Dual-degree Oral and Maxillofacial Surgery Training in the United States: "Back to the Future".

In the present report, we trace the history of education and training of oral and maxillofacial surgeons as it has evolved from the mid-19th century to the present. We consider the effects of the discovery of ether anesthesia, the separation of medicine and dentistry, and other milestones such as antisepsis (Lister), antibiotics (Fleming) and surgical progress during wartime. The main emphasis, however, is on the background, development, and implementation of current dual-degree oral and maxillofacial surgery training programs, the first 5 programs, the pioneer advocates for this training, and progress and challenges for the future.

Correlation of Cephalometric Analyses With Clinical Impression in Orthognathic Surgery Patients: Harvold and Steiner Analyses.

PURPOSE: A variety of linear (Harvold) and angular (Steiner) cephalometric analyses are used to identify the skeletal basis for a malocclusion; there is no universally accepted standard. The purpose of this study was to compare the concordance of Harvold and Steiner analyses with the clinicians' impression of maxillary and mandibular jaw position. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients who underwent orthognathic surgery at Massachusetts General Hospital from 2012 through 2016. Patients were included if they had symmetrical deformities not related to trauma, clefts, or syndromes; complete records; and a clinical diagnosis documented at initial consultation. The predictor variables were Harvold- and Steiner-derived diagnoses of jaw position (hypoplasia, neutral, or hyperplasia). The outcome variables were maxillary and mandibular clinical impressions (hypoplasia, neutral, or hyperplasia). The concordance, sensitivity, specificity, positive predictive value (PPV), and negative predictive value relative to clinical diagnoses were calculated. RESULTS: During the study period 388 patients had orthognathic surgery and 222(112 females, mean age 26.4±9.9 years) met the inclusion criteria. Harvold and Steiner analyses were 82% and 33% concordant with the maxillary clinical impression, respectively (P < .001), and 62% and 52% concordant with the mandibular clinical impression, respectively (P = .044). Steiner analysis had greater concordance in females (P < .001). For maxillary hypoplasia, the maxillary unit length had a sensitivity of 87%, specificity of 36%, and PPV of 92% and the sell-nasion-A (SNA) point had 28%, 84%, and 93%, respectively. For mandibular hypoplasia, the mandibular unit length had a sensitivity of 52%, specificity of 96%, and PPV of 94% and the sell-nasion-B (SNB) point had 52%, 98%, and 97%, respectively. For mandibular hyperplasia, the mandibular unit length had a sensitivity of 46%, specificity of 93%, and PPV of 40% and the SNB point had 73%, 73%, and 23%, respectively. CONCLUSIONS: Harvold analysis was significantly more consistent with the clinical impression of the maxillary and mandibular sagittal position than Steiner analysis. Both analyses were highly specific and had high PPVs to confirm the clinical impression. Clinicians should consider incorporating Harvold analysis during treatment planning for orthognathic surgery.

Residency Interview Experiences in Oral and Maxillofacial Surgery Differ by Gender and Affect Residency Ranking.

