Maxillary Malignancies

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Face Mouth & Jaw Surgery: International Trainee Journal of Oral & Maxillofacial Surgery. 2012; 2(4)

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SHORT COMMUNICATION JTG ABSTRACT -‐ POSTER

Cervical metastasis from maxillary malignancies

Ayesha Dalal Face Mouth Jaw Surg 2012;2(4):93

Royal Devon & Exeter NHS Foundation Trust, Exeter Objectives: The occurrence of occult cervical metastasis from squamous cell carcinoma (SCC) of the maxillary alveolus and hard palate is not well published. We observed many patients who returned after primary resection presenting with delayed cervical metastasis. Method: To define the incidence of cervical metastasis we retrospectively analysed patients treated at the Royal Devon & Exeter NHS Foundation Trust, Exeter, UK for SCC of the maxillary alveolus and hard palate from January 2000 -‐ 2011. Variables analysed were; size, histology, management, incidence of metastasis and survival period.

Results: Total of 30 patients with confirmed SCC of the maxillary alveolus and hard palate. Overall incidence of cervical metastasis in patients with SCC was 13 of 30 patients (43%). The prevalence of cervical metastases was significantly higher for T4 and poorly differentiated SCC (48%) which is consistent with recent literature. Conclusion: SCC has a high propensity for cervical metastasis. It has been observed that elective neck dissection for the clinically negative neck for maxillary SCC remains an uncommon practice. In our study 43% of patients developed early or late cervical metastasis from primary maxillary SCC. Based on the evidence provided, elective neck dissection for maxillary SCC should be very carefully considered.

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Analysis of Craniofacial Skeletal Phenotypes

Debi Dasgupta Face Mouth Jaw Surg 2012;2(4):94

Introduction: Current research and genomics shows us that that are approximately twenty thousand protein coding genes within the mouse and human genomes, most of which are of unknown function. By mutating the mouse genome we are able to create phenotypes similar to those in humans due to the high level of genomic concordance, thus enabling us to model human genetics ethically in this model organism, whilst achieving comparable results. The Sanger Institute are creating a vast public resource of reporter-‐tagged mutations in embryonic stem (ES) cells for the functional annotation of the mouse genome. The aim of our project was to analyse these mutant murine heads for abnormal craniofacial skeletal phenotypes Methods: We were provided with P0 embryos with random ES cell insertional mutations via gene trap vectors for analysis. The methods used to analyse the skulls of the mutant mouse strains were 1) skeletal preparations with standard protocol using Alcian blue staining for the cartilage, and Alizarin red staining for ossified bone and

2) MicroCT reconstruction of the murine samples. Results: Eight skulls were evaluated including a specifically requested heterozygous mutant of one gene. The screen has highlighted a phenotype in both the Mysm1 heterozygous and homozygous mutants. The degree of ossification in the frontal, interparietal and particularly the parietal bones is significantly decreased. The metopic and sagittal sutures appear to be abnormally large for P0 skulls. Conclusions: As there is a difference in the degree of severity of the phenotype between the heterozygous and knockout mutant, it suggests haploinsufficiency of the gene. It is not known whether Mysm1 is expressed during suture closure. Further work is necessary to define the temperospacial expression pattern of mysm1, with specific focus on the calvaria, and identify whether its function has any association with conditions such as cleidocranial dysostosis and craniosynostosis.

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An audit exploring the causes for delay between presentation to the Accident & Emergency department and treatment on the Main Theatres Emergency list -‐ for emergency Oral & Maxillofacial patients

Ammar Al-‐Najjar Face Mouth Jaw Surg 2012;2(4):95

OMFS Department, Royal United Hospital, Bath

There was a feeling that many patients were waiting for unnecessarily long periods of time before being treated on the General Anaesthesia emergency theatre lists. Using the NCEPOD guidelines for emergency theatre lists as a gold standard, the reasons for such delays were investigated. An example would be a fractured mandible which required ORIF under GA -‐ which may be kept waiting following admission to the ward before either a theatre slot becomes available, or indeed until a surgeon is available to perform the procedure. It was found that the main cause of delay was emergency theatre allocation, and steps have been implemented to address this issue.

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Eagle Syndrome: Case report and literature review

Ramunas Nekrasius a Face Mouth Jaw Surg 2012;2(4):96

Shahme Farook1, Mohamed Rezni Nizam Cassim2, Sirosha Mandika Wijeyaratne2, Ravindra Priya Dayasena2, Rohitha Jayamaha2, Duminda Nalaka Gunawansa2, Colin Hopper1

1. Department of Oral and Maxillofacial Surgery, University College Hospital, 235 Euston Road, London, NW 1 2BU, United Kingdom

2. Department of Surgery, University of Colombo, Sri Lanka

This is a syndrome which leads to recurrent throat pain, dysphagia, and facial pain as a result of an elongated styloid process or calcified stylohyoid ligament. Awareness, appropriate clinical examination and radiological investigations could lead to early diagnosis; so that necessary treatment can be instigated to improve the quality of life for the patient. This case report identifies a 37 year old patient diagnosed with Eagle Syndrome who presented with a 10 year history of pain and discomfort in the throat and left eye with cervical extension and flexion leading to signs of cerebral insufficiency. Furthermore we explore the clinical and radiological modalities of diagnosis of this syndrome and discuss how best to manage these patients in a clinical setting.

