Oral & Maxillofacial Surgery

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A clinical decision-making rule to aid utilisation of Cone Beam Computed Tomography (CBCT) in third molar surgery
(Elsevier, 2023-12) Allan, Thomas; Knepil, Gregor; Allan, Thomas; Knepil, Gregor; Medical and Dental
CBCT can provide information to aid surgical planning, risk stratification of nerve injury, informed consent, and type of surgery (coronectomy or complete excision) in preparation for third molar surgery. The Royal College of surgeons has recommended the CBCT may be of use when “a close relationship between the third molar and the inferior dental canal” is identified on plain films.
The melolabial composite graft – a description of its utility, morbidity and outcomes in reconstruction of defects following surgical resection for skin malignancies
(Elsevier, 2020-12-21) Botha, Etienne; Knepil, Gregor; Botha, Etienne; Knepil, Gregor; Medical and Dental
Introduction and aims: Skin grafts are frequently used to reconstruct surgical defects of the nose. Frequently these grafts are poorly matched in terms of texture, colour, and thickness. Meloloabial composite grafts, having both skin and fat, and being harvested in close proximity to surgical defect have the potential for excellent cosmesis, and are conveniently located for ease of harvest by a single surgeon. The aim of this presentation is to describe the meloloabial composite graft, its utility in reconstruction of facial defects, morbidity associated with the procedure and outcomes following surgery.
The role of qualitative research in oral and maxillofacial surgery
(Elsevier, 2022-08-17) Baker, Collin; Knepil, Gregor; Courtney, Paul; Knepil, Gregor; Medical and Dental
Oral and maxillofacial research has utilised predominantly quantitative research approaches and qualitative methodologies have been applied with very narrow scope. Although qualitative surgical research is increasing in popularity there is a lack of patient voice within extant research and important aspects of patients’ experiences including preparation, perceptions of well-being, and functional outcomes are potentially overlooked. This provides researchers with significant opportunities to devise approaches that expand our understanding of the social contexts surrounding surgical interventions and associated outcomes and to develop better-informed approaches to research and practice. Reflecting on a novel research project involving OMFS patients this paper seeks to outline some distinct advantages of qualitative research based on researcher reflections. Firstly, we contend that understanding patients as collaborators within the research process helps to establish a research design that reflects the context and complexities of the phenomenon under investigation and increases the precision of the concepts being addressed. Secondly, interactive group-based data collection approaches create a space in which patients are able to explore aspects relating to OMFS. Thirdly, we suggest that patient interaction optimises the quality of data by providing participants with the opportunity to engage in conversation with those who understand the treatment processes. The final advantage concerns the intentional involvement of patients within the data analysis phase. We contend that interactive approaches to data collection and analysis where data are collected, analysed, compared and refined as new data are acquired helps to develop a conceptual explanation for the phenomenon in question that is both significant and relevant to the setting being studied. We conclude with recommendations for future research.
Reporting standards for occipitomental views in a department of oral and maxillofacial surgery and proposal of minimum data set
(MDPI, 2024-04-08) Rehman, Sooda; Knepil, Gregor; Knepil, Gregor; Rehman, Sooda; Medical and Dental
Objectives: According to the Faculty of General Dental Practitioners (FGDP), a clinical evaluation of any radiographic exposure is mandatory; otherwise, no exposure should be carried out. The occipitomental (OM) views for the assessment of mid-facial fractures—i.e., OM 0° and 30°—are common practice. We reviewed occipitomental radiographs to assess the current practice for clinical evaluation by the referrers. The purpose of this study was to design a template of a minimum data set for the interpretation of OM views and to promote a consistent approach in the clinical evaluation of OM views, thereby improving compliance with radiographic guidelines and quality assurance. Materials and Methods: We conducted a retrospective study to assess the standards of clinical evaluation of OM views by the referrer in the Oral and Maxillofacial Surgery Department of Gloucester Royal Hospital. Based on the initial assessment, we designed a template for the minimum data set. The study sample was then reassessed using the minimum data set template to ensure a consistent approach in the clinical evaluation of OM views. Results: The results highlighted an over-prescription of OM views in 60% of the study sample, as no fractures were identified. This study suggests that a consistent approach in the clinical evaluation of OM views could result in better diagnostic outcomes by reducing the risk of underreporting. Conclusion: The template that we have designed and tested on our study sample is an endeavour to improve local practice in the OMFS department. We hope this provides an opportunity to acknowledge the significance of a consistent approach in the clinical evaluation of radiographic findings and to initiate discussion for new ideas and interventions. Moving forward, we aim to reassess our current practice and compliance with local protocols, and to identify areas requiring further improvement.
