Andrew J. Sidebottom

Development of in-house rapid manufacturing of three-dimensional models in maxillofacial surgery

hree-dimensional imaging and rapid prototyped planning odels provide an excellent diagnostic tool for the assessent of complex facial deformity,1–5 but limitations include he amount of time required,1 particularly in the management f emergency cases,2 and cost.3 The technical and organsational difficulties encountered in the implementation of his technology in a modelling service have already been ddressed.4 Nottingham University Hospital maxillofacial unit has nvested in office-based rapid prototyped technology. We escribe the system and its current applications. Satellite rapid prototyped bureaux are expensive to set p (costly machinery and overheads), rely on wide proviion of services and use by large numbers to make a profit. ffice-based systems are less expensive, require smaller remises and use simpler technology. Choices are limited to hree-dimensional printers (gypsum or starch-based), fused eposition modelling (FDM) systems (ABS plastic-based) or hermojet wax-based. The ZPrinter 310 Plus (Z Corporation, Burlington, Masachusetts, USA) was chosen as it was inexpensive (£25,000), as the fastest build times (4 h for a full skull), and is easy to aintain. It is cost effective (£1/cm3) with low waste, is accuate (±0.1 mm in the Z plane, ±0.2 mm in the X, Y planes), as small proportions and can make hard, soft or flexible odels. It can also be used to identify different types of body issue depending on the predefined threshold setting selected Fig. 1). The main advantage for in-house systems is that the linician, not staff at a bureau, controls the interface with

Oral Mucosal irritation with incorrect use of alendronate

he VDRL test was repeated and the result was 1/128, which onfirmed the diagnosis. The patient was treated with four oses of penicillin G (2 400 000 IU) once a week. Fourteen ays after treatment had started the oral lesions had disapeared completely. HIV may alter the clinical course of syphilis, leading to typical presentations, involvement of the central nervous ystem, and faster progression.1 In HIV positive patients, yphilis may be difficult to diagnose because of false-negative erological results.2 False-negative results are rare, but may ccur either because of impaired response of B lymphoytes to Treponema pallidum, or high antibody titres (Prozone henomenon), in which case the tests become positive with ilution of the serum.3 There is no microscopic feature speific to secondary syphilis; however, the analysis of both linical and histological features may provide reasonable rounds for serology.

Cryoanalgesia in the management of intractable pain in the temporomandibular joint: a five-year retrospective review.

Cryoanalgesia is a controversial adjunct to the management of chronic pain, but we know of no studies that have investigated its effect in the management of temporomandibular joint (TMJ) pain. In this five-year retrospective study we treated 17 patients who had severe pain that had failed to respond to all forms of conventional conservative treatment and were not appropriate for simple open operation. None had a clear indication for open operation on the joint or had too severe disease to warrant a simple procedure. Preliminary diagnostic injections of bupivacaine to the TMJ relieved the pain. We applied the cryoprobe in the region of the auriculotemporal nerve and TMJ capsule. There was a small but insignificant improvement in mean mouth opening together with a significant (p=0.000) improvement in visual analogue pain scores (VAS) from 6.8 (range 4-10) to 2.0 (range 0-7). Two patients had no change in their pain scores, and 2 had complete resolution of their pain. The mean number of pain-free months after treatment was 7 (IQR 3-15). Three patients had long-term pain relief, and 12 temporary relief; 6 of these subsequently had successful relief after total replacement of the TMJ. One patient had further cryoanalgesia, one was referred for specialist pain management, and one controlled the pain with nortriptyline. Of the 17 cases studied, 2 had temporary complications after cryoanalgesia. Cryoanalgesia is a useful adjunct to the management of intractable pain in the TMJ. Short-term pain relief can be achieved, and long-term relief is possible in some, deferring more complex and costly treatments.

Risk factors for intraoperative dislocation of the total temporomandibular joint replacement and its management

Total replacement of the temporomandibular joint (TMJ) is an effective treatment for intractable pain and impaired function that is a consequence of end-stage joint disease. Prospective assessment of 138 joint replacements identified an 8% risk of intraoperative dislocation of the joint, which was associated primarily with coronoidectomy (30%) and inflammatory arthropathy (24%). Management included the use of intermaxillary elastic traction and treatment of masticatory dystonia when present. Of the 11 patients who had light elastic traction for one week, only one required further treatment for dislocation. Patients with no intraoperative dislocation did not require elastics, and joints remained stable postoperatively.

Prospective outcome analysis of total replacement of the temporomandibular joint with the TMJ Concepts system in patients with inflammatory arthritic diseases

We report the outcomes of patients with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis, who had total replacement of the temporomandibular joint (TMJ) using the TMJ Concepts system between 2005 and 2014. We prospectively measured mouth opening (mm), and pain and dietary function (visual analogue scale (VAS), 1 - 100) before operation, and at 6 weeks, 6 months, one year, and beyond. Forty-six joints were replaced in 26 patients (mean age 40, range 16 - 71), 22 of whom were female. Most had rheumatoid (n=17) or psoriatic arthritis (n=7). At one year the mean (SD) pain scores had fallen from 55 (36) to 2 (7) on the left, and from 62 (31) to 2 (5) on the right (p<0.001). Mean (SD) scores for dietary function had increased from 48(25) to 95(9) (p<0.001), and mouth opening had increased from a mean (SD) of 23(10) mm to 35(5) mm (p<0.001). The joints dislocated during the operation in 5 patients, and 4 had temporary weakness of the facial nerve. Outcomes after replacement of the TMJ with the TMJ Concepts system were good in patients with inflammatory arthritis, which further validates the procedure, as damage to the joint is severe in this group.

UK temporomandibular joint replacement database: a report on one-year outcomes

Alloplastic temporomandibular joint (TMJ) replacements are increasingly subspecialised, and supraregional centres that treat sufficient numbers to ensure high standards are emerging. Having recently reported the introduction of a national TMJ joint replacement database that is endorsed by the British Association of TMJ Surgeons (BATS), we now present the first-year outcomes. This was a review of all data in the BATS National Case Registration of TMJ Replacement as of June 2014. A total of 252 one-year outcome records were available. Key outcomes were median (IQR) improvements in interincisal distance of 9 (4-15) mm (p<0.001) and worst-sided pain score of 6 (4-8) (p<0.001). Pain scores improved or remained static at one year in all but 3 (2%) patients. There was a significant improvement in the proportion of patients who reported a good, very good, or outstanding quality of life at one year (38% at baseline to 87% at one year; p<0.001). While outcome reports from single centres for alloplastic TMJ replacements have already been published in the United Kingdom, this is the first dedicated national database in this country that will yield valuable longitudinal follow-up data. Outcomes were comparable with smaller published series and showed improvements in pain, dietary intake, quality of life, and function, with few outliers. The database has recently moved to a new software system and we hope to publish three-year and five-year outcomes in due course.