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Audit on the Surgical Management of Orbital Blowout Fractures Khurrum Hussain Face Mouth Jaw Surg 2012;2(4):97

Manesh Lad, Gary Cousin, Adel El Rashers, Farooq Ahmed East Lancashire Hospitals Trust (ELHT)

The most common form of investigation was plain radiographs with 74%. The subcillary approach was favoured with 54% of clinicians choosing the method. 68% of patients had post operative facial radiographs carried out. 60% of patients received post operative antibiotics Persistent diplopia was recognized as the most common complication, with 7 cases, 16% of patients required a repeat corrective procedure. Conclusions: Time from injury to operation is within recommended time period, Persistent diplopia was the most common complication. Persistent diplopia was most common cause of re-‐operation. Recommendations: To carry out a re-‐audit, to include other fractures associated with orbital floor fractures, to follow up re-‐operated patients. References: 1. Accessed on 30/08/12, available at http://www.rad.washington.edu/academics/ academic-‐sections/msk/teaching-‐materials/online -‐musculoskeletal-‐radiology-‐book/facial-‐and-‐mandibular fractures 2. Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-‐based analysis. Ophthalmology. 2002;109(7):1207-‐10; discussion 10-‐1; quiz 12-‐3. Epub 2002/07/03.

Background: The orbital floor is designed to protect vital structures by allowing fractures to occur. There are significantly higher incidences of fractures to the orbit when compared to open globe injuries. Approximately 60-‐70% of all facial fractures involve the orbit.1 The most significant risk of surgical intervention is permanent blindness.2

Objectives: • To assess current practices of surgical

treatment of Orbital Floor Fractures at ELHT

• To obtain a baseline record of practice at ELHT for future comparison

Method: • Retrospective study – Oct 2008 to Dec

2010. • Use of an audit proforma and data

collection tool. • Inclusion Criteria and exclusion

criterion were defined.

Results: 50 records were identified. Patient’s most common presentation was diplopia (48%). The average number of days from injury till repair was 13.29 days.

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Do different types of smokeless tobacco products cause differing or similar oral lesions?

Hussein Al-‐Mufti Face Mouth Jaw Surg 2012;2(4):98

Farooq Ahmed Results: Oral submucous fibrosis, oral leukoplakia, white keratotic lesion were found to be consistently mentioned with betel quid, betel nut and Qat chewing, respectively. Despite some other types of ST reported other oral lesions, the findings were inconclusive, with evidence lacking in statistical significance, sample size and adequate control over confounding factor. One cohort study reported oral lesions healing users upon stopping the habit. Conclusion: Some types of ST tend to be associated with specific types of oral lesions at the site of ST consumption of risk factors. however, other types of ST need further studies, with adequate sample size and study designs (e.g well conducted cohort study) to achieve conclusive evidence.

Background: Different smokeless tobacco (ST) habits have been associated with the formation of oral lesions. A narrative systematic review was conducted to recap the specific oral lesions for each type of ST and describe the reversibility of these lesions. Methods: A literature review of databases and websites up to 2010 was carried out as well as studies suggested from expert advice. 18 Epidemiological observational studies were identified (14 cross-‐sectional, 3 case-‐control and 1 cohort), which reported various smokeless tobacco products from 11 different countries, and the oral lesions associated with that form of smokeless tobacco. Data extracted in terms of study design, type of ST consumed, country of origin, sample characterization, sample size, publication date, oral lesion types, type of statistical analysis used and confounder control.

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Bisphosphonate-‐Related Osteonecrosis of the Frontal Bone

F McClenaghan Face Mouth Jaw Surg 2012;2(4):99

A Ahmad, S Holmes, C Bridle Oral and Maxillofacial Department, The Royal London Hospital

Results: The international literature currently reports only cases of bisphosphonate related osteonecrosis of the jaw (BRONJ) affecting the mandible and/or maxilla. No cases of BRON involving other parts of the craniofacial skeleton or concerning the effects of significant trauma on bisphosphonate treated bone in other parts of the skeleton have been reported. Conclusions: BRON poses a great challenge to maxillofacial surgeons and warrants further research. Trauma to the craniofacial skeleton in patients with a history of bisphosphonate therapy needs to be recognised as a risk factor for BRON and the treatment modalities for BRON outside of the dento-‐alveolar area need to be explored.

Introduction: A 52 year old female with a history of intravenous alendronic acid therapy presented with osteonecrosis of the frontal bone following significant trauma to the craniofacial skeleton. This case study highlights the difficulties inherent in the diagnosis and treatment of bisphosphonate related osteonecrosis (BRON) in previously unreported areas of the craniofacial skeleton. Methods: The patient sustained compound injuries and skin loss to the forehead and underwent staged frontal craniectomy using extra-‐corporeal plating. The bone was replaced and soft tissue was augmented but bone failed to remodel and overlying soft tissue broke down. The exposed frontal bone was reconstructed in a staged manner using a free flap and polyetheretherketone (PEEK) implant. Bone biopsy confirmed the diagnosis of BRON within the frontal bone.