Antimicrobial Stewardship in Skin Cancer Surgery. Assessing Best Practice in Reducing Significant Post-Operative Complications
(Oxford University Press, 2021-05-04) Walker, Kieran; Keward, Annie; Botha, Etienne; Knepil, Gregor; Walker, Kieran; Keward, Annie; Botha, Etienne; Knepil, Gregor; Medical and Dental
Introduction Antibiotic prescription is variable and with the growing frequency of antibiotic resistance, responsible use of antibiotics is necessary in keeping with Public Health England (PHE) Antimicrobial Stewardship guidelines. An audit was conducted to assess current practice of prophylactic antibiotics prescription in Skin Cancer Surgery in the department of Oral & Maxillofacial surgery. Method A retrospective case note review of patients who had undergone reconstructive surgery following skin cancer excision, recorded use of systemic and topical antibiotics and infective outcomes. Inclusion criteria were patients that had undergone surgical excision and reconstruction of skin cancer, followed by a wound assessment in an outpatient’s clinic with the outcome measure of infection defined by PHE Surgical Site Infection guidelines. A standard of 5% infection rate which is recognised by the British Association of Dermatologists was used. Results There was a 2% significant post op infection rate in patients with topical antibiotics used and 4.5% where neither systemic nor topical antibiotics were used. Immunocompromised patients had no increased incidence in significant post op infections occurring in either group. Conclusions The standard was met illustrating the low infection rate following reconstruction of Skin Cancer defects with or without prophylactic antibiotics and support a more discerning approach to antimicrobial prescribing.
Can we justify the continued use of botulinum toxin A in the management of myofascial pain?
(Elsevier, 2020-07-01) Farrier, Jerry; Farrier, Sarah; Haworth, Simon; Beech, Andrea; Farrier, Jerry; Farrier, Sarah; Beech, Andrea; Medical and Dental
We initially conducted a pilot study to evaluate the impact of botulinum toxin A (BtA) on increased masseteric mass associated with pain. After injection we assessed its impact on the muscle mass and the impact, if any, on reported pain, in a group of 10 patients who were refractory to conservative management. Results of this pilot study indicated that clenched and unclenched muscle dimensions showed no significant reduction (-0.82 clenched and −1mm unclenched). However, what did prove to be significant was an improvement in their pain scores as measured on a visual analogue scale (VAS). The mean VAS score before the injection was 8.2, and at six weeks after the injection it was 1.8. Following the pilot study we focused only on patients’ pain scores. Our main study included 48 patients (81 muscles) who suffered with pain secondary to increased masseteric size, and had recorded their pain score out of 10 on the VAS before placement of BtA into each affected muscle and again six weeks after the injection. Results showed a mean pre-injection pain score of 7.9 and a mean post-injection pain score of 2.9. Following the results of this study on reported pain alone, our Trust has allowed funding to provide the intramuscular injection of BtA in appropriately selected patients.
Complete remission of advanced, locally invasive basal cell carcinoma with vismodegib
(Elsevier, 2020-03-20) Glen, Peter; Farrugia, David; Farrier, Jerry; Glen, Peter; Farrugia, David; Farrier, Jerry; Medical and Dental
We report the case of a 71-year-old woman who developed advanced basal cell carcinoma (BCC) affecting the right eyebrow, invading the orbit. Globe displacement resulted in visual disturbances. Following multidisciplinary assessment, the tumour was deemed technically resectable for excision and right orbital exenteration. The patient however refused ablative surgical treatment; in view of her multiple comorbidities, the tumour was considered unresectable for her. Targeted therapy with vismodegib (Erivedge; Roche Pharmaceuticals) was therefore initiated in accordance with the patient's desire to avoid disfiguring surgery. After nine 28-day cycles of treatment, the tumour showed dramatic regression both clinically and radiographically. Mapping biopsies taken after 9 months confirmed the absence of any residual tumour, negating the need for ablative surgery. Grade 1 adverse events including muscle cramps, loss of taste, and reduced appetite were reported. Treatment was discontinued at 15 months owing to cumulative toxicity. The patient remains in remission 14 months after cessation of vismodegib. The use of vismodegib for advanced BCC is emerging and a number of reports exist. However, its application is mainly reserved for patients with locally advanced or metastatic disease, patients who are medically unfit for surgery, and cases where primary surgical resection would cause unacceptable disfigurement.
