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Multiple choice questions in surgery—Evidence based practice?

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 British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Abstracts
The cervical approach to the jugular foramen in
lateral skull base surgery—Indications and technical
considerations
Jeremy McMahon, Thomas Carroll
Sheffield Teaching Hospitals NHS Trust, United Kingdom
Introduction: An important role for the head and neck sur-
geon in the skull base team is to provide efficient cervical
exposure of the neurovascular structures at the jugular fora-
men. The necessity for this approach arises for both benign
and malignant tumours.
Methods: The experience of the Sheffield Skull Base
Team from January 2004 to July 2005 was reviewed. All
cases undergoing a cervical approach to the jugular fora-
men were reviewed with emphasis on the indications for
surgery, pathology, complications, and outcome. The surgical
approach will be described.
Results: Over an 18 month period seven patients required
a cervical approach to the jugular foramen. The tumours
in this series comprised one meningioma, three neurilem-
moma’s, one adenocarcinoma of the temporal bone and two
cases of temporal bone squamous cell carcinoma. Some of
these tumours have distinct characteristics depending upon
the pathology and extent. These features will be discussed.
One patient with a neurlilemmoma of the XIth cranial nerve
had swallowing difficulties and required subsequent ipsilat-
eral vocal cord medialisation. In none of the three patients
with malignancy of the temporal bone was it possible to pre-
serve VIIth nerve function.
Conclusions: The cervical approach to the jugular foramen
is indicated for a range of pathological processes involving
the lateral skull base. It is easily and rapidly accomplished
and is an important prelude to the safe removal of tumours
involving, or in close proximity to, the petrous carotid, jugular
bulb, and pars nervosa of the jugular foramen.
0266-4356/$ – see front matter © 2006 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.
doi:10.1016/j.bjoms.2006.07.001
Multiple choice questions in surgery—Evidence based
practice?
Patrick Magennis
University Hospital Aintree, United Kingdom
Introduction: Modern medicine sets a high premium on
evidence based practice. It discourages practises based
on unproven hypothesis or prejudice. With the prospect
of the introduction of Multiple Choice Questions (MCQ)
into the oral and maxillofacial surgical intercollegiate Fel-
lowship exam, the time seemed right for a review of
the evidence on the use of MCQ’s in advanced surgical
practice.
Method: Ovid Medline was searched for research publica-
tions on the use of MCQ’s. The resulting literature review
was tabulated and indexed.
Results: Of 276 articles pertaining to MCQ’s, 159 related
to MCQ’s in the assessment of medical training. Of these
56 related to undergraduate examinations and the remaining
103 to basic training in medicine and surgery. Many related to
their value as part of computer based learning programmes.
There are no papers specifically validating the use of MCQ’s
for summative assessment in higher surgical training in any
specialty.
MCQ’s are shown to work best in assessing knowledge and
decision-making where the choices are clear and well under-
stood. As the options become less clear or as the candidates
knowledge of ‘exceptions to rules’ increases, the MCQ pro-
cess assesses personality, knowledge of language, risk taking,
and answering strategies rather than knowledge and under-
standing.
The more counter-intuitive results of research into MCQ’s
will be discussed as well as evidence based strategies for
those required to design or answer these questions.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Sixteen year review of the Southampton Protocol for the
management of craniofacial trauma
Michael Colin Bater, A. Webb, D. Lang, K. Fugleholm, B.
Evans
Southampton University Hospitals, United Kingdom
Aim: To assess long-term combined management of cranio-
facial trauma according to the Southampton Protocol.
Method: A review of a consecutive series of cases treated
under the same protocol since 1988, along with a comparison
of complications of cases treated without combined team-
working prior to 1988. Follow up was by clinical review and
a GP questionnaire.
Results: Between 1986 and 2006, 170 cases were treated.
There has been no postoperative mortality or serious mor-
bidity to date. There have been no cases of post-operative
meningitis in cases treated under the protocol. In contrast we
will discuss the complications of cases treated prior to the
introduction of the combined management protocol.
Conclusions: Craniofacial trauma management according to
the Southampton Protocol is safe and effective.
Is echocardiography more cost effective than repeated
antibiotic use in the asymptomatic ‘heart murmur’
patient?
Kate Starling, Richard C.W. James
Norfolk & Norwich University Hospital, United Kingdom
Introduction: Patients present at hospital departments and
general practices with a history of rheumatic fever or an asym-
tomatic heart murmur that has never been investigated.
Recent Cardiac Society guidelines advise that cardiology
departments should assess these patients. In practice these
patients are often prescribed antibiotic prohylaxis despite
having no proven cardiac abnormality.
The benefits of avoiding blind prescription of antibiotics
are well documented, but in this climate of ‘cost effective
medicine’ this study compares cost of diagnostic echocar-
diograms versus that of repeated doses of antibiotic cover.
Method: Typical treatment schedules for two theoretical
patients with differing oral healths were drawn up.
The cost of a diagnostic echocardiogram and doses of antibi-
otic prophylaxis were sought.
The cost of the amount of antibiotic doses required by the
patients in 2 years was compared to the cost of an echocar-
diogram.
The percentage of patients referred with asymptomatic, undi-
agnosed heart murmurs where echocardiograms resulted in
the need for antibiotic cover was audited.
Results: In 2 years a typical patient with chronic peri-
odontitis will require 11 episodes of treatment requiring
antibiotic prophylaxis—£27.39, and a typical attender 3
episodes—£7.47.
A diagnostic echocardiogram costs £21.01 so is more cost
effective in patient 1 in only 2 years and patient 2 in 6 years.
429
Of 100 patients referred with a history of heart murmur only
approximately 10% require antibiotic prophylaxis.
Conclusions: We have demonstrated that a diagnostic
echocardiogram is more cost effective than repeated antibi-
otic usage in the patient with a history of heart murmur.
Cognitive deficits in metopic synostosis—A 10-year
review
Zarina S. Shaikh, D. Dhariwal, M. Rosser, E. West, G. John-
son, G. Solanki, H. Nishikawa, F. Dean, S. Sgouros, M.S.
Dover
Craniofacial Unit, Birmingham Children’s Hospital, United
Kingdom
Background: The occurrence of cognitive deficits and
behavioural problems in children with isolated metopic syn-
ostosis is well known, however the incidence of this associ-
ation is unclear.
Patients and methods: The records of all patients referred for
assessment of suspected craniosynostosis between 1995 and
2004 were identified. All patients with a confirmed diagnosis
of isolated metopic synostosis were analysed and develop-
mental assessments reviewed to establish the frequency of
language delay, learning disabilities, and behavioural prob-
lems in this group.
Results: In the 10-year period, 81 patients (20 female; 61
male) with isolated metopic synostosis were identified. In
our cohort 80% of referrals were made before 12 months
of age (median 10 months). There were 13 cases identified
in 1995 with a year on year increase to 58 cases in 2004.
There was 176% increase in craniosynostosis cases referred
to the craniofacial unit, but the proportion of metopic refer-
rals was much higher than other types of craniosynostoses
(p = 0.01). Children with isolated metopic synostosis had a
42% incidence of speech and language problems includ-
ing receptive and expressive delay, feeding and language or
global delay. The majority of patients were treated surgically
with fronto-orbital advancement surgery, a small proportion
were managed without surgery. All children with conserva-
tively managed craniosynostosis (100%) showed language
delay.
Conclusion: There appears to be an increased incidence of
isolated metopic synostosis. In this group 42% of children
show cognitive and behavioural abnormalities. We suggest
early referral to a Craniofacial unit and long-term develop-
mental and neurologic follow-up.
Use of the Crabel Score for analysing maxillofacial med-
ical note keeping and the introduction of the percentage
of maximum score (POMS)
I. Basu, D. Chin Shong, S. Farooq, S. Holmes
Barts and The London NHS Trust, United Kingdom
The Crabel Score is an accepted method of auditing medical
note keeping and facilitating quality assurance. A score is
430 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
given to each of the four categories of Initial Clerking (10),
Subsequent Entries (30), Consent (10) and Discharge Sum-
mary (10). We look at its merit.
Materials and methods: Two auditors reviewed the case notes
of 60 patients which were divided into Oncology (n = 30) and
Trauma (n = 30) and applied a score (max = 50) to each set
of notes. The results were analysed statistically and also the
Percentage of Maximum Score (POMS) for each individual
category.
Results: The mean score overall was 45.85. There was a sig-
nificant difference between the scores for Initial Clerking
(P = 0.033) but not for Subsequent Entries (P = 0.152) This
was also reflected in the POMS of the Crabel Score itself.
Notes of the oncology patients scored a consistent 4–5%
higher than their Trauma counterparts. The lowest scoring
category was in Trauma: Initial Clerking (88%) whilst the
highest was in Oncology Consent (97%). Use of POMS also
allowed us to identify the most consistent omission (results
entering).
Discussion: We agree the Crabel Score is a useful tool for
audit and the provision of guidelines but in analysis of Note
keeping weaknesses we found that by looking at the individ-
ual categories and their POMS it was much easier to identify
consistent omissions and to confirm what we suspected clin-
ically. We suggest that when auditing note keeping clinicians
also note the percentage of maximum score for each of the
four Crabel categories.
Outcome of fronto-orbital advancement for craniosynos-
tosis
Daljit Kaur Dhariwal, A. Monaghan, S. Sgouros, H.
Nishikawa, G. Solanki, M.S. Dover
Craniofacial Unit, Birmingham Children’s Hospital, United
Kingdom
Background: There is little published quantitative evidence
of the outcome of fronto-orbital advancement surgery. This
study aims to assess and quantify the outcome of fronto-
orbital advancement surgery in patients with craniosyno-
stosis.
Methods: A retrospective review of patients treated with
fronto-orbital advancement surgery for craniosynostosis
was performed. Pre- and post-operative photographs were
assessed using the Birmingham Craniofacial Score, a numer-
ical 15 point score analysing facial deformity. A high score
indicates an improved aesthetic result. Mean scores pre-
surgery, at 6 months post-operatively and 1-year follow-up
were calculated and used for statistical analysis.
Results: Between 1981 and 2005, 273 patients underwent
fronto-orbital advancement surgery, records were analysed in
175. The male to female ratio was 1:1. The median age at time
of operation was 15 months, 29% were syndromic patients,
71% had non-syndromic craniosynostosis. The median pre-
operative index was 10, at 6 months post-operatively this
improved to 12 and to 13 at 1 year following operation.
The mean difference between pre-operative and 6 month
post-operative indices was 2.3, this improved to 2.9 at 1
year post-operatively (p < 0.001, ANOVA). Non-syndromic
patients showed better scores than syndromic craniosynos-
toses (p < 0.001, ANOVA). Further surgery was required in
10% of patients.
Conclusions: This study presents a scoring system to quan-
tify craniofacial deformities. A significant difference between
pre- and post-operative craniofacial scores following fronto-
orbital advancement and remodelling in children with cran-
iosynostosis has been found. Non-syndromic patients benefit
most from this surgery.
Current practice in the managment of trigeminal neural-
gia amongst maxillofacial surgeons in the UK
Niall McLeod, Jerry Cheniyan, Mustafa Tekeli
Southampton General Hospital, United Kingdom
Aims: To build up a picture of current practice in the man-
agement of trigeminal neuralgia (TN) in the United Kingdom
(UK), and compare this to suggested best practice.
Method: We undertook a postal survey of all consultant max-
illofacial surgeons in the UK, enquiring about their manage-
ment of patients with TN.
We enquired as to what investigations they performed rou-
tinely on new patients presenting with features of typical TN.
We then enquired as to their first choice for management of
the condition and what options they offered if this proved
unsatisfactory. We also asked specifically about which drugs
they prescribed, and whether they offered peripheral surgical
treatments.
Results: The minimum standard for investigating suspected
TN remains controversial. The suggested ideal is not under-
taken by most consultants and this may reflect lack of time
and resources, and the absence of evidence on benefits of
investigation in outcomes.
The current literature suggests that medical management
of TN is appropriate for most patients and this was
reflected in current practice. Most consultants use Carba-
mazepine as their first choice drug and we shall discuss
this and the rationale for alternatives if this proves unsatis-
factory.
Of those offering peripheral surgical treatment for
TN, neurolytic injections, of alcohol or glycerol, and
cryotherapy are the most common choices and we
shall present the advantages and disadvantages of each
these.
Conclusions: Current practice reasonablye reflects what is
suggested in the literature. There is however a lack of
good evidence based guidelines for the management of
TN.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Computer-assisted planning and navigation in craniofa-
cial surgery
Enno-Ludwig Barth, C. Eulzer, F. Tavassol, J. Mölle, M.
Rücker, N.-C. Gellrich, A. Schramm
Department of Oral and Maxillofacial Surgery, Medical
School Hanover, Germany
Surgical treatment of patients with complex cranio-
maxillofacial deformities as a result from craniofacial syn-
dromes or posttraumatic defects is one of the most challeng-
ing tasks in maxillofacial surgery.
Recent advances in computer technology achieve three-
dimensional analysis of complex craniofacial deformities
and virtual planning of surgical procedures. Furthermore,
computer-based virtual three-dimensional simulation meth-
ods for surgical procedures that are based on imaging data
assist the necessary visual understanding of complex patho-
logical situations and provide the ability to perform ‘virtual
surgery’ pre-operatively.
We present our experience with patients suffering from
severe cranio-maxillofacial malformations, who underwent
computer-assisted reconstructive surgery. Based on a sin-
gle Spiral-CT data set the DICOM-files were rendered to
a 3-D surface presentation and used for computer assisted
pre-operative planning and intra-operative navigation. At the
workstation, the patient’s individual anatomy was assessed
in multiplanar and three-dimensional views. Planning begins
with determination of virtual osteotomy lines on the facial
skull, then three-dimensional movement patterns of the seg-
mented bones are set. By superpositioning original and sim-
ulated locations of bone structures, their interferences can
be visualized. This visualization facilitates the evaluation of
the surgical procedure, with special consideration of bone
resections necessary for the movement of complex osteotomy
fragments.
Treatment planning with Voxel-based CT-data sets enables
a detailed view in patient’s anatomy and a detailed evalua-
tion of facial asymmetries. Surgical procedures and expected
operative results can be simulated on a personal computer
using CT-data, intraoperative guidance is performed by
means of navigation. Image fusion of pre- and post-operative
data sets achieves precise evaluation of surgical reconstruc-
tions.
Bisphosphonate induced osteonecrosis in multiple
myeloma patients
Andrew Salama, Ashrof Badros, Alisa Gibson, Robert Ord
University of Maryland Medical Center, United States
Intravenous bisphosphonates are utilized as a medical
adjunct in the treatment of multiple myeloma (MM) and
have been shown to improve survival. There have been
several reports of osteonecrosis of the jaws (ONJ) in patients
receiving bisphosphonates. Intraoral exposure of non-viable
bone is the clinical hallmark of ONJ. The etiology of
431
this condition is unclear and there is no consensus on its
management. This study analyzes risk factors, clinical
presentation and management strategies of ONJ in myeloma
patients.
The records of 90 MM patients were retrospectively reviewed
for details regarding demographics, myeloma therapy and
dental procedures. Follow-up data included surgical proce-
dures, complications, antibiotic therapy and outcomes. Inde-
pendent and continuous variables were entered into a logistic
regression model.
MM treatment consisted of high dose chemotherapy and
stem cell transplant (80%). Eighty four patients received
intravenous bisphosphonates, 22 of which developed ONJ.
Lesions occurred primarily in the dentate posterior mandible.
Debridement and sequestrectomy was performed in 14
patients; 4 had space infections requiring aggressive surgical
drainage, 4 patients required segmental mandibulectomy. The
variables predictive of developing ONJ were dental extrac-
tion (OR 9.1), sequential treatment with pamidronate and
zoledronic acid (OR 6.3), longer exposure to bisophospho-
nates and older age. There was no statistical significance for
gender, disease status, thalidomide or corticosteroid expo-
sure.
ONJ is an emerging problem in patients receiving bispho-
sphonates. Advanced age, dental extractions and sequen-
tial bisphosphonate therapy are major risk factors. There
is a limited role for antibiotics in the treatment of ONJ.
Surgery is helpful in selected patients but does not prevent
recurrence.
Patients’ perception of risk related to operating surgeons’
experience and the level of trainee supervision
Brian Bisase, Cyrus Kerawala, Lucy Hartfree,
Royal Surrey County Hospital, Guildford, United Kingdom
The basis of what informed consent should consist of is laid
down not by medical authorities alone but also legally through
case law. The latter is moving away from the Bolam principle
in negligence claims to supporting what a reasonable patient
might expect. In consent terms, a reasonable patient would
expect to be told of material risk. Risk is material if “in the
circumstances of a particular case, a reasonable person in the
patient’s position, if warned of the risk, would be likely to
attach significance to it”. The experience of a surgeon or the
level of supervision of a trainee may represent a material risk.
The study aimed to determine patients’ attitudes toward the
experience of the surgeon performing their procedure and
the level of supervision of that trainee surgeons should have.
One hundred patients (mean age 65 years, M:F 1:1) undergo-
ing orthognathic surgery or removal of basal cell carcinomas
were questioned, these procedures being chosen because of
their moderate complexity and potential cosmetic impact.
Over two thirds of patients were happy for a trainee to carry
out their surgery if this minimised the waiting time. Most
were happy for trainees to be unsupervised if they had pre-
432 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
viously been adequately trained. Only a minority indicated a
preference for waiting longer if this meant a consultant would
perform their operation.
In the climate of patient-centred care these findings highlight
the continuing need to balance training and service provision
as well as emphasising the requirements of the ever more
rigorous consent process.
Dying to get to the dentist: Fatal oro-facial infections
G.C.S. Cousin, P. Alam, J. Alcock, D.P. Palmer, M.E.
Morton, J.C. Lowry
East Lancashire Maxillofacial Service, United Kingdom
The incidence and severity of oro-facial and odonotgenic
infections in our area is increasing. There is some evidence
that this is because patients find it difficult to find a den-
tist, even for emergency treatment. Patients are admitted with
severe and established infection, often having received antibi-
otic treatment from doctors, but without having the required
dental treatment.
We wish to report two cases of fatal oro-facial infection; one
as a result of airway obstruction, the other as a consequence
of necrotising fasciitis. In addition, there were another two
cases of life-threatening infection, one patient survived three
cardiac arrests, and another a crash tracheostomy.
The management of oro-facial infections is an increasing
part of our emergency work. An almost universal common
denominator in these patients is the prescription of antibiotics
by doctors, as the patients cannot obtain dental treatment.
The Tracheostomy Wound Locator Toggle—A new device
to aid healing and improve early speech following decanu-
lation
Malcolm Cameron, Luke Cascarini
Queen Victoria Hospital, East Grinstead, United Kingdom
We present a new and patented medical device which helps
patients apply adequate finger pressure over a healing tra-
cheostomy wound following decanulation.
It has previously been our practice to dress tracheostomy
wounds after decanulation and instruct patients to press hard
on the dressings when speaking or coughing in order to avoid
disruption of the wound. We have observed that many of our
patients found it difficult to do this effectively for a num-
ber of reasons including chronic musculoskeletal disease,
surgery on the dominant arm, post-operative weakness, loss
of proprioception and sedation. Consequently, we found that
following decanulation, patients were initially hesitant to start
speaking and occasionally there was a delay in wound heal-
ing as a result of repeated wound disruption due to air leakage
through the wound.
This device aids the patient by giving them a toggle to press
on which ensures adequate force is applied to the wound
when speaking and coughing. The toggle itself is very easy to
locate. We have found that patients benefit enormously from
this simple device, they are more confident in their ability to
stop the air leak and, as a result, their early speech is much
improved and we expect fewer cases of delayed tracheostomy
wound healing.
The presentation includes photographs of the Toggle and a
video clip of its use.
A retrospective review of the outcome of hyperbaric oxy-
gen therapy in the treatment of head and neck patients in
a London Hyperbaric Unit
Chris Bridle, S. Harrison, P. Hardee
Whipps Cross University Hospital, London, United Kingdom
The London Hyperbaric Medicine unit is a Category 1 mul-
tiplace hyperbaric oxygen facility serving the South East of
the country. By retrospective review of the chamber activity
log from January 2001 to June 2005, we identified patients
who were refered for the treatment of conditions in the head
and neck region. These conditions included osteoradionecro-
sis, soft tissue radionecrosis, osteomyelitis, radiation induced
myelopathy and the prophylactic use of hyperbaric oxygen
for dental extractions and implants in the irradiated jaw.
We would like to present the findings of our review of the 67
patients identified. From the medical notes we were able to
detect outcome by reference to the signs and symptoms prior
to and after hyperbaric oxygen (HBO) therapy. The results
indicated that subjectively patients experienced improvement
in one or more of their symptoms in a significant number of
cases by the end of the HBO treatment.
In many cases the relevant Primary Care Trusts request sup-
portive evidence for the benefits of HBO therapy. The quan-
tative analysis of the benefit of HBO therapy is difficult to
ascertain in a retrospective study. This review is an observa-
tional study that indicates patients experience a benefit from
HBO therapy. Our review has identified the need for more
specific quantative data collection and more long term review
of patients. The authors recognise that, and would encourage,
further prospective work is required in this area to support our
findings.
Outcomes in the treatment of trigeminal neuralgia using
Gamma Knife radiosurgery
Katharine Fleming, J. Rowe, A.R. Loescher
United Sheffield Teaching Hospitals Trust/University of
Sheffield, United Kingdom
Introduction: Trigeminal neuralgia is a disabling condition
characterised by severe pain within the distribution of the
trigeminal nerve.
Medical management remains the first line treatment modal-
ity. However, this may fail and an alternative must be
found.
This retrospective study determines the effectiveness of
stereotactic (Gamma Knife) radiosurgery in this group of
patients.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Methods: All patients treated at the Stereotactic Unit in
Sheffield since January 2001, who were at least 1 year post
treatment, are included (number = 146). Data was collected
from notes and by telephone.
Pain scores pre and post treatment, time until improve-
ment, medication reductions, sensory changes and corneal
reflex impairment were noted. Patient acceptability was also
assessed.
Results: There was a significant reduction in pain scores post
radiosurgery. The majority were either entirely pain free or
very much improved. This had usually occurred by 6 months
but changes were seen up to 11 months post treatment. Late
relapse was seen in a few patients but not usually to pre treat-
ment levels; most were able to control these symptoms well
with medication.
There was a low but significant rate of sensory loss but all
of these patients were entirely pain free. Just under 4% had
some degree of corneal reflex impairment but none found it
disabling.
Conclusion: Stereotactic radiosurgery is a well tolerated, non-
invasive treatment for trigeminal neuralgia that is performed
under local anaesthetic as a day case. It has minimal side
effects when compared with traditional surgical interventions
and should therefore be considered when medical manage-
ment fails.
A novel and anatomic technique for correction of promi-
nent ears
Luke Cascarini, Philip M. Gilbert
Queen Victoria Hospital, East Grinstead, United Kingdom
We present a new technique for the correction of prominent
ears.
Numerous techniques have been described for the cor-
rection of prominent ears. Most modern techniques are
variants of those described by Mustarde (Mustardé JC.
British Journal of Plastic Surgery 1963;16:170–176) and
Chongchet (Chongchet V. British Journal of Plastic Surgery
1963;16:268–272). These techniques however do not address
the problem of deep conchal fossa and often a further proce-
dure is required such as conchal resection or concho-mastoid
sutures. These techniques also often result in ‘pinned-back’
ears with unnatural features such as: permanent sutures, loss
of post auricular sulcus, lumpiness of the folded cartilage,
knobbly edges and various other abnormalities. In recent
years these unnatural features are becoming increasingly
unacceptable to patients and their parents.
Gilbert’s technique is an anterior scoring technique that
addresses all the causes of prominent ears in one procedure
and restores all the components of the ear to a normal, natural
and anatomic shape without the use of permanents sutures.
Gilbert has been using this technique for many years with
excellent outcomes. The revision rate is low but when it is
required it is a significantly easier procedure than when other
primary techniques have been used.
433
Sepsis syndrome in maxillofacial surgery
Jeremy McMahon, J.A. McCaul, T.A. Handley, M.F. Devlin,
D.A. Koppel
Sheffield Teaching Hospitals NHS Trust, United Kingdom
Introduction: Infection in the head and neck is commonly
associated with dental sepsis. While local spread can result
in airway compromise, systemic involvement is recognised
as the Sepsis syndrome. The Sepsis syndrome is present
when the systemic inflammatory response syndrome (SIRS)
is associated with a defined focus of infection and is asso-
ciated with a 35–45% mortality. Awareness of the cardinal
signs of SIRS and early recognition of these are necessary
for the appropriate management of this systemic condition
using the surviving sepsis guidelines. We aimed to assess
the awareness of these clinical signs and the prevalence of
sepsis syndrome in patients presenting with infection in the
maxillofacial region.
Materials and methods: During two randomly selected 3
month periods data was gathered on all patients presenting
with cervicofacial infection. This was analysed for patient
demographics, management, outcome, length of stay and
recording of SIRS parameters.
Results: Forty one patients were included in the study. Sep-
sis syndrome was confirmed in 52.5%. Data recording was
incomplete, reflecting poor awareness of the syndrome and
its implications among clinical staff.
Conclusions and clinical relevance: Sepsis is present in at
least 52.5% of patients presenting with maxillofacial region
infection and is under recognised by maxillofacial clinicians.
Increased longevity of the dentition will increase presenta-
tion in older patients in whom compromise will be greater.
Recognition of sepsis must improve to optimise clinical out-
comes in this group.
A randomised, single centre, double blind clinical evalu-
ation of collagen filler materials (PRI 1, PRI 2, Zyplast
and Perlane) in facial augmentation
J. Jeff Downie, Ashraf Ayoub, Paul Siebert, Adrian Bowman
Regional Maxillofacial Unit, Southern General Hospital,
Glasgow, United Kingdom
Introduction: In this project we produced virtual 3-D models
of the facial soft tissues using the technology of Stereopho-
togrammetry.
Methods: Over the course of a year 80 female volunteers
were randomly allocated into four groups. We compared
the volume changes following the injection of four differ-
ent collagen filler materials in and around the lips. Patients
were followed up at 1 week, 1 month and 3, 6, 9, 12
months.
A volume analysis was compared to the baseline at each time
point using a facial analysis tool.
Results: The results of the 12 month analysis show that group
B has a significantly higher upper lip volume change from
434 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
baseline at 1 week than the other three groups, which all have
very similar volume changes at this timepoint.
There is no evidence of a statistically significant difference in
the rate of decline from 1 week to 12 months between any of
the groups and thus group B has a consistently higher upper
lip volume change from baseline at all timepoints.
The study remains blinded at present.
Conclusions: We feel that stereophotogrammetry is an accu-
rate non-invasive method for recording soft tissue change
over time.
