Author(s) Puglia F.A.; Hills A.; Dawoud B.; Magennis P.; Chiu G.A. et al.
Source British Journal of Oral and Maxillofacial Surgery; Oct 2021; vol. 59 (no. 8); p. 867-874
Language English
Publication Date Oct 2021
DOI 10.1016/j.bjoms.2020.12.021
ISSN 0266-4356
Database EMBASE
Abstract
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.

• Available in full text at The British journal of oral & maxillofacial surgery

Author(s) Puglia F.A.; Ubhi H.; Dawoud B.; Magennis P.; Chiu G.A.
Source British Journal of Oral and Maxillofacial Surgery; Oct 2021; vol. 59 (no. 8); p. 875-880
Language English
Publication Date Oct 2021
DOI 10.1016/j.bjoms.2020.12.017
ISSN 0266-4356
Database EMBASE
Abstract
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.

• Available in full text at The British journal of oral & maxillofacial surgery

Author(s) Long L. (lily.long1@nhs.net); Douglas J.; Carter L.; Parmar J.; Morton M.
Institution(s) (Long, Douglas, Carter, Parmar) Oral and Maxillofacial Surgery Department, Leeds Dental Institute, Worsley Building, Clarendon Way, Leeds LS2 9LU, United Kingdom
(Morton) Oral and Maxillofacial Surgery Department, Royal Blackburn Hospital, Haslingden Road, Blackburn BB2 3HH, United Kingdom
Source British Journal of Oral and Maxillofacial Surgery; 2021
Language English
Publication Date 2021
Database EMBASE
AbstractTraditionally, surgical management of zygomaticomaxillary complex (ZMC) and orbital fractures occurs within two to three weeks of the injury, followed by an overnight admission to allow for extended eye observations. This is due to the risk of postoperative retrobulbar haemorrhage (RBH) or orbital compartment syndrome (OCS), a rapidly progressive and sight threatening emergency that requires immediate intervention. In September 2016 the oral and maxillofacial surgery (OMFS) department at Leeds Teaching Hospitals redesigned their trauma service with a full-time trauma consultant, a dedicated clinic, and a weekly morning elective trauma theatre list. This allowed for standardisation of the management of patients with OMFS injuries. Furthermore, a formal day-case ZMC and orbital fracture pathway was developed to allow patients to undergo surgical management of such fractures with a same-day discharge. This has since been identified as an area of excellence by the Getting It Right First Time (GIRFT) programme, and is in line with the addition of ZMC and orbital fractures to the procedural list written by the British Association of Day Case Surgery (BADS). Unbeknown to the unit, the volume of day-case procedures was the highest within the UK, demonstrating the importance of GIRFT in highlighting areas of good or unique practice. The aim of this study was to determine the impact of our day-case pathway and designated OMFS trauma service on compliance with recent recommendations by GIRFT and BADS. Secondly, it was to determine the safety of same-day discharge with regards to postoperative complications.Copyright © 2021 The British Association of Oral and Maxillofacial Surgeons

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Author(s) Ho M.W. (michael.ho2@nhs.net); Puglia F. (BAOMSprojectmanager@baoms.org.uk); Tighe D. (david.tighe@nhs.net); Chiu G.A. (geoffchiu.baoms@gmail.com); Ridout F. (fran.ridout@savingfaces.co.uk); Hutchison I. (hutch.london@googlemail.com); Mason M. (mmason@ncepod.org.uk); McMahon J.M. (jeremymcmahon@ggc.scot.nhs.uk)
Source British Journal of Oral and Maxillofacial Surgery; Sep 2021; vol. 59 (no. 7); p. 831-836
AbstractThe BAOMS QOMS pilot was developed and run in six England OMFS units between December 2019 - April 2020. The aims of this pilot project were: to evaluate feasibility of the questionnaires developed for the audit and how effective they were with regards to quality improvement, to test the processes associated with the data collection system and finally, to provide baseline data to support patient data collection without the requirement of prospective consent. The pilot included a series of six audits (oral and dentoalveolar [ODA], oncology, orthognathic, reconstruction, trauma, and skin). Data entry was clinician-led in five OMFS units and in one unit (EKHU), it was additionally supported by members of the clinical coding team. One hundred and twenty-eight REDCap account user details were issued and of these, 45 (35%) completed registration and 22 (17%) were active users who participated in the pilot data entry. Disproportionate focus on individual audits within QOMS was seen, though not all units offered the full range of service audited. Users suggest the skin and ODA audits were sufficiently clear, but improvement is required in the oncology and reconstruction questionnaire particularly. The pilot was successful in aiding the project team identify areas of weaknesses and strength in the design of the REDCap registry and implementation of the next phase of the initiative. The information and experience gained has to date enabled a successful application for section 251 approval from the HRA and progress for the next phase of national data collection.Copyright © 2021

