Audit of minimally-invasive surgery for submandibular sialolithiasis

Sialolithiasis is one of most common diseases to affect major salivary glands, with a symptomatic incidence of 27 cases per million per annum. The majority form within the submandibular gland where minimally-invasive treatments have all but eliminated adenectomy. All records of patients presenting with submandibular stones between 1997 and 2015 were reviewed. Stones <5 mm were retrieved through endoscopic or radiographic techniques, 5-7 mm stones were initially considered for extra-corporeal shock wave lithotripsy, but after poor results were treated through intraoral surgical removal with those >7 mm. Follow up was performed at 1 week and 3 months with current status performed with postal and telephone questionnaires. 378 patients had 424 stones removed, successful retrieval in 94% (n = 356), with 50 having had previous failures. Median number of stones per patient was 1 (range 1-4), with a mean size of 8.6 mm (SD 4.5 mm) mainly located at the hilum (50.5%), anterior duct (30%) and Genu (17%). 256 patients (65%) treated through intraoral surgical extraction, 92 (24%) endoscopic alone. Inpatient stay was 1.4 days in first third and 0.5 days in final third. Adenectomy occurred in 14 patients, due to failure to retrieve the sialolith or unresolved symptoms. Complications involved 11 patients with permanent paraesthesia, 7 ranulas and 14 strictures. Patients with preoperative strictures were more likely to develop complications (p = 0.002) with paraesthesia being most common. Intraoral minimally-invasive surgery is aesthetic, curative and spares the risk to marginal mandibular nerve and submandibular gland. Length of inpatient stay improved and ranula risk reduced throughout the study.     

Anatomical relation of third molars and the retromolar canal

The study was designed to assess, by direct anatomical observations and cone-beam computed tomography (CT), the prevalence of a retromolar canal and foramen in relation to the mandibular third molar in dry human mandibles. Dry mandibles from European skeletons (n = 89) were observed directly and after cone-beam CT scanning (Newtom VGI evo). The following variables were assessed: the presence of a retromolar foramen and canal; the presence of a third molar, and orientation of the third molar. From the total of 89 mandibles selected, 73 showed a retromolar foramen (49 of which were bilateral). A retromolar canal was identified in 64 mandibles based on cone-beam CT assessment, with a total of 101 canals, including 74 that were bilateral. A total of 112 hemimandibles contained a third molar. Orientation of the third molar did not seem to indicate the presence of retromolar foramina or canals. A similar prevalence of retromolar canals was found for both vertically (41/79) and mesially (17/33) orientated third molars. A retromolar foramen and canal were present in most mandibles, with more than half being bilateral. We were unable to confirm a potential relation between the retromolar foramen and canal on the one hand, and the orientation of the third molar on the other.     

Traumatic pseudoaneurysm of the superficial temporal artery

Pseudoaneurysm of the superficial temporal artery is rare. It is typically caused by blunt force to the temporal region, and presents as a painless, preauricular, pulsatile mass during the following weeks. We think that its infrequent incidence and unusual presentation warrants an increase in awareness to aid accurate and timely diagnosis. We present a case that developed a few weeks after a head injury, and its subsequent management.     

Efficacy of secondary closure technique after extraction of third molars: a meta-analysis

The purpose of this study was to assess the influence of two suture methods on the postoperative complications of extraction of mandibular third molars (M3M). We searched the MEDLINE (PubMed), Cochrane Library, and Web of Science databases until 18 May 2018 for randomised controlled trials (RCT) that evaluated the influence of any suture techniques on postoperative complications after the removal of impacted M3M. Pain, facial swelling, and trismus were measured for both the early stage (2–3 days) and late stage (5–7 days) after extraction. We identified 655 records, of which five were assessed for eligibility. All trials included had a moderate risk of bias. The analysis showed that the patients whose wounds had been closed primarily had significantly more pain than those whose wounds were closed secondarily (a wedge of mucosa) during the early stage (standardised mean difference (SMD), ?0.49; 95% CI ?0.71 to ?0.27; P < 0.0001) and the late stage (SMD ?0.36; 95% CI ?0.54 to ?0.19; P < 0.0001) after the removal of impacted M3M. Patients whose wounds were closed secondarily had less swelling (mm) at the postoperative early stage (SMD ?1.12; 95% CI ?1.57 to ?0.66; P < 0.00001) and late stage (SMD ?0.51; 95% CI ?0.68 to ?0.33; P < 0.00001). There was more trismus in the primary closure group than in the secondary group during both stages. Our findings suggest that secondary closure causes less pain, facial swelling, and trismus in both early and late stages of surgical removal of impacted M3M, and therefore it improves the quality of life by reducing postoperative discomfort.     