Acknowledgement
This research project has been funded by Tissue Science Lab-
oratories who provided the materials and necessary support.
Classification and management of pathological fractures
of the mandible: A study of 43 cases
Domenick Coletti, Robert Ord
University of Maryland Medical System, R Adam Crowley
Shock Trauma Center, United States
Introduction: Pathological fracture of the mandible is rare
comprising 0.47% of 847 fractures in one series. Gerhards
et al. reported 30 cases which is the longest series in the
literature. Most other papers are case reports. We review 43
cases treated in the OMS Department at the University of
Maryland.
Methods and materials: A retrospective review of all cases
treated from February 1991 to June 2003 was undertaken.
Data collected included patient demographics, etiology, site,
management and outcome.
Results: Forty three patients with 44 fractures were collected,
there were 26 males and 17 females. The average age was
59 years ranging from 5 to 81 years. Twenty one patients
were diagnosed with osteoradionecrosis (49%), 3 bispho-
sphonate osteonecrosis (7%), 5 primary malignant tumors
(11.6%), 3 metastatic lesion’s (7%), 8 with osteomyelitis
(18.6%), 1 dental cyst (2.3%), and 2 post third molar removal
(4.7%).
Etiology determined the patient’s management. Those with
malignant/benign disease had treatment initially directed
towards the underlying pathology, followed by mandibulec-
tomy when indicated. In cases of diseased bone (ORN,
BON, and osteomyelitis) without the potential for normal
union, resection to healthy bone was performed. Continuity
defects were fixated with locking reconstruction plates, and
reconstructed primarily or secondarily with vascularized or
non-vascularized tissue. In those cases where sufficient bone
buttressing was present, the fracture was repaired with rigid
internal fixation.
Conclusion: We present the longest series of mandibular
pathologic fractures reported with a suggested classification
and management algorithm; our treatment is based both on
the literature and our clinical experience.
Case series study of ski and snowboarding head and neck
injuries in 2001–2002 in Queenstown, New Zealand
Jahrad Haq, J.G. Cowpe, C.A. Woods
University of Bristol, United Kingdom
Objectives: To examine the incidence, pattern and nature of
head and neck injuries sustained to skiers and snowboarders
at two skifields in New Zealand.
Methods: A retrospective case series study of all skiers and
snowboarders suffering head and neck injury at ‘Coronet
Peak’ and ‘The Remarkables’ during the 2001 and 2002
seasons. Personal details, snowsport related parameters and
clinical diagnosis were recorded. Control data of skifield
demographics were collected through a ski patrol survey to
analyse the size and composition of the on-slope population.
Results: Four hundred and thirty-one head and neck injuries
were recorded in 327 individuals. A total of 519,661 visi-
tor days were recorded by the ski patrols. The injury rate
for the study was 0.63 per thousand visitor days. The ratio
of skiers to snowboarders on the skifield was approximately
3:2. Snowboarders are 1.7 times as likely to injure themselves
as skiers considering relative numbers of uninjured parties.
The most frequently injured area in snowboarders was the
maxillofacial region (45%) followed by occipital (18%), c-
spine (17%), frontal (16%) and temporal areas (4%). In the
skiing population, a similar pattern of injuries was noted with
a significant number being maxillofacial (48%). Other fac-
tors identified in increasing injury frequency include: lack of
experience, the attempt at jumping and ‘rail-grinding’, and
the failure to wear a helmet.
Conclusion: Snowboarding carries a greater risk of head and
neck injury especially maxillofacial trauma and concussion.
It is recommended that snowboarders wear helmets during
terrain park activities.
This paper will also be presented as Poster 34.
Strength analysis of six resorbale fixation systems
John F. Caccamese, Pat Ricalde, J. Anthony von Fraunhofer,
Domenick P. Coletti, Clinton Norby, Michael Hartman
University of Maryland, United States
Controversy exists about the use of rigid fixation in the pedi-
atric patient. This stems from concerns regarding the impact
of titanium rigid fixation on facial growth. Resorbable mate-
rials offer one solution to this problem. This in vitro study
compares the load-bearing properties of six commercially
available 2.0 mm resorbable plating systems in a fracture
model.
Sectioned red oak blocks were used to simulate fractures. Six
resorbable plating systems were tested with or without pre-
heating to bending temperature. Six hole, 2.0 mm plates were
adapted to the blocks and secured with six 8 mm resorbable
screws. Specimens were soaked in 37 degree physiologic
saline for 24 hours to simulate an in vivo environment prior
to testing. The specimens were individually tested with a
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
vertical load applied over the simulated fracture at a cross-
head speed of 0.5 mm/min. Force versus displacement was
recorded for each specimen (n = 72).
One plating system composed of 82% l-lactic acid and 18%
glycolic acid performed best with regard to the force required
to cause a clinically significant displacement of 1–2 mm.
This achieved statistical significance in both the 1 and 2 mm
groups and was uniformly superior at 2 mm displacement.
Pre-heating plates to bending temperature had no effect on
their performance.
Our results demonstrate that the immediate strength of the
resorbable systems vary. One polymer configuration per-
formed superiorly. This suggests that not all systems may be
appropriate for the fixation of load bearing pediatric fractures
in the absence of a brief period of immobilization.
Natural expression of telomerase reverse transcriptase
peptides in head and neck tumour cell and their sensi-
tivity to telomerase specific CD8+ T cells induced in vitro
and in vivo
Alasdair McKechnie, Chandan Verma, Adrian Robins, Oleg
Eremin
University of Nottingham, United Kingdom
Aim: If tumour cells fail to express hTERT peptides nat-
urally they will remain insensitive telomerase targetted
immunotherapy. The aim of this study was to determine
whether tumour cells from a telomerase expressing cell line
are sensitive to telomerase specific T cells induced by den-
dritic cells pulsed with peptides of hTERT.
Methods: hTERT specific CD8+ T cells were produced in
vitro and in vivo by ex vivo generated dendritic cells pulsed
with peptides of hTERT. The ability of induced T cells to kill
cells from a hTERT expressing head and neck tumour cell
line was assessed by incubating tumour cells with T cells for
4 h. Cell death and induction of apoptosis were assessed flow
cytometrically. A cell line which is incapable of expressing
endogenous peptides acted as a control. Experiments were
done in triplicate and differences compared using the paired
T-test. Correlation between the number of hTERT specific T
cells and cytotoxicity was also assessed.
Results: Tumour cells from a hTERT specific tumour cell
line were more sensitive to the cytotoxic effects of the T
cells than cells from the control cell line (p < 0.005). When
control cells were pulsed with peptides of hTERT prior to
cytotoxicity assays they became more sensitive to killing by T
cells (p < 0.005). There was a significant correlation between
the number of peptide specific T cells and their cytotoxic
capapity (r = 0.88).
Conclusions: Head and neck tumour cells from this cell
line do appear to express hTERT peptides, indicating that
they would be sensitive to the effects of telomerase targetted
immunotherapy.
435
A 5 year experience of porous polyethylene in repair of
boney orbital defects
Martin Dodd, G. Douglas, G. Kaur, D.C. Jones
Maxillofacial Unit, University Hospital Aintree, United
Kingdom
Introduction: A wide variety of materials are used for orbital
floor/wall repair. Autologous grafts are often used to repair
larger defects. Where defects are smaller alloplasts may be
used to avoid donor site morbidity. However they may be sub-
ject to infection, implant migration and extrusion. Since 2000
the Maxillofacial Units of the Mersey region have largely
used porous polyethylene (Medpor® ) and to a lesser extent
titanium mesh for repair of orbital defects. We have reviewed
our experience of the use of Medpor® with respect to the com-
plications mentioned above and need for secondary surgery.
Methods: Patients undergoing orbital floor repair for pure
orbital fractures, as part of zygomatic complex injuries or
in conjunction with pan facial trauma were identified from
theatre logs in all the units within Mersey region between
2000 and 2005. Case notes and theatre records were reviewed
for evidence of complications and need for revision surgery.
Results: One hundred and fifty-one patients were identified, 2
underwent primary calvarial grafting, 5 had silastic implants,
9 had titanium mesh, and 135 had Medpor® sheets. Two
Medpor® sheets were removed for reasons of infection, and
one patient developed significant enophthalmos and required
secondary surgery.
Clinical significance: This represents one of the largest pub-
lished series of Medpor® use in orbital floor repair. Results
will be compared with those of other published series of
Medpor® and other commonly used alloplasts.
Is there a difference in angiogenic profile between simple
lymph node metastasis and disease with extra-capsular
spread in head and neck squamous cell carcinoma
(HNSCC)?
Sanjay Sharma, Simon Dennis, Rajiv Anand, Constantinos
Mourouzis, Anne Spedding, Peter Brennan
Portsmouth Hospitals NHS Trust, United Kingdom
Aims: To characterise and compare the expression of angio-
genic markers (iNOS, HIF1-a, CD31) in encapsulated lymph
node metastases with that of extra-capsular spread in head
and neck squamous cell carcinoma (HNSCC) and to deter-
mine whether angiogenesis has a role to play in this
process.
Methods: A case–control study using archived paraffin
embedded specimens of patients who had neck dissections
as treatment for their HNSCC. Twenty seven patients with
extra-capsular spread and 21 patients with encapsulated dis-
ease were compared using immunohistochemical techniques.
Appropriate controls were used throughout.
436 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Results: Expression of angiogenic markers were signifi-
cantly higher in the extra-capsular disease group. In par-
ticular iNOS expression was markedly raised with 22 out
of 27 (81%) patients with extra-capsular disease and 8
out of 21 (38%) patients with encapsulated disease stain-
ing positive (P = 0.004). Median expression scores in the
extra-capsular group were twice that of the encapsulated
group.
Conclusions: Extracapsular disease has a higher angiogenic
activity than encapsulated disease in HNSCC. The angio-
genic switch is a discrete step in primary tumour devel-
opment and similar events may take place in metastatic
deposits to allow growth and facilitate extracapsular
spread.
Functional reconstruction of frontal sinus fractures
Ralf Schoen, Nils Werner, Marc Metzger, Rainer
Schmelzeisen
Department of Craniomaxillofacial Surgery, Regional
Plastic Surgery, University Freiburg i Br, Germany
Introduction: The indication for obliteration versus recon-
struction in frontal sinus injuries with involvement of the
nasofrontal duct remains controversial. The results following
functional reconstruction of anterior wall fractures of the
frontal sinus are demonstrated.
Material and methods: Twenty eight consecutive cases of
anterior wall fractures of the frontal sinus were treated dur-
ing January 2000 and February 2005 at the department of oral
and maxillofacial surgery at the university hospital, Freiburg,
Germany. Impressed naso orbital ethmoidal (NOE) fractures
with involvement of the nasofrontal duct region were noted
in 11 out of 28 patients. Open reduction and osteosynthe-
sis using 1.0 and 1.3 titanium microplates (Synthes, Paoli,
USA) and titanium mesh in case of defect fractures were
performed via coronal approaches in 19 patients, by an endo-
scopic assisted approach in 3 patients and via lacerations in 6
patients. Inspection of the frontal sinus and nasofrontal duct
area where performed intraoperatively. The mean follow up
was 2 years.
Results: Uneventful healing following fracture reduction
occurred in all but one patient, who presented with a post-
operative infection. Post-operative follow up by CT scans
and digital volume tomography (cone-bean-scan) verified
anatomic reduction and good sinus function. The open
approach was preferred for reconstruction of the frontal sinus
fractures. The time consuming endoscopic assisted tech-
niques were abandoned due to limitations in fracture reduc-
tion and fixation.
Conclusions: Precise reduction of anterior table frac-
tures of the frontal sinus allows not only for anatomic
reconstruction but also for reconstruction of frontal sinus
function.
Tissue banking in head and neck cancer
Richard Shaw
Regional Maxillofacial Unit, University Hospital Aintree,
United Kingdom
Introduction: Many of the molecular biology research
techniques now in development require high quality bio-
specimens with accompanying clinical and prognostic data. A
common limitation in research is the unavailability of appro-
priate tumour tissue. As head and neck cancer is frequently
surgically treated and the tumours are usually accessible, the
field lends itself to high quality tissue collection. In order
to maximise the benefit to research it is important to define
which patients should be approached, what tissues to be saved
and how they should be stored.
Method: The author received a Department of Health Genet-
ics in Healthcare Fellowship to visit the MD Anderson Cancer
Centre, Houston, TX, in order to report on the essential
characteristics of a large H&N tissue bank. Aspects of tis-
sue procurement were then appraised in the light of typical
arrangements in a UK unit.
Results and conclusions: Over the years, the development of
the H&N tissue bank in MD Anderson (300,000 specimens)
has addressed many technical and logistic issues. The critical
aspects included:
1. Integration of tissue banking with standard pathology
reporting and co-registration of histopathology with
research specimens.
2. Use of tissue bank database and linkage with patient out-
come database.
3. Ethical and consent issues: avoidance of future legal jeop-
ardy.
4. Involvement of PAMs in consent, research technicians in
tissue preparation and storage.
5. Temporal aspects: time interval between disconnection of
blood supply and processing recorded.
6. Specimen types: blood (plasma and WBC), tumour,
advancing front, normal tissue, lymph nodes, saliva.
Maxillofacial injuries in the victims of terrorists attacks
in Iraq
Aliaa Makey
Hospital of Specialized Surgeries, Baghdad, Iraq
Politicians and workers in humanitarian affairs argued about
the definition of terrorism. The definition is clear in the
injuries of this recent ailment in Iraq that became the scene
of the third world war against terrorists. This study describes
the pattern of maxillofacial injuries in victims fragments of
mines and grenades in Iraq.
Patients were treated in the maxillofacial unit, Hospital
of Specialized Surgeries, Medical city, Baghdad, during 1
month (August 2004). We had 26 males and 4 females. Age
ranged from 3 to 75 (mean 29 years). Secondary survey
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
was undertaken once lives saving priorities are accomp-
lished.
Five patients (16.7%) had isolated soft tissue lacerations, 25
patients (83.3%) had facial bone fractures, and 10 patients
(33.3%) had ocular injuries consisting of globe rupture in 7
patients (unilateral in 4 patients and bilateral in 3) and minor
ocular injuries in 2 patients. The keystone feature of these
injuries is the presence of multiple remote injuries present
in 18 patients (60%) comprising injuries to abdomen,
pelvis, thorax, upper limbs, and lower limbs (10.3%,
3.4%, 27.6%, 27.6%, 31% of remote injuries respect-
ively).
The high incidence of remote injuries in this study conform
to the recent global trend of multiple hits to multiple body
regions and underscores the importance of a thorough clinical
examination to elicit remote injuries that have a substantial
effect on treatment plan. It also emphasizes the importance
of managing these causalities in a multi-displinary approach
in which the maxillofacial surgeon plays a pivotal role.
A long term follow up study of complications following
cancellous bone harvesting from the anterior tibia in chil-
dren undergoing alveolar bone grafts
Luke Cascarini, Luke Williams, Miles Duncan, Peter Ward
Booth
Queen Victoria Hospital, East Grinstead, United Kingdom
Introduction: Previous studies have shown the early compli-
cations of bone harvesting from the anterior tibia to be low
and hospitalisation and pain scores lower than iliac crest har-
vesting. There are no long term follow up studies to the best
of our knowledge.
Aims: To assess early and late complications of cancellous
bone harvesting from the anterior tibia in children.
Subjects: Any child who had a tibial bone graft procedure
carried out more than 6 months previously at Queen Victoria
Hospital, East Grinstead.
Method: The patients’ notes were used to collect details of
the procedure and any record of early or late complications.
A standardised telephone questionnaire to parents and
patients was used to assess any late complications which
included pain, reduced function, unacceptable scarring,
attendance at any other hospital or medical practice
and whether the procedure had been repeated for any
reason.
Results: Forty cases were identified over a 5 year period. Early
and late complication rates were extremely low.
Conclusions: In children cancellous bone harvesting from
the anterior tibia is a safe and useful procedure with very low
rates of early and late complications. Anecdotal comments
about late painful donor did not seem to be supported by this
study.
437
Computer-assisted planning and navigation in posttrau-
matic orbital reconstruction
Christopher Eulzer, E.-L. Barth, M. Rücker, A. Schramm,
N.-C. Gellrich
Department of Oral and Maxillofacial Surgery, Medical
School Hanover, Germany
Secondary orbital and periorbital skeletal reconstruction still
remains a surgical challenge. In addition to functional goals,
a satisfactory aesthetic outcome is important for recon-
struction of fronto- and zygomatico-orbital osseous defects.
Current surgical treatment planning systems predict three-
dimensional corrections from two-dimensional data sets and
are inadequate for complex deformities. In these cases com-
puter aided planning and surgery has proved to be an
effective technique for reconstructive orbital surgery. Three-
dimensional imaging techniques provide extensive possibil-
ities for the detailed and precise analysis of the whole cran-
iofacial complex. Furthermore, it achieves virtual simulation
and detailed evaluation of the postsurgical outcome.
We report on 50 cases of reconstruction of complex sec-
ondary orbital and zygomatic deformities using computer-
assisted planning, simulation, intraoperative navigation and
post-operative control. Spiral-CT data sets were acquired
to serve for computer assisted pre-operative planning and
computer assisted surgery. At the workstation, the patient’s
individual anatomy was assessed in multiplanar and three-
dimensional views. Virtual correction could be made by
drawing new contours at the workstation. The “mirror tool”
permits an ideal reconstruction by superimposing the unaf-
fected over the affected or deformed side, thus creating a new
data set. Intraoperative navigation was done using frameless
stereotaxy.
Computer-assisted pre-operative planning and surgery tech-
niques have improved operators confidence in periorbital
reconstructions. Anatomical structures like the optic nerve
can be identified intraoperatively and preplanned reconstruc-
tions can be realized by means of navigation. Especially
image fusion of pre- and post-operative data enables detailed
evaluation of postsurgical outcomes.
Repositioning of septum during rhinoseptoplasty in pri-
mary repair of complete UCLP deformity: Technical note
and short term results
Piet Eduard Haers, Haleh Ghoddousi, Deepti Sinha
South Thames Cleft Center, Guy’s Hospital, United Kingdom
Functional repair of the unilateral cleft lip deformity does
not necessarily lead to a symmetric appearance of the nose or
correct positioning of the septum behind the columella. This
nasal asymmetry is the most frequent indication for early
revision, either for aesthetic or for functional reasons. How-
ever, cleft related nasal asymmetry is difficult to correct and
the more outspoken the asymmetry, the less symmetry will
be achieved following secondary corrections.
438 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
It is therefore important to reduce maximally the amount
of residual nasal asymmetry following primary repair on
condition that this does not adversely affect midfacial
growth.
This paper presents a technique that aims for maximum sym-
metry by repositioning of the nasal alae and septum at the time
of cleft repair. The rationale is explained and early results in
a first series of 10 patients with a follow-up of 12 and 18
months is presented. A digital mirroring technique was used
for assessing asymmetry volumetrically.
Advances in computer assisted orbital reconstruction:
Individually preformed implants for enophthalmos
correction
Ralf Schoen, Marc Metzger, Nils Weyer, Rainer
Schmelzeisen
Department of Craniomaxillofacial Surgery, Regional
Plastic Surgery, University Hospital Freiburg i Br, Germany
Introduction: Due to the complex orbital anatomy three
dimensional orbital reconstruction remains a challenge.
Material and methods: Superior results in primary and sec-
ondary orbital reconstruction are achieved using computer
assisted techniques with virtual models for pre-operative
planning and intraoperative control. A technique to pre-
form titanium mesh implants (Synthes, USA) for orbital
wall reconstruction was developed at the University Hospital
Freiburg, Germany.
We present the results following computer assisted orbital
reconstruction using individually preformed titanium mesh
in 21 patients.
Results: In 15 out of the 21 patients reconstruction of
orbital injuries were performed primaryly. In 7 patients
orbital reconstruction was performed together with repair of
dislocated zygomatic complex fractures, and in 8 patients
with orbital floor and medial orbital wall defects. In 6
patients secondary correction of posttraumatic enophthal-
mus deformities were corrected by reosteotomy of dislo-
cated zygomatic complex and mesh reconstruction of orbital
walls.
Exact placement of the individually preformed implants by
transconjunctival incision was controlled intraoperatively by
computer assisted means. Image fusion of the post-operative
CT scan and the pre-operative planning demonstrated the pre-
cise reconstruction of orbital dimensions with an accuracy of
1 mm.
Conclusions: Using preformed titanium mesh implants for
orbital reconstruction true to original reconstruction of the
orbital cavity was achieved in all patients. The preformed
implants allowed for successful and less time consuming
enophthalmus correction in one operation.
“Jelly joints”: Foreign body rejection of TMJ replace-
ment
Andrew J. Sidebottom, Bernard Speculand, Robert Hensher
Queens Medical Centre, Nottingham, United Kingdom
Introduction: Temporomandibular joint replacement was
established in the early 1960s as a treatment for advanced
degenerative disease, ankylosis and destruction of the TMJ
from various disease processes. Problems with various pros-
theses, notably the Kent VK1, have lead to close analy-
sis of their risks and complications. Recently (1999), one
type of prosthesis changed from an acrylic condyle on
cobalt–chromium fossa to metal-on-metal cobalt–chrome
condyle and fossa (Christensen). This has been a popular
prosthesis in the UK, but since converting to the metal-on-
metal variant we have noted several cases of foreign body
giant cell reaction to the prosthesis and felt that these cases
should be highlighted.
Methods: We retrospectively reviewed the records of all
metal-on-metal prostheses placed by the three authors with
over 1 year follow up.
Results/discussion: Of the 77 metal-on-metal prostheses
placed 5 cases showed a foreign body-type giant cell reac-
tion. A further 2 of 29 cases were seen in metal-on-acrylic
prostheses. Two of the metal-on-metal cases subsequently
were found to have a cobalt allergy, which may explain some
of the problem, but may not be the whole solution. Metal-
lic wear has been found in other revision cases, which is an
alternative consideration as this occurs in orthopaedic metal-
on-metal knee joints.
Conclusion: Patients under consideration for total TMJ
replacement should be tested for metal allergy prior to
implant placement. Metal-on-metal prostheses should be
used with caution in the TMJ. The UK needs a national
database of TMJ implant placement to assess outcomes on
larger numbers of cases.
The Pakistan earthquake and associated maxillofacial
injuries
Sean Laverick
Department of Maxillofacial Surgery, Dundee, United
Kingdom
At 8:52 am on 8 October 2005 a massive earthquake wracked
northern Pakistan and Kashmir. News reports soon indicated
that the number of dead (to date 80,000) and casualties was
enormous and that the logistics of extricating such numbers
from remote inaccessible regions would cause further diffi-
culties.
Various medical teams were mobilised from the United King-
dom, some to work within the field and others to stay cen-
trally within Islamabad and provide specialist care to patients
mobilised from the disaster areas.
Maxillofacial injuries were extremely common, affecting all
age groups. The type of injuries encountered will be dis-
cussed, as will the operating facilities.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Whilst the logistical support by local organisations was excel-
lent we would recommend that a central register of volunteers
should be created to deal with similar situations in the future.
This would allow doctors and nurses with sufficient expe-
rience to be mobilised in times of disaster. It would also
seem sensible to have this organisation liaise with the country
concerned and decide which specialties should be sent and
the number of specialists required. Maxillofacial surgeons
should be an integral part of this disaster team.
The use of Smith spreader as an alternative to periosteal
stripping in mandibular advancement surgery and an
experimental study to demonstrate the effectiveness of
this new technique
Luke Cascarini, Peter Ward Booth
Queen Victoria Hospital, East Grinstead, United Kingdom
Introduction: Periosteal stripping is commonly used in
mandible advancement surgery to remove soft tissue attach-
ments from the distal segment. This is thought to reduce the
peri-mandibular forces which may resist advancement. These
forces may be a factor in early relapse. However extensive
stripping may increase oedema and post-operative pain and
there is the potential for neural and vascular damage.
We demonstrate a novel use of the Smith spreader which
obviates the need for periosteal stripping. The Smith spreader
is used to push the distal segment forward and thereby stretch
the soft tissue attachments.
Objectives/aims: To measure the peri-mandibular forces
intra-operatively before and after this technique is used.
Method: Using digital hanging scales we measure the
length/tension relationship of the distal mandible after bilat-
eral sagittal split osteotomy. This is repeated after the Smith
spreader is used to stretch the soft tissues.
Results: The peri-mandibular forces are directly related to the
degree of advancement, which would concur with the obser-
vation that relapse is more significant after larger advance-
ments. We also show that the forces are significantly reduced
by this stretch technique.
Conclusion: We believe this is a safe and effective technique
to replace periosteal stripping in mandibular advancement
surgery.
Maxillofacial trauma—Patients or repeat offenders?
David Chin Shong, R. Wotherspoon, S. Holmes, L. Cheng
Barts and The London NHS Trust, United Kingdom
Introduction: Repeat attendees at Accident and Emergency
(A&E) following assaults are an interesting cohort of
patients. By definition they are the ones we need to target
for prevention. One of the difficulties with this group is iden-
tifying them. We present an analysis of patients who have
presented with asynchronous maxillofacial injuries.
Materials and methods: Our Trauma Database consisting of
12,598 patients over a period from June 1998 to Decem-
439
ber 2005 was examined for repeated entries. For each record
returned, the name and nature of the injury was identified.
The record numbers (n = 32) were then entered into the hos-
pital database and their number of visits to the Accident and
Emergency department was logged. These patients were then
compared to an age and sex matched control group (n = 32)
We also performed the same search on an age matched con-
trol group of patients (n = 32) who so far had only presented
to us once in 1998.
Results: Following second attendance the repeat group were
likely to attend on multiple occasions (mean = 6.84 visits).
Compared to the control group (mean = 0.93 visits) this is
significant (P = 0.042) The injuries and pattern of attendance
are discussed together with hospital demographics.
Conclusions: This study confirms the anecdotal observations
that a certain cohort of patients will re-attend. Whilst there
maybe valid social reasons for this pattern of illness behaviour
this groups represents an obvious target for secondary pre-
vention.
Assessment of the temporomandibular joint after bipha-
sic callus distraction of the mandible in a canine model
Christian Surwalda , E. Roseb , C. Kunzc , B. Rahnd
a Brighton and Sussex University Hospital NHS Trust, United
Kingdom; b University of Freiburg, Germany; c University
of Bale, Switzerland; d AO-Research Institute Davos Platz,
Switzerland
Biphasic distraction osteogenesis is a new technique for
mandibular lengthening to prevent anterior open bite. The
purpose of the study was to assess tin a canine model the
adaptive capacity of the temporomandibular joint to sagittal
callus distraction followed by an angulation procedure of the
mandible.