PURPOSE: Resident interview experiences are crucial for applicants when ranking programs. The purpose of the present study was to evaluate the interview experience among current oral and maxillofacial surgery (OMS) residents to determine the factors that influenced their selection and ranking of training programs and whether these experiences differed between women and men. MATERIALS AND METHODS: We conducted a cross-sectional survey of OMS residents in 2018. The 12-question survey included demographics, reasons for selecting an interview and ranking programs, and positive and negative experiences during the interviews. Logistic regression models were constructed to evaluate the predictors of unprofessional or negative experiences. RESULTS: A total of 1134 surveys were emailed, with 165 completed questionnaires (14.6%) returned by 35 women (21.2%) and 130 men (78.8%). Their average age was 30.8 years (range, 25 to 42). The racial/ethnic distribution was as follows: white, 75.8%; Asian, 15.8%; and other, 8.4%. Of the 165 respondents, 52% were in MD and 48% in non-MD programs. The top factors in selecting an institution at which to interview were clinical scope and volume, and the reason for ranking a program high was resident friendliness, which was similar among the female and male respondents. Unprofessional behavior or negative experiences were reported by 62 respondents (38%) and occurred by both faculty and residents and during both interviews and social events. Demeaning behavior toward the applicant, residents, and colleagues was the most common negative experience overall, with the women experiencing more gender-specific inappropriate behavior. Female respondents and those who were in dual-degree programs were 2.4 and 2.1 times more likely to experience unprofessional conduct than their peers, respectively (P = .03). CONCLUSIONS: Female and male residents were influenced by the same factors when selecting interviews and ranking residency programs. Unprofessional and inappropriate conduct was reported by 38% of the respondents. Women and dual-degree respondents were 2.4 and 2.1 times more likely to experience unprofessionalism during interviews, respectively. This might have contributed to the low number of current female OMS residents.

Long-Term Stability of Condylectomy and Costochondral Graft Reconstruction for Treatment of Idiopathic Condylar Resorption.

PURPOSE: To assess and update long-term outcomes of endoscopic condylectomy and costochondral graft (CCG) reconstruction for treatment of active idiopathic condylar resorption (ICR). PATIENTS AND METHODS: This study is a continuation of a retrospective cohort study of patients with active ICR who underwent bilateral condylectomies and CCG reconstruction from 1999 to 2016. Predictor variables were demographic and operative factors. The primary outcome variable was occlusal stability, as defined by normal overbite (1 to 4 mm) at latest follow-up. Overbite; overjet; the angle formed by the sella, nasion, and B point (SNB); mandibular plane angle; and ramus-and-condyle unit height were measured. Time points were preoperative (T0) and immediate (T1), 1 year (T2), 2 years (T3), 3 to 5 years (T4), and at least 5 years (T5) postoperative. Descriptive and bivariate statistics were computed. A Firth logistic regression model was used to identify variables associated with occlusal instability. RESULTS: Twenty-six patients (25 female; mean age, 23.1 yr) who underwent bilateral endoscopic condylectomies and CCG reconstruction were included: 14 from the original cohort and 12 additional patients for the present analysis. Median follow-up was 3.65 years (range, 1.11 to 17.1 yr). Preoperatively, all patients had a Class II malocclusion with a mean overjet of 6.89 mm (range, 1.2 to 17.1 mm) and a mean anterior open bite of -2.12 mm (range, -0.4 to -7.9 mm). Normal overbite (1 to 4 mm) and overjet (2 to 4 mm) were achieved postoperatively in all patients. There were no significant changes in overjet, overbite, SNB, mandibular plane angle, and ramus-and-condyle unit height from T1 to T4. At latest follow-up, 88.5% of patients had a normal overbite. Three patients developed an anterior open bite postoperatively: 1 at 2 years (0.1 mm; preoperative, -3.4), 1 at 9 years (-0.8 mm; preoperative -7.9), and 1 at 11 years (-1.3 mm; preoperative -1.1). Subjects at T5 (n = 9 of 26) had mean overjet and overbite of 3.48 and 1.56 mm, respectively. Non-white race and follow-up time were significant predictors of occlusal instability in the regression model. CONCLUSIONS: Stable and predictable long-term outcomes can be achieved using endoscopic condylectomy and CCG reconstruction for treatment of active ICR.

Risk Factors for Cervical Spine Injury in Patients With Mandibular Fractures.