Coronectomy: not just for Wisdom Teeth
(MA Healthcare, 2020-10) Owen, Brandon; Oliver, Graham; Macey-Dare, Lucy; Knepil, Gregor; Knepil, Gregor; Medical and Dental
Coronectomy is most commonly associated with the management of impacted lower third molars where complete removal poses a high risk of inferior alveolar nerve damage. However, coronectomy may be indicated for the management of other teeth with a significant risk of morbidity. A case of a LL6 extended coronectomy is presented. The aim was to prevent inferior alveolar nerve damage, and ensure adequate crown and root removal to facilitate orthodontic alignment of the teeth. Surgery was aided by cone beam CT, and a piezo-surgical technique.
213 A Novel, Cost-Effective and Convenient Model for Simulating Facial Wound Repair
(Oxford University Press, 2021-05-04) Rowe, Aimee; Rapaport, Benjamin; Al-Najjar, Yousif; Chaudhry, Bilal; Leow, Julian; Al-Najjar, Yousif; Medical and Dental
We describe the use of a novel synthetic simulation pad for learning complex facial wound management including local flaps. The simulation pad is a cost effective and convenient model of facial wounds. We have compared the use of animal tissue to the simulation pad in the context of a workshop for surgical trainees and collected feedback from delegates. Methods Feedback was collected from 14 of 16 attending delegates. Results It was clear from feedback that animal tissue is not an ideal model of facial wounds with 71% of delegates stating that they did not consider it to be high-fidelity. The synthetic pad was rated more favourably with 100% of delegates reporting that it was a valuable exercise and well designed for local flaps. Conclusions It is imperative that training opportunities are high quality and useful to clinical practice. Techniques learnt in the context of a course or workshop are more valuable where targeted practice may occur following learning. The use of a synthetic pad is more amenable to continued practice where it may be taken home following a workshop. Feedback from this event suggests a well-designed synthetic pad is more useful than animal tissue in learning local flaps.
Implementation of “local safety standards for invasive procedures (LocSSIPs)” policy: not merely a tick-box exercise in patient safety
(Elsevier, 2020-02-25) Liew, Jonathan; Beech, Andrea; Liew, Jonathan; Beech, Andrea; Medical and Dental
The importance of patient safety in medicine and dentistry cannot be understated. Wrong tooth extractions account for approximately 25% of wrong-site surgery, and the implications for the patient, the team, and the institution can be profound. The development of national safety standards for invasive procedures (NatSSIPs) has led to the introduction of specialty-specific local safety standards for invasive procedures (LocSSIPs), with the aim of improving safety further. The implementation of outpatient LocSSIPs is recommended in clinical dentistry when surgical interventions regularly take place. We have implemented an outpatient LocSSIPs checklist for all procedures done under local anaesthesia in the oral and maxillofacial surgical unit of a large district general hospital. Feedback from a staff survey six months after its introduction was positive from both clinicians and nursing staff. Since its implementation 18 months ago no serious incidents have been reported and staff think that safety has improved. The reporting of incidents, for example, missing clinical notes and faulty equipment, has become more common (showing better awareness) and the development of a team-led approach has improved the running of the department.