Methods: Bilateral, mandibular distraction was performed in
30 adult beagle dogs using an extraoral, multiplanar distrac-
tion device The protocol consisted of 5 day latency and a
distraction rate of 1 mm/day for 10 days, at day 11 a cra-
nial angulation of 20◦ /30◦ was performed, the consolidation
period was 6 and 13 weeks, respectively. After the animals
were sacrified, the temporomandibular joints were harvested,
processed for histologic examination and histomorphometric
analysis.
Results: Significant adaptive remodeling was observed in
the temporomandibular joint of all animals of the study
group. After 6 weeks the alteration were mainly found
at the condyles, but after 13 weeks they occurred at the
condyles and the glenoid fossae. The width of the carti-
lage was significantly changed in the central and lateral
areas. In individual cases regressive adaptive changes, such
as focal, subchondral bone necrosis, deep vascularisation,
osteoclastic resorption and formation of chondral clefts were
observed.
Conclusion: The temproromandibular joint demonstrated its
high adaptive capacity to compensate incongruence between
440 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
the condyle and the glenoid fossa caused by distraction osteo-
genesis of the mandible. One should be aware of degenerative
changes in the temporomandibular joint after biphasic dis-
traction of the mandible.
A randomised trial of brief interventions for patients with
alcohol related facial injuries
Ameeta Joshi, B. Hanif, J. Taylor, H. Worthington
Maxillofacial Unit, Royal Lancaster Infirmary, United King-
dom
Aim: To assess the value of brief interventions for patients
with alcohol related facial injuries.
Setting: University teaching hospital in Manchester.
Participants: Adults referred with facial injuries to OMFS
via A&E during an 18 month period.
Intervention: Following consent, patients were randomised
into one of three groups: leaflet, 5 min intervention (FMI)
and no intervention. Patients completed an ethnicity form
and five questionnaires: AUDIT, SADQ, RCQ, SIP2L and
SIP2-R at baseline, 6, 12 and 18 months.
Results: Five hundred and eighty-four patients with OMF
injuries were screened and 409 patients consented. Three
hundred and thirty-five (91%) males and 36 (84%) females
were British or Irish white. Only 27 (6.4%) were from other
ethnic backgrounds. One hundred and forty-five patients
received a leaflet, 130 received a FMI and 134 patients
received no intervention. Three hundred and two (83%) males
and 33 (77%) females were hazardous or harmful drinkers, of
these 160 (44%) males and 15 (35%) females showed alcohol
related harm. A reduction in alcohol consumption on a typi-
cal day was noted in all groups from baseline to 18 months
with the most significant being the FMI group (p = 0.02). A
reduction in drinking six or more drinks on one occasion was
noted in all groups: leaflet (p = 0.001); FMI (p = 0.01) and
no intervention (p = 0.01). The majority were mildly alcohol
dependent, and after 18 months, there was a 3% reduction.
Group 2 were ready to change at 18 months with an increase
of 28.5%. A leaflet or a FMI are equally effective in men and
women for hazardous alcohol consumption.
Use of botulinum toxin in the management of TMJ
myofascial pain
Amira Al-Ahmar, Andrew J. Sidebottom
Queens Medical Centre, Nottingham, United Kingdom
Introduction: Botulinum toxin has been described for use in
myofascial pain syndromes elsewhere in the body. Its use has
proven to be safe in the management of masseteric hypertro-
phy and other muscular problems in the head and neck. As a
side-effect in its use for masseteric hypertrophy it was noted
that patients had a reduction in muscle pain.
Methods: This study retrospectively analyses the outcome in
21 patients treated with botulinum toxin injection into the
masseter and/or temporalis muscle for TMJ myofascial pain
whom had failed to respond to routine conservative measures.
Follow up was for at least 6 months.
Results: Six of the 21 patients had no pain at follow up. Nine
of the 21 had improved pain, whilst 6 out of 21 reported no
improvement.
Conclusion: Botulinum toxin injection is a useful adjunct
in the management of TMJ myofascial pain, providing
improved symptoms in 73% of patients in this study.
Resorbable bicortical screw fixation in the sagittal split
osteotomy of the mandible: Early experience
Darryl M. Coombes, Jeremy McKenzie, Alex Cash, Kenneth
J. Sneddon
Department of Maxillofacial Surgery, Queen Victoria Hospi-
tal, East Grinstead, United Kingdom
Introduction: The use of resorbable systems for fixation in
orthognathic surgery still remains controversial but is gradu-
ally gaining acceptance in some maxillofacial surgery units
within the United Kingdom. Some of the difficulties relating
to the resorbable system include the nature and stability of
the materials involved and in the surgical techniques.
One particular area of controversy is in the fixation of the
mandible with a resorbable system following a sagittal split
osteotomy. Previous studies from our unit have concentrated
on resorbable plate fixation of the osteotomised mandible.
Aims: This study aims to evaluate the use of the resorbable
bicortical screw fixation of the mandible following sagittal
split osteotomy.
Materials and methods: Forty consecutive patients were
selected for the study. These patients had undergone either
a bimaxillary procedure or a sagittal split osteotomy. Data
presented includes the direction and magnitude of the move-
ments and the operative time. Cephalometric data will be pre-
sented to determine the stability of this method of resorbable
fixation.
Applied clinical imaging for distraction osteogenesis
Scott Rice, Jimmy Makdissi
Barts and The London NHS Trust, United Kingdom
Over the last 10 years distraction osteogenesis has established
itself as a reliable and successful technique for use in the cran-
iomaxillofacial region. Its applications are varied and work
on the principle of creating new bone through osteotomy,
mechanically separating the bone segments and stimulating
regeneration of bone at the site. It has been successfully used
for both orthognathic surgery and management of craniofa-
cial abnormalities.
The success of complex orthognathic surgical procedures
is critically dependent on careful planning, utilising precise
diagnostic information. Much of this information is gained
from appropriate imaging. Plain films form base line imaging
in virtually all patients. However, more complex modalities
are also used; three-dimensional computed tomography scan-
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
ning is increasingly utilised and can lead to the production of
stereolithographic acrylic models, providing a life-size three-
dimensional reproduction of the facial skeleton. Addition-
ally, the introduction of computer animation packages have
enabled the clinician to ‘virtually’ simulate the procedure
and extrapolate the angles and vectors involved. During dis-
traction ultrasound scanning is emerging as a useful adjunct
to assess bone callus formation. This enables to operator to
reliably predict the success of the initial distraction.
With the advent of new and more complex surgical tech-
niques, the requirement of accurate imaging techniques also
increases. Both traditional and complex radiographic meth-
ods will be demonstrated along with non-ionizing methods.
Two cases will be presented showing the imaging modal-
ities utilized from pre-operative planning through to post-
operative evaluation.
Technical note: A method for transferring treatment plan
from stereolitography model to theatre
Simonas Grybauskas, Linkevicius Tomas, Puisys Algirdas
Vilnius Implantology Center, Lithuania
Stereolitographical skull models are by no means indispens-
able mean of treatment planning in contemporary orthognatic
and reconstructive surgery. Treatment plan for jaw osteotomy
can be easily simulated on the model and virtual osteotomies
previously planned on the screen can be tried on the model
before bringing patient to theatre. However, the SL model
with all it simulations will stay just for a plaything if there is
no reliable and precise mean for transferring osteotomy lines
and distraction vectors to theatre.
We present an easy method for production of splints which
can precisely guide operating surgeon through the osteotomy
lines and vectors preplanned on SL model during operation.
Orthognathic prediction using dolphin imaging software:
How accurate is it?
Prakash Arthur Promod, K.J. Sneddon, J. Collyer
Queen Victoria Hospital, East Grinstead, United Kingdom
This study aims to evaluate the accuracy of profile prediction
using Dolphin Imaging Software.
Fifty patients undergoing orthognathic procedures were
included.
A profile prediction based on the surgical treatment plan was
produced with the Dolphin programme and compared with
a photograph of the actual surgical result a minimum of 6
months post-operatively.
The results were evaluated using an analysis comparing the
position of soft tissue landmarks on the profile by the same
observer, to minimise variation.
441
Excuse me I have a runny nose! Pardon! My hearing isn’t
what it used to be! Unusual otorhinological complications
following maxillary osteotomies—Should our patients be
informed ?
Simon Peter Van Eeden, N.R. Saeed, A. Currie, S.E. Bond
John Radcliffe Hospital, Oxford, United Kingdom
Otorhinological sequelae following maxillary osteotomies
are well described and most can be avoided by system-
atic planning and attention to detail at the time of surgery.
Secretomotor rhinopathy and auditory tube dysfunction with
associated otalgia and changes in hearing sensitivity are rarer
but well described complications1–4 . We would like to present
our experience of three patients who required myringotomies
post-maxillary osteotomy and three patients with secretory
rhinopathy. The anatomy and possible pathophysiology will
be discussed. It is our recommendation that changes in hear-
ing sensitivity be discussed when consenting the patient.
References
1. Marais J, Brookes GB. Secretomotor rhinopathy after
le Fort 1 maxillary osteotomy. Int J Oral Maxillofac Surg
1993;22:17–9.
2. Baddour HM, Watson J, Erwin BJ, et al. Tympanomet-
ric changes after total maxillary osteotomy. J Oral Surgery
1981;39:336–9.
3. Barker GR. Auditory tube function and audiogram changes
following corrective orthognathic maxillary and mandibular
surgery in cleft and non-cleft patients. Scand J Reconstr Surg
1987;21:1333–138.
4. DeRuyter F, Diefendorf AO. Hearing sensitivity and mea-
surements of middle ear and Eustachian tube function after
maxillary osteotomy with advancement surgery. J Oral Surg
1980;38:343–7.
A formative induction OSCE for maxillofacial SHOs
Iain H. McVicar
Maxillofacial Unit, Queen’s Medical Centre, Nottingham,
United Kingdom
The Objective Structured Clinical Examination (OSCE) is
used commonly in medical education to assess clinical skills.
When a new SHO starts work in a department very little
objective information is known about their clinical abilities.
This OSCE is designed to assess areas that are important for
the SHO in their post. It also allows the senior staff to identify
potential areas where further training is required for the indi-
vidual. This assessment is formative rather than summative,
i.e. there is no pass or fail but is designed to focus further
training.
The assessment involves six stations where the candidate has
7 min to perform each clinical task.
1 Principles of suturing;
2 intravenous access for venupuncture and administration of
fluids;
442 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
3 male catheterisation;
4 interpretation of radiographs;
5 drug prescribing and the use of the BNF (British National
Formulary);
6 basic cardiovascular and respiratory examination.
This assessment tool has been used for the past 18 months in
our unit. It requires little in the way of resources to perform
and has been found to be very helpful for the SHOs and the
senior staff alike.
The results of the assessments have identified areas of good as
well as less than optimal performance. It gives all involved
in the process exposure to and experience with the format
of this type of examination either as a participant or as an
examiner.
The use of microdialysis in monitoring free flaps in the
head and neck
John Robert Bowden, Peter Brennan
Queen Alexandra Hospital, Portsmouth, United Kingdom
Accurate assessment of free flaps in the early post-operative
period is essential in order to detect any potential compro-
mise to the flap. Several monitoring techniques are available,
though not widely used due to factors such as portability and
technical difficulties. Clinical assessment remains the most
widely used tool though this can be difficult with flaps in the
oropharynx and buried flaps.
Microdialysis is a sampling technique that studies the bio-
chemistry of organs or tissues. A double-lumen microdialysis
catheter is inserted, and using a micro-pump, perfusion fluid
equilibrates across a dialysis membrane. This fluid is col-
lected in microvials at regular intervals and analysed for
glucose, glycerol, pyruvate and lactate in a bedside anal-
yser/monitor. An on-screen graphical display demonstrates
the values for these metabolites and their respective ratios
reflecting the viability of the tissue being monitored. Micro-
dialysis has been used in free tissue monitoring in breast
reconstruction.
We report on the use of microdialysis in the monitoring of free
flaps in the head and neck, and demonstrate in one particular
case how it indicated arterial compromise in a radial fore-
arm flap at the time of surgery, before this became clinically
apparent.
The technique is relatively easy to use and the early indica-
tion of flap compromise could be an indicator of its potential
promise for routine use in free flap monitoring.
Cytoglobin: A novel candidate tumour suppressor gene
in HNSCC
Richard Shaw, Triantafillos Liloglou, John Field, Janet Risk
Molecular Genetics & Oncology Group, School of Dental
Sciences, University of Liverpool, United Kingdom
Introduction: Cytoglobin (CYGB) is a putative tumour
suppressor gene on chromosome 17q, which by classical
genetic studies, has been linked with rare forms of famil-
ial oesophageal cancer. CYGB, a protein only recently
described, is an intracellular globin whose role in cancer is
as yet unclear but may be related to detoxification of oxy-
gen free radicals (and thus may consequently be involved in
mechanisms of radioresistance). It appears likely that epige-
netic silencing of CYGB may be important in a variety of
aerodigestive tract cancers including HNSCC.
Methods: DNA and RNA were extracted from snap frozen
tissue derived from a series of HNSCC patients. Quantitative
DNA promoter methylation analysis was carried out using
pyrosequencing. Real time reverse transcriptase PCR tech-
niques were performed on mRNA to establish expression data
(after normalising with known reference genes ␤-actin and
␤2microglobulin).
Results: Promoter CpG methylation was found to be sig-
nificantly higher in tumour when compared to normal tis-
sue (P = 0.002). Forty four percent of tumour specimens
exhibited high levels of promoter methylation. Comparable
results were also obtained from lung cancer and sporadic
oesophageal cancer. mRNA expression data reveals the asso-
ciation between promoter methylation and reduced expres-
sion in HNSCC.
Conclusions: There is currently no published data linking
CYGB and cancer. The epigenetic data presented in this study
adds weight to the hypothesis that CYGB is a tumour sup-
pressor gene highly methylated in upper aero-digestive tract
squamous cancer. This gene forms the focus for ongoing stud-
ies within our research group.
An audit to investigate the percentage of positive margins
on definitive SCC and BCC excisional biopsies
Sara Tabiat-Pour, Peter Ward Booth
East Surrey Hospital, United Kingdom
Objectives/aims: An audit was performed to investigate the
percentage of positive margins on definitive excisional biop-
sies. Aim was to achieve 90% complete excision margins.
Subjects: Patients who had excisions of SCC/BCC lesions
over a 6 month period.
Results: Ninety percent of SCC lesions were completely
excised with 5% incomplete and 5% lab not stated whether
the excision was in/complete.
Ninety four percent of BCC lesions were completely excised,
5% had positive margins and 1% of patients the lab had not
stated whether the excision was in/complete.
Conclusions/discussions: The aim was achieved. Only 5%
of the excisions had positive margins and this percentage is
acceptable especially on excisional biopsies carried out in
head and neck region.
However this audit highlighted few shortcomings:
• Clinicians not completing the lab form in full.
• Pathology department does not have a system for sepa-
rating biopsies carried out by general practitioners and
hospital clinicians. Also there is no system to differen-
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
tiate between types of biopsies. Thus a great deal of time
was wasted on selecting the criteria.
• In some excisions the lab had not stated whether the biopsy
was in/complete.
• Additionally the lab may have stated that the margins were
unable to be assessed but not stated why, which can be at
times useful for the clinician to see if there could be room
for improvement.
The audit also highlights the importance of the results to be
discussed at clinical governance sessions to discuss the results
with both clinicians and the pathology team to aim for better
communications and results.
A review of the fast track head and neck lumps clinic at
Derriford Hospital
Pradeep Anand, David Courtney
Derriford Hospital Maxillofacial Department, Plymouth,
United Kingdom
In November 2004, NICE published their document “Improv-
ing Outcomes In Head and Neck Cancer”—The Manual.
They recommended that patients who presented with per-
sisted head and neck lumps should be referred to a rapid
access lumps clinic and then on to a multi-disciplinary team,
if found to have cancer.
Historically, only a few hospitals were able to offer a one stop
clinic with immeadiate cytological reporting.
In December 2004, a fast track Head and Neck Lumps clinic
was set up at Derriford Hospital. It is a Consultant led service
comprising of Maxillofacial, ENT and General Surgeons.
Consultant Radiologists are present to perform ultrasound
scans and guided FNA’s. A Consultant Histopathologist is
present to give immeadiate reporting on cytology. All clini-
cians are sited on the the same designated clinic providing a
truly comprehensive service.
We have analysed the data collected over the last 12 months
and will present an audit of the clinical outcomes. We will
also present a patient satisfaction survey and an audit com-
paring the adequacy of FNA’s performed before the One stop
clinic was set up to those taken on the clinic and reported
immeadiately.
Finally an analysis of the cost implications will be dis-
cussed.
Perivascular epitheliod cell tumour (PEComa) of the
cheek
Naseem Ghazali, L. Cascarini, B. Barrett, K. Lavery
Maxillofacial Unit, Queen Victoria Hospital, East Grinstead,
United Kingdom
We present the unusual case of a perivascular epithelioid
cell tumour (PEComa) occurring within the cheek of a
32 year old female. PEComa is a rare, recently described
family of tumours with notably melanocytic and muscle
markers with diverse clinicopathological expression. It is
443
known to occur mainly in the abdominopelvic regions and
rarely in parenchymatous organs, skin, and the oral cav-
ity. To our knowledge, this is the first reported case of
PEComa occurring in the soft tissues of the face. The main
differential diagnosis considered was benign mesenchymal
tumour of possible neural or smooth muscle origin. How-
ever, the morphological, immunohistochemical profile and
ultrastructural studies were those of PEComa. The tumour
was completely excised but lifelong follow up was recom-
mended due to the uncertain malignant potential of this
entity.
The provision of an enteral feeding service to a Head and
Neck Unit: A prospective study of 450 consecutive percu-
taneous endoscopic gastrostomies performed by a single
maxillofacial surgeon
Fazilet Bekiroglu, S. Wright, E.B. Larkin
The Royal Wolverhampton Hospitals NHS Trust, United
Kingdom
Introduction: The role of percutaneous endoscopic gastros-
tomy (PEG) in patients undergoing resection of head and
neck malignancy is well established. A PEG service has tra-
ditionally been performed by gastroenterologists and general
surgeons and more recently surgical care practioners. The
role of a maxillofacial surgeon in the provision of a PEG
service is still, however controversial.
Material and method: We report a prospective study, com-
mencing in 1999 of more than 400 consecutive patients
referred from Head and Neck oncology unit: presenting
outcome data including complications. Series included 421
oncology and 36 trauma patients. All were inserted by a sin-
gle surgeon. PEGs were retained for a mean duration of 107
days.
Results: Immediate complications less than 48 h were rare.
The end of first week was the peak time for acute problems.
Eighteen patients (4%) had to have their PEG tube removed
due to air leak, ileus or discharge. Five laparotomies were
performed for acute problems related to sepsis or bleeding.
The overall laparotomy rate was 3% (12 patients). There was
one death related to a missed diverticular abscess and not
related to PEG sepsis.
Conclusion: Our experience with PEG tubes confirm that
maxillofacial surgeons with the abilities to perform exam-
inations under general anaesthesia, biopsies and exodon-
tia are well placed to take on this role. This also helps
maintain continuity of care for the patient and avoids the
complexity of scheduling multiple procedures with multiple
specialities.
444 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
The presentation, management and outcome of osteora-
dionecrosis
Jacob D’Souza, J.S. Brown, E.D. Vaughan, S.N. Rogers
Maxillofacial Unit, University Hospital Aintree, Liverpool,
United Kingdom
Aim: The aim of this study is to review the presentation,
management and outcome of patients presenting with osteo-
radionecrosis between 1996 and 2003.
Methods: Patients were identified by reference to records at
the Liverpool Dental Hospital histopathology records, Mur-
rayfield Hyperbaric Unit, Liverpool Head & Neck Oncology
database and the University Hospital Aintree patients man-
agement system. Their case notes were reviewed in Septem-
ber 2005.
Results: In the 8-year period there were 23 patients (13 males,
10 females). The commonest site affected was the mandible
(21 patients). Tumour surgery was the most likely cause
leading to the development of ORN followed by exodontia.
Sixteen patients received HBO. Surgical treatment included
debridement in conjunction with a short course of antibiotics
(6 patients), repeated debridement with prolonged course
of antibiotics (5 patients), and surgical resection of the
necrotic fragment and reconstruction with a composite flap
(12 patients). Patients requiring free flap had not responded
to debridement/antibiotics and had extensive areas of wound
breakdown with bone exposure, fistula formation, and/or
pathological fractures. Eight of these patients received HBO.
Furthermore, in the free flap group, 6 patients were alive (5
free of ORN, 1 ongoing ORN) and 6 deceased (4 free of ORN,
1 ongoing ORN). The time from last treatment to death in the
deceased group varied from 1 month to 4 years.
Conclusion: The management of ORN is challenging and
long-term cure and survival can be difficult to achieve. As
outlined in this presentation careful case selection is essential.
Fluorescence spectroscopy combined with 5-ALA
induced PpIX fluorescence in detecting oral leukoplakia
Waseem Khalid Jerjes, A. Sharwani, V. Salih, C. Hopper
Department of Oral & Maxillofacial Surgery, University
College London, United Kingdom
Background: Studies have shown that early detection of
potentially malignant or malignant lesions in the oral
cavity can improve the patient’s prognosis. This study
presents fluorescence imaging with the topical application
of 5-aminolevulinic acid as a way to improve detection of
various oral potentially malignant lesions. This procedure
depends mainly on comparing the intensity of red and green
fluorescence emitted from these tissues during examination.
Materials and methods: Seventy-one patients who presented
with clinically suspicious oral leukoplakia were recruited
for this study. Each of the patients was required to have
5-aminolevulinic acid in the form of mouth rinse prior to
fluorescence imaging. Following this a surgical biopsy was
acquired from the exact examination site. The results of
the fluorescence spectroscopy have been compared with
histopathology.
Results: A student’s t-test was applied to test the viability
of the ratio between red and green fluorescence. The red-
to-green ratio was found to increase significantly when the
lesion was identified as dysplastic or carcinoma in situ. By
applying a threshold line to discriminate between normal and
dysplastic lesions; a sensitivity of 83–90% and specificity of
79–89% were obtained.
Conclusion: Fluorescence spectroscopy combined with 5-
aminolevulinic acid induced protoporphyrin IX was found
as a valuable tool in the diagnosis of oral premalignancy.
This technique offers the potential to be advantageous over
other non-optical techniques in terms of providing real-time
diagnosis, in situ monitoring, cost effectiveness and more
tolerated by patient compared to surgical biopsy.
Is there a role for routine computed tomography of the
chest in the staging of early squamous cell carcinoma of
the tongue?
Brian Bisase, Cyrus Kerawala, Jon Lee
Royal Surrey County Hospital, Guildford, United Kingdom
Computed tomography of the chest (CT chest) is frequently
used to detect simultaneous pulmonary disease in patients
with upper aerodigestive tract (UADT) carcinoma. Although
some data exists suggesting a modest detection rate of such
abnormalities the available literature reports heterogeneous
groups of patients with new primaries, recurrent disease,
diverse index tumour sites and varying TN stages.1 Resources
within the NHS remain limited and in the future may well
need to be rationalised but with little evidence base for spe-
cific patient groups the justification of some diagnostic pro-
cedures may prove challenging.2
The aim of this study was to establish the value of CT chest
in the routine staging of patients with oral squamous cell car-
cinoma of the tongue. In a study of 75 patients (mean age 66,
M:F 1:1.1) information was retrospectively obtained from
hospital records regarding the number and type of abnor-
malities demonstrated in CT chest images. Changes in the
proposed treatment of patients with pulmonary abnormali-
ties was also sought. The data accumulated suggests a low
rate of thoracic abnormalities which may well justify further
rationalisation of the routine use of CT chest in this homoge-
nous cohort of patients.
References
1. Ong TK, Kerawala C, Martin IC, Stafford FW. The role
of thorax imaging in staging head and neck squamous cell
carcinoma. J Craniomaxillofac Surg 1999;27(6):339–44.
2. Improving outcomes in head and neck cancers. National
Institute for Clinical Excellence; 2004.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Elastic scattering spectroscopy in the head and neck:
Detection of premalignant and malignant lesions
Waseem Khalid Jerjes, A. Sharwani, B. Swinson, V. Salih,
M. El-Maaytah, C. Hopper
Eastman Dental Institute & University College London,
United Kingdom
Background and objective: Although optical spectroscopy
systems have been involved in various clinical fields; the
main interest is still in the diagnosis of potentially malig-
nant/malignant lesions. We aimed to use elastic scattering
spectroscopy (ESS) in patients with possible oral squamous
cell carcinoma (OSCC) or oral dysplasia.
Materials and methods: Three studies have taken place in
University College London; first study was aimed to detect
intranodal metastasis in 13 patients with OSCC; second study
were aimed to detect carcinoma in mandibular margins in
21 patients with OSCC; while the third study involved 25
patients diagnosed with oral leukoplakia. An ESS system
composed of pulsed xenon-arc lamp with a spectrometer was
used in the three studies. Surgical biopsies were acquired
from each of the examination sites; the results were then
compared with histopathology.
Results: Linear discriminant analysis was used in the three
studies, a sensitivity of 98%, 87%, 70% and a specificity of
68%, 80%, 79% were obtained from the three studies respec-
tively.
Conclusion: Currently, there is continued development, not
only in spectroscopy technology and data acquisition, but
also in the data analysis methods used.
The ultimate aim of this development is to be able to use
instantaneously in the clinical setting without taking surgical
biopsy to confirm the optical signature.
All the preliminary studies show encouraging results. With
standardisation of instrumentation and proper diagnostic
algorithms, more accurate results can be obtained.
The facial artery musculomucosal (FAMM) flap: A cadav-
eric study of 10 subjects to determine the size, number and
position of venae comitantes in order to facilitate surgical
technique and flap viability
Arshad Siddiqui, John Shaw-Dunn, Torquil MacLeod, Joseph
McManners
Forth Valley Acute Hospitals NHS Trust, United Kingdom
Aims: Facial artery musculomucosal (FAMM) flap is an axial
flap based on the facial artery. The venous drainage for this
pedicled flap comes from venae comitantes associated with
facial artery. The intriguing question has been to answer how
far the facial artery can be skeletonised when islanding the
flap to improve the manoeuvrability of the flap. We have con-
ducted an anatomic study to try and answer this question.
Materials: Ten cadaveric specimens, the circulation spe-
cially prepared with an injected medium, were randomly
selected from a large pool of specimens. An area of cheek
445
to include the territory of the facial artery, extending from
the medial canthus to the lower border of the mandible, was
excised as an elipse. Histology sections were made at the
level of nasal ala, oral commisure and lower border of the
mandible.
Method and measurements: Measurements were taken using
a special ‘DP Olympus’ software package with the micro-
scope enabling measurement of numbers and areas of vessels.