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'Horses for Courses' – When it is better to Enucleate and when it may be better to Marsupialise large Mandibular Cysts using two different cases as examples Grant Isherwood Face Mouth Jaw Surg 2012;2(4):100

Sunil Bhatia, Elizabeth Gruber, Grig Mihalache Oral and Maxillofacial Surgery Dept, Royal Shrewsbury Hospital

and there was no numbness / lymphadenopathy. She was medically fit. An Orthopantomogram revealed a cyst extending from the sigmoid notch to the LR5 region. There was only an egg-‐shell thickness of bone in most of the right mandible. Biopsy confirmed a Dentigerous cyst. Cyst 1 was removed by Enucleation. Cyst 2 was removed by Marsupialisation. These are illustrated by clinical photographs. Discussion If Cyst 2 was Enucleated, there would be a greater chance of fracture due to reduced structural integrity. Marsupialisation may be the preferred method in many cases to reduce pathological fracture. Conclusion It can be seen from these cases that it is important to learn both techniques and use them appropriately. Post-‐operative bony infill was judged to be excellent in each case. Careful consideration must be given when choosing to adopt one surgical technique over another.

Background Cysts may be defined as a pathological cavity having fluid or semi-‐fluid contents, which has not been created by the accumulation of pus. These are normally epithelial lined, but not always. Surgical management of large mandibular cysts can vary, however, the two most common approaches are enucleation and marsupialisation. Case Report 1 A 68 year old man was referred by his general dentist with a large cyst at the left angle of the mandible. On examination, there was expansion of the angle of the mandible and egg-‐shell cracking on palpation. An Orthopantomogram revealed an impacted LL8 intimately associated with the inferior dental bundle. He had a history of cardiac bundle branch block but was otherwise fit. Biopsy confirmed a Dentigerous cyst. Case Report 2 A 42 year old lady was referred by her general dentist regarding a cyst at the right angle of the mandible. The patient was edentulous beyond LR5, an expansion of the right jaw was evident

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Osteonecrosis of the Jaw Following Simple Extractions On A Patient With Diabetes

Grant Isherwood Face Mouth Jaw Surg 2012;2(4):101

Sunil Bhatia, Elizabeth Gruber, Grig Mihalache Oral and Maxillofacial Surgery Dept, Royal Shrewsbury Hospital, Mytton Oak Rd.,Shrewsbury

The teeth were extracted under local anaesthetic without any complications. One week later, osteonecrosis was evident in the lower left quadrant. A clear fistula existed between the oral cavity and the skin. Debridement, currettage and chlorhexidine irrigation were performed. A flap was placed over the defect and antibiotics prescribed. The patient was reviewed three days later. Extra-‐oral bruising of the area was obvious, but the mucoperiosteum was healing despite evidence of sloughing. The patient is showing signs of healing five weeks later. We illustrate this case with clinical photographs. Discussion More quality research is needed concerning osteonecrosis risk and diabetes. A link between osteonecrosis and bisphosphonates is established. Conclusion Practitioners should be aware of the increased risk of osteonecrosis in immunocompromised patients following oral surgery. Most practitioners are aware of the link between osteonecrosis and bisphosphonates. Most actively seek and document these drugs and risks already.

Background Osteonecrosis may be defined as exposed bone in the mandible, maxilla that persists for at least 8 weeks, in the absence of previous radiation or metastases in the jaws. It is a recognised post-‐operative complication for patients taking bisphosphonates but it can also affect patients who are not; particularly immunocompromised patients such as insulin-‐dependent diabetics. This case serves to highlight a rare complication that can be easily forgotten. Case Report A 63 year old man was referred by his general dentist for extraction of LL6 and LL7. Medical problems included hypertension, angina, two Myocardial Infarctions in 1996 and 2010, for which an implantable cardioverter defibrillator was placed. He has insulin-‐dependent diabetes and previous extractions have resulted in localised alveolar osteitis. On examination, both teeth were carious and Grade II mobile. No swelling / sinus was present. An Orthopantomogram was taken and chlorhexidine rinses prescribed twice daily for a week prior to the extractions.

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Head and Neck cancer database at Northwick Park

Greg Logan Face Mouth Jaw Surg 2012;2(4):102

Northwick Park Hospital Background:

going basis in stead of waiting until after out patient clinical review. Methods: The creation of a 33 variable intuitive Excel spread sheet from Name, Age, Date of Birth to Staging at MDT and MDT outcome, date of first operation to adjuvant therapy planed etc.

Results: The collection of detailed information on all oncology patients since May. Allowing for the creation of an audit team analysing the mined information

Discussion: Over the next year the goal is to scale up to Collection to all Cancer patients seen at NPH. With the first addition of ENT patients. As a group discuss the variables which we feel best to capture in lines with current national guideline. To ensure robustness and completeness of database streamline the data collection. Perhaps utilising pro-‐formas, completed after the MDT and upon post operative Discharge and review appointments.