Redeployment of junior maxillofacial surgery staff during COVID-19—the Gloucester ITU experience
(Elsevier, 2020-09-03) Richards, Jessica; Walker, Kieran; Coyle, Margaret; Beech, Andrea; Godden, Daryl; Richards, Jessica; Walker, Kieran; Coyle, Margaret; Beech, Andrea; Godden, Daryl; Medical and Dental
No abstract available
Exploring oral and maxillofacial dental core trainees’ perceptions of preparedness for practice after a high-fidelity simulation course to teach emergencies
(Elsevier, 2025-08-21) Cameron, Alice; Holden, Adam; Cameron, Alice; Holden, Adam; Medical and Dental
Many dental core trainees (DCT) feel unprepared to manage unwell patients and emergent situations. Simulation-based education (SBE) is a widely used educational intervention that can facilitate learning without compromising patient safety, and increase preparedness for emergencies. To supplement the predominantly positivist relevant literature, this study endeavoured to answer a research gap through in-depth, meaningful enquiry. The aim was to explore the perceptions of preparedness for practice of oral and maxillofacial surgery (OMFS) DCTs following a one-day, high-fidelity SBE course. The construct under study was preparedness for practice. The study was grounded in the conceptual frameworks of social cognitive theory, constructivist principles, and experiential learning theory. DCTs who had attended an SBE course underwent semi-structured interviews. Thematic analysis of the data generated four main themes: realism; safe learning environment; community of practice; and DCT as a unique experience. The results outlined the importance of physical and psychological fidelity within the SBE design, debrief facilitated by experienced, multidisciplinary faculty, and incorporation of learning through peer-observation, as important SBE features to advance DCT learning and subsequent preparedness. The conclusions reflected participants’ positivity about SBE as an educational technique to increase their preparedness. Overall, the findings illustrate a wide range of benefits from SBE in this context, the concepts of which other educationalists could consider adopting as a medical education strategy to improve DCTs’ preparedness for OMFS.
Conserving resources in the diagnosis of intraoral fibroepithelial polyps
(Elsevier, 2020-06-06) Lees, Thomas; Bogdashich, Lidiia; Godden, Daryl; Lees, Thomas; Bogdashich, Lidiia; Godden, Daryl; Medical and Dental
Fibroepithelial polyps (FEPs) are common, benign intraoral lesions that tend to develop slowly at predictable sites, often in response to local irritation or trauma. Historical precedent often results in referral to oral and maxillofacial surgery (OMFS) departments for biopsy, often irrespective of symptoms, and histological assessment. OMFS and pathology services are struggling to cope with an increasing workload that will potentially lead to widespread delays to diagnosis and treatment. Over the past 20 years, clinical pathways and guidance have been developed to ensure that healthcare interventions, such as the removal of third molars, tonsils, skin tags, and benign moles, are evidence-based, have a net patient benefit, and ensure the best use of finite NHS resources. However, no such guidance exists for intraoral lesions and we regard this as an oversight. We analysed the removal of 682 FEPs over a seven-year period and report sensitivities of 92.4% for a "confirmed clinical suspicion of an FEP" and 99.7% for a "confirmed clinical suspicion of a benign diagnosis". The incidence of non-benign disease was 0.3%. Primary care dentists should be able to diagnose and monitor FEPs and refer only if symptoms are serious or in high-risk patients or sites. Adopting this practice across the UK could free up to 1825 four-hour OMFS clinics, 405hours of consultant histopathologists' time, and recurring savings to the NHS estimated to be in the region of £620 000/annum. We believe that the removal of FEPs should be reclassified as an "intervention not normally funded", and the time and resources put to better use treating patients with lesions of questionable pathology.
58. A single centre review of oral biopsy samples of suspected vesiculobullous lesions sent for direct immunofluorescence study – a repeat offender
(Elsevier, 2022-12-19) Bean, Tom; Thomas, Mike; Farrier, Jerry; Bean, Tom; Thomas, Mike; Farrier, Jerry; Medical and Dental
Vesiculobullous diseases encompass a collection of chronic inflammatory disorders resulting from a self-antibody directed response against structural proteins within the oral mucosa.
