Daljit K. Dhariwal

Multicentre study of operating time and inpatient stay for orthognathic surgery

Orthognathic surgery has advanced considerably since its development in the mid-twentieth century, and in most maxillofacial units mandibular and maxillary osteotomies are routine procedures. However, to enable accurate health planning and costing, and to obtain meaningful consent, it is important to have reliable data for duration of operation and inpatient stay. Virtually every aspect of orthognathic surgery has been researched, but we know of no recent studies that have looked specifically at how long the procedures take and how long patients stay in hospital. We retrospectively studied a sample of patients who had had orthognathic operations at six maxillofacial units in the United Kingdom (UK) to assess these measures. We looked at 411 operations which included 139 bilateral sagittal split osteotomies, 53 Le Fort I osteotomies, and 219 bimaxillary osteotomies. The study showed that the mean (SD) operating time for bilateral sagittal split osteotomy is 2h 6min (46min), 1h 54min (45minutes) for Le Fort I osteotomy, and 3h 27min (60min) for bimaxillary osteotomy. The duration of postoperative hospital stay was also measured. Fifty percent of patients spent one night in hospital after bilateral sagittal split osteotomy, whereas 39% and 9% of patients spent two and three nights, respectively. Forty-five percent of patients spent one night in hospital after Le Fort I osteotomy, whereas 34%, 13%, and 2% spent two, three, and four nights, respectively. Forty-one percent of patients spent two nights in hospital after bimaxillary osteotomy, whereas 34%, 21%, and 3% spent one, three, and four nights, respectively. This data provides evidence for national benchmarks.

Orbital fractures in children: A review of outcomes

The third most common facial fractures in children are fractures of the orbit, and the medial wall and floor are the commonest sites affected. The aetiology, clinical presentation, and timing of operation all differ from those of adults. If there are few or no clinical signs, but oculocardiac reflex is present, it is highly suggestive of trapdoor injury. This retrospective study includes all consecutive children (younger than 18 years) referred with confirmed fractures of the orbital floor over a 5-year period (2005-2010). A total of 24 patients were identified with a mean age of 13.5 years, and most injuries were secondary to falls. Isolated injury to the orbital floor occurred in 14 (58%); the rest involved other fractures of the orbital wall or face, or both. There were 11 trapdoor fractures (46%), and 9 open blow-out fractures (38%). Overall, nausea and vomiting occurred in 13 patients (54%); 8 of these had trapdoor fractures. Most patients had operations (22, 92%), and the mean time to operation was 4 days. Complications increased with delays to theatre. Those operated on within 1 day had fewer complications than those who had operations after 3 days. Postoperatively, diplopia (n=6/11) and restricted eye movement (n=3/11) were associated with trapdoor injury, while enophthalmos (n=1/9) and paraesthesia (n=3/9) were related to open blow-out fractures. To reduce compromised outcomes, prompt operation is warranted in all children with fractures of the orbital floor regardless of the configuration.

Role of parental risk factors in the aetiology of isolated non-syndromic metopic craniosynostosis

To try and identify potential parental risk factors for isolated non-syndromic metopic craniosynostosis, we did a telephone survey of parents of children who attended the craniofacial centre at Birmingham Childrens Hospital (BCH), UK, from 1995 to 2004. We calculated the prevalence of a number of potential risk factors and compared them with those of the general population. A total of 103 children with syndromic or non-syndromic isolated metopic craniosynostosis were seen, of which 81 (79%) had non-syndromic, isolated metopic craniosynostosis (M:F ratio 3:1). The response rate to the telephone survey was 72%. The prevalences of maternal epilepsy and the use of valproate, antenatal maternal complications (hypertension or pre-eclampsia, haemorrhage, and urinary tract infection), and fertility treatment in our sample were significantly higher than among the general population (p=0.01 or less in all cases). The likely roles of maternal epilepsy and taking valproate in the aetiology of isolated non-syndromic metopic craniosynostosis are further consolidated by our study. The finding that antenatal complications are possible risk factors for craniosynostosis has not to our knowledge been published previously.

Infantile fibromatosis: a case report and review of the literature

Desmoid tumours are benign fibrous neoplasms originating from musculoaponeurotic structures throughout the body. These tumours are rare in the mandible and the literature is limited to case reports and retrospective reviews and to date there is no agreed protocol for the management of these lesions in the paediatric mandible. The definition, diagnosis and management of juvenile fibromatosis still presents a challenge to the modern surgeon, radiologist and pathologist. We describe a case of paediatric mandibular infantile fibromatosis which presented a diagnostic dilemma, and review the currently available literature.

A rare case of localised oral amyloid of the labial mucosa

Amyloidosis is often a systemic process, and localised oral amyloidosis is rare. We present the case of a young woman with amyloid deposition in the labial mucosa of her lower lip. Systemic involvement was excluded by comprehensive assessment at the UK Amyloidosis Centre. Of 40 previously reported cases of localised oral amyloidosis we found only one that was limited to the labial mucosa.