Since May there has been a capture of 33 variables from all Northwick Parks Head and Neck Oncology patients. Utilising, the guidelines of the National Head and Neck Audit Project. It is the absence of accurate systematic prospective data collection that poses a major obstacle to improving Oral and maxillofacial oncology care in the United Kingdom. The aim of the database is provide a mine of information to better understand clinical oncology practice at Northwick Park. Therefore allowing the production of outcome and stage adjusted survival data, elucidating any associations of co morbidities in our patient populations and their effects on practice. Allowing future analysis to accurately risk adjust provides continually a source of auditable material for publication. The public should have access to accurate and risk adjusted clinical Information.

Capture: Every Cancer Patient seen by OMFS in Northwick park is filed for data input such as notes, pathology reports and Then database is populated by one of the SHO and SCFs. This information is then stored on the departments shared drive, allowing current post operative patients information to be update on a on-‐

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An overview of the building bespoke bone, the next step in tissue engineering. Integrating Embryonic Stem Cell Culture Using Encapsulation of ES and Culture in Bioreactors for the Production of Bone. Greg Logan Face Mouth Jaw Surg 2012;2(4):103

Northwick Park Hospital

hypothesis is that encapsulation of ESCs in 3-‐D alginate beads would result in an environment that would be conducive for the maintenance of ESC, EB formation, and osteogenic differentiation. This will allow for automation, control, optimisation, and intensification of the process producing the clinically relevant numbers of osteogenic cells required in clinical applications. Furthermore, the use of alginate beads presents several advances because they are biocompatible, have FDA approval, are easy to dissolve, or can be used to inject directly into the patient with encapsulated cells.

The transition from an undifferentiated mouse Embryonic Stem Cell (mESC) to bone tissue using traditional protocols in 2-‐D culture is fragmented, undefined, involves high maintenance, difficult to sample, and highly variable. Traditional Embryonic Stem Cell (ESC) culture in 2-‐D cultures involves three stages: a) ESC maintenance, b) Embryoid Body (EB) differentiation, and c) lineage-‐specific differentiation. Each stage requires manipulation and stage-‐specific protocols. The goal for this project is the integration of the various steps in ESC culture using bioreactors resulting in the reproducible, straightforward, high intensity culture of ESCs for clinical bone tissue engineering applications. The

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Early Orthopeadic retraction of the premaxilla in bilateral complete cleft lip and palate (BCLP): An innovative approach to a difficult problem Rizwan Mahmood Face Mouth Jaw Surg 2012;2(4):104

Oral and Maxillofacial Unit, Aintree University Hospital

BCLP occurs in 20% of cleft patients. Many approaches have been adopted to manage the protrusive premaxillary segment in bilateral cleft lip and palate cases. Some advocate the use of intraoral appliances, occasionally combined with invasive surgery, which often requires revision at a later date. The authors describe the case of a 3 year old child born with BCLP presenting with a protuberant premaxilla with an overjet greater than 25mm. Prompt intervention was warranted in this case due to the potential traumatic compromise to the dentition of the premaxillary segment and a distinct lack of social integration reported by the parents. The patient was managed with a novel, innovative approach using orthodontic traction and minimally invasive surgery. The literature has been reviewed and the patient’s subsequent physiological and psychosocial development has been monitored and has since undergone successful alveolar bone grafting.

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Dental implant complications: Extra-‐oral fistula

Rizwan Mahmood Face Mouth Jaw Surg 2012;2(4):105


debridement and curettage of the area, bioguide membrane was placed over the fenestrated defect and the implant maintained. 6 month review indicated sound bony healing Conclusions/Clinical relevance Although dental infections rank highly amongst the complications associated with implants, to date there have been no reports which document the formation of an extra oral sinus associated with a dentoalveolar implant. Furthermore this case indicates that despite the formation of a sinus tract that adequate debridement can allow the infected implant to be maintained. It also demonstrates how robust dental implants can be in the midst of a chronic dental infection

Introduction The use of dental implants for oral rehabilitation has shown great success in recent years reaching up to 95% at five years. However, as with every surgical procedure implants do suffer from post-‐operative complications. In most cases it is due to a combination of oral infection and host inflammatory responses or a lack thereof. This can result in infection which can result in mobility or loss of the implant, orofacial infection, and even the production of intra oral fistulas. In this case we report on a middle aged lady presenting with an extra-‐oral fistula associated with a dental implant Case Report A 66 year old lady presented with a discharging sinus on the cheek. Implants had been placed 3 months prior in the upper premolar region and despite improvement at review, a recurrent infection ensued. This warranted exploration under general anaesthetic. Following comprehensive

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Case Report: Synovial Chondromatosis mimicking synovial sarcoma

Rizwan Mahmood Face Mouth Jaw Surg 2012;2(4):106


Discussion Several aetiologies have been postulated without one being particularly definitive. Combined CT and MRI Imaging is crucial in excluding the presence of malignancy, allowing for non-‐calcified as well as calcified lesions to be visualised. Conservative procedures have shown to be effective in smaller lesions however; incomplete excision can lead to recurrence. We would therefore recommend wider access to allow for complete excision particularly in larger lesions. Conclusion Although the prevalence of SC is rare, it should be included in a differential diagnosis in patients presenting with TMJ symptoms. The penetration of the skull base presents a very rare finding and the use of CT & MRI in tandem facilitated this diagnosis, emphasizing their complementary role in the diagnosis of SC. Although success has been achieved in some conservative techniques, we would recommend wide access to allow for comprehensive excision.