140. The Impact of COVID-19 on Head and neck Surgical Specialties in Southwest England: Planning for Training Recovery
(Elsevier, 2022-12-19) Cameron, Alice; Holden, Adam; Beech, Andrea; Coyle, Margaret; Cameron, Alice; Holden, Adam; Beech, Andrea; Coyle, Margaret; Medical and Dental
Introduction/Aims The COVID-19 pandemic disrupted delivery of many surgical services and surgical training programmes. It is now clear that the most negative impact on training has been experienced by those in surgical specialties. We surveyed head and neck surgeons and report the impact of disrupted operating on training and discuss strategies for training recovery. Materials and Methods We disseminated a ten-question online survey to OMFS, ENT and Ophthalmology surgeons of multiple grades, working across 5 hospital sites in southwest England. We surveyed demographic aspects including age, gender, grade, and workplace. Questions were directed to analyse the impact of the pandemic on operating, training, surgical skills and CPD. Results/Statistics The response rate was 70%. 96.55% of respondents' elective operating was less than pre-pandemic numbers. 86% reported PPE had made their operating more difficult. 37% of respondents reported feeling they have de-skilled and 27% felt their confidence had reduced. 54% reported compromised training opportunities. However, many felt they had learned new skills, with 70% responding they now had better virtual working and remote consulting skills. Conclusions/Clinical Relevance Our multi-site survey quantitatively demonstrates the impact the pandemic has had on head and neck surgeons' operating and training. Training recovery is now a priority across all surgical specialties. We suggest a multifaceted approach to training recovery within OMFS, including use of simulation-based education.
Potential no man’s land for the 4th year dental graduate
(Elsevier, 2021-05-02) Bradshaw, Tristan; Godden, Daryl; Coyle, Margaret; Finley, Bart; Beaumont, Iffy; Beech, Andrea; Godden, Daryl; Coyle, Margaret; Finley, Bart; Beaumont, Iffy; Beech, Andrea; Medical and Dental
The Royal College of Surgeons of England stipulates that to hold a substantive specialty or associate specialist (SAS) grade post a person must be a minimum of 4 years post-graduation and have at least 2 years’ experience in their chosen speciality. We have noticed an increasing number of excellent applications for specialty doctor adverts posted by our trust without the necessary 4 years of post-graduate experience. Many of these applicants who do not comply with the RCS stipulations may be forced to take a job outside of their chosen career path. The reasons for this may be multifactorial, but it could have a worrying impact on their own future career and hospital service provision. We looked at the number of SAS grade adverts placed on NHS jobs in the year 2019 and the type of job advertised. We also considered the possible reasons for a rise in the number of applicants for SAS roles in oral surgery and oral and maxillofacial surgery, and what changes, if any, could be made to support this group of clinicians.
Juvenile Ossifying Fibroma in a 24-Year-Old Female with Systemic Comorbidities: A Rare Case Report
(Lippincott, Williams & Wilkins, 2025-07-22) Hajjat, Abdulnour; Al Burghil, Yasser Osama; Alqudah, Abdallah; Alsadi, Mohammad; Alqudah, Abdallah; Medical and Dental
Introduction: Juvenile Ossifying Fibroma (JOF) is a rare, benign, fibro-osseous lesion characterized by aggressive growth and potential for recurrence. It primarily affects children and adolescents, with two histopathological subtypes: trabecular JOF (TrJOF) and psammomatoid JOF (PsJOF). TrJOF typically presents in the jaws of younger individuals, often before the age of 15. Case Presentation: A 24-year-old female with chronic kidney disease (CKD) and hypertension presented with progressive teeth displacement, mobility, and facial asymmetry. Radiographic evaluation revealed a well-defined radiolucent lesion affecting both jaws, displacing teeth, and perforating the cortical bone. Biopsy confirmed the diagnosis of TrJOF. Due to the aggressive growth and contraindications for chemotherapy or radiation therapy, surgical excision was performed. Postoperatively, the patient remains under observation, with ongoing management of CKD to prevent complications and ensure recovery. Discussion: TrJOF is an uncommon and aggressive variant of JOF that typically affects younger patients. This case is atypical due to the patient's age and the involvement of both jaws. While JOF usually grows slowly, the lesions in this patient expanded rapidly, emphasizing the importance of prompt diagnosis and intervention. Surgical management remains the preferred approach, especially in cases complicated by systemic conditions like CKD. Recurrence rates vary widely, necessitating long-term follow-up. Conclusion: This case underscores the significance of early detection and multidisciplinary care in managing rare, aggressive jaw lesions such as TrJOF, particularly in patients with systemic comorbidities. Tailored surgical interventions and vigilant postoperative monitoring are crucial to achieving optimal outcomes and preventing recurrence.