Author(s) Adam D.; Broderick D.; Kyzas P.; Vassiliou L.
Source British Journal of Oral and Maxillofacial Surgery; Jun 2021; vol. 59 (no. 5); p. 524-533
The use of microvascular anastomotic coupling devices (MACD) is an established technique for venous anastomosis. However, literature on arterial MACD is conflicting. We report, to our knowledge, the first registered systematic review of its kind to evaluate the safety and efficiency of arterial MACD in free flaps. We performed a PRISMA-guided systematic review (PROSPERO-registered) and identified reports using a search algorithm in MEDLINE/EMBASE. The rate of arterial thrombosis was set as the primary outcome. Secondary outcomes included flap survival, failure rates, and comparison of MACD and the conventional hand-sewn technique. From the 17 studies identified, 2672 free flap reconstructions were performed and 640 arterial anastomoses with MACD attempted (622 completed, 97.2%). The pooled incidence of arterial thrombosis was 2.1% (13/622), and overall flap failure rate 4.34% (116/2672). The total number of arterial MACD procedures performed first time, with no perioperative complications, revisions, or thrombosis, was 88.9% (569/640). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality analysis revealed low quality and significant heterogeneity. The use of arterial MACD is a safe and efficient alternative to hand-sewn anastomosis, with more recent literature showing excellent results. However, further evaluation is required with controlled trials.Copyright © 2020

Author(s) Gray W.K.; Day J.; Morton M.
Source British Journal of Oral and Maxillofacial Surgery; Nov 2020; vol. 58 (no. 9); p. 1151-1157
Language English
Publication Date Nov 2020
When patients attend the emergency department with facial fractures that require surgery and are immediately admitted, surgery can be delayed as theatre time is prioritised for other more urgent patients. One solution is to send the patient home and admit them as an elective patient at a later date. The aim of this study was to investigate the outcomes of patients admitted directly and those seen as elective patients following fracture of the mandible or zygomatic complex. Data were taken from the hospital episodes statistics (HES) dataset for 2011-2018, and all hospital admissions for mandibular and zygomatic complex fractures within the National Health Service (NHS) in England were extracted. Patients were categorised as those admitted on attendance at the emergency department and given definitive treatment during the admission, and those not admitted on attendance at the emergency department but discharged home and seen as elective admissions within 30 days of attendance. Data were available for 39 606 patients. For both types of fracture there was substantial variation between NHS trusts in the proportion of patients admitted electively and the proportion admitted directly as emergencies. Elective admission was independently associated with shorter overall stay and lower emergency readmission rates. We found no evidence that delays to definitive surgery through elective admission had a negative impact on emergency readmission rates. Patients admitted electively had a significantly shorter hospital stay.Copyright © 2020

Author(s) Gray W.K.; Day J.; Morton M.
Source British Journal of Oral and Maxillofacial Surgery; 2020

When patients attend the emergency department with facial fractures that require surgery and are immediately admitted, surgery can be delayed as theatre time is prioritised for other more urgent patients. One solution is to send the patient home and admit them as an elective patient at a later date. The aim of this study was to investigate the outcomes of patients admitted directly and those seen as elective patients following fracture of the mandible or zygomatic complex. Data were taken from the hospital episodes statistics (HES) dataset for 2011-2018, and all hospital admissions for mandibular and zygomatic complex fractures within the National Health Service (NHS) in England were extracted. Patients were categorised as those admitted on attendance at the emergency department and given definitive treatment during the admission, and those not admitted on attendance at the emergency department but discharged home and seen as elective admissions within 30 days of attendance. Data were available for 39 606 patients. For both types of fracture there was substantial variation between NHS trusts in the proportion of patients admitted electively and the proportion admitted directly as emergencies. Elective admission was independently associated with shorter overall stay and lower emergency readmission rates. We found no evidence that delays to definitive surgery through elective admission had a negative impact on emergency readmission rates. Patients admitted electively had a significantly shorter hospital stay.Copyright © 2020

Author(s) Langton S.; Cousin G.C.S.; Pluddemann A.; Bankhead C.R.
Source British Journal of Oral and Maxillofacial Surgery; Oct 2020; vol. 58 (no. 8); p. 898-917