Introduction Synovial chondromatosis (SC) is a rare, benign metaplastic arthropathy originating in joints containing a synovial membrane, which is even rarer in the temporomandibular joint (TMJ). The use of MRI and CT are imperative in establishing diagnosis and appropriate management. Several curative surgical approaches have been documented. However, skull base penetration warranted malar osteotomy for complete excision. Description The patient presented with a three year history of a lump on the side of the face which increased in size when chewing and clenching. Due to the position of the mass, an unconventional, relatively radical approach was employed. This involved a hemi-‐coronal flap, with malar osteotomy. Histopathology reported SC although there were signs indicative of malignancy.

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A Rare Complication Following Orbital Floor Repair

M Mezher Face Mouth Jaw Surg 2012;2(4):107

T Teemul, J McCaul Maxillofacial Unit, St. Luke’s Hospital,Bradford

diagnosed with isolated oculomotor nerve weakness. This was treated conservatively as the cause was thought to be due to swelling and oedema from the initial trauma and added insult from surgery. After five months normal movement of the globe was restored, however he continues to have a sluggish papillary reflex. The patient is still under review. Conclusion A comprehensive literature review found only 2 cases of oculomotor injury following orbital floor trauma and repair, suggesting this is either a very rare complication, or simply underreported. Reimaging showed ideal position of the reconstruction plate with no evidence of impingement of neurovascular structures. Third cranial nerve weakness may follow surgery to correct an orbital floor fracture. This may be due to a double insult from trauma followed by surgical intervention. It is important to rule out other causes that can affect the nerve along its long course. Where imaging shows no impingement of neurovascular structures, conservative management is appropriate.

Introduction We report a case of isolated oculomotor nerve weakness following an orbital floor repair. This is a rare complication and presented a management challenge. Method Case report and literature search. Results A 45 year old male presented with facial injuries following an alleged assault. Initial ophthalmology review reported that ocular mobility was grossly intact, while further orthoptic assessment revealed slight limitation of the globe on upward gaze. A CT scan confirmed a left orbital floor blowout fracture, with herniation of the inferior rectus muscle and orbital fat into the maxillary sinus. He subsequently had an orbital floor exploration, and the defect was repaired with a titanium plate. In the immediate post operative assessment, he was found to have a fixed, slightly dilated pupil and was unable to move the globe medially from the central position. Following an ophthalmology assessment, he was

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A 24 case retrospective audit on Orthognathic patient outcomes at Barnet Hospital

Miller CE Face Mouth Jaw Surg 2012;2(4):108

M Gaukroger, Z Sheriteh, M Gaukroger of surgery (90%). 50% of patients returned to work within 5 weeks of surgery (90%). 96% of patients should have post surgery orthodontics completed within 8 months of surgery (80%). 54% of patients should have an OB and OJ of 2-‐4mm (80%) the remainder all had reduced OBs. 75% of patient had no altered sensation at 6 months compared to 96% at 2 year follow up (95%). Conclusion: Patients met standards for orthodontic preparation time, provision of operation date, postoperative orthodontic times, infection rates and the need for blood transfusion. However, our patients need to be assisted in leaving hospital following a shorter length of stay and in reducing the time they spend away from work. They would benefit from a greater degree of post-‐operative overbite and need long term follow up regarding altered sensation. There will be a re-‐audit in 2 years time and a further audit of these patients will be published on patient satisfaction with regards to outcome of surgery.

Introduction The north London orthodontic audit group compiled a list of orthognathic standards using the British Orthodontic’s Society guidance. Originally 13 regional audit standards were complied and audited by Northwich Park, Wexham Park, Watford, Barnet and Chase Farm Hospital in 2011. This is an audit of 24 cases assessed retrospectively at Barnet Hospital. Data was collected from models, notes and radiographs. Results Audit results found 79.2% of patient were ready within 24 months of having appliances fitted (80%). 96% of patients were offered a surgery date within 18 weeks of going on the surgical waiting list (100%). No patients needed blood transfusions (95%). 71.8% of patients had an intact IDN (95%). No patients needed repeat surgery (95%). All patients were infection free after surgery (95%). 25% of patients were discharged within 48 hours

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Diagnostic accuracy of fine-‐needle aspiration cytology versus core-‐needle biopsy of the major salivary glands N Pattni Face Mouth Jaw Surg 2012;2(4):109

RL Orr, PT Doyle Chesterfield Royal Hospital , UK

distinguishing non-‐neoplastic from neoplastic pathology FNAC and CNB had an accuracy of 92% and 100% respectively. CNB had a better negative predictive value (NPV) (100% vs 89%) and sensitivity (100% vs 75%) than FNAC, but the positive predictive value (PPV) and specificity were the same (100%). When determining if a neoplastic lesion was benign or malignant both methods had similar accuracy (FNAC 94% vs CNB 95%). The PPV, NPV and sensitivity for FNAC was 94%, 100% and 100%; this was similar to CNB (93%, 100%, 100%). The specificity of CNB was better than FNAC (83% vs 50%). Conclusions FNAC and CNB are safe diagnostic tools for the assessment of salivary gland pathology. CNB is better than FNAC in distinguishing non-‐neoplastic and neoplastic lesions, and although both have similar diagnostic accuracies when determining if a neoplasm is benign or malignant, the high non-‐diagnostic yield for FNAC makes CNB a superior investigative modality.