The number of venae comitantes, both inside and outside the
adventitia, the mean distances of the venae comitantes from
the facial artery and mean surface area of all venae comitantes
and facial artery were measured at the three levels.
There was great variation in the distance of the venae comi-
tantes from the facial artery and in their number. These results
will be fully analysed and presented. The findings will be
related to an improved technique for safely raising the FAMM
flap.
Malignant minor salivary gland tumors: An analysis of
the Mayo Clinic experience
Deepak Kademani, David Rallis, Jason Lewis, Sreenivas
Koka, Eugene Keller, Sunni Barnes
Mayo Clinic, USA
Background: Salivary gland tumors account for 2% of all head
and neck tumors. Minor salivary gland tumors account for
approximately 15% of all salivary gland neoplasms. Approxi-
mately 50% of all minor salivary gland tumors are malignant.
Due to the obscurity of these tumors there is limited data
regarding treatment and patient outcomes.
Purpose: To review the treatment and outcome of patients
with malignant minor salivary gland tumors who presented
to the Mayo Clinic from 1993 to 2004.
Methods: A retrospective chart review of patients with minor
salivary gland malignant tumors was reviewed from the Mayo
Clinic Tumor Registry. Data was statistically analyzed using
univariate and multivariate models in an attempt to identify
predictors of recurrence and disease-free survival.
Results: One hundred and thirteen patients met inclusion cri-
teria this included 64 males (57%) and 49 females (43%).
The population included mucoepidermoid (41.5%), adenoid
cystic (34.5%), adenocarcinoma (17.5%), PLGA (3.5%) and
acinic cell carcinomas (2.5%). The primary treatment modal-
ity was surgical resection which was performed in 74 (65.5%)
cases. Additionally adjunctive radiotherapy was included in
21 (18.5%) cases and chemotherapy in 2 (2%) cases.
Conclusion: The overall survival for this study population
was 86.7%. Local, regional, and/or distant recurrences were
noted in 16.8% of cases. Surgical tumor extirpation was
the most effective method of primary treatment. The histo-
logic subtype of minor salivary gland tumor did not seem to
correlate with recurrence or overall survival while surgical
treatment seemed to be the most effective single modality
treatment for the majority of patients.
446 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Contrast enhanced harmonic imaging in free flap
perfusion
Rajiv Anand, S. Sharma, S. Walji, J. Bowden, K. Greaves, R.
Senior, P. Ramchandani, V. Ilankovan
Poole Hospital NHS Trust, United Kingdom
Introduction: Monitoring of free flaps is routine and the
most common methods employed are clinical and hand held
Doppler examination. These are invaluable in buried flaps.
No experimental method to date is able to visualise the entire
free flap micro-circulation in real time. We evaluated the use
of contrast enhanced harmonic imaging (CEHI) in head and
neck reconstruction with free tissue transfer.
Methods: This is an open non-randomised pilot study with
21 patients analysed to date. All types of free tissue transfers
were included. Infusion of a second generation microbubble
contrast agent was carried out at 12, 24 and 48 h after comple-
tion of anastomosis. Tissues were analysed in multiple planes
for replenishment kinetics (mean transit time blood velocity)
and flow dynamics (blood volume). Ultrasound parameters
were optimised on successive patients.
Results: CEHI was feasible and simple to use at the bedside.
It was able to evaluate the blood flow in nearly all parts of
free flaps on a real-time basis. It successfully imaged blood
flow in buried flaps and predicted 2 failing flaps with no false
positives in the remaining 19. New data regarding blood flow
kinetics within free flaps was possible using quantification
software.
Conclusions: This pilot study demonstrates the feasibility and
safety of using CEHI for imaging the microcirculation in free
flaps. Physiological data regarding blood flow in free flaps is
also generated.
Management of basal cell carcinoma by oral and maxillo-
facial surgeons—National benchmarking study
Stephen Layton, Patrick Magennis
Clinical Effectiveness Sub-Committee of BAOMS, United
Kingdom
Introduction: The management of basal cell carcinoma
(BCC) is an important part of modern oral and maxillofa-
cial surgery practice.
Method: Computer read questionnaires were circulated to the
fellows and members of the British Association of Oral and
Maxillofacial Surgeons (BAOMS).
Results: At the time of writing this abstract, forms had been
returned from 64 surgeons 55 consultants, 4 SAS and 5 SpR
grades. Of these 55 have a practice involving the management
of BCC’s, with 44% treating 10–50, 16% 50–100 and 31%
greater than 100 per year.
All surgeons discussed other treatment options (radiotherapy,
photodynamic therapy, micrographic surgery and cryother-
apy) with patients at least sometimes.
Regarding Mohs Micrographic Surgery, 7% performed it
rarely, the remainder did not. Those not performing Mohs,
30% would refer patients requiring this surgery within their
trust at least some of the time, 47 said they would refer it out-
side their trust, usually to dermatology. Sixty percent would
resect a BCC and await pathology before reconstructing in
place of Moh’s.
When the skin margin was involved, 64% would included
observation in their management, 84% re-excision, 16%
radiotherapy, and 13% Mohs.
For deep margin involvement, 27% would include observa-
tion, 91% re-excision, 31% radiotherapy and 15% Mohs.
In anatomically difficult areas, 40% would include observa-
tion, 76% re-excision, 40% radiotherapy and 40% Mohs.
Of those answering the question on audit (54), 56% (30) had
audited their practice and the average involved margin rate
was 8% with this falling to 6.0% for consultant surgeons.
The role of carotid Duplex scanning in head and neck free
flap reconstruction
Mark Stephen Wilbourn, Rajiv Anand, Major Ben Davies,
Constantinos Mourouzis, Peter Brennan
Queen Alexandra Hospital, Portsmouth, United Kingdom
Introduction: Vascular pathology in patients who have under-
gone surgery for head and neck cancer is common. Risk
factors for both head and neck cancer and peripheral vascular
disease are well known and thought to be similar. Studies on
the patency of the carotid tree in patients with head and neck
cancer are limited and to date, no studies have specifically
investigated carotid artery disease prior to free tissue trans-
fer. Failure to pre-operatively identify carotid stenosis can
result both in inadequate perfusion of the free flap and neuro-
logical complications. We evaluate the use of carotid Duplex
scanning in patients requiring free flap reconstruction.
Methods: A prospective study of the carotid vasculature in
all patients undergoing surgery for oropharyngeal carcinoma
requiring free flap reconstruction using carotid Duplex scan-
ning.
Results: Twenty four patients were included in the study (no
patients were excluded). Carotid artery stenosis was iden-
tified in six patients (25%), and two patients had signifi-
cant vascular disease. One of these necessitated concomitant
carotid endarterectomy and patch grafting and creation of a
neopedicle.
Conclusions: Carotid Duplex is an inexpensive, non-invasive,
sensitive and specific investigation for the evaluation of
carotid artery disease. Given the significant morbidity of
free flap failure in patients with unrecognised carotid dis-
ease, and the morbidity of neurological sequelae, we rec-
ommend carotid Duplex in the routine work up of patients
undergoing microvascular reconstruction of the head and
neck.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Results of a public awareness campaign for oral cancer
Roderick Morrison, A. Carton, L. Cohen, G. Smith, L.
MacPherson, J. Rodgers, J. Devine, S. Hislop, J. McMan-
ners
West of Scotland Regional Maxillofacial Unit, Southern Gen-
eral Hospital, Glasgow, United Kingdom
Background: In 2002 the West of Scotland Cancer Aware-
ness Project (WoSCAP) was awarded £1.3 million to develop
a public awareness campaign. WoSCAP commissioned the
Centre for Social Marketing at Strathclyde University to con-
duct research to inform the development of an early detection
campaign tackling mouth cancer.
Aims: To develop a public awareness campaign using the
principles of social marketing. To encourage the ‘at risk’
population to present earlier with signs and symptoms of oral
cancer.
Method: Research examined ‘consumer awareness’ of mouth
cancer as well as assessing understanding of signs and symp-
toms of the disease. A qualitative research methodology using
focus groups was used. These focus groups, made up of peo-
ple within the target ‘at risk’ group, were also used to pre-test
advertising concepts. Using this information a campaign was
developed.
Results: A public awareness campaign was conducted in two
phases between October 2003 and February 2004. TV and
Radio ads were run and posters and leaflets were distributed.
Key findings from follow up surveys were—83% of public
questioned recognised the TV advert and felt that it was easy
to understand. Ninety two percent of GDPs in the West of
Scotland were aware of the campaign and 60% referred dur-
ing the campaign. Of patients attending clinics, 64% were
aware of the campaign and 68% sought advice sooner due to
the publicity.
Conclusions: Research following the campaign has shown
a high message penetration, a strong campaign identity and
that it has raised awareness of the disease and its symptoms.
Reconstruction of rhinectomy defects—The Salisbury
experience
Madanagopalan Ethunandan, I.P. Downie, T.R. Flood
Salisbury District Hospital, Salisbury, United Kingdom
Reconstruction following rhinectomy has remained a chal-
lenge since ancient times. Surgical reconstruction of large
defects is often delayed, complex and less than satisfac-
tory and previous prosthetic rehabilitation have been com-
promised by poor stability and adverse tissue reactions.
Advances in biomaterials and increasing experience with
craniofacial implants offer the opportunity to satisfactorily
reconstruct post rhinectomy defects with an implant retained
prosthesis.
We describe our 12 year experience at Salisbury district hos-
pital, using implant retained prosthesis to reconstruct large
nasal defects.
447
The factors analysed included the demographic details of the
patients, primary pathology and its management, the use and
timing of radiotherapy and hyperbaric oxygen. The number,
type and location of implants were noted in addition to the
type and timing of prosthetic rehabilitation. The success of
the implants and prosthesis were assessed using standard sta-
tistical methods. In addition, the patient’s satisfaction was
assessed using a 16 point questionnaire and the aesthetic out-
come was evaluated using a 4 point scale.
Our technique of post-rhinectomy reconstruction and the
detailed results will be presented.
One stop clinic for OMFS soft tissue surgery
Michael Millwaters, Shiyana Eliyas, Kannan Balaraman,
Wayne Halfpenny
Chase Farm Hospital, United Kingdom
One stop clinics are widespread in many surgical specialties.
Their use in OMFS has been more limited with one previ-
ously published example.
We present our experience of our soft tissue one stop clinic
which has been running for over 3 years. The initial 3 years
were audited which showed that 306 patients were treated.
These included a wide range of conditions with the most
common being FEP’s (102) and mucocoels (26). No problems
were encountered over this time with regard to managing the
clinic and all patients, when offered this service, accepted.
The pattern we follow is to book referrals from practitioners
directly into this clinic which runs in parallel to the general
clinic. The patients are treated and then contacted by phone
with the biopsy result. Hard copy is sent to the referring prac-
titioner with the discharge letter. If any unexpected result is
found, the patients are sent a further appointment.
These clinics are cost-effective and a sample patient satis-
faction survey revealed that patients prefer this approach. A
further advantage is that urgent biopsies may be immediately
carried out without interrupting the general clinic.
This paper will also be presented as Poster 45.
Complications and risk factors associated with locking
reconstruction plates used for mandibular continuity
defects
Domenick Coletti, Robert Ord, John Caccamese
University of Maryland Medical System, R Adam Crowley
Shock Trauma Center, USA
Introduction: The development of locking reconstruction
plates (LRP) has revolutionized the treatment of mandibu-
lar continuity defects following ablative or trauma surgery.
Although LRP address many inadequacies of non-locking
plates, they are not infallible. We review 110 cases treated
with LRP at the University of Maryland and discuss the asso-
ciated risks and complications.
Materials/methods: A retrospective review of patients requir-
ing LRP following mandibular resection from July 1996
448 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
to June 2003 was undertaken. Data collected included
patient demographics, diagnosis, site, defect length, post-
operative occlusion, type of reconstruction, and complica-
tions.
Results: One hundred and ten patients were reviewed, 46
females and 58 males. The average length of follow up was
56 months, 69 (63%) were treated for malignancies and 41
(37%) for benign disease. The average continuity defect was
8.6 cm, 25 were anterior defects, 67 lateral, 7 condyle/lateral,
and 10 anterior/lateral. Post-operatively 66% of patients had
at least a partial dentition and 33% were edentulous; fifty
(45%) patients received radiation therapy. The overall com-
plication rate was 35%. Twelve patients (11%) developed
plate fractures; all were lateral defects, a partial/full dentition,
and 83% did not receive a bony reconstruction. Twelve (11%)
had infections; 33% receiving radiation therapy and/or a vas-
cularized reconstruction. Ten (9%) had plate exposures; 80%
receiving radiation therapy and 70% a vascularized recon-
struction. Four (3.6%) had malocclusions, and one was with
loose hardware (0.9%).
Conclusion: Presented is the University of Maryland’s data
for complications and risks factors associated with LRP. We
also discuss our treatment strategies to reduce this complica-
tion rate.
Analysis of death certification in early stage oral cavity
squamous cell carcinoma
Deepak Kademani, Evre Baltati, Jason Lewis, Sreenivas
Koka, Eugene Keller
Division of Oral and Maxillofacial Surgery, Mayo Clinic Col-
lege of Medicine, USA
Purpose: Oral cavity squamous cell carcinoma accounts
for 30,000 newly diagnosed cases with approximately 8000
deaths in the US each year. T1 tumors have the most favor-
able prognosis, however there continues to be 15% mortality
rate The aim of this study was to report the specific cause
of death in patients diagnosed and treated for T1 OCSCC as
recorded by death certification.
Methods: Two hundred and fifty three patients with T1
OCSCC were identified from the Mayo Clinic Tumor Reg-
istry between 1988 and 2001. All patients had no prior history
of malignancy. The majority of patients were treated by
primary surgical resection. Overall survival rate was 76%.
Local and regional recurrences were observed 8.5% and
16% of patients respectively. Recurrent tumors were treated
with multimodal therapy. Eighty-eight patient deaths were
reported. Forty death certificates were available for review
order to establish the specific cause of death in the T1OCSCC
population.
Results: Twenty-two patients were male and 18 were females
with an average age of 75.2 years. In 17 (42.5%) OCSCC
was the leading factor contributing to the patient’s death. In
7 (17.5%) other malignant process was the major contribut-
ing factor in patient’s death and in the remaining 16 patients
(40%) a major medical cormorbidity was the considered the
leading cause of death.
Conclusion: Despite multi-modality treatment of recurrent
OCSCC there continues to be a significant mortality rate asso-
ciated with oral cavity tumors. Analysis of death certificates
provides valuable information regarding the specific cause of
death in this patient population.
The impact of substance abuse on the occurrence and out-
come of odontogenic deep space infections
Domenick Coletti, John Caccamese, Arshyia Sharafi,
Michael Hartman
University of Maryland Medical Systems, R Adam Crowley
Shock Trauma Center, USA
Introduction: The management of deep space infections
(DSI) is common practice for the oral and maxillofacial sur-
geon. Little is reported regarding the impact of substance
abuse (SA) on the frequency of DSI or length of stay (LOS)
in these patients. We review 92 patients with DSI treated
utilizing an aggressive surgical protocol at the University of
Maryland.
Material and methods: A retrospective review of 92 DSI
patients from July 2002 to June 2004 was undertaken.
Patient age, sex, medical co-morbidities, drug or alcohol
use, involved anatomic space, length of hospital or intensive
care unit (ICU) stay, and the need for tracheotomy or post-
operative intubation was reviewed. All patients had surgery
within 12 h of initial evaluation.
Results: Substance abusers comprised 28% of the patients
and the male to female ratio was higher in the SA group
(2.25:1 versus 0.73:1). There was no statistically significant
difference in age, LOS, length of intubation, tracheotomy,
leukocyte count, or number of spaces involved between the
SA and non-SA populations. SA patients were twice as likely
to be immune compromised and four times more likely to use
alcohol. There was a trend for SA patients to require more
time in the ICU. There were no mortalities in either group.
Conclusion: We present 92 DSI patients, nearly a third of
which were substance abusers. Despite the increased fre-
quency of SA in our patient population, outcomes were com-
parable between the two groups, especially regarding LOS
and ICU utilization. We attribute the overall favorable out-
comes to aggressive surgical management.
Applications of the harmonic scalpel in head and neck
oncology surgery
David Laugharne, K. Jones, S. Crank, D. Hyam
Derbyshire Royal Infirmary, Derby Hospitals NHS Founda-
tion Trust, United Kingdom
Background: The use of the harmonic scalpel is an accepted
technique in gastro-intestinal laparoscopic surgery. Descrip-
tion of its application in the head and neck region is largely
limited to tonsillectomy and thyroid surgery. To date, this
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
technique has not been described in head and oncology
surgery.
The harmonic scalpel cuts and coagulates simultaneously
using high frequency mechanical vibration rather than high
temperature. Haemostasis is by coaptation of vessels with the
blade prior to division.
The advantages of this technique are it reduces:
operative time;
morbidity;
intra operative blood loss;
post-operative drainage.
Method: We present our experience of elective neck dis-
section using the harmonic scalpel. The prospective study
examines the application in 20 neck dissections over a 12
month period. Operative time, blood loss, number of liga-
tures used, post-operative drainage volume and associated
morbidity were recorded.
Discussion: We show and discuss the technique, the benefits
and limitations of this instrument. It is a safe, useful and cost
efficient alternative to cold knife or electrocautery for neck
dissection.
Outcome audit of intensive care input in free flap surgery:
Does it make a difference?
Rajiv Anand, S. Sharma, G. Murdoch, E.O. Sullivan, S. Walji,
C. Mourouzis, R. Webb, C. Pratt, T. Mellor, V. Ilankovan, P.
Brennan
Queen Alexandra Hospital, Portsmouth, United Kingdom
Introduction: The use of microvascular free tissue transfer
is well established in reconstruction of defects of the head
and neck. Radial forearm free flap survival figures have been
well documented at up to 95%. Post-operative complications
have been also well described and correlated with premorbid
factors and indices. To our knowledge there has been only
one study evaluating the use of intensive care facilities in the
immediate post-operative period.1 The current policy in our
unit is for patients undergoing free tissue transfer to return to
the ward; in other units on the rotation most patients have a
short stay in ITU post-operatively.
This study aims to show if a post-operative stay in ITU con-
fers any advantage. If no differences are seen there are then
governance and cost implications.
Methods: A multi-centre retrospective audit of patients who
have undergone radial forearm free flap (RFFF) for recon-
struction in the head and neck. Three units are included in the
study with 30–50 patients from each. A standard technique
for flap harvest and donor site graft was used. Data collection
was by case note analysis using a specially designed proforma
to collate data on pre morbid factors, length of stay, flap sur-
vival, general and local complications.
Results/conclusion: Multiple outcome measures will be dis-
cussed, along with the potential implications in terms of
patient care and cost.
449
Reference
1. Godden DR, Patel M, Baldwin A, Woodwards RT. Need
for intensive care after operations for head and neck cancer
surgery. Br J Oral Maxillofac Surg 1999;37(6):502–5.
Aspiration following treatment of oropharyngeal carci-
noma patients perception versus reality
Helena Pappa, M. Iqbal, C.N. Penfold, C.J. Lloyd, S.W.
Gollins, S. Vyas, S. Ford
Glan Clwyd Hospital, N Wales, United Kingdom
Introduction: The predictive role of objective swallowing
assessment in patients treated for oropharyngeal carcinoma
is not known.
Aim: The aim of this study was to compare objective evidence
of aspiration with patients perception based on the relavant
information, obtained from the EORTC quality of life ques-
tionnaire (QLQ-H&N35).
Method: Prospective cohort study over a 4 year period
2001–2004. All the patients had swallow studies using the
‘Kay Swallowing Workstation’ (Kay Elemetrics, NJ) and
completed an EORT QLQ, before treatment, at 6 months and
1 year after completion of treatment.
Results: Forty seven patients treated for stages III and IV pri-
mary squamous cell carcinoma of the oropharynx. Twenty
four patients had surgery and post-operative radiotherapy
and 23 received radical chemoradiation alone. Twenty seven
patients had evidence of aspiration on the swallowing studies.
The association between objective measurements of aspira-
tion and the patients perception is presented and the clinical
implications are discussed.
Tongue reconstruction using free vastus lateralis muscle
flap
Neil Scott, B. Visavadia, C. Kerawala
The Royal Surrey County Hospital Oral and Maxillofacial
Department, United Kingdom
Introduction: The Anterolateral thigh flap (ALT) is a fascio-
cutaneous flap based on a cutaneous perforator, which can
then be traced back to the lateral femoral circumflex artery
and vena commitans. These flaps have since been used widely
in the Far East but have not gained wide spread acceptance
in the United Kingdom for head and neck reconstruction.
In an obese patient the flap can be difficult to raise and may
then require subsequent thinning. Identification of the per-
forator vessels is difficult and the anatomic variation makes
dissection difficult.
We present a technique for harvesting Free Vastus Lateralis
muscle flap in a patient undergoing hemiglossectomy as a
result of a squamous cell carcinoma.
This technique does not require the identification of perfora-
tor vessels.
Discussion: The flap offers the following advantages:
Identification of perforator vessels is not required.
450 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
The donor site possesses multiple components skin, adipose,
fascia and muscle.
Minimal long term donor site morbidity.
Donor site may be closed primarily.
Ideal for large defects such as tongue that require bulk but
without lining.
Reliable vascularity and a long pedicle can be obtained with
wide diameter of arterial and venous vessels.
The flap can be easily harvested using a 2-team approach
without patient repositioning.
There is the possibility of chimeric applications.
We conclude that this particular flap technique can gain wide
spread acceptance in oncological head and neck reconstruc-
tion owing to the many advantages it has to offer.
Are we managing potentially malignant oral lesions cor-
rectly?
Roger Michael Webb, Clive Pratt, Alice Boynton, Reg
Anand, Michael Bater, Carrie Newlands
St Richard’s Hospital, Chichester, United Kingdom
Introduction: Following the recent work of Sudbo et al.1 into
ploidy status of oral premalignant lesions, there is now grow-
ing interest in the management of those oral lesions which
may have some malignant potential. We present the results
of an audit assessing the management of potentially prema-
lignant oral lesions in the South Thames and South Coast
regions.
Method: A questionnaire based on that originally designed
by Marley et al.2 was circulated to all the Maxillofacial Units
in the area. Clinicians of all grades who routinely assess
such patients in clinic were asked to identify their treat-
ment decisions for a number of clinical scenarios. Methods
of documentation, choice of special investigation and factors
influencing the decision to biopsy were compared. Once a
diagnosis was made, further questions were asked analyzing
treatment regimes and follow up protocols.
Results: Analysis of the data demonstrated considerable com-
placency in the management of apparently non dysplastic
lesions.
Conclusions: Management traditionally based upon clinical
and histological findings may become obsolete in the future if
evaluation of ploidy status becomes routine. In the meantime,
NHS pressures to discharge patients from follow-up may be
very inappropriate.
References
1. Sudbo, et al. New Engl J Med 2004;350:1405–13.
2. Marley, et al. J Oral Pathol Med 1998;27:489–95.
Ultrasound guided core biopsy in the diagnosis of symp-
tomatic neck lumps
Michael Williams, D.C. Howlett
Eastbourne District General Hospital, United Kingdom
Ultrasound guided core biopsy (US-CB) was performed in 82
consecutive patients presenting with neck masses. Compari-
son was made with the results of subsequent surgical biopsy if
performed. Lesions arising sonographically from the salivary
or thyroid glands were excluded from the study.
US-CB reached a firm histological diagnosis in 76 patients
(93%) and 25 of these patients had subsequent surgery with
100% correlation between US-CB and surgical results. In
4 patients US-CB gave an equivocal result (reactive nodal
hyperplasia or lymphoma) and in 2 patients US-CB was non-
diagnostic. Seventy-eight patients had nodal pathology, with
4 non-nodal diagnoses. Of 18 patients with an US-CB diag-
nosis of lymphoma only 3 required subsequent surgery to
provide additional information for treatment purposes.
We conclude that US-CB provides a safe, accurate and well-
tolerated means of evaluating cervical masses. US-CB pro-
vides potential advantages over fine needle aspiration cytol-
ogy (FNAC), in particular in the diagnosis and typing of
lymphoma and in the differentiation of lymphoma from reac-
tive nodal hyperplasia and reduces rates of diagnostic surgical
biopsy. Improvements in US-CB diagnosis over FNAC may
be particularly apparent in the district general hospital set-
ting, where only immunohistochemistry is provided and other
ancillary techniques, used to improve FNAC accuracy, are not
widely available.
An audit of long-term percutaneous endoscopic gastros-
tomy in head and neck cancer patients
Naseem Ghazali, Luke Cascarini, Brooke Quinteros, Jo Kerr,
Kenneth Lavery
Maxillofacial Unit, Queen Victoria Hospital, East Grinstead,
United Kingdom
Head and neck cancer patients have altered swallowing pat-
terns, weight loss and are already malnourished at first
presentation. This state is exacerbated by treatment. As a
result, many patients require enteral routes that by-passes
the oropharynx for nutritional access. Percutaneous endo-
scopic gastrostomy (PEG) is an established method of enteral
access. Patient dependence and use of PEG varies. In a small
proportion of patients, PEG are heavily relied upon lead-
ing to long term and life long dependency. The aims of this
audit were twofold: to determine current practice and to gen-
erate treatment protocols for patients with long-term and
lifelong PEG. A retrospective case notes review of patients
inserted with PEG at the Queen Victoria Hospital from
April 1998 to November 2004 was undertaken. Data collec-
tion was achieved using a proforma detailing demographical
data, tumour characteristics, treatment received, PEG fea-
tures (insertion, removal, reinsertion, length of placement,
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
complications), swallowing assessments and nutritional sta-
tus (pre and post-PEG insertion). On the basis of the results
obtained, we have proposed a protocol for the management
of head and neck patients with PEG tubes, in particular, the
long-term and lifelong PEG users.
The non-surgical management of skin cancer
Phillip Ameerally, G.B. Colver
Chesterfield Royal Hospital, United Kingdom
Skin cancer is the most common maligancy affecting humans
and its incidence is rising more rapidly than any other tumour.
Skin cancer is treated by a number of medical and surgical
specialities including dermatology, maxillofacial, plastic and
general surgery.
In order to provide fully informed consent all treatment
options must be explained to the patient. Most skin cancers
are managed by surgical excision. Non-surgical methods of
treating skin cancer are also important and can be advanta-
geous in some situations. These techniques are however not
usually familiar to most surgeons and are therefore rarely
used.
The aim of this paper is to highlight the types of skin can-
cers amenable to non-surgical treatment as well as those that
should definitely not be treated by non-surgical methods.
The advantages and disadvantages of non surgical treatment
methods will be reviewed. The role of curettage and cautery,
cryotherapy, radiotherapy, photodynamic therapy and topical
chemotherapeutic agents will be discussed.
