Printed titanium implants in UK craniomaxillofacial surgery. Part II: perceived performance (outcomes, logistics, and costs).

This second part explores perceptions and understanding of clinical performance, turnaround, and costs for printed titanium implants or plates in common procedures, evaluating both 'in-house' and 'outsourced' CAD-CAM pathways. A cross-sectional study, supported by the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team, was conducted over 14 weeks. A total of 132 participants took part (demographic data is reported in Part I). For fibular-flap mandibular reconstruction, most participants (69% - 91%) perceived printed titanium as superior to intraoperatively or preoperatively hand-bent plates for surgical duration, accuracy, dental restorability, and aesthetics. There was less agreement about complications and plate-failure risks. Most perceived printed plates to be superior to traditional wafer-based maxillary osteotomy for surgical duration (61%) and maxillary positioning (60%). For orbital floor repair, most perceived improvements in surgical duration (83%, especially higher-volume operators p=0.009), precision (84%), and ease of placement (69%). Rarely (less than 5%) was any outcome rated inferior to traditional techniques for any procedure. Perceived turnaround times and costs were variable, but the greatest consensus was for two-segment fibular-flap reconstructions and orbital floor repair. Industry estimates were generally consistent between two company representatives, but manufacturing-only costs differed when using in-house (departmental) designers. Costs and turnaround times are questionable barriers since few understand 'real-world' figures. Designing in-house can dramatically alter costs. Improved accuracy and surgical duration are common themes but biomechanical benefits are less-well understood. This study paints a picture of the potentially routine applications and benefits of printed titanium, capacity for uptake, understanding amongst surgeons, and areas for improvement.

Printed titanium implants in UK craniomaxillofacial surgery. Part I: access to digital planning and perceived scope for use in common procedures.

This first part of a two-part study examines perceived applications for and barriers to using printed titanium in light of current caseloads, funding pathways, and use of digital planning. It aims to demonstrate the scope for printed titanium in modern practice and to guide industry about the needs of UK surgeons. A cross-sectional study over 14 weeks was performed electronically with support from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team. Ethics approval was obtained at the lead centre. A total of 132 participants joined the study (70% consultants, 25% specialty registrars, and 5% other), approximating a 29% response rate from consultant/registrar BAOMS members throughout mainland UK. Eighty-eight per cent used CAD-CAM design, with highly variable funding/access, design/manufacturing workflows (in-house/outsourced). Eighty-eight per cent were involved with trauma, 61% with orthognathic, and 52% with oncology-reconstruction surgery. Favourite applications for printed titanium were orbital floor repair (89%) and free-flap jaw reconstruction (87%). Most participants also cited maxillary/zygomatic osteotomies and cranioplasty (range 61%-73%). Although a popular application (78%), the evidence base in temporomandibular joint surgery is limited. Those performing orthognathic surgery perceived more indications than those who did not (p=0.013). Key barriers included cost, turnaround time and logistics, and the need to be trained in traditional techniques. Printed titanium was useful for both common and niche procedures, but was specifically limited in emergency trauma. Most surgeons had experience in CAD-CAM surgery but technical understanding appeared unclear. Limiting factors included variable funding and production pathways, perceived costs, and logistics, but in-house design can minimise them. In part II, we quantify perceived benefits and limitations and whether surgeons' understanding and knowledge are sufficient to rationalise them.

Lessons learnt from the first dual-specialty conference in oral and maxillofacial surgery led by medical students.

There remains limited formal teaching and placements in oral and maxillofacial surgery (OMFS) in medical schools. OMFS incorporates surgical techniques and attends to conditions that overlap with specialties such as plastic, and ear, nose, and throat (ENT) surgery. With an aim to introduce medical undergraduates to OMFS and promote links to clinical OMFS departments, we hereby report the successful organisation and impact of a locally-arranged, undergraduate, dual-specialty conference.

A Transoral Excision of a Deep Parotid Lobe Lesion Using Ultrasound-Guided Wire Localization: A Multi-disciplinary Team Approach.

PURPOSE: Removing deep parotid lobe lesions often requires a mandibulotomy procedure which carries with it a risk of significant morbidity. A transoral approach may help mitigate against complications but is technically demanding due to limited access in an area with a close relation to the internal carotid artery. METHODS: We describe a multi-disciplinary approach with the use of intraoral ultrasound-guided wire localization of a low-grade acinic cell carcinoma located in the deep lobe of the right parotid gland. RESULTS: Our multi-disciplinary approach facilitated the complete removal of this deep lobe parotid lesion via a transoral approach with minimal post-operative sequelae or complications. CONCLUSION: In selected cases, with appropriate expertise, this dynamic approach can potentially be used even for malignant disease to limit post-operative morbidity when managing small deep parotid lobe lesions.