Introduction Fine-‐needle aspiration cytology (FNAC) and core-‐needle biopsy (CNB) are commonly used investigative modalities for differentiating between different pathological processes of the major salivary glands. The aim of this study was to determine the diagnostic ability of FNAC and CNB to differentiate between neoplastic and non-‐neoplastic lesions, and benign and malignant neoplasms of the major salivary glands. Materials and methods Clinical notes of patients who had an FNAC and/or CNB of any of the major salivary glands between January 2006 and October 2011 were retrospectively reviewed. Only those with a histologically confirmed diagnosis by surgical excision were included. All samples were obtained under ultrasound guidance by a consultant radiologist. Results 40 FNAC and 45 CNB samples were obtained without complications. The non-‐diagnostic rate for FNAC was 37.5% and 4.4% for CNB. When

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MaxFaxLink.org: Utilising RSS feed technology to deliver up-‐to-‐date course and conference information for Oral and Maxillofacial Surgery trainees

Mijan Miah Face Mouth Jaw Surg 2012;2(4):110

Karl FB Payne, Alex MC Goodson, Arpan Tahim, Kathleen Fan Oral and Maxillofacial Surgery Department, King’s College Hospital

The benefit of MaxFaxLink over similar schemes is the ability to provide both home and on-‐the-‐go access. By downloading the WordPress app for iPad or any smartphone model, a trainee can sync the MaxFaxLink feed to their device and obtain real-‐time updates. Furthermore all these services are free of charge. Feedback so far has been incredibly positive and we continue to expand both the website and content. Our intention is to create a community-‐led resource open to all levels of trainee. We encourage trainees to contact us with news on upcoming courses relevant to OMFS. In an ever-‐advancing technological age, OMFS continues to be at the forefront of utilising Internet and smartphone technology for the educational benefit of its trainees. We continue this tradition.

The modern Oral and Maxillofacial Surgery (OMFS) trainee is expected to attend a plethora of courses and conferences, both for educational and career furthering purposes. From personal experience and that of colleagues, we often found this information difficult to find and time consuming to research. This is further compounded by the dual-‐qualified nature of OMFS, and the necessity to stay abreast of both medical and dental developments. As a solution to this problem we created MaxFaxLink.org, a new online resource for trainees in OMFS. MaxFaxLink provides trainees with up-‐to-‐date information about useful courses and conferences in one easy to find place. Using a WordPress platform we deliver a news stream in an RSS feed format.

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Should skin cancers be excised by an Oral Maxillo-‐Facial Surgeon in 2012?

Paul Serrant Face Mouth Jaw Surg 2012;2(4):111

Oral and Maxillofacial Surgery, Wigan Royal Albert Edward and Manchester Royal Infirmary

Results/Statistics Investigations, diagnosis, requisite LSMDT / SSMDT discussion and treatment were delivered within the 31/62 day target by a single surgical led team which streamlined the patient care pathway and number of professionals the patient needed to see. Right segmental resection of mandible with overlying skin, type III modified radical neck dissection and reconstruction with a micro-‐vascular chimeric scapula /latissimus dorsi osteomusculocutaneous free flap was performed, with adjunctive radiotherapy with no recurrence at 11 months follow up. Clinical Relevance Guidance recommends that only official core members of local teams should perform surgery on skin cancers and only experienced HNS should perform cervical oncologic lymphadenectomy. Oncologic OMFS have particular utility in this context. Membership of both LSMDT and SSMDT in this case facilitated the expedient management of this.

Introduction An Oral and Maxillo-‐Facial Surgeon (OMFS) can fulfill the national requirement for a head & neck surgeon (HNS) as a core member of both local and specialist skin cancer multi-‐disciplinary teams (LSMDT, SSMDT). Materials A case is presented of advanced recurrent head and neck skin squamous cell carcinoma with regional metastasis Staging: rT0N1M0 following previous excision of moderately differentiated pT1cN0 SCC of the right upper lip excised with 3mm margin by another surgical team. Management included presentation at both LSMDT and SSMDT by the OMFS.

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Case report, a Maxillary radiolucency

Paul Serrant Face Mouth Jaw Surg 2012;2(4):112

Oral and Maxillofacial Surgery, Wigan Royal Albert Edward and Manchester Royal Infirmary

Clinical Management The following surgery was undertaken,

• Enucleation of Cyst under GA. • Apicoectomy of the compromised

ul1,ul2. • Specimen transferred for

histopathalogical investigations. Investigations/Discussion Histopathological investigations reveal a Radicular cyst. The Radicular (peri-‐apical) cyst is the most common cyst of the jaw, There was no evidence of dysplasia/ malignancy. Around 60% of all jaw cysts are radicular or residual cysts The development of the radicular cyst is caused by the growth of remnants of Malassez cells involved in the development of the dental organ. Its size rarely exceeds 1 cm in diameter and is often seen in patients between 30 and 50 years old Several treatment options are available for a radicular cyst. This patient presented with a relatively large cyst for medical therapy or endodontic treatment to be considered. In this situation, surgical enucleation was considered as the best option.