PURPOSE: Patients with mandibular fractures are known to be at risk of concomitant cervical spine injuries (CSIs). The purpose of this study was to determine the incidence of and risk factors for CSIs in these patients. PATIENTS AND METHODS: We conducted a retrospective cohort study of adult trauma patients with mandibular fractures from June 1, 2007, through June 30, 2017. Patients were identified through the Massachusetts General Hospital trauma registry and were included as study patients if they had a mandibular fracture and computed tomography or magnetic resonance imaging of the cervical spine. The primary predictor variable was the site of the mandibular fracture; the primary outcome variables were the presence of CSIs and death. The other variables were demographic characteristics (age, gender, alcohol use, and drug use), Injury Severity Score, Glasgow Coma Scale, presence of midface and extra-craniofacial injuries, and etiology. Data analysis consisted of univariate correlations and construction of a multivariate model to determine independent risk factors for CSIs. RESULTS: Of 23,394 patients in the trauma registry, 3,950 (17%) had craniomaxillofacial fractures and 1,822 (7.7%) had CSIs. The frequency of CSIs in the overall cohort of mandibular fracture patients (n = 1,147) was 4.4%, and for admitted patients (n = 495), it was 10%. The mean age of patients with mandibular fractures plus CSIs was 40 years (range, 19 to 93 years); 84% were men. Patients with a ramus-condyle unit fracture, mandibular fracture plus any midface fracture, non-craniomaxillofacial injury, and motor vehicle crash etiology had the highest frequency of CSIs. Ramus-condyle unit fractures and chest injuries were independent risk factors for CSIs in the multivariate model (P = .0334 and P = .0013, respectively). The mortality rate was 4-fold higher in patients with CSIs versus those without CSIs. CONCLUSIONS: The presence of ramus-condyle unit fractures and the presence of chest injuries were independent risk factors for CSIs. Oral and maxillofacial surgeons should be diligent in ruling out CSIs in mandibular fracture patients.

An Algorithm for Management of Dentofacial Deformity Resulting From Juvenile Idiopathic Arthritis: Results of a Multinational Consensus Conference.

PURPOSE: Juvenile idiopathic arthritis (JIA) frequently affects the temporomandibular joints and may cause dentofacial deformity and dysfunction. The adverse effects of JIA on dentofacial growth, morphology, and function may be due to erosion of the existing mandibular condyle(s), the inhibitory effect of the arthritis on the growing mandible, or both. No algorithm exists for management of JIA-induced skeletal and dental abnormalities; treatment varies widely. MATERIALS AND METHODS: On the basis of the available literature and expert opinion obtained by a consensus conference held by the Temporomandibular Joint Juvenile Arthritis (TMJAW) group-a multidisciplinary and multinational clinical and research network dedicated to the diagnosis and management of temporomandibular joint arthritis caused by JIA-we present an algorithm to be used as a conceptual framework for management of dentofacial deformity resulting from JIA. RESULTS: An algorithm for management of dentofacial deformity resulting from JIA is presented and exemplified by 5 clinical cases. CONCLUSIONS: A standardized algorithm will improve clinical decision making and facilitate outcome research by allowing valid comparisons between published research studies. We emphasize the importance of multidisciplinary evaluation, management, and long-term follow-up.

Imaging of the Temporomandibular Joint in Juvenile Idiopathic Arthritis: How Does Quantitative Compare to Semiquantitative MRI Scoring?