Neck observation versus Elective neck dissection in the
management of T1-T2N0M0 Oral squamous cell carci-
noma
Zubair Khan, Huw T. Davies
The Ipswich Hospital NHS Trust, United Kingdom
Aims: To assess role of elective neck dissection in manage-
ment of T1-T2N0M0 oral squamous cell carcinoma.
Methodology: Medical notes of all the patients who under
went surgery for T1-T2N0M0 oral squamous cell carcinoma
between 1994 and 1999 were examined. All the patients who
died because of medical causes other than oral SCC during 5
year follow up period were excluded. Patients who presented
with lip SCC were also excluded from the study. Total num-
ber of patients included in the study was 36. Patients’ age of
presentation, ASA grade, source of referral, mode of presen-
tation, site of presentation, risk factors, clinical staging, type
of surgery performed, pathological staging, detail of adju-
vant and neoadjuvant therapy, complications during 5 years
post-operative period, recurrence, site of recurrence and man-
agement of recurrence was recorded. Patients were divided
in two groups for analysing data. Group 1: Neck observation
group, Group 2: Elective neck dissection group.
Results: Local excision + Neck observation group: 5 years
survival with out disease 60%, 5 year survival 75%, overall
451
recurrence 40%, neck recurrence 35%, local recurrence 5%,
survival after neck recurrence 28.75%, survival after local
recurrence 100%.
Local excision + Elective Neck dissection group: 5 years sur-
vival with out disease 71.42%, 5 year survival 78.57%, occult
neck disease found in 12.5%, overall recurrence 28.57%,
neck recurrence 14.28%, survival after neck recurrence 0%,
survival after local recurrence 50%.
Conclusion: We did not found any significant difference
between two groups in terms of 5 year survival or 5 year
survival without disease.
Is silent aspiration clinically important in oropharyngeal
carcinoma patients?
Mazhar Iqbal, Helena Pappa, Sunil Vyas, Sylvia Ford, Simon
Gollins, Christopher Lloyd, Christopher Penfold
Glan Clwyd Hospital, Bodelwyddan, North Wales, United
Kingdom
Introduction: Swallowing difficulty is a well recognised com-
plication after treatment for oropharyngeal carcinoma. The
clinical implication of laryngeal penetration identified by
videofluouroscopy and fibreoptic evaluation of swallowing
(FEES) remains unknown.
Aim: To assess the clinical significance of laryngeal pene-
tration identified by videofluouroscopy and FEES in patients
after treatment for oropharyngeal carcinoma.
Study design: Prospective longitudinal study.
Method: Forty seven patients were assessed with regards to
their swallowing function at 6 and 12 months after treatment
for oropharyngeal carcinoma. Hospital records were exam-
ined for signs and symptoms of aspiration and compared with
the results of FEES and videofluoroscopy.
Results: Of the 47 patients, 27 had objective evidence of
aspiration of which 17 were silent aspirators. The difficulty
of predicting clinically significant aspiration from objective
measures such as FEES and videofluoroscopy will be dis-
cussed.
Orbital malignancies and methods for reconstruction
Raja Kummoona
Surgical Speciality Hospital, Baghdad, Iraq
Orbital cancer is rare, according to the Iraqi cancer Reg-
istry for the years 1976–1985; tumors of the eye and CNS
constitute 3.54% of the total malignancies. The aim of this
study is to show our experience in management of these cases
with minimum morbidity and deformity. This study consists
of 6 patients (5 female and 1 male). Age ranged from 3
to 75 years (mean 54.7 years). After examination includ-
ing ophthalmologic assessment and imaging, all patients
were treated surgically with adjuvant pre or post-operative
radiotherapy. Reconstruction of the defect was undertaken
utilizing various types of flaps. Follow up ranged from 1–5
years. Tumor types were SCC, BCC, conjunctival SCC,
452 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
retinoblastoma in 2, 1, 2, 1 patients respectively. Treatment
consisted of complete excision of orbital content (orbitec-
tomy) in 4 patients and wide excision of the tumor in 2
patients. Closure of the defect was accomplished using var-
ious flaps including Mustarde, facio-cervical advancement,
facio-orbital advancement, fronto-orbital rotation in 2, 1, 1,
2 patients respectively. Temporalis muscle flap was used for
augmenting the orbit in 4 patients. No complications were
encountered. Survival rate was quite good. There is no sin-
gle best method for reconstruction of the orbital defects left
after tumor resection and the different flaps applied for recon-
struction have given satisfactory results related to the type and
complexity of the deformity. Temporalis muscle flap in this
contest had proved to be versatile and highly reliable flap in
terms of bulk and vascularity.
DNA methylation as a tumour biomarker in OSCC
Richard Shaw, Triantafillos Liloglou, Simon Rogers, James
Brown, David Vaughan, John Field, Janet Risk
Regional Maxillofacial Unit, University Hospital Aintree,
Liverpool, United Kingdom
Introduction: Interest in cancer epigenetics has extended to
the assay of circulating DNA methylation and its potential
application as a tumour biomarker. The technical challenge
is to establish a sufficiently sensitive technique that will allow
the study of the minute amounts of DNA present in patient
specimens but yet to avoid false positives.
Method: In a cohort of 75 patients, for whom the epigenetic
signature of their OSCC was known, we prospectively
collected 320 plasma specimens. For a smaller cohort of
patients, saliva and urine specimens were also collected.
Following DNA extraction and bisulphite treatment we have
analysed methylation status using established MSP and
pyrosequencing and also a novel technique: methylation
enrichment pyrosequencing (MEP). Three genes with
known tumour specific DNA promoter hypermethylation
were used (p16, cyclin A1, cytoglobin) necessitating over
1000 PCR reactions and subsequent pyrosequencing.
The presence of aberrant DNA is subsequently corre-
lated with clinical parameters such as pTNM and clinical
outcome.
Results: Aberrant DNA reflecting the epigenetic profile of
the primary tumour was identified in plasma (9%), urine
(20%) and saliva (45%) specimens. In some cases the
presence of this aberrant DNA in longitudinally collected
plasma specimens correlated with the clinical course of the
patient.
Conclusion: It seems likely that the source of at least some
of the circulating aberrant DNA was other than tumour tis-
sue. This and other technical issues currently may limit early
clinical application of these techniques, however the MEP
method descibed may represent a signifcant advance in the
field of circulating DNA analysis.
Patients experience with long-term PEG
Stanley Parikh, Richard Thomson, Derek Lowe, Paul
O’Toole, Simon N. Rogers
Regional Maxillofacial Unit, University Hospital Aintree,
Liverpool, United Kingdom
Percutaneous Endoscopic Gastrostomy feeding (PEG) has an
important role in providing nutritional support in selected
patients undergoing treatment for oral and oropharyngeal
cancer. Although morbidity data have been published there
is very little from the patient perspective.
The aim of this project was to devise, pilot and survey a PEG
specific questionnaire and relate outcomes to health-related
quality of life.
Method: A cross-sectional survey was conducted in April
2005 of patients who were alive and disease free and treated
by primary surgery for oral and oropharyngeal squamous
cell carcinoma between 1992 and June 2004. The survey
comprised the University of Washington Quality of Life ques-
tionnaire and a 24 item PEG questionnaire.
Results: Of 344 alive and disease free patients, 243 (71%)
responded. Clinical characteristics of responders and respon-
ders were similar. Mean age of responders was 65 (S.D. 12)
and 59% were male. There were 193 (79%) patients who
never had a PEG as part of their treatment, 30 (12%) who
had had their PEG removed (median 7 months), and 20 (8%)
who still had a PEG (median 34 months). Patients with PEGs
reported significant deficits in all UW-QOL domains com-
pared to non-PEG or PEG-removed patients. No patient with
a PEG reported outstanding or very good HRQOL, compared
to 50% of PEG-removed patients. The major PEG related
problems were not those of discomfort, leakage or block-
age, but interference with family life, intimate relationships,
social activities, and hobbies.
Conclusion: More can be done to counsel and support patients
with long-term PEG placement.
An epigenetic profile of oral cancer: Quantitative methy-
lation analysis using pyrosequencing
Richard Shaw, Triantafillos Liloglou, Simon Rogers, James
Brown, Derek Lowe, John Field, Janet Risk
Regional Maxillofacial Unit, University Hospital Aintree,
Liverpool, United Kingdom
Introduction: The role of promoter hypermethylation has
become a focus for cancer research. Epigenetic silencing
of tumour suppressor genes is central to the development
of malignancy. We investigate quantitative methylation sta-
tus in HNSCC using a new method known as pyroseque-
ncing.
Method: Fresh tumour and normal control tissue was obtained
from 79 consecutive patients undergoing resection of OSCC.
DNA was extracted and bisulphite treated. PCR primers were
designed to amplify 75–200 bp regions of the CpG rich gene
promoters of p16, E-cadherin, cytoglobin and cyclin A1.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Methylation status of 4–5 CpG sites per gene was determined
by pyrosequencing.
Results: Significant CpG methylation of gene promoters
within tumour specimens was found in 28% for p16, 73% for
RAR␤, 42% for E-cadherin, 65% for cytoglobin and 53% for
cyclin A1. Promoter methylation was significantly elevated
in tumours compared to normal tissue for p16 (P = 0.048),
cytoglobin (P = 0.002) and cyclin A1 (P = 0.001) but not
in RAR␤ (P = 0.088) or E-cadherin (P = 0.347). Concor-
dant methylation was demonstrated in this tumour series
(P = 0.03). Significant differences in degree of methylation of
individual CpG sites were noted for all genes except RAR␤;
these differences were in a characteristic pattern reproduced
between samples. Cyclin A1 methylation correlated inversely
with histological grade (P = 0.05).
Conclusions: Pyrosequencing reveals valuable quantitative
methylation data from several CpG sites. Our data indicate
that P16 methylation is highly tumour specific, in contrast
to previous data, whilst CYCA1 methylation, not previously
been investigated in oral cancer, also appears to be tumour
specific.
What is the value of panendoscopy in detecting simulta-
neous primary tumours in patients presenting with early
squamous cell carcinoma of the tongue?
Brian Bisase, Cyrus Kerawala, Jon Lee
Royal Surrey County Hospital, Guildford, United Kingdom
The routine of use of panendoscopy in patients presenting
with oro-pharyngeal squamous cell carcinoma is justified by
its potential ability to detect simultaneous primaries of the
upper aerodigestive tract (UADT) which in turn are thought
to be due to prolonged risk factor exposure. Although some
reports suggest a prevalence of second primary tumours
between 9% and 17%, these studies tend to amalgamate
simultaneous, synchronous and metachronous disease.1,2 In
addition the patients studied tend to be a heterogeneous group
of varying TNM stages and anatomical sites.
The aim of this study was to establish the value of panen-
doscopy in the detection of simultaneous primary tumours
of the UADT in a homogenous group of patients presenting
with early carcinoma of the tongue. In a retrospective review
of 75 patients (mean age 66, M:F 1:1.1) information was
obtained from hospital records regarding the number and type
of abnormalities demonstrated at panendoscopy performed
under general anaesthesia. The prevalence of simultaneous
UADT tumours and abnormalities was low suggesting that
the routine use of panendoscopy under general anaesthesia
may not be justified in these clinical circumstances.
References
1. De Vries N, Van der Waal I, Snow GB. Multiple pri-
mary tumours in oral cancer. Int J Oral Maxillofac Surg
1986;15(1):85–7.
2. Kramer FJ, Janssen M, Eckardt A. Second pri-
mary tumours in oropharyngeal squamous cell carci-
453
noma. Clin Oral Investg 2004;8(2):56–62 [Epub March 16,
2004].
Incidence and impact of MRSA infection in post-
operative major head and neck cancer surgery patients:
A 3 year retrospective study
Rabin Pratap Singh, A. Rennie, A. Abdullakutty, S. Parmar,
T. Martin
University Hospitals Birmingham, United Kingdom
Introduction: Methicillin-resistant Staphylococcus aureus
(MRSA) infection in the hospital environment has attracted
intense media interest in recent years. There is currently
scarcity of studies in the literature that have investigated
post-operative complications specifically related to head and
neck surgery. Our study reports on the incidence and financial
impact of MRSA infection after major head and neck cancer
surgery over a 3-year period.
Methods: The study is a retrospective analysis of medical
records of MRSA infected patients in the Oral & Maxillo-
facial and Otolaryngology departments of Queen Elizabeth
Hospital, Birmingham, from 6 April 2001 to 5 April 2004
representing three consecutive UK financial years.
Results: One hundred and eighty four patients underwent
major head and neck cancer surgery over the period of the
study, of which 42 patients were infected with MRSA post-
operatively. The incidence rates of MRSA infection were
34.5%, 11.6% and 14.6% in the first, second and third finan-
cial years respectively. The commonest site of infection was
neck wound followed by tracheostomy site. Antibiotic ther-
apy was the mainstay of treatment. We noticed changing
pattern of sensitivity of MRSA over the 3 years, from Ery-
thromycin sensitivity to that of resistance. The total cost
due to infection-related complications in terms additional
days in hospital, laboratory investigations and treatment was
£72031.93 per annum, equivalent to £1715.05 per person.
Conclusions: Our study revealed significant financial burden
to hospitals due to MRSA infection after major head and
neck cancer surgery. Several issues surrounding prevention
and treatment of MRSA infection are discussed.
Reconstruction of severe vertical defects of alveolar ridge
by means of distraction osteogenesis
Simonas Grybauskas, Linkevicius Tomas, Puisys Algirdas
Vilnius Implantology Center, Lithuania
Severe post-traumatic vertical defects of alveolar ridge
present prosthetic and aesthetic difficulties in restoring denti-
tion. Performing implant surgery in this situation as is would
result in unaesthetic high crowns and would produce unsatis-
factory results for patients with high smile line. Guided bone
regeneration is hardly feasible when vertical defect is greater
than 1 cm due to insufficiency of soft tissues.
We present consecutive cases of reconstruction of vertical
alveolar ridge defects by means of distraction osteogenesis
454 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
followed by implant placement and delivery of aesthetic pros-
thesis.
Adult head and neck soft tissue sarcomas: A report on
experience of a major orthopaedic oncology unit from
1990 to 2005
Rabin Pratap Singh, R. Grimer
Royal Orthopaedic Hospital, Birmingham, United Kingdom
Introduction: Soft tissue sarcomas of head and neck region
are rare accounting for less than 10% of all soft tissue sarco-
mas and approximately 1% of all head and neck neoplasms1 .
Nevertheless, they represent an important group of tumours
and are associated with significant morbidity and mortality.
There is currently scarcity of studies in the literature on the
subject area and to our knowledge there is only one published
study that is based in an UK hospital in the last 15 years.2
Aims and objectives: To analyse the experience of Royal
Orthopaedic Hospital, Birmingham in the management of
adult head and neck soft tissue sarcomas.
Methods: This is a retrospective analysis of database and med-
ical records of 36 patients who have attended our department
with soft tissue sarcomas in the head and neck region from
1990 to 2005.
Data/analysis: We intend to report on patient demographics,
tumour variables, diagnostic measures, treatment modalities,
post-treatment complications, and follow up of the patients.
Relapse-free, disease-specific and overall survival rates will
be compared between the subgroups and treatment modali-
ties. We will also analyse the influence of various prognostic
factors on survival.
References
1. Mendenhall WM, Werning JW, Riggs CE. Adult head and
neck soft tissue sarcomas. Head Neck 2005;27(10):916–22.
2. Eeles RA, Fisher C, A’Hern RP, Robinson M, Rhys-Evans
P, Henk JM, Archer D, Harmer CL. Head and neck sarco-
mas: prognostic factors and implications for treatment. Br J
Cancer 1993;68(1):201–7.
Survival rates of dental implants in unilateral cleft lip and
palate patients
Alistair Andrew Morton, T.R. Flood
Salisbury District Hospital, United Kingdom
The rehabilitation of unilateral cleft lip and palate patients is
often complicated by the associated hypodontia in the cleft
area.
There are a number of prosthetic and orthodontic options for
the replacement of the missing teeth, but recent developments
in implant dentistry have opened new potential alternatives
to an old problem.
This study assesses the survival rates of implants placed in 20
unilateral cleft lip and palate patients. Data will be presented
on:
- age;
- sex;
- site of cleft;
- number of implants;
- type of restoration;
- use of additional bone graft;
- implant probing depths;
- presence of bleeding, pain or infection;
- radiographic changes;
- time implants loaded in a function;
- implant failure rates.
Poster abstracts
Bisphosphonates and osteonecrosis of the jaws: A diag-
nostic dilemma
James Ross Adams, K. Edwards, J.M. Ryan, K.R. Postleth-
waite
City Hospitals Sunderland, United Kingdom
In November 2005, Novartis Pharmaceuticals UK Ltd. were
advised by the European Medicines Agency to inform all reg-
istered dental clinicians of recent concerns about osteonecro-
sis of the jaws occuring in cancer patients receiving intra-
venous bisphosphonates.
This communication followed an amendment made in 2004
to both Aredia (pamidronate disodium) and Zometa (zole-
dronic acid) precautions section of the U.S. packaging.
Both commonly used bisphosphonates had been linked with
osteonecrosis of the jaws in patients receiving treatment for
malignancy.
We present two cases of gross osteolytic jaw lesioins involv-
ing the mandible and maxilla in patients with multiple
myeloma. Both patients were receiving intravenous bispho-
sphonate treatment regimens. Clinical, radiological and his-
tological data support the diagnosis of osteonecrosis of the
jaws.
These cases highlight the clinical, radiological and histologi-
cal features of this pathology. Difficulties in its diagnosis and
treatment are discussed.
A look through the hourglass of ‘tracheotomy’
Anjum Ahmed-Nusrath, M.A. Nusrath, C.M. Avery
University Hospitals of Leicester, United Kingdom
Tracheostomy has been performed as early as 3000 BC and
has been recorded on Egyptian slabs. It is one of the oldest
surgical procedures and has been mentioned in the Rig-Veda
around 2000 BC. Alexander supposedly punctured the tra-
chea of a choking soldier with his sword! Arabic physicians
such as El Zahrawi (936–1013) and Ibn Zuhr (1091–1161)
wrote surgical texts on this subject.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Antonio Musa Brasavola, an Italian physician, performed the
first documented case of a successful tracheostomy. He pub-
lished his account in 1546. The patient, who was suffering
from a laryngeal abscess recovered from the procedure. Tra-
cheostomy has been termed as laryngotomy, bronchotomy
and pharyngotomy during the medieval times. Sanctorius
(1561–1636) was the first to use a trochar and a cannula.
George Martine (1702–1743) one of the earliest British ‘tra-
cheotomist’ described the first double cannula, with the
inner cannula being removed for cleaning without remov-
ing the outer one. Francis Home was the first to advocate
tracheostomy for croup in 1765 and this proved to be use-
ful in the diphtheria epidemic of the early 19th century. The
mortality rate for this procedure was as high as 30%!
The poliomyelitis epidemic of the 1950s brought about the
use of tracheostomy for mechanical ventilation, leading to
similar treatment in tetanus, cardiac surgery, burns and pre
term infants.
Percutaneous tracheostomies are becoming the norm in inten-
sive care as part of the weaning protocol in ventilated
patients.
The science and uses of infrared coagulator in maxillofa-
cial surgery
Phillip Ameerally, G.B. Colver
Chesterfield Royal Hospital, United Kingdom
The infrared coagulator (IRC) is a portable, relatively cheap
device that emits energy in the near infrared range (960 nm).
It is easy to use with simple training and does not require any
additional equipment or personnel. It is very safe for both the
patient and operator and unlike the laser there is no risk of
injury to the eyes or fire hazard. Treatment can be performed
using local anaesthetic in an outpatient setting in most cases.
The IRC is effective in controlling parenchymal haemorrhage
following surgery or trauma to the liver, spleen and kidneys.
It is an excellent tool in the management of several conditions
seen by maxillofacial surgeons including those affecting the
skin (venous lakes, tattoos, port wine stains and other vas-
cular malformations) and oral mucosa (telangectasia, kaposi
sarcoma and other vascular lesions). Because it produces a
predictable level of injury, the IRC is also a useful research
tool in the study of tissue injury and its treatment.
The components and principles of operation of the IRC will
be described as well as its uses in maxillofacial surgery. The
limitations of the instrument will also be discussed.
Smith–Lemli–Optiz syndrome
Mazen Att, T. Flood, I. Downie, R. Anand
Salisbury Hospital, United Kingdom
Introduction: Smith–Lemli–Optiz syndrome (SLOS) is an
autosomal recessive multiple congenital anomaly syndrome
first described by Smith et al. in 1964. The most com-
mon findings include growth retardation, characteristic facial
455
anomalies, cleft palate, and mental retardation. Some patients
have more severe manifestations, including major struc-
tural malformations and early lethality, and the aim is to
try and familiarise maxillofacial surgeons with this rare
syndrome.
Method/clinical report: A 29-year-old lady had been diag-
nosed at birth to have SLOS. She had multiple med-
ical/clinical problems which included chronic bronchi-
tis, palatal deformity, hypo-plastic jaws, thickening of
the skull vault, micrognathia, telecanthus and epicanthic
folds.
MRI scans has been used to make sure that there is no struc-
tural malformation of the Brain.
Results: She had closure of the palatal cleft at the age of
18 months due to her heart condition, and by the age of
19 years old she had bimaxillary osteotomy at Salisbury
hospital, then a genioplasty advancement when she was 24
years old, not forgetting of course the orthodontic treat-
ment that lasted for around 2 years during the orthognathic
period.
She is now under regular annual review by multiple spe-
cialities for routine follow-ups since she made a remarkable
improvement from medical/clinical point of view.
Discussion: Carrier frequency for SLOS is approximately
1:30 in those of northern Europe descent, suggesting inci-
dence between 1:5000 and 1:8000 births.
The actual incidence may be lower due to fetal losses.
SLOS has been described in patients from the U.S., many
Northern Europe countries, Japan, South-America, and
others.
Modified adjustable length tracheostomy tube
Christopher Avery, C.J. Siegmund
University Hospital Leicester (Leicester Royal Infirmary),
United Kingdom
In the overweight patient or patient with a full neck excessive
coughing or moving of the head might easily dislodge the
tube out of the trachea into the pretracheal tissues with the
risk of complete obstruction of the upper airway. To avoid
this complication a longer tracheostomy tube would be of
benefit. Commercially available tracheostomy tubes come in
different diameters and lengths but most of the tubes available
to us failed to have a sufficient locking mechanism to keep
the tracheostomy tube at the adjusted length and hence in a
secure intratracheal position.
We report a technique where a commercially available
Mallinckrodt tracheostomy tube (TracheoSoft PERC,
Mallinckrodt Medical, Ireland) was modified in a way that
the flange was loosely secured in place with two plastic bag
ties. The final position of the flange can now be adjusted
according to the desired length and secured by pulling the
bag tie tight. Finally the flange is fixed in situ to the skin by
sutures.
456 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Superficial lobe preservation for deep-lobe parotid
tumours: A technical note
Christopher Avery, C. Siegmund
University Hospital Leicester (Leicester Royal Infirmary),
United Kingdom
Parotid tumours of the deep lobe are relatively uncommon.
Traditionally, these tumours have been approached by super-
ficial parotidectomy, with preservation of the facial nerve
whenever possible, followed by excision of the deep lobe
tumour either separately or en-bloc. The significant loss of tis-
sue volume leaves a large unsightly deformity, often despite
surgical maneouvres to minimise the defect.
We report a small series of cases in which the superficial
part of the gland has been retained and repositioned after
removal of the tumour. The superficial lobe is pedicled on
an inferior base of tissue. The parotid duct is not routinely
ligated. This simple technique has substantially improved the
aesthetic outcome and avoided the need for local flaps, such
as the sternocleidomastoid flap, or secondary surgical proce-
dures at a later stage. There have been no complications to
date.
How much is too much? Do clinical staff have any idea of
how their decisions impact the NHS?
Robert Banks, Judith Stocker
Sunderland Royal Hospital, United Kingdom
Decisions made by medical staff have cost implications in any
department, not just maxillofacial surgery. We have proved
that appropriate education of maxillofacial senior house offi-
cers leads to compliance with the NICE guidance for ordering
pre-operative tests. However, we still see over ordering of
tests for in-patients and it appears that clinical staff pay lit-
tle heed to potential cost implications. Medical staff seem to
have little idea of cost effectiveness and its potential advan-
tages to the NHS, preferring the ‘tick all boxes’ approach
without heed to cost.
Method: We performed a questionnaire survey of doctors and
dentists in two large district hospitals, recording data regard-
ing specialty, qualification date, postgraduate qualifications
and seniority. We included staff from a range of medical
and surgical specialties. Respondents were asked to give an
approximate cost for a number of tests—including haematol-
ogy, biochemistry, immunology and radiology. The data was
analysed according to specialty and seniority.
Results: Clinical staff invariably had little idea of the cost
of special tests. This result varied little between specialties
although there was some relationship with seniority and more
accurate cost prediction.
Conclusions: Education of junior staff has been shown to
lead to appropriate ordering of pre-operative tests. However,
a poor appreciation of the cost of special tests and a ‘blanket’
approach to their ordering may result in excess expenditure.
We suggest a more pragmatic approach to education – for
staff at all levels – may alleviate this and be cost beneficial
to the NHS.
Audit comparing the use of portable coagulation monitor
to the laboratory for testing the INR of patients who take
warfarin and require dental extractions
Shruthi Bellur, Anne Morgan, C.H. Chan
Luton and Dunstable Hospital, United Kingdom
Patients who require dental extractions and take warfarin
need to have their International Normalised Ratio (INR) level
obtained prior to proceeding to determine if it is of an accept-
able level. Currently, a venous sample is obtained and sent
for laboratory testing, which is time consuming. The audit
was carried out to determine if the use of a portable coagula-
tion monitor was a feasible alternative. Thirty patients who
attended the department for extractions and took warfarin
had their INR measured by both the laboratory, assumed to
be the gold standard, and the portable coagulation monitor
and the results compared. The mean difference recorded by
the coagulation monitor was −0.22 with a standard devia-
tion of 0.35, and a 95% confidence interval for the population
mean of −0.10 to −0.34. Using the paired t-test the difference
was found to be significant. However, there is a difference
between statistical and clinical significance and no result
obtained by the portable coagulation monitor would have
altered the clinical treatment.
A large teratoma of the hard palate: A case report
John Russell, G. Fabbroni, R. Benson
Leeds General Infirmary, Leeds Teaching Hospitals, United
Kingdom
Teratoma is defined by Weaver et al., 1976, as a tumour con-
sisting of multiple tissues that are not indigenous to their
site of origin. They are true neoplasms of presumed primor-
dial germ-cell derivation that consist of tissues from all three
embryonic germ layers.
This interesting case describes the management of a cau-
casian female, born prematurely with a large epipalatine
teratoma (epipalatus) and complex congenital heart defects.
