall? Br J Oral Maxillofac Surg 2020 (online ahead of print).

The British Association of Oral and Maxillofacial Surgeons (BAOMS) has been at the centre of the transition of our specialty in the UK from a branch of dentistry to one of the 10 UK surgical specialties. In this role it has, at different times, pushed boundaries against resistance from other specialties, and redirected the ambitions of the deputy chair of the Postgraduate Medical Education and Training Board (PMETB) review to produce recommendations that were exactly what OMFS needed. The editorial Our specialty. The future. Is the writing on the wall? is just the most recent iteration of half a century of internal debate. Whilst there are some issues with how the authors have presented recruitment data (their figures omit ST1 run-through and do not recognise that the same single, unfilled post may be present for two or more national selection rounds) their first paragraph A debate that we feel is long overdue presents the greatest concern. In this short communication, we illustrate that in the last 20 years the specialty has not been short of debate. In the absence of new and specific evidence that any other route forward would be supported by our national training committee (OMFS SAC), our regulator (GMC), the breadth of our specialty (including our current specialists and our current and future trainees) and, most importantly, would actually address our problems, we should avoid putting energy into an empty debate. Our focus should be on delivering the PMETB recommendations and inspiring our future trainees.

Changing the Oral and Maxillofacial Surgery (OMFS) training pathway in the United Kingdom - an illustrative retrospective.

OMFS training is perceived as a long and expensive pathway although papers have shown it compares favourably with other surgical specialties. Every OMFS clinician has a vested interest and duty continually to improve the quality of training and minimise costs, especially to trainees at junior levels. Any serious proposal to fundamentally change the format of training, must be given due consideration by all stakeholders. In 2016, a British Medical Journal article whose authors included the BAOMS President of that year and OMFS Specialty Advisory Committee (SAC) Chair, posed the question - should the future of OMFS training revert to single dental degree, change to single medical degree - or continue as a dual degree specialty? The BMJ publication was discussed at the British Association of Oral and Maxillofacial Surgeons (BAOMS) Council in March 2016 and all present unanimously supported the dual degree pathway. Later that year a formal proposal was made by the BAOMS immediate past President that training in the UK change to single medical degree 'Maxillofacial Surgery' similar to the training in Spain, France or Italy. Evidence around the risks and benefits of making this change to OMFS training was assembled and reviewed by BAOMS Council in March 2017. BAOMS Council once again unanimously supported continuing OMFS as a dual degree specialty with the observation that the quality of patient care which this training provided was the specialty's Unique Selling Point or USP. The requirement for both degrees to provide care for OMFS patients had been confirmed by external scrutiny on two separate occasions by the responsible regulators. In this paper, we outline the key steps to be considered when making major changes in the OMFS training pathways using this event as an example and the suggestion that those proposing changes should assemble and present evidence to support their proposal using the template provided.

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP).

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.

British Association of Oral and Maxillofacial Surgeons' National Facial Injury Surveys: hard tissue facial injuries presenting to UK emergency departments.

The British Association of Oral and Maxillofacial Surgeons (BAOMS) and Saving Faces undertook two national prospective surveys 11 years apart. They recorded the facial injuries treated in UK emergency departments and collected data on 14872 patients. In this paper, which aims to act as a feasibility study for a third national survey of facial injuries, we have reviewed hard-tissue injuries and specifically focused on temporal changes in their morphology. The two sets of directly comparable, categorical, unpaired, cross-sectional data were evaluated independently for statistical significance. In 1997, there were 1977 hard-tissue facial injuries (33%) but in 2008 this had decreased to 1899 (22%) (p<0.05). In 1997, there were 1315 fractures (22%) and 662 dental injuries (11%) compared with 1462 (17%) fractures and 438 (5%) dental injuries in 2008 (p<0.05). There were proportional increases in orbital (21%), nasal (139%), and cranial fractures (340%) (p<0.05). The data showed a small reduction in the total number of hard-tissue injuries, but this was a considerable reduction as a proportion of the total injuries. Analysis of the type and subtype of injury generally pointed towards a reduction in their energy and severity, and to likely changes in mechanism. The project has proved the feasibility of a third national survey of facial injury.