Optimizing donor site analgesia after bone harvest from iliac crest.

At Queens Medical Centre, Nottingham, alveolar bone grafts (ABG) for patients with cleft lip and palate (CLP) were performed by two surgeons following the same surgical protocol, but with different postoperative iliac crest donor site analgesia: surgeon A used a donor site bolus of levobupivacaine, whilst surgeon B used a donor site epidural catheter (EC) infusing levobupivacaine. A healthcare evaluation was conducted in two phases to establish the effectiveness of analgesia for CLP patients undergoing ABGs. Data were collected prospectively in 2016 and 2018. Cleft patients postoperative to ABG were included. Outcome measures were pain scores at 2, 4, 6, 12, and 24 hours, time to mobilization, and time to food intake. Mean pain scores at the first evaluation were <1 out of 10 for all time points, except 24 hours (score 2.0 for bolus, 1.8 for EC). There was no statistically significant difference between the groups for any of the outcomes measured. As EC conferred no advantage, surgeon B changed to bolus administration and a second evaluation was performed. The mean pain score for the second evaluation was 1.7 and higher pain scores were more common with lower doses of levobupivacaine. The data suggest that bolus injection can produce safe, effective pain control provided an adequate dose is given.

The predictive value of obstructive sleep apnoea severity on clinical outcomes following maxillomandibular advancement surgery.

We aimed to evaluate whether the severity of preoperative obstructive sleep apnoea (OSA) has potential predictive value for the clinician assessing patients referred for maxillomandibular advancment surgery. We performed a retrospective analysis of consecutive patients who underwent maxillofacial operations for OSA at our institution. We stratified them into 2 groups according to apnoea/hypopnoea index (AHI) scores calculated from a preoperative sleep study: mild-moderate OSA (AHI less than 30) and severe OSA (AHI 30 and above). Both groups were matched for baseline demographic and clinical characteristics. We compared postoperative scores for the AHI and Epworth sleepiness scale (ESS), and lowest recorded oxygen saturation between groups. We identified 51 patients of whom 39 had complete data available for inclusion in our analysis. We found no statistically significant difference in the postoperative AHI scores between the two groups. The reduction in the mean ESS after operation was greater in the severe group than in the mild-moderate group (mean (SD) ESS 4 (3) compared with 9 (6), p<0.05). There were high rates of surgical success (postoperative AHI less than 15) in both groups, and results were comparable (mild-moderate group 82%, severe group 86%). The preoperative AHI does not appear to be a good predictor of surgical success after maxillomandibular advancement surgery. Patients with severe OSA postoperatively demonstrated a greater improvement in their subjective symptoms, when compared to subjects with mild-moderate OSA.

Partial avulsion of the inferior rectus: an unusual cause of diplopia after blunt orbital trauma.

A 14-year-old boy had a severe blow to the right orbit, which caused a blow-out fracture of the orbital floor and damage to the inferior rectus with resultant diplopia. After two operations his vision is still not perfect.

Orthognathic surgery in osteogenesis imperfecta: a case report with management considerations.

Osteogenesis imperfecta is a disease of connective tissues with additional metabolic defects. It is associated with recognisable facial disproportion and sometimes warrants surgical intervention for aesthetic, functional and psychological reasons. A severe case of osteogenesis imperfecta type 3 is presented to illustrate the feasibility of bimaxillary surgery using a mandibular body step osteotomy and maxillary down grafting at the Le Fort I level. The medical, anaesthetic, surgical and specific maxillofacial implications of surgery in these patients are discussed.

Chondrosarcoma of the mandible presenting as periodontal lesions: report of 2 cases.

A review of the literature and the addition of 2 cases in the mandibular symphyseal region serve to illustrate the protean presentation of chondrosarcomas. These 2 cases presented as periodontal lesions with associated bone loss. A high index of suspicion is required to make an early diagnosis. The importance of submitting biopsy specimens for histology is stressed, and it is recommended that definitive treatment be carried out as rapidly as possible after diagnosis is known. The surgical procedures undertaken were conservative, and patients have remained disease-free after 3.5 years and 3 years respectively. For small lesions, early segmental resection is not necessary in this region. Only recurrence should be treated by symphyseal resection with its increased morbidity. Close follow-up is mandatory.

Periosteal Gaucher-like cells in beta-thalassemia major.

A 24-year-old Chinese woman who has undergone staged surgery for craniofacial deformity secondary to beta-thalassemia major is presented. Local clusters of Gaucher-like cells were found in the periosteum of the mandible. The histologic and ultrastructural features of these cells are described and the pathogenesis and differential diagnoses discussed. To the best of our knowledge, this is the first reported case of Gaucher-like cells occurring outside the lymphohematopoietic system in thalassemic patients.

The desmo- and osteoplastic ameloblastoma. Histologic variant or clinicopathologic entity? Case reports.

Two cases of desmoplastic ameloblastoma (DA) are presented, bringing the total number of reported cases to 29. One case of the so-called "hybrid lesion" is added to the presentation. Immunohistochemical studies indicate that the desmoplasia is caused by active de novo synthesis of extracellular matrix proteins. Moreover, the DA may also show osteoplasia, and this probably explains the characteristic radiographic appearance of many DAs, i.e. the occurrence of both radiolucent and radiopaque changes, suggestive of a fibro-osseous lesion. Many more cases of DA are needed to clarify the true nature of this most interesting tumor.

Variants of the adenomatoid odontogenic tumor with a note on tumor origin.

Three rare variants of the adenomatoid odontogenic tumor (AOT) are described. A follicular AOT associated with an impacted and displaced 28, an extra-follicular variant mimicking a radicular cyst around the apex of 23 and a peripheral (epulis-like) variant exhibiting a periodontal bone defect palatal to 21. On reappraisal of the origin and pathogenesis of the AOT, it would seem that this tumor or hamartomatous lesion is derived from odontogenic epithelium of the dental lamina complex or its remnants.