Teratoma had been diagnosed by incidental ultrasonography
at 19 weeks.
The aesthetic and functional implications of such a mass were
discussed with the parents. Unfortunately, the mother gave
birth by spontaneous vaginal delivery at home. Immediate
transfer was made to the local hospital and transfer to a ter-
tiary centre enabled full multidisciplinary management and
tracheostomy at 4 h post delivery.
Examination of the lesion revealed a large (8 cm × 7 cm ×
5 cm approximately) obstructive polypoid mass with areas
covered in skin, hairs and cystic tissue. Computerised tomog-
raphy showed a complex mass protruding from the palate. It
consisted of cystic, fat, bony and neural elements, with tooth
definition within the bone.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Diagnosis was of epipalatus and surgical removal was carried
out at 4 weeks. Skin, fat, bone, cartilage, squamous and respi-
ratory epithelium, lymphoid tissue, salivary gland type tissue
and neuroglial tissue with choroid plexus and ependyma were
all found within the mass.
This case is supported by interesting clinical pictures and
hopes to add to the limited literature on this rare congenital
lesion.
Tuberosity osteotomy—A forgotten technique in low
level LeFort I osteotomy?
Girish Bharadwaj, Barry O’Regan
Queen Margaret Hospital, Dunfermline, United Kingdom
Introduction: The incidence of serious post-operative haem-
orrhage in standard LFI osteotomy is low. Attempts to reduce
this further have led to the development of alternative tech-
niques to prevent vascular injury (most commonly to the
descending palatine artery) during pterygomaxillary separa-
tion. These include a tuberosity osteotomy technique1 which
has not been widely adopted by UK surgeons. A recent
national survey revealed that only 12 (7%) of 175 responding
orthognathic surgeons currently use the technique.2
Aims:
1. To prospectively study the incidence of serious haemor-
rhage in LFI osteotomy using the tuberosity technique;
2. To routinely identify and protect the descending palatine
artery.
Methods: We have used a tuberosity osteotomy technique
for pterygomaxillary separation in 30 consecutive LFI
osteotomies.
Results: No patients developed a serious post-operative
haemorrhage. Routine vessel identification and preservation
was achieved in 59 of 60 descending palatine arteries.
Conclusion: The tuberosity osteotomy is a reliable tech-
nique for pterygomaxillary separation. It facilitates routine
descending palatine artery preservation and may reduce the
risk of pterygoid venous plexus bleeding. It aids the safe
removal of mechanical bony obstruction in impaction and
setback movements.
References
1. Trimble LD, Tideman H, Stoelinga PJW. A modifica-
tion of the pterygoid plate separation in low level maxillary
osteotomies. J Oral Maxillofac Surg 1983;41:544–6.
2. O’Regan MB, Bharadwaj G. Pterygomaxillary separation
in Le Fort I osteotomy: UK OMFS consultant survey, Brit J
Oral Maxillofac Surg, in press.
457
The use of EUA and panendoscopy in patients presenting
with oro-pharyngeal squamous cell carcinoma
Brian Bisase, Cyrus Kerawala
Royal Surrey County Hospital, Guildford, United Kingdom
The routine of use of examination under anaesthesia (EUA)
and panendoscopy in patients presenting with oro-pharyngeal
squamous cell carcinoma is justified by some surgeons
because they feel it helps in the assessment of the index
tumour’s dimensions, permits the detection of simultane-
ous primaries and predicts a patient’s response to the long
anaesthetic that may facilitate their ultimate treatment. A
body of published evidence however suggests that most oro-
pharyngeal carcinomas can be assessed by cross-sectional
imaging and clinical examination alone, the rate of simulta-
neous primaries of the upper aerodigestive tract is low and
that modern day anaesthesia does not require a “test” anaes-
thetic. The routine use of EUA and panendoscopy may also
increase the waiting time of an individual prior to definitive
treatment.
This study used a standard telephone questionnaire of 50
maxillofacial units to assess the current use of EUA and
panendoscopy. Over two thirds were still using the technique
on a routine basis irrespective of the site and clinical staging
of the index tumour as well as an individual patient’s risk
factor profile and performance status.
These findings suggest that in the modern era of medical
practice an evidence-based approach is still not being adopted
by all.
The Shrewsbury stent
Samantha Bunn, G.A.E. Burke, N. Srihari
Royal Shrewsbury Hospital, United Kingdom
Reproducible patient positioning during fractionated confor-
mal radiotherapy for intra-oral malignancy is problematic.
The difficulty in reproducibly excluding non-target tissue
from the irradiated field raises concerns of increased risk of
radiation-related acute and late side effects, especially in the
young and the elderly.
We describe a simple method of fabrication of a customised
oral radiotherapy stent to counter this problem. The poten-
tial benefits include the ability to deliver higher doses to the
target tissue with a greater level of safety than has previ-
ously been possible. Adjacent non-target tissues additionally
receive a reduced dose, minimizing side effects and compli-
cations. The simplicity of construction and ease of use allows
the individual to consistently return to the same jaw relation-
ship during radiotherapy as assessed on verification CT scan.
458 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Venous thromboembolism risk in oral and maxillofacial
daycase surgery
Lachlan Macdonald Carter, Vikram P. Kavi
Hull Royal Infirmary, United Kingdom
The incidence of venous thromboembolism (VTE) in max-
illofacial surgery is low, with most events occurring among
in-patients undergoing major surgery; the risk in day-case
procedures is unknown. Short operating times and healthy
patients warrant day surgery procedures with low risk VTE
status, but is this a reality?
Patients attending for GA daycase oral and maxillofacial sur-
gical procedures, from November 2004 to April 2005, were
assessed retrospectively for VTE risk, using the Hull local
guideline, which is based on recommendations from THIRFT
and SIGN 62.
Data were obtained for 62 patients. Twenty five patients were
aged 13 years old or younger and were thus excluded from
VTE risk assessment. Twenty six (70.3%) of the remaining 37
patients had a moderate or higher VTE risk score. The mod-
erate or high VTE risk was related to surgical time greater
than 30 min, age, oral contraceptive pill use or a combina-
tion of these risk factors. No VTE prophylaxis was used, as
VTE risk assessment is not presently undertaken in daycase
surgery.
While the incidence of VTE is unknown in daycase oral and
maxillofacial surgery it can be assumed to be low. This does
not negate the real VTE risk for individual patients. We rec-
ommend that VTE risk assessment and risk specific VTE
prophylaxis should be used for daycase patients, particularly
in longer procedures and those taking the oral contraceptive
pill.
Oral cancer awareness of hospital nurses
Lachlan Macdonald Carter, Vikram Kavi
Hull Royal Infirmary, United Kingdom
Nurses play a pivotal role in the oral health care of hospi-
talised patients. This ranges from oral health care assessment
upon admission, to undertaking regular mouth care tasks
for those patients who are unable to undertake their own
oral health care. Nurses can be the only health profession-
als to examine and care for the mouths of some patients.
This offers a unique opportunity to screen for oral diseases
including oral cancer. However, oral health assessment and
related care is a neglected area in nursing education and
practice.
Hospital nurses within Hull were questioned regarding their
oral examination habits, oral disease knowledge, oral can-
cer risk factor and clinical appearance knowledge and their
previous training on oral diseases.
One hundred and twenty-one nurses from various special-
ties returned questionnaires. Forty three percent of nurses
reported that more than 50% of their patients required oral
health care assistance. 48.8% of nurses performed an oral
health check on admission. 62.8% identified smoking but
only 28.1% identified alcohol as risk factors. Knowledge of
other oral cancer risk factors was generally poor. 72.7% were
unable to identify more than one clinical sign of oral cancer.
Nineteen percent reported having had no oral health training
at nursing school and 50.4% reported having no training on
oral health after graduation.
Nurses’ oral cancer awareness was found to be poor and high-
lights the need for education of this important group of health
professionals in oral diseases and oral cancer.
Honey I glued the kids
Luke Cascarini, Anand Kumar, Rachna Sharma
Queen Victoria Hospital, East Grinstead, United Kingdom
We present a case of an 8-year-old boy who presented to the
emergency department with a laceration to the brow region
which had been glued by his father using ‘superglue’.
The father had previously been to the emergency department
with a forearm laceration and had this wound closed with
what he was told was ‘superglue’.
The child’s laceration was explored and closed with sutures
under general anaesthesia. The adhesive was found deep
within the wound and there was extensive inflammation.
We discuss the development of cyanoacrylate based adhe-
sives and explain how tissue adhesives differ from ‘super-
glues’.
We summarise the safe usage of tissue adhesives and con-
clude that it is dangerous and incorrect to tell patients and
relatives that ‘superglue’ is being used.
Bilateral TMJ dislocation in a 23 month old infant
Luke Cascarini, Malcolm Cameron
Queen Victoria Hospital, East Grinstead, United Kingdom
Temperomandibular joint disclocation is rare in infants, prob-
ably due to the lack of development of the articular eminence.
We present the youngest case of bilateral TMJ dislocation in
European literature and the second youngest in world litera-
ture.
We discuss the presentation of this rare condition with pho-
tographs and the reasons for the misdiagnosis (mumps) by
emergency department doctors.
There is a brief review of the literature and a summary of
management.
Recurrent sinuses of the neck and chest associated with
cervical lymphadenitis in a case of treated tuberculosis
Leo H.H. Cheng, Graham Bothamley, Suziye Mehmet,
Saadia Farooq, Amith Pinto
Oral & Maxillofacial Surgery and Respiratory Medicine,
Homerton University Hospital, London, United Kingdom
Introduction: Cutaneous ulcers and sinuses during the process
of tuberculous cervical lymphadenitis are no longer common
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
due to early treatment. When these do occur, surgical exci-
sion with the underlying cervical lymph node is the treatment
of choice.
Case report: We report a case of a 29 year old man with
cervical lymphadenitis, and associated recurrent and mul-
tiple sinuses despite directly observed treatment with four
drugs for fully sensitive tuberculosis. He also developed pre-
tracheal and axillary lymphadenitis. Recurrent sinuses with
associated lymph nodes were excised from mid cervical,
supraclavicular and presternal regions. Multiple fine needle
aspirations from cervical and presternal lymphadenitis, spu-
tum and lymph node specimens with microbiological cultures
did not show any evidence of active tuberculosis. His axil-
lary lymphadenitis gradually resolved with a course of steroid
treatment.
Conclusion: It is extremely rare for previously treated
tuberculosis for cervical lymphadenitis to develop mul-
tiple and recurrent cervical and pretracheal cutaneous
sinuses despite no evidence of active tuberculosis. We sug-
gest that the patient may have an unusual immunologi-
cal response to dead or inactive tuberculous bacilli which
then manifested as recurrent lymphadenitis with discharging
sinuses.
A review of thyroid surgical cases in a District General
Hospital
Leo H.H. Cheng, Suziye Mehmet, Noha Seoudi, Saadia
Farooq, Peter Freedman, John Anderson
Oral & Maxillofacial Surgery and Endocrinology, Homerton
University Hospital, London, United Kingdom
Introduction: Thyroid disease is common and surgical treat-
ment is indicated when the thyroid mass causes compressive
symptoms or shows suspicious changes. We present a retro-
spective survey of the demographic details and complication
rate of over 60 patients who underwent surgery at Homerton
University Hospital, London, by one surgeon (LC) in a 2 year
period.
Findings: Over a third of patients were either Afro-Caribbean
or Asian in origin. Nearly half of the referrals were from the
endocrinologists. Compressive symptoms with neck mass
accounted for the majority of presenting complaints. Sus-
picious nodules and compressive symptoms were the most
common indication for surgery. Hemithyroidectomy fol-
lowed by total thyroidectomy for neoplasm were common
surgical procedures. Nodular hyperplasia and follicular ade-
noma followed by thyroid malignancies were common his-
tological findings. Post-operatively, there were no perma-
nent hoarseness but 5% of temporary vocal cord changes.
Less than 2% had sero-haematoma and less than 5% had
hypocalaemia.
Conclusion: The post-operative complication rates in our
review were compatible with the agreed international stan-
dard. A multidisciplinary approach with endocrinologists is
key to provide the best service for thyroid patients.
459
Maxillofacial SHO job advertisements: Can we improve
it?
Simon Cove, Suman Das, Pinaki Sen
MRI and Wrexham Park Hospital, United Kingdom
Background: Applying for jobs as a SHO in maxillofacial
surgery is an experience all trainees encounter. Our expe-
rience of applying for post suggested wide variation in the
advertisements and the journal advertised.
Aim: To suggest applicants the journal they should look for
advertisement and improve the information contained in the
advertisements.
Method: BMJ and BDJ was reviewed retrospectively for all
SHO job advertisements from August to December 2006.
Result: Fifty four SHO posts were advertised over the 6 month
period. Forty eight percent of these SHO posts were adver-
tised in both BMJ and BDJ. Thirty five percent of these posts
was advertised in BMJ and not in BDJ and 14% in BDJ but
not in BMJ. Among the jobs advertised 35% were 6 month
duration and 35% 6 month duration but extendable. There
was no mention regarding on call crossover with different
speciality in 55% of the advertisement and only 31% clearly
stated it was only maxillofacial on call. The type of on call
rota/shift not mentioned in 64%. Twenty six percent of jobs
accepted curriculum vitae, 39% application and curriculum
vitae and 35% web based application and curriculum vitae.
Conclusion: One has to look into both BMJ and BDJ in order
to avoid missing the advertisement or post they desire. The
wide variation in the details of the advertisement makes it
prudent to get the job description before considering applying
for the post.
A modification of the Bjork flap for tracheostomies per-
formed in head and neck surgery
Stephen Crank, D. Laugharne, D. Hyam, A.W. Baker
Derbyshire Royal Infirmary, United Kingdom
Tracheostomy is well recognised as a safe and effective
technique for securing the airway in patients undergoing
major head and neck surgery. There are many variations
in tracheostomy technique with respect to opening the
trachea—these include incisions with or without the use of
stay sutures, the formation of a window in the anterior tra-
cheal wall and the use of a Bjork flap.
We present a technique which is a modification of the Bjork
flap. This technique is simple to perform and we believe
has the advantage in providing a more secure airway with
less likelihood of the tracheostomy tube being dislodged
in the operative or early post-operative phase. Additionally,
this technique allows the possibilty of an early but safe tra-
cheostomy tube change and early decannulation. This has
benefits to the patient in maintaining their post-operative
progress.
The technique is illustrated and our initial experience of util-
ising this technique presented.
460 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
The outcome of patients following TMJ arthroscopy—the
Derby experience
Stephen Crank, S. Chawoo, D. Laugharne, D. Hyam, P. Kor-
czak
Derbyshire Royal Infirmary, United Kingdom
Temporomandibular joint arthroscopy is a recognised tech-
nique in the management of TMJ disorders. It provides min-
imally invasive access to the TM joint to demonstrate joint
pathology and additionally has therapeutic benefits through
lysis and lavage of the joint.
Patients with TMJ disorders are usually treated with con-
servative measures prior to consideration of arthroscopy.
Following arthroscopy patients may be offered surgical treat-
ment or return to a conservative regime of management.
The aim of this study is to assess the outcome of patients
who have undergone TMJ arthroscopy. We have performed
a retrospective review of patients who have undergone TMJ
arthroscopy in our unit between January 2002 and Decem-
ber 2003. Initially we have considered the patients present-
ing symptoms, clinical diagnosis and length of time from
initial consultation to TMJ arthroscopy. We have assessed
the outcomes following arthroscopy with respect to patients
symptoms, further surgical treatment performed and contin-
ued review or discharge.
The results and conclusions will be discussed.
Standarising care after mandible fractures
Andrew J. Dickenson, Shahid Chawoo
Derbyshire Royal Infirmary, United Kingdom
Background: Mandible fractures constitute a substantial pro-
portion of all facial injuries, accounting for 36–59% of max-
illofacial fractures. This volume of trauma has implications
for the unpredictable use of outpatient time, which inevitably
results in overbooking of clinics.
Aim: To determine outpatient attendance patterns of patients
with mandible fractures.
Methods: A two-part study was undertaken to determine
patient attendance rates before and after introducing a set
of guidelines. The preliminary study examined attendance
rates of 73 patients and these results were used to create the
guidelines. Fifty subsequent fractures were analysed.
Results: The preliminary study confirmed that 59% of
patients fully, and 20% partially, complied with the review
appointments. Twenty one percent failed to attend any out-
patient review.
The guidelines limited attendance to week 1 and 6 post-injury.
Attendance rates increased to 98% (week 1) and 90% (week
6). Condylar fractures were reviewed more frequently (weeks
1, 2 and 6) and achieved 98% compliance.
Conclusion: Reviewing mandible fractures generates addi-
tional work load for the outpatient clinic. Compliance is
generally poor and the failure rate increases after the first
appointment, resulting in wasted clinic capacity.
Standardising the review interval to week 1 and 6 achieves
an overall compliance rate of 94%.
Mandibular advancement devices for obstructive sleep
apnoea: Design concepts for the partially dentate patient
Andrew J. Dickenson, Paul Smith, Robin Thorpe, Alasdair
Fry
Derbyshire Royal Infirmary, United Kingdom
Background: The high incidence of obstructive sleep apnoea
(OSA) has only recently been given the attention it deserves,
mainly because the symptoms of this particular sleep-related
disorder are subtle. While the management of OSA remains
complex and varies according to local protocols, maxillofa-
cial surgeons are frequently being approached for their input
into the management of these patients.
The use of mandibular advancement devices (MAD) in
snoring is well documented in the specialist dental liter-
ature. Recent evidence confirms that MAD is as effec-
tive as nasal continuous positive airways pressure (nCPAP)
for managing mild OSA. Unfortunately, while these arti-
cles inform the practitioner of the aetiology, assessment
and medical complications of OSA, they fail to provide
technical support on how to construct the devices. Com-
mercially available devices rely on an intact dentition with
mandibular retrognathia. However this not always the case
and more edentulous or partially dentate patients are pre-
senting for treatment. This poses a technical problem for the
surgeon.
Aim: To illustrate the concepts, rationale and technical aspects
of appliance design.
Method: Variations in appliance design will be illustrated,
including the use of hybrid designs for use in edentulous
patients.
Conclusion: The MAD offers significant benefits for patients
with mild OSA. They increase the posterior airway space, sta-
bilize the mandible in an anterior and closed position, advance
the tongue base and increase genioglossus muscle activity.
They are reliable, reversible and cost-effective if designed
and constructed correctly. We discuss the design aspects of
MAD fabrication and illustrate options available in the chal-
lenging cases.
The feasability of 24 h stay thyroid and parathyroid
surgery—The Torbay experience
Michael Esson, D. Cunliffe, R. Dyer
Depts of Maxillofacial Surgery & Endocrinology, Torbay
Hospital, United Kingdom
The length of stay following thyroid and parathyroid surgery
is affected by many variables. These may be patient, surgeon,
operation or institution related. A national audit conducted by
the British Association of Endocrine Surgeons in 2003 found
90% of patients following thyroidectomy remain in hospital
for 4 post-operative days. However, there are a number of
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
published reports of short stay or even day case admissions
for these procedures in selected cases.
During the last 12 months we have adopted a policy of plan-
ning discharge on the first post-operative day where possible
with the help of local protocols.
We present our experience demonstrating that the majority of
patients can be safely discharged on the first post-operative
day but highlight barriers that can occur.
Routine use of awake fibre-optic endoscopy for vocal cord
and airway assessment immediately prior to thyroid and
parathyroid surgery
Michael Esson, D. Cunliffe, A. Varvinski
Torbay Hospital, United Kingdom
Pre-operative vocal cord assessment is performed routinely
in many centres carrying out thyroid or parathyroid surgery.
This investigation is usually carried out in the out-patient
setting and may require either a separate appointment or an
earlier hospital admission prior to surgery. It helps to establish
the degree of vocal cord function before surgical treatment,
particularly as litigation may follow a recurrent laryngeal
nerve palsy. It is especially important to highlight the pre-
operative state in patients with a history of voice change,
previous thyroid surgery or when due to be operated on for
thyroid malignancy. CT scan and flow-volume loop investi-
gations can be used to assess airway anatomy when potential
obstruction is suspected, however they may not reflect the
true situation.
We have adopted a policy of using awake fibre-optic
endoscopy at the time of general anaesthetic induction to
visualise vocal cord function and airway anatomy with
emphasis on its displacement, patency and degree of obstruc-
tion.
We describe the procedure performed and present the results
of using this method of vocal cord assessment which adds
little to the overall anaesthetic time and allows early identifi-
cation of the difficult airway. Additionally, it is well-tolerated
by the patients and helps reduce the duration of patient hos-
pital admission.
The use of a surgical planning proforma in head and neck
oncology
Katharine Fleming, C.M.E. Avery
Leicester Royal Infirmary, United Kingdom
Surgical treatment of the head and neck oncology patient is
complex with many different stages, each with a great deal of
information to be transmitted. Although the general approach
is similar for most patients each will have their specific prob-
lems and so the treatment plan will be individually tailored
to their needs.
In order to facilitate this process an oncology planning pro-
forma has been designed and is utilized in the pre-operative
phase. This will be shown.
461
The proforma is divided into three major sections:
1. Diagnostic/MDT meeting phase.
2. Treatment planning/investigations.
3. Patient information/counselling.
At each outpatient consultation a full record of investiga-
tions ordered, information given to the patient and treat-
ment planning decisions made is recorded using a tick box
system.
This has improved practice in several ways. Patient work up
is more structured and investigations are not missed. Infor-
mation required for the head and neck oncology database can
be quickly identified.
As patients may be seen by different clinicians this contem-
pory record helps with continuity of care. Each clinician signs
the document after a consultation and this acts as both a com-
prehensive documentation of pre-surgical counselling and a
support for the consent process.
Finally and perhaps most importantly it provides a framework
for the surgical trainee to develop the best surgical practice.
Facial numbness and loss of taste as first clinical signs of
a benign acoustic neuroma
Rajitha Gadipally, Christian Siegmund, C.M.E. Avery
Leicester Royal Infirmary, United Kingdom
Benign acoustic neuroma classically presents with decreased
hearing, ringing in the ears or a change in balance. Further
growth may create headaches, difficulty walking and damage
to the cranial nerves. Late symptoms are pain, numbness or
weakness in the face.
Trigeminal nerve involvement as first sign of an acoustic neu-
roma is very unusual.1
We report a case of a 51-year old female patient with a
past medical history of breast cancer who presented with
unilateral progressive loss of taste on the right tongue and
increasing numbness on the right lower lip, cheek and tragus
area. She subsequently developed ipsilateral hearing loss. In
the interim an MRI scan revealed a large acoustic neuroma of
the right brainstem. She underwent translabyrinthine resec-
tion of the tumor and subsequently developed facial palsy.
The symptoms of paraesthesia largely resolved but resolu-
tion of the facial palsy was incomplete.
Reference
1. Holt DJ, Foy PM, Field EA. Orofacial paraesthesia:
unusual presentation of acoustic neuroma. Dent Update
2002;29(3):141–2.
462 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Should out of hours suturing by SHO’s be a thing of the
past?
Robert Goodard, Karim Kassam
King’s College Hospital, London, United Kingdom
This audit arose as a result of concerns by the A&E
staff/Maxillo-faciac team regarding an increased workload
and intensity.
The aims were as follows:
(1) To decrease the out of hours suturing in A&E.
(2) To decrease the time spent to suture lacerations and thus
to reduce patient morbidity.
(3) To decrease the workload of A&E and Maxillo-facial
junior staff.
We proposed to implement these aims by introducing a daily
suturing Out-patient clinic on a permanent basis.
Following the introduction of this clinic, we were able to
achieve the following:
(1) A reduction of out of hours suturing with no apparent
increase in patient morbidity.
(2) A reduction in operating time.
(3) A subjective increase in SHO suturing experience with
greater senior Maxillo-facial support.
Use of telemedicine in oral and maxillofacial surgery in
the UK
David Grimes, Kathleen Fan
King’s College Hospital, United Kingdom
Telemedicine is the process of transferring information elec-
tronically. It enables fast communication between medical
staff at distant sites to specialist at centralised sites. There are
strong driving forces that encourage confederation of OMFS
into centralised site with satellite hospitals (BAOMS 2002).
Centralisation of services may lead to problems of transfer of
patients and in particular accompanying information between
units.
Aim: The aim of our study was to discover the current usage
of this telemedicine in Oral and Maxillofacial Surgery.
Methods: A questionnaire sent to all the units in the UK.
Information was obtained regarding use of telemedicine,
type of information transmitted and between which depart-
ments/hospitals.
Results: Telemedicine was only in used in 12% of respon-
dents. All users felt that it improved their service. Seventy
percent of respondents believed their service could benefit
from telemedicine. Thirty percent of respondents reported
that their department had the intention of using telemedicine.
Conclusion: Telemedicine is utilised by only a small number
of Oral and Maxillofacial Surgical units in the UK, all of
which reported a benefit. Majority of units also reported that
access to telemedicine would improve their service.
There is a case for promoting telemedicine for Oral and
Maxillofacial Services based on successful models already
in place.
Correction of facial deformity prior to removal of TMJ
ankylosis: Report of two cases
Simonas Grybauskas, Linkeviciene Laura, Puisys Algirdas,
Linkevicius Tomas
Vilnius Implantology Center, Lithuania
TMJ ankylosis results in severe facial deformity if not treated
early. It presents two problems: functional and cosmetic. If
ankylosis is released and reconstruction of TMJ is performed
first, there is facial bone deformity to be dealt with next. Cor-
rection of facial bone deformity is performed but treatment
results can be less than ideal and not stable due to the anatomy
and function of the TMJ affected mandible: severely short-
ened ramus and contracted masticatory muscles which force
to relapse.
We present two consecutive cases of correction of facial
deformity by means of distraction osteogenesis prior to
removal of TMJ ankylosis. This method may ensure a sym-
metric reconstruction of facial bones and a stretch of soft
tissue resulting in a reduction of load on newly reconstructed
TMJ after removal of TMJ ankylotic mass.
Use of tracheostomy in major oral cancer resection: A
retrospective audit
Ben Gurney, D. Pierse, I.C. Martin, A. Burns
Sunderland Oral and Maxillofacial Surgery Department,
United Kingdom
Introduction: Tracheostomy has a varying role in the opera-
tive treatment of patients with oral cancer undergoing radical
resection and reconstruction. The protocols for airway man-
agement in these patients varies from unit to unit.
Aims: This study sets out to assess when a tracheostomy has
been required for patients at a tertiary referral centre which
does not routinely perform tracheostomies electively for its
major oral cancer resections.