Patient reported experiences and treatment outcomes of orthodontic patients treated within secondary care settings in the South West of England during the COVID-19 pandemic
(SAGE Publications, 2021-07-09) Jopson, Jenifer; Ellis, Pamela; Jerreat, Amelia; Kneafsey, Louise; Moore, Matthew; Day, Christian; Scott, Julia; Griffiths, Helen; Lee, Tara; Oliver, Graham; Fowler, Peter; Sherriff, Martyn; Ireland, Anthony; Oliver, Graham; Medical and Dental
Objective: To assess the impact of the temporary cessation of orthodontic services on patients undergoing treatment during the COVID-19 pandemic. Design: Two-phase multicentre service evaluation. Setting: Secondary care orthodontic departments in the South West of England. Materials and methods: Phase 1 - Patient-Reported Experience Measure questionnaire (PREM). The questionnaire was distributed to patients who had undergone orthodontic treatment during the COVID-19 pandemic once services had resumed. Phase 2 - assessment of treatment outcomes, specifically with the Peer Assessment Rating (PAR) Index. A total of 280 PAR scores were obtained from a cohort of patients treated before and during the pandemic. Results: A total of 711 PREM questionnaires were completed. Participants generally felt relaxed when visiting secondary care settings, orthodontic departments and whilst wearing orthodontic appliances during the pandemic. Nearly 40% of participants were concerned that the pandemic would impact on their treatment, particularly treatment length. Treatment outcomes revealed that patients treated before and during the pandemic experienced percentage PAR score reductions of 83.9% and 80.6%, respectively. Patients receiving treatment during the pandemic experienced longer treatment durations of 126 days. Conclusion: During the pandemic, low levels of anxiety were reported with respect to receiving orthodontic treatment in secondary care settings. Irrespective of the pandemic, a high standard of orthodontic treatment was provided. However, patient concerns regarding treatment length were justified.
Omega flap, A additional consideration for upper lip reconstruction
(Elsevier, 2023-09-12) Holden, Adam; Cameron, Alice; Felstead, Andrew; Holden, Adam; Cameron, Alice; Medical and Dental
No abstract available
Role of Enzymic Antioxidants in Mediating Oxidative Stress and Contrasting Wound Healing Capabilities in Oral Mucosal/Skin Fibroblasts and Tissues
(MDPI, 2023-06-30) Lohana, Parkash; Suryaprawira, Albert; Woods, Emma; Dally, Jordanna; Gait-Carr, Edward; Alaidaroos, Nadia; Heard, Charles; Lee, Kwok; Ruge, Fiona; Farrier, Jerry; Enoch, Stuart; Caley, Matthew; Peake, Matthew; Davies, Lindsay; Giles, Peter; Thomas, David; Stephens, Phil; Moseley, Ryan; Farrier, Jerry; Medical and Dental
Unlike skin, oral mucosal wounds are characterized by rapid healing and minimal scarring, attributable to the "enhanced" healing properties of oral mucosal fibroblasts (OMFs). As oxidative stress is increasingly implicated in regulating wound healing outcomes, this study compared oxidative stress biomarker and enzymic antioxidant profiles between patient-matched oral mucosal/skin tissues and OMFs/skin fibroblasts (SFs) to determine whether superior oral mucosal antioxidant capabilities and reduced oxidative stress contributed to these preferential healing properties. Oral mucosa and skin exhibited similar patterns of oxidative protein damage and lipid peroxidation, localized within the lamina propria/dermis and oral/skin epithelia, respectively. SOD1, SOD2, SOD3 and catalase were primarily localized within epithelial tissues overall. However, SOD3 was also widespread within the lamina propria localized to OMFs, vasculature and the extracellular matrix. OMFs were further identified as being more resistant to reactive oxygen species (ROS) generation and oxidative DNA/protein damage than SFs. Despite histological evaluation suggesting that oral mucosa possessed higher SOD3 expression, this was not fully substantiated for all OMFs examined due to inter-patient donor variability. Such findings suggest that enzymic antioxidants have limited roles in mediating privileged wound healing responses in OMFs, implying that other non-enzymic antioxidants could be involved in protecting OMFs from oxidative stress overall.

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