Oral cancer is referred to specialists by both general practitioners (GPs) and dentists, with varying proportions reported in different studies. However, some have noted that dentists more commonly refer oral cancer in the absence of patient-perceived symptoms and may refer at an earlier stage. Unfortunately, approximately half the UK adult population do not receive regular dental care. We have conducted a systematic review of studies that compare GPs and dentists in the referral of oral cancer and have focused on three aspects: the proportion of diagnosed oral cancers, stage on presentation, and delay. Searches of the databases Medline, Embase, Scopus, Google Scholar, Web of Science, and CINAHL, together with additional searches of reference lists, authors, and conference proceedings, found 22 studies from 10 countries, which included a total of 4953 oral cancers. The percentage of medical referrals ranged from 13% to 86%; dental referrals ranged from 15% to 80%. Random-effects meta-analysis indicated a combined relative risk of medical referral to dental referral of 1.36 (95% CI: 0.99 to 1.86). For UK-based studies, the relative risk was also 1.36 (95% CI: 1.05 to 1.76). There was considerable heterogeneity for all studies and for a subgroup of UK studies: I296.4% (95% CI 95.4 to 97.1) and 81.0% (95% CI 63.3 to 90.1), respectively. Several studies showed a lower stage for dentally-referred cancers; the combined risk for dentists and GPs referring early (stages 1 and 2) disease was 1.37 (95% CI: 1.17 to 1.60), and one cause may be the much higher number of cases referred by dentists in the absence of symptoms. No studies showed a significant difference in delay. Oral cancer is referred by both GPs and dentists, typically about 50% and 40%, respectively, although there is a wide range, probably depending on local circumstances. Both groups require skills in oral examination, recognition of lesions, and knowledge of the risk factors. Effectively, regular dental attenders are a select group that is regularly screened for oral cancer, and it is likely that screening is not delivered to those with the highest risk. We suggest that further work is required on how to access high-risk individuals both for possible screening and preventive interventions.Copyright © 2020 The British Association of Oral and Maxillofacial Surgeons

​Author(s) Hasan A.; De Gea Rico A.; Cousin G.
Source British Journal of Oral and Maxillofacial Surgery; Feb 2020; vol. 58 (no. 2); p. 245

Author(s) Chandran A.; Bhanji A.; Rao J.
Source British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)
Introduction/Aims A surgeon's experience undertaking larger case volumes is often linked to better performance. The aim was to assess a single surgeons performance in NMHNSC excisions over five years. We analysed time and case number to reach a consistent competency with regards to excision margins. Materials/Methods Skin pathology data sets were collected retrospectively from 2014 to 2018 The data collected involved a single surgeon operating in multiple hospitals and settings. Information regarding patient demographics, histological features of NMHNSC and excision margins were collected from pathology reports for each operation.

Results/Statistics The results showed from January 2014 to April 2014 there was a 6.8% involved margin rate and a 11.4% close margin rate. This improved with further case volume over the five years. By September2018 to December 2018it was noted that the involved margin rate had reduced to 3.8% and the close margin rate had increased slightly to 13.4%. We present the longitudinal statistics.

​Conclusions/Clinical relevance This study has shown that there appears to be improvement in performance of excisions of NMHNSC as the surgeon gains experience over time to reach a consistent performance. There was a clear initial learning curve to achieve this which took several cases. This likely differs from numbers presented in the literature believed to achieve competency in other bodily surgical procedures.Copyright © 2019

Author(s) Markose G.; Corsar K.; Graham R.M.
Source British Journal of Oral and Maxillofacial Surgery; Dec 2019; vol. 57 (no. 10)
With advances in CT scanning and 3D printing facilities the use of surgical models / stents in maxillofacial surgical planning for implants and oncological work is fairly routine. We present a case where the use of custom cutting guides aided 3D sculpting of a rather overgrown mandible in a young girl with a central giant cell granuloma. En bloc resection can be challenging due to the variable size and location of the tumours and their proximity to surrounding vital tissues. To overcome the challenge of precise resection, computer-aided models were used to assess vital structures, the extent of the affected area and plan surgery.

​The models were able to accurately identify the course of the mandibular canal. A mirror image of the normal side of the mandible was superimposed on the overgrown mandible and patient-specific guiding templates for resection were fabricated which allowed significant recontouring of the mandible with relative ease. The guiding templates provide significant advantages by guiding surgery, leading to more precise resection of the bone with less blood loss, shorter operation time and avoiding damage to the inferior alveolar nerve. We discuss the pre-operative and operative steps in the surgery and review the results.Copyright © 2019