Method: A retrospective review of our unit’s data stored on the
‘Head and Neck Oncology Database, Liverpool’ was carried
out. A total of 150 patients underwent neck dissection with
resection of the tumour and free flap reconstruction between
2000 and 2005. Variables identified included pre-op TNM
staging, site of tumour, medical co-morbidity, patient age and
sex, extent of neck dissection, and timing of any tracheostomy
insertion relative to surgery. All patients routinely had an
overnight post-operative ITU stay, and underwent nasotra-
cheal intubation.
Results: Routine elective tracheostomies are not performed
for our patients. Subsequent emergency tracheostomy in our
large cohort of patients was exceedingly small, justifying our
clinical practice. A complete description of the correlative
analysis is presented.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Conclusions: Although the airway of patients with oral can-
cer can be potentially difficult, they can be managed safely
without the routine use of tracheostomy. Nasotracheal intuba-
tion is a safe alternative if managed properly, but does require
ITU care in the immediate post-operative period.
Can a leaflet reduce alcohol consumption in patients with
alcohol related facial injuries?
Babra Hanif, Ameeta Joshi, Jan Taylor, Helen Worthington
University of Manchester, United Kingdom
Aim: To assess the value of a leaflet given to patients with
alcohol related facial injuries.
Design: Patients with OMF injuries were screened and
recruited to a randomised trial.
Setting: University teaching hospital in Manchester.
Participants: Adults referred with facial injuries to OMFS
via A&E during an 18 month period.
Intervention: Following consent, patients were randomised
into one of three groups: leaflet, 5 min intervention (FMI) and
no intervention. Patients completed an ethnicity form and 5
questionnaires: AUDIT, SADQ, RCQ, SIP2L and SIP2-R at
baseline, 6, 12 and 18 months.
Results: Five hundred and eighty-four patients with OMF
injuries were screened and 409 patients consented. Three
hundred and thirty five (91%) males and 36 (84%) females
were British or Irish white. One hundred and forty five
patients received a leaflet, 130 received an FMI and 134
patients received no intervention. Three hundred and two
(83%) males and 33 (77%) females were hazardous or harm-
ful drinkers, of these 160 (44%) males and 15 (35%) females
showed alcohol related harm. A reduction in alcohol con-
sumption on a typical day was noted in all groups from
baseline to 18 months with the most significant being the FMI
group (p = 0.02). A reduction in drinking six or more drinks
on one occasion was noted in all groups with the leaflet group
being the most significant (p = 0.001); FMI (p = 0.01) and no
intervention (p = 0.01). A leaflet or a 5 min intervention were
equally effective in men and women for hazardous alcohol
consumption. Provision of such a leaflet at out-patient OMFS
clinics may positively reduce future alcohol-related injuries.
Antimicrobial regimes used in mandibular fractures in
UK maxillofacial units
Prianka Hansrani, Craig Wales, Lachlan M. Carter
York District Hospital, United Kingdom
Purpose: The aim of this study was to investigate what antimi-
crobial regimes are used in the management of fractured
mandibles in the UK.
Method: Telephone interviews were conducted using a stan-
dardised questionnaire from October to December 2005. The
participants were junior maxillofacial doctors on call; usually
senior house officers.
463
Results: Ninety five out of 112 maxillofacial units in the UK
responded to the telephone interview (84%). Eighty seven
percent of units administered antimicrobials on admission
to the ward, whereas, only 8% administered whilst in A&E.
A variety of antimicrobials were used, including; augmentin
alone (44%), augmentin and metronidazole (18%), penicillin
and metronidazole (14%) and cefuroxime and metronidazole
(19%). Antimicrobials were given on discharge in 87% of the
units. The duration of discharge antimicrobials varied, some
units prescribing for 3 days (3%), 5 days (69%) and others for
7 days (18%). Only 34% of units had a departmental protocol.
Many doctors stated that their antimicrobial regime differed
among consultants.
Conclusions: This study highlights the lack of consensus
when prescribing antimicrobials for fractured mandibles
within the UK. It would be invaluable for each department to
utilise a formally written protocol for antimicrobial regimes.
This will improve prescribing, especially where there is a high
turnover of junior staff in maxillofacial units and in units that
have cross-cover out of hours.
Case series study of ski and snowboarding head and neck
injuries in 2001–2002 in Queenstown, New Zealand
Jahrad Haq, J.G. Cowpe, C.A. Woods
University of Bristol, United Kingdom
Objectives: To examine the incidence, pattern and nature of
head and neck injuries sustained to skiers and snowboarders
at two skifields in New Zealand.
Methods: A retrospective case series study of all skiers and
snowboarders suffering head and neck injury at ‘Coronet
Peak’ and ‘The Remarkables’ during the 2001 and 2002
seasons. Personal details, snowsport related parameters and
clinical diagnosis were recorded. Control data of skifield
demographics were collected through a ski patrol survey to
analyse the size and composition of the on-slope population.
Results: Four hundred and thirty one head and neck injuries
were recorded in 327 individuals. A total of 519,661 visi-
tor days were recorded by the ski patrols. The injury rate
for the study was 0.63 per thousand visitor days. The ratio
of skiers to snowboarders on the skifield was approximately
3:2. Snowboarders are 1.7 times as likely to injure themselves
as skiers considering relative numbers of uninjured parties.
The most frequently injured area in snowboarders was the
maxillofacial region (45%) followed by occipital (18%), c-
spine (17%), frontal (16%) and temporal areas (4%). In the
skiing population, a similar pattern of injuries was noted with
a significant number being maxillofacial (48%). Other fac-
tors identified in increasing injury frequency include: lack of
experience, the attempt at jumping and ‘rail-grinding’, and
the failure to wear a helmet.
Conclusion: Snowboarding carries a greater risk of head and
neck injury especially maxillofacial trauma and concussion.
It is recommended that snowboarders wear helmets during
terrain park activities.
This poster will also be presented as Programme no. 20.
464 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Epidermal growth factor receptor-tyrosine kinase
inhibitors augment photodynamic therapy-antitumour
activity and down-regulate in vitro invasion
W. Jerjes, A. Sharwani, C. Hopper, M. El maaytah, V. Salih
Eastman Dental Institute for Oral Healthcare Sciences,
United Kingdom
Photodynamic therapy (PDT) is a new treatment that involves
interaction of light and drug in the presence of oxygen, which
results in cell death. Combining PDT with other treatment
modalities (e.g. small molecules) could improve treatment
outcome and reduce resistance to therapeutic agents. In
this study, human oral squamous cell carcinoma cells were
treated with PDT and Iressa (ZD1839) or PD153035. The
growth was evaluated by MTT colorimetric assay; while
the invasive and metastatic potentials were evaluated using
2-D and 3-D models. Additive and synergistic anti-tumour
effects were obtained as well as significant inhibition of both
migration and invasion of the tumour (p < 0.001). Order of
the treatment was a crucial factor.
Cisplatin augments photodynamic therapy-anti-tumour
activity and down-regulate invasion
W. Jerjes, A. Sharwani, C. Hopper, V. Salih
Eastman Dental Institute for Oral Healthcare Sciences,
United Kingdom
Several studies around the world have shown that combining
two or more therapeutic techniques in cancer treatment, leads
to a substantial improvement in patient’s prognosis. Surgery
and radiotherapy is the traditional combination in head and
neck field; but because of surgery invasive nature; the prog-
nostic outcome still unsatisfactory. Combining chemothera-
putic agents and radiotherapy have also proved to be very
successful in cancer treatment.
Photodynamic therapy (PDT) is a new technique, which
involves the administration of a light sensitising drug in the
presence of oxygen, which results in cell death.
The aim of this study was to examine the effect of PDT and
cisplatin in human oral squamous cell carcinoma (OSCC)
cells.
The PDT-cisplatin treated cells adherence capacity toward
extracellular components and their invasive and metastatic
ability were evaluated using both 2D and 3D models. Our
results showed that combining PDT with cisplatin gives addi-
tive anti-tumour effects. The adhesion of VB6 and H376 was
completely lost at 24 h post treatment. Compared to untreated
controls, the expression Of EGFR by VB6 and H376 cells
increased by 21 (p < 0.001) and 2-folds (p < 0.001), respec-
tively; the migration and invasion of OSCC cells was inhib-
ited (p < 0.001).
Cellular uptake and photodynamic efficacy of Foscan on
head and neck carcinoma cells
W. Jerjes, A. Sharwani, C. Hopper, V. Salih
Eastman Dental Institute for Oral Healthcare Sciences,
United Kingdom
Photodynamic therapy (PDT) is a cutting-edge treatment
modality used to treat head and neck neoplasia. The tech-
nique is based on the combination of a photosensitive drug
and visible light which causes disruption of cell function and
induction of cytotoxicity. The main rate limiting step remains
in determining the optimal dose of drug, light exposure and
the precise mechanisms behind cell damage. In this study we
tried to evaluate the effects of a second generation photo-
sensitive drug, meta-tetrahydroxyphenyl chlorin (m-THPC;
Foscan), and 652 nm diode laser light, on human oral squa-
mous cell carcinomas (OSCCs) in vitro.
Human OSCC cell lines extracted from the head and neck
region were used as ‘targets’ for PDT in this study. Cell via-
bility was determined using the MTT assay. Control cultures
received either m-THPC or light treatment, but not both. Flow
cytometry was used to measure cellular up-take of Foscan.
The levels of phototoxicity of Foscan-mediated PDT were
induced in a dose-dependent manner by both the drug and
light. This phototoxicity was related to intracellular concen-
tration of Foscan. Significant phototoxicity was observed for
all cell lines with foscan 4 ␮g/ml and 4 J/cm2 light dose. A
survival rate of 50% (LD50) was varied.
This study showed that growth inhibition occurred in a dose-
dependant manner for both the drug and light; this may be of
therapeutic value.
Monitoring of photobleaching in photodynamic therapy
using fluorescence spectroscopy: Assessment of clinical
outcome
Waseem Khalid Jerjes, A. Sharwani, V. Salih, C. Hopper
Eastman Dental & University College London Hospitals,
United Kingdom
Background: Photodynamic therapy utilizing aminolevulinic
acid (ALA-PDT) as a photosensitiser has been used to treat
premalignant/malignant skin conditions including superficial
basal cell carcinoma (BCC) with excellent cosmetic outcome.
Clinicians continue however to face difficulties in determin-
ing the exact dose that is sufficient to achieve a complete
healing from the condition. The aim of this study was to
monitor photobleaching in patients with BCC undergoing
ALA-PDT and compares this to the clinical outcome.
Materials and methods: Fourteen patients presenting with
BCC were recruited for this study. ALA-PDT was the treat-
ment of choice and the response rate was assessed by visual
inspection and palpation. The photobleaching of protopor-
phyrin IX (PpIX) was monitored by fluorescence imaging.
Four readings were acquired from each patient “pre-PDT”,
“peri-PDT” (333 s), “peri-PDT” (660 s) and post-PDT.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Results: Red fluorescence value decreased markedly during
PDT, and was considered to be significant when compared
to pre-PDT (P = 0.0018) and post-PDT (P = 0.0025). The red
fluorescence value in pre-PDT was found to be higher in
cheek and scalp (where the response rate, RR = 100%) when
compared to the temple (RR = 75%) and nose (RR = 33%). By
comparison, the post-PDT red fluorescence values in cheek
and scalp were lower than that of the temple and nose, respec-
tively.
Conclusion: Fluorescence combined with ALA induced
PpIX was found to be a valuable tool to monitor sensitizer
photobleaching. In addition, red fluorescence may be useful
indicative of the response rate of tissue to therapy.
Primary hyperparathyroidism presenting with denture-
related pain
Anjali Karania, M.D. Esson, D. Cunliffe, R. Dyer
Torbay Hospital, United Kingdom
Primary hyperparathyroidism is relatively uncommon with
an incidence of approximately 25–30 cases per 100,000
people. This condition is usually caused by hyperplasia or
adenoma of the parathyroid leading to raised plasma parathy-
roid hormone and calcium levels. This biochemical change is
responsible for the presenting features which include tired-
ness, altered mood, bone lesions, abdominal pains and symp-
toms related to renal tract stones (“stones, bones and abdom-
inal groans”).
We present a case where pain related to a lower den-
ture was a presenting feature in an 83-year-old female. An
OPG radiograph demonstrated an underlying radiolucency
in the mandible consistent with a brown tumour of hyper-
parathyroidism. Skeletal survey demonstrated widespread
bony lesions consistent with osteitis fibrosa cystica. Clin-
ical and biochemical investigations confirmed a diagnosis
of primary hyperparathyroidism. This patient underwent a
parathyroidectomy for a parathyroid adenoma which led to a
rapid resolution of her symptoms. Biochemical analysis and
radiographic follow up confirmed a successful outcome.
This case highlights the role a maxillofacial surgeon can play
by instituting prompt and effective diagnosis and treatment,
thereby preventing complications of irreversible renal dam-
age.
Endoscopically guided core biopsy of the condylar head
Cyrus Kerawala, Manolis Heliotis
Royal Surrey County Hospital, Guildford, United Kingdom
The mainstay of managing large cysts and tumours of the
mandible involves obtaining an accurate tissue diagnosis
prior to definitive treatment. In general biopsies of mandibu-
lar lesions are performed by the acquisition of tissue speci-
mens representative of the lining or contents of the lesion.
Access to such lesions is generally simple being gained
through bony windows in readily accessible areas of the
465
mandible. The acquisition of tissue samples from discrete
lesions involving just the condylar head is however difficult
without an extensive lateral dissection.
We report the case of a 57-year-old lady who presented with
an isolated condylar radiolucency and describe how the tissue
diagnosis of metastatic breast carcinoma was obtained using
an endoscopically guided core biopsy.
‘Chin point’ osteotomy to improve access to tongue base
and pharyngeal tumours: A modified lingual release tech-
nique
David Laugharne, K. Jones, D. Hyam, S. Crank
Derbyshire Royal Infirmary, Derby Hospitals NHS Founda-
tion Trust, United Kingdom
Background: The surgical management of oral cavity and
oropharyngeal tumours requires sufficient access and expo-
sure.
Access procedures should aim to have minimal morbidity
with respect to both function and cosmesis.
We describe a modification to the previously described lin-
gual releasing approach which avoids the lip split incision,
provides excellent access for surgical resection of tumours
involving the tongue base or pharynx, while avoiding any
disruption to the occlusion. The technique restores the oral-
diaphragm and maintains suspension of the hyoid and laryn-
geal apparatus, helping to minimise alteration to speech and
swallowing.
Method: Subplatysmal skin flaps are raised and subperiosteal
dissection exposes the anterior mandible, mental nerves
are identified and protected. The chin point is osteotomised
sub-apically, distal to the mental foramina but above the
genial tubercles. Once the osteotomy is completed the chin
point is carefully mobilised inferiorly and the mylohyoid
divided bilaterally allowing the floor of mouth and tongue
to be delivered into the neck. The chin point is pedicled on
the anterior belly of diagastric muscles as well as the intact
geniohyoid and genioglossus muscles providing excellent
access. This can be quickly and easily reduced and fixed
post resection and reconstruction. The surgical technique
is discussed and demonstrated and post-operative function
evaluated.
Discussion: The advantages over the traditional lingual
release approach are highlighted and disadvantages dis-
cussed. The authors believe this is a significant improvement
to the traditional lingual release approach. Lip split is not
required, operative time reduced, aesthetics and function are
good.
Readability of patient information leaflets
Mhairi Little, Martin Clark
Department of Oral and Maxillofacial Surgery, Dumfries and
Galloway Royal I Infirmary, United Kingdom
Patient information leaflets are used in most hospital depart-
ments as a convenient way to provide information. Their
466 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
value may be reduced if the content of the leaflet is too com-
plex for patients to understand.
We used the SMOG and Flesch-Kincaid Indices of Readabil-
ity to assess the difficulty of a variety of patient information
products including those provided in-house and from the
B.A.O.M.S. website.
Most leaflets within this hospital achieved high SMOG and
Flesch-Kincaid scores. There was variation between hospi-
tal departments. The B.A.O.M.S. documents had among the
highest scores of all products.
It has been recommended that patient information leaflets
should be written at the sixth grade level or less. Therefore
the complexity of most patient information leaflets needs to
be reduced to ensure their content is understood.
Management of maxillary ameloblastomas
Shawn McClure, Andrew Salama, Robert Ord
University of Maryland Medical Systems, Department of Oral
and Maxillofacial Surgery, United States
Ameloblastoma of the jaws is a rare odontogenic tumor,
and maxillary ameloblastomas comprise 15–20% of all
ameloblastomas. While histologically identical to their
mandibular counterparts, they carry a reputation for aggres-
sive clinical behavior. The thin walls of the maxilla provide
poor barriers to tumor invasion. Direct extension into the
infratemporal fossa and base of skull are potentially life
threatening. Recurrence rates in curetted lesions approaches
100%, and subsequent radical surgery controls disease in less
than half of patients. Initial en bloc resection confers the best
means of local disease control.
We retrospectively reviewed the records of 21 patients diag-
nosed with maxillary ameloblastomas over 12 years. We
analyzed the demographics, clinical presentation, treatment
and outcomes of this cohort based on a surgical philosophy
of radical en bloc resection.
Twenty-one patients (including one recurrence) were
reviewed with an average follow-up of 22 months. Fifteen
patients had a maxillectomy (2 subsequent to curettage by
other clinicians), 6 either deferred or refused treatment. The
average age was 54.7 years with a male to female ratio of
2.5:1. The posterior dentate maxilla was involved in 80% of
cases. Common presenting symptoms were facial swelling,
gingival mass and sinus symptoms. There were no recur-
rences involving the 15 patients within this surgical cohort.
Although benign, maxillary ameloblastomas have the poten-
tial to behave aggressively and become incurable. Onco-
logically sound management including wide resection with
histologically negative margins is recommended. Although
relatively brief in this study, close clinical observation for a
minimum of 10 years if preferable.
Do oral and maxillofacial units make appropriate use of
the blood transfusion services? Would appropriate edu-
cation make a difference?
Ross James McDowall, Muireann O’Donovan, Judith
Stocker
Department of Oral and Maxillofacial Surgery, Sunderland
Royal Hospital, United Kingdom
Introduction: The NHS executive paper on ‘Better Blood
Transfusion’ recommends that blood should only be given
when necessary to save life or prevent deterioration. Blood
products for transfusion are expensive and in short supply,
costing the NHS approximately £80 million/year. Transfu-
sion carries risk, although the ‘Serious Hazards of Transfu-
sion’ annual report 2000–2001 highlights that most compli-
cations result from giving the wrong blood or products rather
than transmission of infection. Over ordering of pre-operative
cross-matched blood results in blood wastage, blood short-
ages, wasted laboratory time and cost.
This study aimed to:
1. Investigate whether we appropriately cross-match blood
prior to major surgical procedures.
2. Ascertain appropriateness of current transfusion practices.
3. Relate cross match practices to level of SHO experience.
Method: Retrospective data collection over 18 months for
patients who underwent oral cancer surgery, salivary gland
and orthognathic surgery at Sunderland Royal Hospital. Data
collected included: age; sex; operation; haemoglobin con-
centrations; number of units cross-matched, or whether the
patient was ‘grouped and saved’; number of units transfused
and reason for transfusion.
Results: The cross-match:transfusion ratio, the blood order-
ing quotient and the transfusion index were calculated to
analyse results. Results were compared with studies from
other surgical specialties and those specific to oral and max-
illofacial surgery.
Conclusions: Our findings concur with similar oral and max-
illofacial studies. Cross matching is only required for exten-
sive oral cancer operations, ‘group and save’ is adequate for
remaining major procedures. SHO experience seems to affect
cross matching practices; further education is planned to ame-
liorate this.
One stop clinic for OMFS soft tissue surgery
Michael Millwaters, Shiyana Eliyas, Kannan Balaraman,
Wayne Halfpenny
Chase Farm Hospital, United Kingdom
One stop clinics are widespread in many surgical specialties.
Their use in OMFS has been more limited with one previ-
ously published example.
We present our experience of our soft tissue one stop clinic
which has been running for over 3 years. The initial 3 years
were audited which showed that 306 patients were treated.
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
These included a wide range of conditions with the most
common being FEP’s (102) and mucocoels (26). No problems
were encountered over this time with regard to managing the
clinic and all patients, when offered this service, accepted.
The pattern we follow is to book referrals from practitioners
directly into this clinic which runs in parallel to the general
clinic. The patients are treated and then contacted by phone
with the biopsy result. Hard copy is sent to the referring prac-
titioner with the discharge letter. If any unexpected result is
found, the patients are sent a further appointment.
These clinics are cost-effective and a sample patient satis-
faction survey revealed that patients prefer this approach. A
further advantage is that urgent biopsies may be immediately
carried out without interrupting the general clinic.
This poster will also be presented as Programme no. 62.
Use of an evacuated bead mattress to aid patient position-
ing during free flap harvest
Michael Millwaters, Wayne Halfpenny, Iain Hutchison
Barnet and Chase Farm NHS Trust, United Kingdom
Optimal patient positioning for free flap harvest is crucial for
ease of access and to reduce operating time. This is a partic-
ular problem for sub-scapular system flaps where usually the
patient is turned mid-operation and re-prepped. This is time
consuming and decreases the popularity of clinically useful
flaps.
In our practise, we utilise an evacuated bead support. This
comprises a mattress filled with polystyrene beads and air.
It may be moulded prior to the air being evacuated and it
then holds its new shape. We utilise this property to optimally
position the patient at the start of surgery to leave both surgical
sites accessible for simultaneous preparation and draping. We
propose this novel technique to avoid patient re-positioning
for sub-scapular system flaps.
We have subsequently found that this mattress may be used
for positioning for free fibula and DCIA flaps. The advan-
tages here are that the mattress may be specifically tailored
to position the individual patient.
Tension pneumoorbitum: Not to be taken likely
Francine Ryba, Aneesh Mohindra, David Chin Shong, Simon
Holmes
The Royal London Hospital, United Kingdom
Orbital emphysema is a common finding in fractures of the
facial skeleton. It is usually managed conservatively. We
present two cases of preseptal emphysema resulting in tension
pneumoorbitum that required immediate surgical decompres-
sion in order to preserve vision.
Case 1: Acute presentation due to a communication of the
paranasal and orbital contents, via a nasomaxillary fracture.
This created a one way valve effect that was exacerbated
by a mask and bag ventilation used at the scene. Prompt
recognition of the reduced eye signs and proptosis led to
467
immediate surgical decompression via lateral cantholysis, to
conserve the patient’s vision.
Case 2: Delayed presentation involving periorbital swelling,
blurred vision and pain 12 weeks following uneventful repair
of an orbital floor fracture with PDS membrane. On exami-
nation he had reduced visual acuity and colour recognition,
pain, resistance to retropulsion and proptosis of the globe. CT
scan confirmed air in the inferior orbit. He was immediately
taken to theatre for surgical decompression. It subsequently
transpired that the patient had been suffering from a head
cold and maxillary sinusitis and a valve had formed through
a small bony dehiscence.
These cases serve to highlight the risk to vision from maxillo-
facial injuries that may be occult. The first case demonstrates
the danger when ventilating via bag and mask in the presence
of midface fractures. And the second represents a new late
complication in these patients.
Not just horsing around—A review of the nature and
severity of equestrian related facial injuries seen at two
centres
Rory D. Molloy, S. Akhtar, J.G. Smith, M.E. Morton, G.C.S.
Cousin
Royal Preston Hospital, Blackburn Royal Infirmary, United
Kingdom
Introduction: Horse-riding is an increasingly popular sport,
with an estimated 600,000 to one million horses and ponies
in the United Kingdom.
Equestrian related injuries from minor lacerations and abra-
sions to death from spinal injury.
Studies have repeatedly shown that there is a high prepon-
derence of young females among the injured with a peak
incidence of 14 years.
The most common horse-riding related injuries are long bone
fractures and head injury.
Most injuries occur during recreational riding, approximately
15% occur in non-riding activities such as feeding, handling,
shoeing and saddling.
The wearing of safety helmets is now widespread and studies
have confirmed their role in the reduction of serious head
injury.
In our experience, the majority of facial injuries occur in non-
riding activities and a standard open helmet, if worn, would
have conferred little or no protection for the face.
Aim: To document and describe our experience in the man-
agement of equestrian-related facial injuries at two teaching
hospitals.
A selective case-note analysis of patients attending with
equestrian-related facial injuries.
We documented the age and gender of patients and looked
at circumstances surrounding the injury to see if it was
avoidable.
Details of the pattern and severity of injury were recorded
to assess if full-face or caged helmet would offer better
protection.
468 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Hidden jewels of the RCS Edinburgh, Surgeons Hall
Museum—The collection of David Middleton Greig and
its importance to craniomaxillofacial surgery
Roderick Morrison, K.F. Moos, D. Kemp, A. Connell
West of Scotland Regional Maxillofacial Unit, Southern Gen-
eral Hospital, Glasgow, Scotland, United Kingdom
Introduction: The skull collection of David Middleton Greig
(1864–1936) is one of the most extensive and well docu-
mented of its kind in the world. It contains over 250 skulls
as well as extensive records, and illustrations. The collection
was donated to the Royal College of Surgeons of Edinburgh
in 1920 and continues to be the subject of study and discovery
to this day.
Biography: David Middleton Greig studied medicine at St
Andrews and Edinburgh. After graduating in 1885 he joined
his father’s medical practice in Dundee thereafter moving to
the Baldovan Institute for Imbecile Children. He later worked
as a military surgeon and served in the Boer War before
returning to Dundee to take up a post as a surgeon and lec-
turer. In 1920 he became Conservator of the Surgeons Hall
Museum and brought with him his collection of skulls and
other specimens.
Greig’s work: Greig had a deep interest in bone disease and
abnormalities of the skull. He was a ceaseless writer pub-
lishing articles on surgery, mental deficiency, syndromes and
a treatise on Surgical Pathology of bone. David Greig gave
his name to two syndromes: Greig’s Cephalosyndactyly Syn-
drome (Greig I) and Greig’s ocular hypertelorism syndrome
(Greig II).
Relevance today: The excellent condition of the collection
along with records, often including photographs and post-
mortem results, mean that many of these skulls are the earliest
remaining examples of many craniofacial deformities. Recent
developments in genetic analysis have allowed further study
of and will hopefully continue to shed light on these speci-
mens.
Acrobatic tongue
Muzzamil Nusrath, C.M. Avery
University Hospitals of Leicester, United Kingdom
A 17-year-old Caucasian female was referred to the depart-
ment of maxillofacial surgery for a hyper mobile tongue. She
was able to make her tongue completely disappear into the
oropharynx posteriorly and make it appear externally in the
neck. Ehlers Danlos syndrome was suspected. Family history
was negative for cardiovascular, ophthalmic, skin and joint
problems. Examination of her oral mucosa, teeth and tem-
peromandibular joints was normal, A short lingual and labial
fraenulum were present. General joint laxity can be measured
using the Beighton scale, which comprises of five different
positions, and a score of 5/9 suggests hyper mobility, a score
of 2/9 was achieved.