PURPOSE: Contrast-enhanced magnetic resonance imaging (MRI) is commonly used to evaluate temporomandibular joint (TMJ) disease in patients with juvenile idiopathic arthritis (JIA). However, MRI assessments have been limited by qualitative reporting, the presence of enhancement in normal joints, and a lack of standardized protocols. The purpose of the present study was to compare a quantitative MRI analysis using an enhancement ratio (ER) to a new semiquantitative system developed by Outcome Measures in Rheumatology and Clinical Trials (OMERACT). MATERIALS AND METHODS: We performed a retrospective cross-sectional study of children with JIA who had undergone TMJ MRI with gadolinium enhancement at Boston Children's Hospital. The predictor variables were demographic data (sex, age at MRI) and disease-related findings (JIA subtype and arthritis medication at MRI). The outcome variables were OMERACT scores and ER (ratio of TMJ synovium and longus capitis muscle pixel intensities). The ER was compared with the OMERACT total, inflammatory, and damage scores using Pearson's correlation analysis and multivariable linear regression. Statistical significance was evaluated using the Student t test and analysis of variance with significance set at P < .05. Inter- and intraexaminer reliability were evaluated using intraclass correlation coefficients (ICCs). RESULTS: The sample included 50 subjects (84% female) with a mean age of 12.7 ± 3.9 years and 124 MRI scans. The mean ER was 2.5 ± 0.9 (normal, <1.55). The mean OMERACT total was 4.9 ± 3.3. Controlling for age, sex, JIA subtype, and medication, for every 1-U increase in ER, the OMERACT increased by 3.11 for the total (P < .001), 1.01 for the inflammatory (P < .001), and 0.86 for the damage (P < .001) scores. The intra- and interrater consistency was better for the ER (ICC, 0.83 and 0.96, respectively) than for OMERACT (ICC, 0.77 and 0.35, respectively). CONCLUSIONS: Quantitative evaluation of TMJ synovial enhancement using the ER is easier to score and has superior intra- and interrater agreement; however, it can only assess inflammation. Semiquantitative assessment of TMJ using the OMERACT adds data about chronic changes. Using both systems might provide the most accurate assessment of JIA status.

Dr Guralnick's 'Secret' Mission.

Walter C. Guralnick, a major figure in Oral and Maxillofacial Surgery, educational innovator, master surgeon and mentor died, surrounded by family, on September 6, 2017 at Massachusetts General Hospital, the institution he loved and served for 65 years. Like others of his generation, Dr Guralnick served in the Armed Services in Europe during World War II. Little was known of his activities with the 7th General Hospital and of his contributions to the war effort. This paper brings together material from military, local and overseas archives to provide an insight into his life and work during those years.

Long-Term Effects of Distraction Osteogenesis of the Mandible.

PURPOSE: 1) To assess the fate of the permanent teeth in and adjacent to the regenerate in pediatric patients who underwent mandibular distraction osteogenesis (DO) and 2) to compare the postoperative growth of the distracted mandible with age- and gender-matched controls. PATIENTS AND METHODS: This was a retrospective cohort study of children who underwent mandibular DO during the primary or mixed dentition period and before completion of somatic growth (boys aged ≤14 years and girls aged ≤12 years) at Massachusetts General Hospital from 1996 to 2014. From the DO registry, patients were selected who had complete clinical and radiographic records and at least 1 year of follow-up. Patients with disorders of dental development (eg, ectodermal dysplasia) were excluded. Panoramic radiographs were used to assess changes in morphology, eruption, and orientation of the dentition. Standardized digital lateral cephalograms were used to assess the mandible (sella-nasion-B point, mandibular unit length, ramus height, body length) preoperatively, at the end of distraction, at 1 year after device removal, and at longest follow-up. RESULTS: A total of 118 patients of all ages in the registry underwent some form of DO during the study period. For assessment of the effects on dentition, 26 subjects, who had 36 osteotomies and distraction wounds, met the inclusion criteria. In this sample, 22 of 26 subjects (85%) had 52 adverse effects in 38 of 90 permanent teeth (42.2%) assessed. Cephalometric measurements indicated that there was net mandibular growth at longest follow-up, after a period of skeletal relapse from the end of distraction to 1 year after device removal; however, only 2 of 25 subjects (8%) regained a growth rate in the vector of DO that matched or exceeded normal age- and gender-matched controls. CONCLUSIONS: DO commonly results in adverse effects on the dentition within and adjacent to the DO gap, with only a minority resolving over time. Net growth of the mandible occurs after DO but at a slower rate and lesser magnitude than that of age- and gender-matched controls.

Evaluation of Andrews' Analysis as a Predictor of Ideal Sagittal Maxillary Positioning in Orthognathic Surgery.