Background Cysts of the jaws are mostly Odontogenic in origin, but may be also of non-‐odontogenic source. The Mandible and Maxilla are the bones with the highest prevalent of cysts in the human body owing to odontogenic and developmental epithelial remnants, common dental infections and dental impactions. Presenting Problem 24 Year old male, Referred from local General Dental Practitioner to Wigan Royal Albert Edward Infirmary Oral and Maxillo-‐Facial surgery Department, Complaining of Swelling of left naso-‐labial region for one year, Pain in the region, teeth becoming displaced and a lump in the gum with occasional foul tasting discharge. Computerised Tomography imaging revealed:-‐

· Large cystic mass occupying most of the left Maxillary Antrum.

· The left Maxillary Antrum is expanded, with bowing of its anterior, medial, lateral and inferior walls.

· There is narrowing of the left nasal cavity, and depression of the hard palate.

· Nasal septum deviated to right side with right sided bony nasal spur.

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Sporting Injuries in the West of Ireland: A Prospective Data Capture Study

Tom W M Walker1,2 Face Mouth Jaw Surg 2012;2(4):113

Ruben A van der Valk2, Michael J Kerin3, Patick J McCann1 1. Department of Oral & Maxillofacial, University Hospital, Galway, Ireland 2. King’s College, London, Dental Institute, Guy’s Hospital, King’s College, London, UK 3. Department of Surgery, National University of Ireland, Galway, Ireland

Results A total of 325 presentations to emergency departments over this 1-‐week period were attributable to facial injuries. 26.8% of these facial injuries were specifically due to sporting activities. Two thirds of all sporting injuries were caused by Gaelic football, hurling or camogie. 38% of these were attributable to Gaelic football where there is no requirement for protective helmets. Eight-‐seven people received soft tissue injuries due to sport. 29 people sustained a facial bone fracture due to sport. Helmets appear to protect against facial lacerations, but those wearing helmets in hurling and camogie sustain a higher proportion of facial fractures. Conclusion This study illustrates the high incidence of sporting related facial injury in the West of Ireland and highlights the need for suitably designed facial protection and mouth guards for both hurling and Gaelic football.

Introduction The aim of this study was to identify the prevalence, cause and nature of sports related facial injury in the west of Ireland. In addition we aimed to elucidate how frequently protective helmets and mouth guards are worn. Methods A multi-‐centre prospective data collection study was performed over a one-‐week period in the West of Ireland. All patients attending the eleven emergency departments in the region with a facial injury were included in the study. Injuries solely of the scalp and neck were excluded. The proforma included basic demographic information, the cause of the injury, the nature of the injury and the presence of protective facial equipment.

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Atypical Fibroxanthoma: Case Series of Patients from a District General Hospital

Sridhayan Mahalingam Face Mouth Jaw Surg 2012;2(4):114

Andrew Stewart Epsom & St Helier University Hospitals NHS Trust

forehead, and 1 on the cheek. Mean diameter was 9.8mm (range 3-‐22), and depth was 5.8mm (range 3-‐8). Modes of treatment were curettage and cauterization (5 cases, of which one case had local recurrence); and complete excision (2 cases). Those that were excised were assessed to have a clearance of 5mm in both cases, and developed no further recurrence. The most common positive immmunohistochemical markers were smooth muscle actin and vimentin. Discussion We report a series of patients with a greater male: female when compared to previous literature. Curettage and cautery offers a good prognosis with low risk of recurrence and, excision with adequate clearance margins may offer a definitive management plan. Our immunohistochemistry is comparable to previous data. We aim to increase awareness of this condition, and highlight important characteristics in order for it to be accurately identified and managed by trainees in OMFS.

Background Atypical Fibroxanthoma (AFX) is a rare cutaneous neoplasm, seen primarily in the head and neck region of elderly patients with previous sun exposure. Despite being uncommon, recognition is essential as it can mimic squamous cell carcinoma and malignant melanoma. By using a series of patients who presented with AFX at our district general hospital, in conjunction with previous literature, we, intend to highlight the important characteristics of AFX. Methods In this retrospective study, case notes of all patients diagnosed with AFX from 1980 were reviewed. We assessed patient demographics, presenting symptoms, appearance on clinical examination, management options, excision margins, pathology reports, and progression during follow-‐up. Furthermore we have compared our data with previous literature. Results 7 patients were included in this series (6 men and 1 woman, mean age 75.9 years, range 58 to 89). All patients presented with a solitary lesion. 5 were found on the scalp, 1 on the

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The role of Tbx1 in palatogenesis

Stephanie Bryan Face Mouth Jaw Surg 2012;2(4):115

MT Cobourne Queen Alexandra Hospital, Portsmouth

fold change in expression levels (p<0.05). In this investigation we have verified these candidates using high-‐throughput quantitative Polymerase Chain Reaction (qPCR). Prominent amongst these genes were members of the calcium signalling pathway, markers for skeletal muscle development and members of the matrix metalloproteinase family. Collectively, these results suggest that Tbx1 has a direct role in mediating palatogenesis.

