Ian Sharp

Re: Will maxillofacial surgeons remain dental surgeons first?

The Calman reforms have led to a reduction in the length of all surgical training. Before the reforms, dental graduates had a shorter pathway than medical graduates to achieve maxillofacial consultant status, with exemptions from primary FRCS and 3-year medical courses. Now that 3-year dentistry courses for medical graduates have been established, medical graduates and dental graduates can complete their second degrees in the same length of time. Furthermore, medical graduates with the MRCS diploma are exempted from parts A and B of the MFDS, whereas dental graduates with MFDS have no exemptions from the MRCS examinations. Dental graduates may need more time as senior house officers to take these extra examinations. This could lead to dental graduates taking longer time than medical graduates to achieve consultant status. Traditionally, maxillofacial surgery has recruited the overwhelming majority of its trainees from dental graduates and has had close links with dental surgery. However, these recent developments in training make maxillofacial surgery far more attractive to medical graduates. Whether maxillofacial surgery continues to recruit the majority of its trainees form a dental background remains to be seen.

Postoperative Complications Following LeFort 1 Maxillary Advancement Surgery in Cleft Palate Patients: A 5-Year Retrospective Study

Objective: To investigate the postoperative complication rates of LeFort 1 maxillary advancement surgery in cleft patients when performed by a single surgeon over a 5-year period. Design: A retrospective case note review of 79 cleft palate patients. Setting: All surgery was performed by a single oral and maxillofacial surgeon in a tertiary care center. Participants: All cleft palate patients over 17 years of age who opted for surgical correction of maxillary hypoplasia with a LeFort 1 between 2010 and 2015. Patients required full surgical and clinical records. Interventions: Complete surgical advancement of the maxilla ranging from 2.0 to 18.0 mm performed by conventional osteotomies (87%) or distraction osteogenesis (13%). Main Outcome Measure(s): Postoperative patient- and clinician-reported complications at set-interval follow-up appointments. Results: Twenty-one patients (26.58%) reported no complications; 11 postoperative complications were identified in the remaining cohort. Temporary paresthesia of the infraorbital nerve was the most common complication (53.16%) followed by infection (13.92%). Other complications included relapse (11.39%), maxillary instability (6.33%), velopharyngeal impairment (6.33%), nasal obstruction (5.06%), chronic sinusitis (3.80%), bony dehiscence (1.27%), gingival necrosis (1.27%), partial necrosis of the maxilla (1.27%), and loss of tooth vitality (1.27%). Conclusions: LeFort 1 maxillary advancement surgery in cleft palate patients is associated with a wide range of postoperative complications, most commonly temporary paresthesia of the infraorbital nerve. Detailed, informed consent is essential prior to surgery.

Direct traumatic optic neuropathy in a temporal laceration: A case report

Facial lacerations are a common presentation in emergency departments. It is important to appreciate the mechanism of injury and the anatomy of structures involved in penetrating lacerations in the maxillofacial region. A 65-year-old man suffered an accidental penetrating injury with a sharp kitchen knife to the right temporal region. There was a single laceration to the right temporal region. The right eye had no perception to light, a total afferent and efferent pupillary defect and partial ophthalmoplegia. Computerised tomography scan revealed signs of penetration through the skin, temporalis, postero-lateral orbital wall and orbital apex. There was no injury to the globe or either retrobulbar or intracranial haemorrhage. A diagnosis of direct traumatic optic neuropathy was made following consultation with opthalmology and neurosurgery teams. Only two similar cases of penetrating trauma in the temporal region resulting in direct traumatic optic neuropathy have been identified in the literature. This case presentation highlights the structures that are at risk of damage from penetrating trauma in the maxillofacial region.

Simple novel technique to accurately control the depth of drill holes during transbuccal osteosynthesis of mandibular fractures

Sensory complications often caused by internal fixation canrange from transient to permanent dysaesthesia.Sincethepreferredareaforplatefixationisgenerallycloseto the inferior dental neurovascular canal, roots of eruptedteeth, and impacted wisdom teeth, it is often difficult, evenforanexperiencedsurgeon,toavoidiatrogenicinjurytothesestructures. The cutting tip of a standard transbuccal drill islongerthanthatrequiredfor6or8mmscrewsandisnoteasilystopped before it damages deeper structures. We acknowl-edge that use of a 90 degree drill makes this complicationless likely, but they are not yet widely available in the routinesurgical armamentarium.We report the novel use of suction catheter tubing, whichis placed over the drill bit during ORIF of a fractured angle

Re: P. Gentile, F. Nicoli, R. Caruso, G. Gravante, V. Cervelli. Alternative strategy to reconstruct the nose after excision: extra-oral implant anchored to bone [Br. J. Oral Maxillofac. Surg. 47 (2009) 50-51].

esions of the fracture.2 These methods vary in complexity, nventiveness, use of special instruments, and amount of force equired.2,3 We evaluated the efficacy of reduction using a finger in a rospective non-randomised study of 16 patients with simle uncomplicated fractures of the zygomatic arch who were reated under local anaesthesia between 2 and 34 h after njury. The physician inserted his index-finger into the ginivobuccal furrow on the same side as the fracture, rupturing he mucosa and exerting an outward force on the medial surace of the fractured bones (Fig. 1). This was successful in 4 patients (Fig. 2). It failed in two cases partly because both atients had had the fracture for more than 24 h, and had anaged with other methods. This method of treatment must e used shortly after the fracture if it is to be successful. here were no complications, and at long term follow up 8 months–5 years) consisting of clinical examination with o radiological control, and a patient’s self-assessment quesionnaire, there were no permanent functional or unpleasant esthetic complications. We consider this old clinical practice to be a simple, quick, nd low cost method of reduction that should be kept in ind for suitable cases, or when instruments are unavailble.

Antibiotics and the combined oral contraceptive pill

Broad spectrum antibiotics have been implicated in the failure of contraception in women taking the combined oral contraceptive pill.1 Over 20% of women in the United Kingdom are regular users,2 and the Faculty of Family Planning of the Royal College of Surgeons of Obstetricians and Gynaecologists recommend that for them “additional contraceptive precautions should be taken whilst taking a short course of a broad spectrum antibiotic and for 7 days after stopping. If these 7 days run beyond the end of a packet, the next packet should be started immediately without a break”.3 It is important for surgeons who prescribe antibiotics to be aware of this advice and ask patients if they are taking the pill. In the United States, a patient successfully sued a clinician after she became pregnant following a course of antibiotics.2 Several other cases of pregnancy after a course of antibiotics whilst patients were taking oral contraceptives have been reported when additional precautions were not taken.1,4 To find out if a group of oral and maxillofacial senior house officers (SHOs), who were attending a lecture at Birmingham University, were aware of these recommendations, we circulated a questionnaire. They were asked what advice they would give three different patients after the removal of lower third molars. In all the cases, the patients were given antibiotics but one patient was taking the combined oral contraceptive pill. Of a total of 15 SHOs, 11 stated correctly that this patient should use additional contraceptive precautions. However, advice over the period that these precautions should be used varied between 5 and 28 days. No SHO mentioned that for some patients the contraceptive pill should be continued without a break. From this small sample, it seems that the majority of SHOs are aware of that antibiotics can interact with the combined contraceptive pill but are not aware of the precise advice that should be given to patients. Some SHOs were not aware that any specific advice should be given. We, therefore, recommend that the Faculty of Family Planning advice should be included in the guidelines of all maxillofacial units. When this advice has been given to a patient, a record should be made in the patient’s casenotes.