PURPOSE: There is no universally accepted method for determining the ideal sagittal position of the maxilla in orthognathic surgery. In "Element II" of "The Six Elements of Orofacial Harmony," Andrews used the forehead to define the goal maxillary position. The purpose of this study was to compare how well this analysis correlated with postoperative findings in patients who underwent bimaxillary orthognathic surgery planned using other guidelines. The authors hypothesized that the Andrews analysis would more consistently reflect clinical outcomes than standard angular and linear measurements. MATERIALS AND METHODS: This is a retrospective cohort study of patients who had bimaxillary orthognathic surgery and achieved an acceptable esthetic outcome. Patients with no maxillary sagittal movement, obstructive sleep apnea, cleft or craniofacial diagnoses, or who were non-Caucasian were excluded. Treatment plans were developed using photographs, radiographs, and standard cephalometric measurements. The Andrews analysis, measuring the distance from the maxillary incisor to the goal anterior limit line, and standard measurements were applied to end-treatment records. The Andrews analysis was statistically compared with standard methods. RESULTS: There were 493 patients who had orthognathic surgery from 2007 through 2014, and 60 (62% women; mean age, 22.1 ± 6.8 yr) met the criteria for inclusion in this study. The mean Andrews distances were -4.8 ± 2.9 mm for women and -8.6 ± 4.6 mm for men preoperatively and -0.6 ± 2.1 mm for women and -1.9 ± 3.4 mm for men postoperatively. For women, the Andrews analysis was closer to the goal value (0 mm) postoperatively than any standard measurement (P < .001). For men, the linear distance from the A point to a vertical line tangent to the nasion from the McNamara analysis performed best (P < .001), followed by the Andrews analysis. CONCLUSION: The Andrews analysis correlated well with the final esthetic sagittal maxillary position in the present sample, particularly for women, and could be a useful tool for orthognathic surgical planning.

Unicystic Ameloblastoma Revisited: Comparison of Massachusetts General Hospital Outcomes With Original Robinson and Martinez Report.

PURPOSE: Robinson and Martinez established unicystic ameloblastoma (UA) as a distinct pathologic entity in 1977. Using their original description, the aims of this study were to compare the clinical presentation and outcomes of UA treated at Massachusetts General Hospital (MGH) with outcomes reported in the original article. PATIENTS AND METHODS: This was a retrospective cohort study of MGH patients treated for UA during a 15-year period. Patients were included if they had a confirmed clinical and histologic diagnosis of UA. The primary predictor variable was the source of the study sample (MGH vs Robinson and Martinez). Secondary variables included age, gender, radiographic appearance, treatment, and histologic subtype. The primary outcome variable was the number of recurrences over time comparing the 2 groups. RESULTS: There were 19 patients (10 female and 9 male patients) in the MGH group and 20 patients (10 female and 10 male patients) in the Robinson and Martinez study. The lesions were predominantly unilocular (13 in MGH group and 19 in Robinson and Martinez group), located in the mandible (18 in MGH group and 20 in Robinson and Martinez group), and tooth associated (12 in MGH group and 14 in Robinson and Martinez group). No statistically significant demographic differences were noted between the 2 groups. In the MGH group, 13 cases (68%) exhibited mural or intramural ameloblastic epithelium, 4 (21%) were luminal or intraluminal, and 2 were unknown. However, histologic configuration was not reported in the Robinson and Martinez group. MGH patients were treated by enucleation (n = 7, 37%) or resection (n = 12, 63%) compared with enucleation in 100% cases in the Robinson and Martinez group. Overall, the disease-free survival rate was higher in the Robinson and Martinez group, but the difference was not statistically significant (P = .089). Within the MGH group, 100% of recurrences occurred in patients with mural invasion treated by enucleation. CONCLUSIONS: The results of this study support UA as a distinct entity based on demographic, clinical, and radiographic criteria. Outcomes in the MGH group were influenced by the degree of ameloblastic epithelial invasion and suggest that this variable should be considered when planning treatment.