Examination of skin, ophthalmic, cardiovascular including an
ECG was normal. An MRI of the oropharynx, submandibular
and mylohyoid was normal.
Is this a new variant of Ehlers Danlos or is it a new clinical
entity?
Evaluating the quality of information regarding oral can-
cer on the Internet
Muireann O’ Donovan, Ross McDowell, Judith Stocker
Sunderland Royal Hospital, United Kingdom
Introduction: Information is of utmost importance for oral
cancer patients and their family members. The number of oral
cancer related web sites on the Internet is huge and growing
rapidly. Many provide much in the way of relevant and useful
information, but the quality, accuracy and currency of infor-
mation can vary greatly between sites. Quality assessment
of Internet information is vital to ensure patients and their
family members recieve valid and reliable information.
Aim: The aim of this study was to assess the quality of infor-
mation regarding oral cancer on the internet.
Method: We accessed the top three most commonly used
search engines, for information on oral cancer using set text.
From our results we reviewed the top 10 websites from each
search engine using set criteria.
Results: We recorded the following information regarding
each website: the country of origin, the transparency of fund-
ing, the transparency of provider of site and the quality of
information based on a scale of 1–5 as evaluated by the Head
and Neck team. We present these results in detail.
Conclusions: The internet is a major source of health infor-
mation however there are concerns that some of this infor-
mation is inaccurate, misleading and possibly dangerous. It
is paramount that patients are provided with good quality
reliable information from reputable websites. We advise a
grading system of websites to help patients avoid being over-
whelmed with irrelevant and confusing literature and also,
recommended websites that provide the best information for
patients.
An 18-month prospective audit of maxillofacial emergen-
cies in a district general hospital following the introduc-
tion of a new emergency database
Noel John Perkins, F. Al-Sayer
Chesterfield and North Derbyshire Royal Hospital, United
Kingdom
Aims: To improve the standard of data capture for emergency
patients managed by the Maxillofacial Team, and to provide
a secure standardised database for future audit of the emer-
gency workload of the Maxillofacial Department.
Method: A Maxillofacial Emergency Data Capture Form
(MEDCF) was designed to encompass the departmental min-
imum data set for emergencies. The MEDCF was piloted
prior to its introduction in February 2004. The database was
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
created in Microsoft Access, and structured in a drop-down
menu format to facilitate easy data entry by the OMFS Senior
House Officers (SHOs).
Results: Seven hundred and eighty cases were entered onto
the database between 9/02/04 and 3/08/05. The majority of
cases (91%) were referred from the Accident and Emer-
gency Department, with 92% being appropriate referrals.
Most referrals (82%) were trauma-related, with falls (47%)
and interpersonal violence (22%) being the most common
aetiologies. Isolated soft tissue injuries (67%) and dental
injuries (14%) were the most common diagnosis categories.
The majority of patients were treated under local anaesthe-
sia (58%). Follow-up was performed for 43% of patients by
their general medical/dental practitioner, while 28% were
reviewed on OMFS outpatient clinics. SHO compliance with
MEDCF completion and data entry ranged from poor to
excellent, depending on the SHO team during the initial 6-
month period and subsequent 1-year period.
Conclusion: SHO compliance in maintaining accurate
records of the emergency cases managed is important in
obtaining a high standard of data capture for subsequent anal-
ysis. This information can assist decision-making regarding
appropriate resource and manpower allocations.
Surgical emphysema secondary to extraction of a
mandibular third molar: A case report
Noel John Perkins, R.L. Orr, P.T. Doyle
Chesterfield and North Derbyshire Royal Hospital, United
Kingdom
Background: Surgical emphysema occurs when air under
pressure is forced beneath the dermis leading to subcutaneous
emphysema. The contiguity of many of the fascial spaces in
the head and neck can lead to tissue-space emphysema with
involvement of deep anatomic structures, including the medi-
astinum and peritoneum, with potentially life-threatening
complications. Surgical emphysema related to dental treat-
ment has been reported following restorative dentistry, peri-
odontal surgery, endodontic treatment, and the extraction of
teeth. It is most common during or after surgical removal of
teeth, particularly mandibular molars, where an air turbine
handpiece has been used for bone removal and/or tooth sec-
tioning.
Case report: This report describes a case of extensive subcuta-
neous emphysema in a 28-year-old man that occurred during
surgery to extract the lower right third molar, performed with
the use of an air turbine dental handpiece. The patient was
admitted to hospital for airway monitoring, rehydration and
intravenous antibiotic therapy. His condition improved over
the next 24 h and he was discharged with a course of oral
antibiotics. The patient recovered uneventfully.
Conclusion: Air turbine dental handpieces should not be used
for surgical extractions. It is important for dentists and other
health care professionals to be able to diagnose patients with
surgical emphysema, so that inappropriate therapy is avoided.
469
As the severity of the condition varies with each individual
case, referral to an Oral and Maxillofacial Surgery Depart-
ment should be considered, so that a full evaluation of the
patient’s status can be made and an appropriate management
regime instituted.
Name that instrument?—Do the junior surgeons know
the names of the surgical instruments used in OMFS pro-
cedures?
Dermot Pierse, M. O’Donovan, B. Gurney, R. Banks
Sunderland Royal Hospital, United Kingdom
Introduction: Knowledge of the instruments being used is
essential for those performing surgery. It is a requisite for
good communication during operative sessions. The reduc-
tion in training time has reduced the opportunities to assimi-
late instrument names. It may now be time to integrate formal
sessions in instrument recognition as part of training.
Aims:
1. Assess how familiar junior staff in the North Eastern
region were with the names and intended uses of stan-
dard surgical instruments.
2. Correlate the level of knowledge of the instruments to the
level of experience.
Method: A series of slides of commonly used surgical instru-
ments accompanied by a questionnaire were shown to a cross
section of OMFS trainees and SAS grades. The participants
were asked to give the eponymous name and generic name or
intended use of the surgical instruments. The 20 instruments
used were cross-referenced to standard texts and manufac-
turers catalogues.
Results: The number of instruments identified correctly by
eponymous and generic name or intended use was recorded.
The data were correlated with the level of experience and
time spent in post. A complete description of the correlation
analysis will be presented.
Conclusions: Our results indicate that accurate knowledge of
generic names and intended use of the instruments is bet-
ter than for eponymous names. From our findings we would
recommend further training in instrument recognition.
The acquisition of methicillin resistant Staphylococcus
aureus (MRSA) in maxillofacial patients
Nicolaos Pigadas, S. Bangue, S. Critchlow, B.T. Musgrove
Manchester Royal Infirmary, United Kingdom
MRSA is a major cause of hospital acquired infection, with
significant implications for both patients and heath care sys-
tems. There is limited data regarding the MRSA acquisition
and infection in Oral and Maxillofacial Surgery. The aim
of this project was to study a possible association between
ITU/HDU admission as well as administration of antibiotic
prophylaxis and MRSA acquisition.
470 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
Method: Retrospective analysis of the pattern and length of
admission, type of surgery and antibiotic prophylaxis of all
the patients on the Head and Neck ward that acquired MRSA
during a period of a year.
Results: Forty eight percent of the patients that acquired
MRSA during their admission were admitted post-
operatively in ITU/HDU. The vast majority of the MRSA
(+)ve Maxillofacial patients underwent complex head and
neck surgery including free flap reconstruction. Although at
the time of the study, this group of patients was treated with
a 5-day-course of perioperative antibiotic prophylaxis, only
11% of patients acquired MRSA.
Conclusions: Isolation measures and screening of all the
patients transferred from ITU/HDU facilities to the surgical
ward appear reasonable measures. The post-operative mor-
bidity we noticed in the group of patients undergone complex
head and neck surgery is significantly lower than that reported
by Avery et al.1 but the differences seen may be due to mul-
tiple factors.
Reference
1. Avery CM, Ameerally P, Castling B, Swann RA. Infection
of surgical wounds in the maxillofacial region and free flap
donor sites with methicillin-resistant Staphylococcus aureus.
Br J Oral Maxillofac Surg, in press.
The European working time directive and its effect on
continuity of patient care
Richard Ramsey, R. Anand, S. Sharma, S. Harmer, C.
Mourouzis, P. Brennan
Queen Alexandra Hospital, Portsmouth, United Kingdom
Introduction: The European Working Time Directive
(EWTD) is both a challenge and an opportunity for the NHS.
Continuity of care is viewed as the ongoing relationship
between a patient and a single practitioner. The introduction
of the EWTD with partial shifts for junior staff could reduce
continuity and weaken the doctor–patient relationship. This
study aims to examine the extent of patient contact with indi-
vidual clinicians during their patient journey.
Methods: Initial consultation(s), pre-clerking, daily morning
ward rounds and subsequent review appointments were used
as points of contact with 75 consecutive patients requiring
in patient surgery. A specially designed proforma was added
to the patients’ notes before their first appointment. Each
clinician (SHO, SpR and Consultant) was responsible for
entering their name at each appointment. The proforma was
removed from the notes at the final appointment, taken to be
the end of active treatment.
Results: Each patient experienced 5.58 (mean) points of con-
tact. The percentage of patients experiencing contact with
the same clinician seen at the initial appointment decreased
with grade. A Consultant was involved in the care of the
patient in 83% of all points of clinical contact, and in 74%
of cases this was with their named consultant in comparison
to 62% (any registrar) and 42% (same registrar) for regis-
trars, 72% (any SHO) and 33% (same SHO) for senior house
officers.
Conclusion: This study sets a baseline with which to compare
other units. It also highlights the problems of the EWTD on
surgical training, continuity and holistic patient care.
Spitz naevus of lip: Case report and review of literature
Jadbinder Seehra, P. Sen, R.E. Lloyd
Manchester Royal Infirmary, United Kingdom
Background: Spitz naevus was first described by Spitz1 in
1948. Historically this lesion has had many synonyms which
include juvenile or benign juvenile melanoma reflecting its
prevalence in children and adolescents.2 There has been one
reported case of an oral Spitz naevus in the literature.3
Case report: A young male presented with a pigmented
lesion of the upper lip which was histologically confirmed
to be a Spitz naevus. Despite the benign nature of this
lesion the recommended management of a Spitz naevus
is local excision.1 Local recurrences can be attributed to
incomplete excision.4 Cases of malignant change have been
documented5 and due to the histological similarities between
a Spitz naevus and malignant melanoma, close follow-up is
advised.
Conclusion: Spitz naevus should be considered as a differ-
ential diagnosis when investigating pigmented lesions and
follow up is essential.
References
1. Spitz S. Melanomas of childhood. Am J Pathol
1948;24:591–609.
2. Han MH, Koh KJ, Choi JH, Sung KJ, Moon KC, Koh JK.
Pagetoid spitz nevus: a variant of Spitz nevus. Int J Dermatol
2000;39:555–7.
3. Song JY, Kwon JA, Park CJ. A case of Spitz nevus
with multiple satellite lesions. J Am Acad Dermatol
2005;52:S48–S50.
4. Echevarria R, Ackerman LV, Spindle and epitheloid cell
nevi in the adult. Clinicopathologic report of 26 cases. Cancer
1967;20:175–89.
5. Allen AC, Spitz S. Malignant melanoma. A clinicopatho-
logical analysis of the criteria for diagnosis and prognosis.
Cancer 1953;6:1–456.
The BHB trauma proforma and database
Jeremy Sherman, Juliet Lai
Beds, Herts and Bucks Maxillofacial Network, United King-
dom
Maxillofacial centres with an ever increasing trauma compo-
nent to their service commitment often rely on the most junior
member of their teams to record and collect the relevant data.
Lack of experience and fatigue can be a dangerous combi-
nationin terms of record-keeping for our SHO’s when they
are busy, especially at night. Over the past 3 years, we have
devised and developed a simple trauma proforma. Not only
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
does it fit on to both sides of an A4 sheet of paper, but it
also functions as an aide-memoire, prompting good record-
keeping of all the necessary medico-legal details, should
further documentation be required by the police or judiciary.
This may easily photocopied before the original is placed in
the notes.
In addition, the proforma records details of further man-
agement including any operative delays. This information
may then be prospectively inserted into the Access-based
customised database to provide a computerised audit of work-
load, casemix and delays to theatre. We currently have access
to the database both in the departmental offices and our main
operating theatre.
The database may then be used as a foundation for dialogue
with managers for the provision of trauma lists, and modulat-
ing clinical service commitments in view of changing local
trends in OMFS trauma.
Guidelines for the replacement of the TMJ in the UK
Andrew James Sidebottom, John Cooper, Robert Hensher,
David Koppel, Peter Korczac, Peter Revington, Nadim Saaed,
Mike Simpson, Bernard Speculand, Steve Worrall
Queens Medical Centre, Nottingham, United Kingdom
BAOMS has requested guidelines for the replacement of the
temporomandibular joint in order to appropriately guide in
the management of this complex issue.
The poster will present the principles for selecting appro-
priate cases for joint replacement agreed by the surgeons
currently carrying out this form of surgery in the UK. These
guidelines have been formulated following an open question-
naire survey and subsequent request for approval of the final
document described.
Is ameloblastic fibro-odontoma a precursor of complex
odontoma?
Christian Siegmund, C.M. Avery, I.W. Ormiston
University Hospital Leicester (Leicester Royal Infirmary),
United Kingdom
Ameloblastic fibro-odontoma is a member of the family
of mixed odontogenic tumours. It is a rare hamartomatous
lesion (0.7–3.7% of all odontogenic tumors, Reichart and
Philipsen1 ). The tumour is characterized by an epithelial
and an ectomesenchymal component demonstrating induc-
tive changes that lead to formation of enamel matrix in addi-
tion to dentine or dentinoid material resembling an immature
complex odontoma.
We present a case of a 3-year old boy referred for an asymp-
tomatic facial swelling, displacement of deciduous teeth and
non-eruption of permanent teeth. The orthopantomogram
revealed an enormous multilocular radiolucency with areas
of radio-opacity extending from the ascending ramus to the
parasymphyseal area. Multiple biopsies confirmed the diag-
nosis of ameloblastic fibro-odontoma and conservative sur-
471
gical enucleation with preservation of most of the unerupted
teeth was performed 9 weeks post biopsy. The histopatho-
logic finding of the final specimen was reported as com-
plex odontoma only. Clinical, radiological and histopathol-
ogy features are presented and the management options
reviewed.
Reference
1. Reichart PA, Philipsen HP. Odontogenic tumors and
allied lesions. London: Quintessence Publishing, 2004.
p. 134.
Descending necrotizing mediastinitis from odontogenic
infection
Christian Siegmund, C.M. Avery, N.J. Clifton
University Hospital Leicester (Leicester Royal Infirmary),
United Kingdom
The majority of cases of infectious mediastinitis result from
oesophageal perforation or often follow sternotomy during
cardiothoracic surgery.
Acute mediastinitis originating from an oropharyngeal infec-
tion was termed descending necrotizing mediastinitis by Estr-
era et al.1 It is a very rare entity with a high mortality rate,
which ranges from 14% to 50%, despite aggressive treatment.
We report the case of a previously healthy 25-year-old man
with descending necrotizing mediastinitis secondary to odon-
togenic infection despite prompt removal of the tooth, high
dosage antibiotic treatment and surgical exploration of the
neck. The thoracic infection was treated by placement of an
intercostal thoracic drain. After a total of 6 weeks in the Inten-
sive Care Unit and on the ward the patient made a complete
recovery.
Reference
1. Estrera AS, et al. Descending necrotizing mediastinitis.
Surg Gynecol Obstet 1983;157:545–52.
Monocular loss of vision and progressive temporary
diminution of colour perception after dental extraction
Christian Siegmund, C.M. Avery
University Hospital Leicester (Leicester Royal Infirmary),
United Kingdom
Ophthalmologic complications after dental treatment are very
rare and mostly related to the administration of local anaes-
thetic with vasoconstrictor.
We report a case of a 26-year old female patient with pre-
existing mild right sided amblyopia who developed left
sided progressive loss of vision 4 h after an uncompli-
cated routine extraction of the second left premolar by her
dentist.
Neuro-ophthalmological examination of the left eye showed
reduced visual acuity of 3/60. Colour vision assessment
revealed progressively declining values to 6/17 and the
“swinging flashlight test” demonstrated a moderate Rela-
tive Afferent Pupillary Defect (RAPD). All other tests were
472 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
within normal range. Ultrasound, MRI and CT scan exam-
inations did not show any obvious pathology. A functional
disorder was excluded and the provisional diagnosis was a of
left optic nerve ischaemia.
Treatment with high dose steroid medication improved the
colour vision but the left eye remained severely amblyopic.
The mechanism of injury is reviewed.
Primary oral tuberculosis imitating squamous cell carci-
noma
Christian Siegmund, C.M. Avery
University Hospital Leicester (Leicester Royal Infirmary),
United Kingdom
Tuberculosis is one of the major causes of ill health and
death worldwide. Despite multi-drug treatment options its
incidence is rising in England and Wales due to increasing
drug resistance.1
Nevertheless primary oral tuberculosis of the oral cavity and
adjacent tissues is very rare, most of the cases are secondary
to pulmonary disease.
Here we report a case of primary oral tuberculosis in a 65 year
old lady from Asia who was living in England since 25 years.
She presented with an exophytic lesion in the area of her left
commissure of her mouth extending to the adjacent cheek
and a large lymphnode at level II at the same side. Multi-
ple biopsies confirmed inflammatory ulceration with several
granulomata. Ziehl-Neelson staining for acid-fast bacilli was
positive. Her chest X-ray was unremarkable and a diagnosis
of primary oral tuberculosis was made.
Tuberculosis should always be considered as a differen-
tial diagnosis in chronic oral ulcerations and may be con-
fused with squamous cell carcinoma especially when lym-
phadenopathy is present at the same time.
Reference
1. National survey of tuberculosis in England and
Wales 1998. Communicable Disease Report. CDR Weekly
1998;8:209–212.
Fast tract referal of suspected oral cancer: Are the refer-
als always appropriate?
Ganeshwaran Sittampalam
Worcestershire Royal Hospital, United Kingdom
Government cancer plan has set targets with regard to see-
ing patients in hospital within 2 weeks of being referred by
the primary care team with a suspect lesion. In maxillofa-
cial surgery the vast majority of referrals are from either the
general dental practioner or the general medical practioner.
The aim of this project is to evaluate the appropriateness
of the referrals. A questonnaire was filled in following the
first visit consultation of all fast tract referrals detailing the
appropriateness of the referal. A copy of the questionnaire is
included in the poster. We will discuss the results and perhaps
the need for improved education of primary care profession-
als in the signs and symptoms of oral cancer. The aim is to
reduce unnecessary urgent referrals and the resultant worry
and anxiety to the patient and waste of resources to the health
service.
Are anaesthetists satisfied with the standard of pre-
operative assessment by dentally qualified hospital staff?
Ganeshwaran Sittampalam
Worcestershire Royal Hospital, United Kingdom
The majority of maxillofacial SHOs are qualified only in den-
tistry. As part of their duties they are expected to carry out
pre-operative assessment for major operations. This lack of
a formal medical training can lead to questions being raised
about the competence of dentally trained SHOs to assess and
work up patients for complex operations. The aims of this
project were:
(1) To seek the opinion of consultant anaesthetists regarding
the competence of maxillofacial SHOs with regard to
pre-operative assessment.
(2) To compare the competence of maxillofacial SHOs with
medically trained SHOs with respect to pre-operative
assessment as perceived by consultant anaesthetists.
Method: A questionnaire was sent to the department of anaes-
thesia of every hospital with a maxillofacial unit. Anaes-
thetists involved with maxillofacial lists were asked for
their opinion regarding the competence of maxillofacial
SHOs with respect to pre-assessment. Three aspects of pre-
assessment were looked at, history taking, examination and
prescribing. The second part of the questionnaire evaluated
differences clerking between maxillofacial SHOs and med-
ically trained SHOs as perceived by the respondents. Again
areas compared were history taking, examination and pre-
scribing.
The results will be discussed with suggestions on how any
potential problems of having dentally trained SHOs manag-
ing patients on the ward can be addressed.
Bisphosphonate induced osteonecrosis—The Wolver-
hampton experience
Dilip Srinivasan, S. Shetty, N. Grew, N. Whear, B. Millar
The Royal Wolverhampton NHS Trust, United Kingdom
Bisphosphonates are widely used by rheumatologists and
oncologists. They are very useful in the treatment of osteo-
porosis and skeletal malignancies. They have been shown
to improve quality of life and life expectancy in these
patients.
One of the undesirable side effects of this treatment is
osteonecrosis of the jaw. This has been well documented
in the American literature in recent times. However, to our
knowledge there has been no published report of this condi-
tion in the British maxillofacial literature. As clinicians who
are most likely to be dealing with this condition we need to
 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
be able to diagnose and manage this condition. However, the
condition is still not well understood.
We report two cases of osteonecrosis of the jaws that have
been diagnosed in our department in the last 12 months. These
cases have been managed using antibiotics, analgesics and
mouth washes. Surgical management of this condition is dif-
ficult as the entire skeleton is affected by bisphosphonate
treatment. We will discuss the various management issues
and estimate the scale of the likely problem.
Pachydermoperiostosis: A mandibular reconstructive
challenge
Kemal Mustafa Tekeli, P.A. Chambers, D.N. Sutton, S.F.
Worrall, P.J. McCann
St Luke’s Hospital, Bradford Teaching Hospitals Foundation
Trust, United Kingdom
Introduction: Pachydermoperiostosis (PDP) is the primary
idiopathic form of hypertrophic osteoarthropathy (HO) char-
acterised by clubbing of digits of hands and feet, enlargement
of the extremities secondary to periarticular and osseous pro-
liferation.
This condition in a 51 year old Caucasian male with recurrent
adenoid cystic carcinoma of the submandibular gland requir-
ing mandible resection and reconstruction posed significant
surgical challenges.
We discuss the pre-operative anatomical findings, investiga-
tions and perioperative treatment planning in this complex
case.
Conclusion: Osseocutaneous radial free forearm flap proved
a successful choice despite reservations and pre-operative
findings.
References
1. Lindmaier A, Raff M, Seidl G, Jurecka W. Pachyder-
moperiostosis. Clinical aspects, classification and pathogene-
sis. II. Universitats-Hautklinik Wien. Hautarzt 1989;40(12):
752–7.
2. Bhaskaranand K, Shetty R, Bhat K. Pachydermoperiosto-
sis: three case reports. J Orthop Surg 2001;9(1):61–6.
3. Akdeniz BG, Seckin T. Periodontal and Alveolar bone
abnormalities associated with Pachydermoperiostosis. Peri-
odontal Clin Investig 2001;23(1):5–10.
Retrospective audit on pattern of sports and physical
activity related injuries to the head and neck region in
merseyside
Suraj Thomas, C. Jones, S. Laverick, N. Bell, S. Paul
University Hospital Aintree, United Kingdom
Introduction: A retrospective study of injuries to the head and
neck during sports and physical activity. The aim of the study
was to assess the extent, aetiology and outcome of maxillo-
facial injuries associated with sports.
Materials and methods: Data was collected from the Mersey-
side Maxillofacial Trauma Database and medical records.
473
The total number of patients on the database with sports
injuries over a 12 month period was 317 out of a total 6617,
with 222 of these having complete medical records.
Results: The study concluded that the majority of head and
neck sports injuries occurred in males aged 11–30 years of
age. Forty seven percent of injuries were sustained playing
football, with rugby accounting for a further 26%. Eighty
one percent of sports injuries occurred in a sporting arena.
Of the types of injuries sustained majority were soft tissue
injuries (43%) with fractured zygomas (20%) and fractured
mandibles (15%) following. Twenty five percent of patients
were admitted to hospital for maxillofacial care and 22%
of patients required treatment under a general anaesthetic.
Eleven percent of patients sustained bodily injuries other than
the maxillofacial region, half of them were admitted under
other specialities.
Conclusions: This study shows the high risk of dento-facial
injuries associated with football and rugby some of which
can be potentially dangerous. Players should be made aware
of the research proven protective effect of mouthguards and
headgear in preventing facial injuries during sports.
Congenital infiltrating lipomatosis of the face
Navin Vig, Iain Hutchison
Barts and The London NHS Trust, United Kingdom
Congenital infiltrating lipomatosis of the face (CIL-F) is a
rare yet distinct clinicopathological entity. Lipomas of the
head and neck are well documented, but lipomatous lesions,
with intramuscular invasion, involving this part of the body
are very uncommonly described in the literature.
The condition is typically noted at birth as a moderate uni-
lateral facial asymmetry which then rapidly progresses to
produce a marked disfigurement. This is due to diffuse infil-
tration of mature adipose tissue into the underlying struc-
tures. Significant unilateral bony hypertrophy and preco-
cious dental development are seen. There may also be ocular
involvement.
We present the case of a 4-year-old boy, believed to be the
most recent of approximately 35 published cases of this con-
dition. We present his diagnosis and management at our unit,
as well as a review of the current thinking behind the possible
aetiology of CIL-F and controversies over its management.
Ameloblastoma: A case report with unusual presentation,
its management and review of current literature
Simon Wright, C. Broughton, E.B. Larkin, M.D. Paley
Maxillofacial Department, St John’s Hospital, Livingston,
United Kingdom
Ameloblastomas are rare slow growing tumours of odonto-
genic origin. The tumour is thought to originate from sources
that include residual epithelium from tooth germ; epithelium
of odontogenic cysts; stratified squamous epithelium; and
epithelium of the enamel organ. Eighty percent of the lesions
474 Abstracts / British Journal of Oral and Maxillofacial Surgery 44 (2006) 428–474
occur in the mandible and most commonly affected area is the
third molar region. Reported cases of ameloblastoma occur
over a wide range of ages with the mean age in the 20s or
30s, and with equal frequency in men and women.
Ameloblastoma is divided into three clinicoradiologic
groups: solid or multicystic, unicystic and peripheral. The
solid ameloblastoma is the most common form of the lesion;
it has a tendency to be more aggressive than the other types
and had a higher incidence of recurrence. Several histopatho-
logic types of ameloblastoma are described in the literature,
including those with plexiform, follicular, unicystic, basal
cell, granular, clear cell, acanthamatous and desmoplastic
patterns.
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Case report: A 76-year-old gentleman was referred to
the Maxillofacial Clinic with a swelling in the anterior
floor of his mouth. The lesion has been present for sev-
eral months and he has no associated pain from it. Clin-
ical examination revealed an exophytic mass measuring
roughly 6 cm × 4 cm. Radiographic examination revealed a
‘scalloped-out’ area of anterior mandible from LL5 to LR6
area. An incisional biopsy revealed it to be an amelobla-
stoma.
We will present the management of this case and its outcome
and also review the current gold standard in management
options of the different types of ameloblastomas.