A comparison of cost-effectiveness of computer-assisted 2-and 3-dimensional planning techniques in orthognathic surgery

The aim of this randomised controlled trial was to compare the costs and benefits of computer-based 2-dimensional and 3-dimensional predictions in orthognathic surgery.Subjects aged 18–30 years with severe class III malocclusion had their treatment planned with both 2- and 3-dimensional techniques. They were randomised in a 1:1 ratio for one or other planning technique. Costs (financial, time, and dose of radiation) were compared with benefits (accuracy and health-related quality of life (HRQoL)). In total, 57 subjects (27 women and 30 men, mean (range) age 21 (18–28) years) completed the study. Comparisons showed no significant difference in total time spent, but a large advantage for the 2-dimensional technique in financial costs (p < 0.001); it also required a significantly lower dose of radiation (p < 0.001). The cost-effectiveness analysis showed a reduction in time of 0.53 minutes/HRQoL-point gained, and an increased economic cost of US$15/HRQoL point gained for the 3-dimensional technique. It also showed that the two techniques consumed an equal amount of time, but that the 2-dimensional technique had lower financial costs, and the 3-dimensional technique a larger dose of radiation.     

Ectopic parathyroid adenoma in the submandibular region: a case report

Ectopic parathyroid adenomas that affect the submandibular region have not been widely reported. We describe a 34-year-old man who presented with a painless swelling of the submandibular region. The identification of hypercalcaemia encouraged us to engage a multidisciplinary team to evaluate further serum changes. Parathyroid hormone analysis, ^99mTc-methoxy-isobutyl-isonitrile (^99mTc-MIBI) scintigraphy, and single-photon emission computed tomography (SPECT-CT) were done to rule out hyperparathyroidism. Raised parathyroid hormone together with ^99mTc-MIBI and SPECT-CT examination were consistent with a tumour caused by the hyperparathyroidism. Removal of the lesion resulted in rapid improvement in serum calcium and parathyroid hormone, and the normalisation of the serum creatinine, concentrations. Histopathological analysis confirmed a parathyroid adenoma. We conclude that ectopic parathyroid adenomas should be considered as part of a differential diagnosis for tumours of the submandibular region.     

Role of live animals in the training of microvascular surgery: a systematic review

As training in microvascular surgery often involves the use of live animals, it is important that such a practice is regularly revisited and justified, particularly in the context of emerging training strategies such as virtual simulation. This systematic review was therefore designed to assess the ongoing need for their use over other methods. A search of PubMed and MEDLINE using the major MeSH terms: anastomosis, surgical vascular procedures, microsurgery, and training, yielded 1386 titles from which 153 abstracts were read, 70 papers analysed, and 17 included. Nine of these papers were randomised studies that compared different methods of training. Other publications were included if the use of live animals was assessed or commented upon, or both (8 publications). Only one study randomised trainees to a non-living animal model or a living model, with detailed assessment that included clinical transfer to live surgery. It showed no significant difference in the quality of training, and excellent techniques of assessment. There was much discussion on the advantage of regular training and opportunities to practise without tuition, but there was no clear advantage for the use of live animals. Our review emphasises the lack of evidence regarding the need for live animals in the training of microsurgical or microvascular skills. Although the assumption remains that the use of live rats is essential, there is a clear need for a high-quality, comparative study to justify the continued use of such models given the quality of the alternatives now available.     

Surgical strategy for long-standing dislocation of the temporomandibular joint: experience with 16 medically compromised patients

