Customized titanium reconstruction of post-traumatic orbital wall defects: a review of 22 cases.

The authors present the clinical results of their method of customized reconstruction of orbital wall defects using titanium mesh or sheet. High resolution computed tomography (CT) data are imported and processed to create a three-dimensional (3D) image which is used to reconstruct the orbital defect. Mirror imaging of the air in the contralateral maxillary sinus is used to overcome artefact defects in the floor. A stereolithographic model is constructed, from which titanium mesh or sheet is shaped and sized to the required contours for implantation. Twenty-two patients were treated using this technique from 2003 to 2008. Postoperatively 10 patients reported early resolution of their diplopia. Six patients noticed significant improvement of their symptoms with mild residual diplopia in one direction only and at the extremes of gaze at final review. One patient required ocular muscle surgery. Enophthalmos resolved in eight of the nine cases. No patients developed enophthalmos or diplopia as a postoperative complication. The use of titanium mesh for orbital floor reconstruction has been shown to be safe and effective. Customized titanium implants accurately reproduce orbital contours thus restoring orbital volume. This reduces operative time and improves the functional and aesthetic outcomes of post-traumatic orbital reconstruction.

A randomised controlled trial comparing fixation of mandibular angle fractures with a single miniplate placed either transbuccally and intra-orally, or intra-orally alone.

This study compared fixation of simple mandibular angle fractures with a single miniplate either placed from a combined transbuccal and intra-oral approach, or intra-orally alone. 140 consecutive patients were randomly allocated to the two treatment groups. Complications were noted and compared. An email questionnaire to all the participating surgeons examined their personal preferences between the two methods. 20% of plates needed to be removed during the 3 month study period in the combined transbuccal/intra-oral group compared with 36% in the intra-oral alone group (p

Necrotising fasciitis of the submandibular region; a complication of odontogenic origin.

Inadequate treatment or neglect of odontogenic infections can have serious consequences. The potential for spreading through fascial planes and intracranially can cause compromise of the airway and cavernous sinus thrombosis respectively. On rare occasions this can lead to a rapidly progressing necrotising fasciitis, with destruction of soft tissue, making reconstruction difficult. Antibiotic administration without removal of the cause is inadequate and can complicate subsequent management. We report the presentation and successful management of a 13-year-old boy, who developed necrotising fasciitis in the submandibular region as a result of inadequate initial treatment of a carious, lower molar resulting in significant skin and soft tissue loss.

Bilateral mandibular condylysis in a patient with systemic sclerosis.

A case of progressive osteolysis of the mandibular condyles in a 55-year-old female patient with systemic sclerosis (SSc) is described. Orofacial involvement and radiological manifestations of SSc are discussed.

A form for referral of injured patients between maxillofacial and ophthalmology units.

We have designed a form to facilitate referral of injured patients between maxillofacial and ophthalmology units. This form improves communication, gives a written record of referral, and can be used for audit.

Blood transfusion requirements in bimaxillary osteotomies.

The over-ordering of cross-matched blood to cover operations can result in blood shortages and is costly; it can never be free of risk. Current published guidelines recommend cross-matching 2 units of blood for bimaxillary orthognathic procedures with an additional 2 units if combined with a genioplasty. We reviewed the records of 115 consecutive cases of simultaneous bimaxillary osteotomies at Morriston Hospital over a 5-year period (January 1996 to December 2000). Ordering and use of blood were investigated and the cost analysed. Blood loss was minimised using a strategy of controlled moderate hypotension and meticulous haemostasis. Nine patients were given transfusions of blood but five of these were deemed inappropriate. No predisposing factors for transfusion were identified. We recommend that the tariff for ordering blood for bimaxillary osteotomies should be revised to a "group and save" with antibody screen, providing that a 30-min indirect antibody cross-match is available.

Post-traumatic orbital cellulitis.

Orbital cellulitis is uncommon. It may arise as a sequel to eyelid infection, or from direct spread of infection from the paranasal sinuses; it may be of odontogenic origin and has been reported after meningitis and after nasoorbital fractures with pre-existing sinusitis. Clinically, orbital cellulitis is of great importance, as it is a severe disease with potentially disastrous consequences. It may lead to optic neuritis, optic atrophy, blindness, cavernous sinus thrombosis, superior orbital fissure syndrome, meningitis, subdural empyema, and even death. We report two cases of severe post-traumatic orbital cellulitis with subperiosteal abscesses. These were managed surgically and vision was preserved. We describe the anatomy, a classification of orbital infection, and the importance of multidisciplinary management of these cases.

Can warfarin be continued during dental extraction? Results of a randomized controlled trial.

A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalised Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by patients at home. Continuing warfarin when the INR is < 4.1 may lead to an increase in minor post-extraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding. As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered.

Patients with reconstruction of craniofacial or intraoral defects: development of instruments to measure quality of life.

Patients with reconstruction of craniofacial or intraoral defects experience a profound impact on their quality of life (QOL). This impact on QOL is influenced by the patients' medical conditions and the treatment interventions. Instruments to measure general QOL have been available for many years. A major criticism of QOL instruments is that too often the questions are not specific to the particular problems of a disease or condition. A search of the literature regarding QOL measurement for patients with maxillofacial implant-supported prostheses produced a short list of instruments, none of which were sufficiently developed or suited to the patients involved in reconstructive treatment. This study was designed to develop pretreatment and posttreatment questionnaires for measuring QOL for patients with reconstruction of a craniofacial defect and patients with reconstruction of loss of specific intraoral structures utilizing an implant-supported prosthesis (e.g., severe resorption of the maxilla or mandible or both). The goal was to develop brief, targeted instruments for this specific patient population. The produced instruments were sensitive and easy to administer and score, and no disruption of clinical care occurred with the administration of the questionnaires. The instruments were used with equal success both in face-to-face interviews and via mail.

SPECT bone scintigraphy in the diagnosis and management of mandibular condylar hyperplasia.

Isotope bone scans have been used for a number of years to assess growth activity in the mandibular condyle in patients who present with facial asymmetry. The aim is to distinguish normal bone growth within the condyle from increased activity that may be the cause of the asymmetry. Previous studies have, however, relied only on planar images. SPECT (single photon emission computed tomography) has been used with quantitative assessments of one mandibular condyle to clivus or lumbar spine, but we have compared one condyle with the other, which is more sensitive and accurate in detecting abnormal activity. A relative percentage uptake of 55% or more in the affected mandibular condyle is considered to be abnormal, and this has been validated by comparison with an age-matched control group. We have used SPECT as an aid to diagnosis and treatment in 18 patients with asymmetrical growth and have constructed a therapeutic algorithm to aid the treatment of these patients.

Orbital metastasis due to interval lobular carcinoma of the breast: a potential mimic of lymphoma.

A 53-year-old woman had an orbital mass composed of a neoplastic small round cell infiltrate and no apparent extraorbital primary tumor. Although the initial diagnosis was primary orbital lymphoma, a combination of mucin histochemistry and immunohistochemical staining for cytokeratin and estrogen receptors led to the discovery of an impalpable lobular carcinoma of the breast. We discuss how detailed histopathological assessment can lead to beneficial therapy.