Partial deletion of chromosome 22q11 is the commonest microdeletion seen in human populations, occurring with a frequency of around 1:4000 live births. This deletion is associated with three distinct clinical conditions, including the DiGeorge (DGS), velocardiofacial (VCFS) and conotruncal anomaly face (CAFS) syndromes, all characterised by the presence of cardiac defects and craniofacial abnormalities. Amongst the craniofacial anomalies, oro-‐facial clefting and micrognathia dominate, with cleft palate occurring in around 10% of subjects, making this deletion one of the commonest causes of human syndromic clefting. Amongst the genes that reside in the affected region of chromosome 22q11, Tbx1 is a major candidate for many of the developmental and structural anomalies that occur. An absence of Tbx1 function in the mouse results in a severe DGS/VCFS phenotype with a fully penetrant cleft of the secondary palate. Tbx1 is expressed within epithelium of the secondary palate throughout palatogenesis, suggesting a direct role for this transcription factor during palatogenesis. In order to further investigate potential molecular targets of Tbx1 during formation of the secondary palate, we previously carried out a microarray screen on wild type and mutant murine palatal shelves, identifying sixty two genes with at least a two-‐

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A TMJ database

Karim Kassam Face Mouth Jaw Surg 2012;2(4):116

Sandeep Bahra , Luke Cascarini Department of OMFS, Northwick Park Hospital

A re-‐audit cycle revealed that 92% of patients had accurate clinical documentation and 90% had accurate radiographic information. To date the database is >70 patients strong and in use by all clinicians within the department. Overall aims are to use the results from the database to improve clinical management and ensure long term followup to evaluate which procedures are beneficial to our patients. One way to expand the database would be to introduce it to other nationwide units and pool the findings. In this way we can produce long term results of procedures leading to the creation and subsequent use of evidence based guidelines.

The evidence regarding the long term outcome of TMJ treatment is sparse in the English scientific literature. This could be one reason to why the management of TMJ patients in the UK can differ from one centre compared to the other. A retrospective audit into documentation regarding TMJ patients in a large Southern England Maxillofacial unit was conducted between 2010 and 2012. 90% of patients had inadequate documentation. These poor results led to the creation of a standardised proforma for all TMJ patients and the creation of a TMJ database in our department. This proforma is filled for patients undergoing a MRI investigation of their TMJs prior to the following treatments: arthroscopy , arthrocentesis , meniscopexy, high condylar shave, eminectomy and TMJ replacement. Information is gathered both pre-‐operatively and post operatively. Relevant co-‐morbidities are assessed. A clinical and radiographic investigation is carried out using universally accepted markers such as Wilkes and Pain (VAS) scores. Complications are noted.

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A case report of a rare Ectomesenchymal Chondromyxoid Tumour (ECMT) in the oral cavity

N Crutchley Face Mouth Jaw Surg 2012;2(4):117

R Taylor, A Carton, N Hammersley, C Forsyth Monklands Hospital, Airdrie

Introduction Appearing exclusively in the oral cavity and in particular the anterior tongue, the rare Ectomesenchymal Chondromyxoid Tumour (ECMT) is considered a benign neoplasm of uncertain histogenesis. Case report We present a soft tissue lesion of unknown histogenesis excised from the anterior dorsal surface of the tongue, in a 27 year old girl. The resected specimen has been extensively reviewed by a large number of pathologists at four separate institutions including national specialists in head and neck and soft tissue pathology. Clinically, histologically and microscopically this lesion possess features similar to the known primary chondromyxoid lesions of the oral cavity in particular the rare Ectomesenchymal Chondromyxoid Tumour (ECMT), although as yet a definitive diagnosis remains uncertain. Discussion We review the published data on the clinical, microscopic and histological findings of ECMT and compare the findings in this case.

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Dental Abscesses

Mazen Att Face Mouth Jaw Surg 2012;2(4):118

Introduction Dental abscess usually has a swelling confined to space(s) that is related to the main source of the abscess. In the following case, the abscess presented in an unusual way that led to the initial diagnosis of necrotizing fasciitis and was treated accordingly Case A 62 year old lady presented after being referred by her GP regarding a large neck ‘ulcer’, which was present for two weeks. Clinical examination revealed very poor oral hygiene. There was a 5x3 cm hole in the middle of the neck corresponding to the 3rd, 4th and 5th tracheal rings exposing the underlying trapezius muscle. There was a necessity to exlude a high possibility of necrotising fasciitis and SCC. The patient was admitted, started on high dose intravenous ciprofloxacin, benylpenicillin and clindamycin, with a view to an urgent EUA and biopsy ASAP, MRI and haematological investigations. The surgical procedure went unremarkable. A sinus tract present was traced, which lead to the lower right molar region.

The patient however was not keen on surgery and the wound left to granulate and had healed with an excellent cosmetic result. Results Histopathological analysis proved to be diagnostically challenging. This ruled out earlier doubts regarding the possibility of SCC. The changes were pseudoepithelimatous reactive change from a dental abscess. Discussion The presentation of dental abscesses can be predictable. In rare cases, the consequences can lead to severe destruction of the affected tissues, and an initial treatment for more possible serious conditions may be recommended.

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Maxillary Malignancies