How far reaching is our research? An analysis of the journals in which oral and maxillofacial surgery research is cited.

In this study we investigate the five most cited articles in the British Journal of Oral and Maxillofacial Surgery (BJOMS). Articles cited were usually published in other OMFS journals (40%) or dentistry journals (32%). The mean (SD) SCImago Journal and Country Rank, (SJR) (an interface to access the bibliometric database of journals) for cited papers was 0.64 (SD=0.56). Nearly one third of citations were of research in OMFS and dentistry, suggesting its relevance to the wider academic community.

Medical students' understanding of oral and maxillofacial surgery: an Irish perspective.

Oral and Maxillofacial Surgery (OMFS) remains an enigmatic specialty in Irish medicine and many students are unaware of its scope and the unique career pathway involved. We completed a multicentre cross-sectional study to identify their ability to identify the requirements for entry to specialty training year 3 (ST3) in OMFS, to assess their awareness of OMFS surgeons, and their general awareness of, and exposure to, the specialty. Data were collected through an electronic questionnaire. Participants were asked to select the most suitable surgical specialty to treat a number of common conditions in the head and neck, and to choose the requirements they deemed essential for specialist training. Knowledge was measured by the number of correct responses. A total of 443 medical students participated (University College Cork (UCC) n=328, 74%; Royal College of Surgeons in Ireland (RCSI) n=113, 26%). A total of 318/374 (85%) had had no previous experience of OMFS, 38/374 (10%) had had theoretical teaching only, and 18/374 (5%) had had clinical experience. A total of 212/329 (64%) wished for greater exposure as a student, but only 34/329 (9%) would consider a career in the specialty. The median (IQR) number of correct responses for OMFS procedures was 3.0/10 (2.0), with women, direct entrants, and RCSI students scoring highest. Only 11/367 (3%) could identify the minimum entry requirements for a post of specialist registrar. This study has identified a potential gap in the undergraduate curriculum. Although medical students are rarely taught about OMFS, they show an interest in learning more.

A review of oral surgery-related papers published in the British Journal of Oral and Maxillofacial Surgery during 2011 and 2012.

This paper is a synopsis of all articles relating to oral surgery that were published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) between January 2011 and December 2012. Of the 57 published, 40 (70%) were full-length articles that predominantly focused on implantology, dentoalveolar surgery, and bisphosphonate osteonecrosis of the jaws (BONJs). In addition, a number of short communications, technical notes, and letters to the editor described rare cases, unusual complications, and novel surgical techniques.

A review of TMJ-related papers published in the British Journal of Oral and Maxillofacial Surgery in 2011 and 2012.

This review summarises the articles relating to the temporomandibular joint (TMJ) that were published in the British Journal of Oral and Maxillofacial Surgery (BJOMS) between January 2011 and December 2012. In total 24 papers were published. Of these, 16 (67%) were full-length articles, which included prospective, retrospective, and laboratory-based studies as well as reviews. The remaining 8 papers were short communications, technical notes, and letters to the editor, which report on, amongst other things, unusual cases, rare complications, and novel surgical techniques.

Can I be a student again? How medical graduates make the decision to return to dental school prior to a career in oral and maxillofacial surgery.

INTRODUCTION: Oral and maxillofacial surgery (OMFS) trainees in the UK have traditionally completed their dental undergraduate studies prior to returning to medical school. Recently, there have been increasing numbers of medical graduates who return to dental school before embarking on OMFS specialist training. There is limited research into the career motivation within this group and little guidance on how they may integrate the dental undergraduate course into their postgraduate training path. This study aims to evaluate these factors in more detail. METHODS: Questionnaires and focus groups were used to evaluate prior surgical experience of qualified medics who return to dental school with the intention of pursuing a career in OMFS, along with the factors that affect the timing of their return to dental school. RESULTS: The average age of medical graduates entering dental school decreased during the study period. The average number of months each cohort of students spent as a practicing doctor prior to starting dentistry also reduced. Postgraduate experience in OMFS was highly variable, but the numbers of students who received alternative exposure to OMFS, such as undergraduate special study modules, medical school elective or taster weeks, increased. The key barriers that were carefully considered by these trainees before returning to university included the perceived increase in the length of training, trainees' prior surgical experience, financial implications and the impact on quality of life. CONCLUSIONS: A trainee's decision to return to study dentistry is a multifactorial process. Understanding when trainees decide to return to sit their dental degree is vital not only to provide guidance for future trainees but also to assist future workforce planning, thus aiding training, education and development within OMFS.