We evaluated the surgical outcomes in 16 patients with long-standing dislocation of the temporomandibular joint (TMJ): eight men and eight women, mean (range) age 72 (21-94) years. They all had multiple underlying diseases, either dementia or a mental disorder, and the joint had been dislocated for four weeks or longer. Manual reduction had been ineffective. They were operated on after assessments by the Department of Geriatric Medicine. The procedures were successful in 14 of the 16 patients: eminectomy (n = 5), eminectomy and discectomy or condylectomy (n = 2), eminectomy, discectomy, and condylectomy (n = 3), release of the lateral pterygoid muscle (n = 3), and curettage of a fibrotic scar in the mandibular fossa (n = 1). Reduction was “easy” (n = 4), “moderately difficult” (n = 3), or “very difficult” (n = 9). Complete reduction could not be achieved for two of the “very difficult” patients. After reduction, three patients had the mandibular condyle tethered to the mandibular fossa. Operation was successful in 12 of the 16 patients. Two patients died, one of cardiopulmonary arrest, and one of chronic pulmonary insufficiency, while reduction was incomplete in two. There were no recurrences. The difficulty of reducing the joint in most of our patients suggests that detailed preoperative surgical planning is essential, patients at risk should be carefully selected, and indications for techniques to prevent recurrence should be carefully evaluated.     

Melanotic neuroectodermal tumour of infancy: Refining the surgical approach

Melanotic neuroectodermal tumours of infancy (MNTI) are particularly rare and although predominantly benign, are infiltrative and locally aggressive. Presenting in the first year of life, prompt diagnosis and effective management are critical in minimizing morbidity and the risk of recurrence.A retrospective review of 11 MNTI managed at Great Ormond Street Hospital (GOSH) from 2000 to 2017 was undertaken. Eight tumours presented in the maxilla, two in the skull and one in the mandible. The primary modality of treatment was surgery in 10 cases with one patient receiving neoadjuvant chemotherapy. In spite of microscopically incomplete resection in seven cases, only three recurred. Overall, there was a local recurrence rate of 27% with no distant metastases noted.Disease-free survival was 100% with a follow-up ranging from 0.75 to 17 years (median 5 years). Taking our results in conjunction with the available literature, there is a role for conservative initial surgery of MNTI and this should be coupled with delayed reconstruction and intensive short-term follow-up. We propose an adapted treatment algorithm that aims to balance the risk of recurrence and malignant change with surgical morbidity in an infant population.     

Impact of salivary contamination during placement of implants with simultaneous bony augmentation in iliac bone in sheep

Our aim was to investigate the possible impact of contamination with saliva on osseointegration during placement of implants with simultaneous bone augmentation. Six hemispheric shape bone defects (8 mm in diameter × 4 mm deep) were prepared in each iliac bone of six sheep. A dental implant (2.9 mm in diameter × 10 mm long) was placed in the centre of each defect, and then pairs of defects were filled with one of the following bone augmentation materials: autogenous bone, autogenous bone plus bovine bone, or resorbable biphasic ceramic bone substitute. One site in each augmentation group was impregnated with saliva (contaminated group), while the other was not (non-contaminated group). Bone-to-implant contact (BIC) and bone area fraction occupancy (BAFO) within implant threads were measured after a healing period of five weeks, both in respect of the implant inserted in the augmented bone and in that inserted in the residual bone. Overall results showed that there was a significant difference between the contaminated and non-contaminated group for BIC in the augmented implant (p = 0.028), while there were no significant differences in the implant in residual bone (p = 0.722). For BAFO, there were no significant differences between the contaminated and non-contaminated groups among the different augmentation materials. The results showed that contamination with saliva during placement of an implant with simultaneous bone augmentation had a serious deleterious effect on osseointegration of the aspect of the implant within the augmented defect. Contamination with saliva during placement of an implant with simultaneous bone augmentation should therefore be avoided.     

Neck masses in children: a 10-year single-centre experience in Northwest China

Neck masses in children are a common clinical concern but there is a paucity of published information about them. We organised this retrospective study to analyse their prevalence and treatment in Northwest China. The records of 207 children who presented with neck masses between 2008 and 2017 were retrieved from the Department of Oral and Maxillofacial Surgery, Lanzhou University Second Hospital, and age, sex, clinical presentation, preoperative investigation, surgical procedure, histopathological diagnosis, and complications were recorded. Their mean (range) age was 10 years (6 months to 21 years), and the male:female ratio was 1.23:1. In total 128 patients (62%) had congenital lesions, 35 (17%) had inflammatory lesions, and 44 (21%) had neoplastic lesions. The most common mass was a thyroglossal cyst (31%), followed by plunging ranula (17%) and lymphangioma (16%). Temporary injury to the facial nerve and wound infection were the major complications of surgical treatment. The types of neck masses in Northwest China differ from those previously reported, which may be attributed to genetic alterations in people of this race. The present report adds to the knowledge of diagnosis and treatment of neck masses in children in Northwest China, and brings out the demographic differences between races.