Adjuvant Antiangiogenic Treatment for Aggressive Giant Cell Lesions of the Jaw: A 20-Year Experience at Massachusetts General Hospital.

PURPOSE: To document long-term outcomes using a standardized treatment protocol of enucleation with preservation of vital structures and adjuvant subcutaneous interferon for aggressive giant cell lesions (GCLs) of the jaws. MATERIALS AND METHODS: A retrospective cohort study was designed. We evaluated all patients treated at Massachusetts General Hospital from April 1995 through September 2015 by enucleation with preservation of vital structures and adjuvant daily subcutaneous interferon for aggressive GCLs. The sample included patients with complete medical records consisting of clinical, radiographic, histopathologic, and follow-up data. The exclusion criteria included patients with incomplete records, contraindications to interferon therapy, non-aggressive GCLs, and GCLs associated with syndromes or with hyperparathyroidism. The primary outcome variable was long-term progression-free survival (PFS). The secondary outcome variables were adverse effects and laboratory abnormalities classified by type, frequency, and severity. Predictor variables for recurrence or failure included age, gender, location and features of lesion, type of procedure, duration of interferon treatment, amount of bone fill at end of treatment, and adverse effects. Descriptive statistics, Kaplan-Meier survival analysis, and Cox proportional hazards regression analysis were computed. RESULTS: Of a total of 77 patients, 45 (mean age, 18.8 ± 12.5 years; 29 female patients; 36 in whom the mandible was affected) met the inclusion criteria. The mean duration of interferon therapy was 7.9 ± 2.3 months. After follow-up of 4.8 ± 3.9 years, 6 patients showed progression of the lesion, considered recurrence (13.3% failure rate, 82.6% PFS rate). Most patients had mild (n = 42; 93.3%) and/or moderate (n = 31; 68.8%) side effects, which were readily managed. Adverse effects required stoppage of interferon in 7 patients, whereas no patients had long-term toxicity. No variable was significantly associated with PFS. CONCLUSIONS: The results of this study indicate that enucleation with preservation of vital structures in combination with adjuvant interferon alfa is a reliable treatment for aggressive GCLs of the jaws associated with a low recurrence rate.

Is Intra-Articular Steroid Injection to the Temporomandibular Joint for Juvenile Idiopathic Arthritis More Effective and Efficient When Performed With Image Guidance?

PURPOSE: To compare short-term outcomes and procedure times for intra-articular steroid injection (IASI) to the temporomandibular joint (TMJ) with and without the use of intraoperative image guidance for patients with juvenile idiopathic arthritis (JIA). MATERIALS AND METHODS: This is a retrospective study of children with JIA who underwent TMJ IASI at Boston Children's Hospital (Boston, MA). Patients were divided into groups according to IASI technique: 1) "landmark" group if performed by an oral and maxillofacial surgeon using an anatomic landmark technique with no intraoperative image guidance or 2) "image-guided" group if performed by an interventional radiologist using intraoperative ultrasound and computed tomography. Predictor variables included IASI technique (landmark vs image guided), age, gender, JIA subtype, category of medications for arthritis, and presence of family history of autoimmune disease. Outcome variables were changes in patient-reported pain, maximal incisal opening (MIO), synovial enhancement ratio (ER), and total procedure time. RESULTS: Forty-five patients with 71 injected TMJs were included. Twenty-two patients with 36 injected TMJs were in the landmark group and 23 patients with 35 injected joints were in the image-guided group. There were no relevant differences in age, gender, family history of rheumatologic disease, or disease subtype between groups. There were no differences in resolution of pain (P = 1.00), increase in MIO (P = .975), or decrease in ER (P = .492) between groups, but procedure times averaged 49 minutes longer for the image-guided group (P < .008). CONCLUSIONS: There were no statistical differences in short-term outcomes, but procedure times were longer for the image-guided group. Although specific indications for the use of image guidance might exist, routine use of this procedure cannot be justified.