Academic background of oral and maxillofacial specialty trainees in the United Kingdom.

INTRODUCTION: The academic profile of a specialty can be measured in a number of ways. In the selection process for entry into higher training in oral & maxillofacial surgery (OMFS) and for interface fellowships in surgery trainees are awarded points for papers published, presentations, teaching and learning, grants and higher degrees. General information about career development can provide trainers, and trainees, with information and guidance. METHODS: A web-based questionnaire was developed and distributed via electronic mailing lists to all OMFS specialist trainees. Basic demographic information was collected. Previous, current and future career plans were questioned, as was academic background in terms of publications, presentations, prizes and research grants as well as further degrees and examinations. RESULTS: One hundred and five OMFS specialty registrar trainees (StR) replied (76.6% response rate). 83.3% were male and the average age of all trainees was 37 years old. 74.7% obtained a training post on the first application. 62.6% of trainees were keen to practice in trauma surgery. 76.6% were keen to undertake a fellowship. 20.9% were keen to be involved in academia (teaching) and 9.9% in academia (research). 22.1% of trainees had obtained grants. CONCLUSION: Those involved in appointing to training programmes will now be able to see the level of competition. Future applicants to training programmes in oral and maxillofacial surgery in the United Kingdom are now aware of the level of competition. OMFS is not immune to the 'academic crisis' that exists in other surgical specialties, and the completion of higher degrees and entry in to academic careers should be encouraged and supported among trainees with an interest.

A parathyroid adenoma: benign disease presenting with hyperparathyroid crisis.

Hyperparathyroid crisis is a rare manifestation of parathyroid disease. We present the case of a 53-year-old gentleman with a review of the current literature. He presented in acute renal failure with epigastric pain and vomiting. His serum-corrected calcium (CCa(2+)) was raised at 5.2 mmol/L, in addition to a massively raised parathyroid hormone (PTH) level (3957 ng/L). Ultrasound studies of the neck revealed a 2 cm well-defined mass inferoposterior to right thyroid lobe. CT scans of the neck showed a normal mediastinum and confirmed no associated lymphadenopathy. Having undergone medical resuscitation for 9 days, a neck exploration revealed a cystic mass, which was excised. Histological investigations revealed a 9.25 g, cystic parathyroid adenoma with no features of malignancy. His PTH and CCa(2+) returned to normal postoperatively. This suspicious presentation of benign disease, including a marked elevation in PTH, highlights the challenges facing the endocrine surgeon in dealing with parathyroid disease.

Inflammatory mediators convert anandamide into a potent activator of the vanilloid type 1 transient receptor potential receptor in nociceptive primary sensory neurons.

The endogenous ligand, anandamide activates at least two receptors on nociceptors; the excitatory vanilloid type 1 transient receptor potential receptor, the activity of which is indispensable for the development and maintenance of inflammatory heat hyperalgesia, and the inhibitory cannabinoid 1 receptor, the activity of which reduces that pathological pain sensation. Recent data are equivocal on whether increasing anandamide levels at the peripheral terminals of nociceptors in pathological conditions increases or decreases inflammatory heat hyperalgesia. Here, by using the cobalt-uptake technique we examined whether vanilloid type 1 transient receptor potential receptor activity evoked by 10 nM-100 microM anandamide is increased or decreased in inflammatory conditions. An inflammatory milieu for cultured rat primary sensory neurons was established by incubating the cells in the presence of the inflammatory mediators, bradykinin and prostaglandin E2. Anandamide, similarly to the archetypical vanilloid type 1 transient receptor potential receptor agonist, capsaicin induced concentration-dependent cobalt-uptake in a proportion of neurons. However, the potency of anandamide was significantly lower than that of capsaicin. While pre-incubation of cultures with bradykinin and prostaglandin E2 alone did not evoke cobalt-entry, the inflammatory mediators potentiated the effect of both capsaicin and anandamide. Application of the competitive vanilloid type 1 transient receptor potential receptor antagonist, capsazepine, or inhibitors of protein kinase A, protein kinase C or phospholipase C inhibited the anandamide-evoked cobalt-uptake both in the presence and absence of bradykinin and prostaglandin E2. These findings show that inflammatory mediators significantly increase the excitatory potency and efficacy of anandamide on vanilloid type 1 transient receptor potential receptor, thus, increasing the anandamide concentration in, or around the peripheral terminals of nociceptors might rather evoke than decrease inflammatory heat hyperalgesia.