TS IS
A TE OF M XILLOFA ITU CI ST AL IN
ISTS & TECHN OL HET ST OG RO
P
TH E
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Advancement & knowledge for the benefit of patients
ISSN 1366-4697
WINTER 2014 VOLUME 13 ISSUE 1
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Contents
8
5.
Note from the Editor
6.
Editorial team & IMPT Council 2014
Featured articles
8.
Hollow prosthetic eyes
Dr Emma Worrell PhD, MIMPT
13. Post-burns splint therapy for the treatment of hypertrophic
scarring
Miss Sian Hayward BSc Dr Emma Worrell PhD, MIMPT
18. A unique orofacial “bottle opener” prosthesis.
13
Mrs H Silk MIMPT, Mr M Townend FIMPT, Mr A Kusanale, Prof Ilankovan, Mr SGS
22. Compartment Syndrome: Complications & Rehabilitation
Dr Emma Worrell PhD, MIMPT
26. Use of PEEK in maxillofacial reconstruction: a 6-year
review of cases
33.
Magnetic ocular prosthesis
18
S. Madhavarajan FRCSEd (OMFS), A. Abdullakutty BDS, MBBS, MRCS, J. Collyer FRCS, OMFS, K. Sneddon FRCS, OMFS
Dr Emma Worrell MIMPT Mrs Susan Insole MIMPT
35. Sports-related maxillofacial injuries; a critical review of
the literature
Muhanad M. Hatamleh, BSc, MPhil, MSc (Health Mgmt), Dip (MaxFac), MIMPT, PhD Ahed M. AL-Wahadni, BDS, MDSc, PhD, FFD RCSI, CPM
39. Technical note – Custom-made cusp trimming guidance splint
Mr Adrian Kearns MIMPT DPS
40. Articles of interest
26
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41. Instructions for authors
IMPT WINTER 2014 3
IMPT SCIENTIFIC CONGRESS
Guy’s, Kings and St Thomas’ Hospital London, England
9th – 11th September 2015
The scientific programme comprises of keynote lectures, short papers, a scientific poster exhibition and trade stands. A broad range of innovative and interesting maxillofacial prosthetics and technology topics will be discussed. All welcome. Enquiries to: naimesha.patel@kcl.ac.uk
Note from the Editor
Dear Members,
Welcome to the Winter edition of the IMPT journal.This sees a return to the printed format following positive feedback from the membership at the 2013 IMPT conference. An on-line version can also be found on the IMPT website. The journal’s aim is to promote an environment for study, discussion, add to our current evidence base and ultimately improve practice for all IMPT members. This publication has a variety of interesting papers and significantly, a first contribution from one of our profession’s new trainee practitioners (STPs). With a further 3 papers currently under revision for the next edition from another trainee practitioner, this bodes well for the future of publishing our journal and progressing our profession. The STP programme has now completed its first year. It is the responsibility of IMPT membership to help our trainees in any way possible: they are the future of our profession. As journal editor I would like to welcome our new 1st first year STPs but also I would like to wish all eight second year students good luck with their future MSc research projects. I eagerly await their submission to the journal. Much has happened this year and this is set to continue into 2015. The first World Coalition for Anaplastology (WCA) journal has recently been published and much positive feedback has been received. The IASPE conference in Linz, Austria was well attended from a UK IMPT perspective with contributions to the programme from myself, Heidi Silk, Jason Watson, Sian Hayward (STP) and Emma Worrell. In 2015 there is the IAA conference in Brazil in addition to our own IMPT conference, albeit a little closer to home in the equally sunny London. On the horizon is the possibility of a joint world conference between the IMPT, IAA, and IASPE, this is under discussion at the monthly WCA meetings. The best journal article from the last two editions will be awarded at the 2015 IMPT conference. A panel of 3 IMPT members will be selected to elect the best article. This award was won last year by Caroline Reed for her excellent article on prosthetic toes. Finally, may I take the time once again, to thank all who help in making the IMPT journal a possibility, in particular the deputy editor Emma Worrell, as all the editorial team, paper reviewers and contributors including authors, advertisers, publishers and printers. Barry Edwards MIMPT, MSc IMPT Journal Editor 2014 Mr Barry Edwards MIMPT, MSc Editor Barry has served on council before as minutes secretary and applied to rejoin after completing his MSc. He has now been editor of the Journal for four years.
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IMPT WINTER 2014 5
Editorial Team & IMPT Council 2014
Design & Publication H&P Design
Journal Editor 110a Main Road, Wilford, Nottingham NG11 7AL
Mr. Barry Edwards MIMPT, MSc
T. 0115 9140 640 www.handpdesign.co.uk
Queen Victoria Hospital, Maxillofacial Department, Holtye Road, East Grinstead, West Sussex RH19 3DZ barry.edwards@qvh.nhs.uk
Advertising Sales
Deputy Editor
Position vacant – anyone interested contact the journal editor
Emma Worrell MIMPT, PhD
Queen Victoria Hospital, Maxillofacial Department, Holtye Road, East Grinstead, West Sussex RH19 3DZ emma.worrell@qvh.nhs.uk
Copyright
Editorial Board
ISSN 1366-4697 © The Institute of Maxillofacial Prosthetists and Technologists 2006. No part of this publication may be reproduced without the permission of the editor. Permission is not required to copy abstracts on condition that a full reference to the source is shown.
Ginny Kingsmill BDS, PhD, FDS, RCS (Rest Dent)
Senior Clinical Lecturer, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AD
Pauline E Paul MIMPT, MSc
Principal Maxillofacial Prosthetist, Maxillofacial Laboratory, Neurology Building, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF
Muhaned Hatamleh MIMPT, BSc, Mphil, MSc, Dip (Max Fac), PhD
Kings in London. Senior Maxillofacial Prosthetist/ Reconstructive Science, Cranio-Maxillofacial Prosthetics Unit, King’s College Hospital NHS Foundation Trust, London, SE5 9RS
Membership and change of address All correspondence relating to membership of the IMPT should be sent via post or email to: Mark Cutler FIMPT, MBE
Queen Victoria Hospital, Maxillofacial Department, Holtye Road, East Grinstead, West Sussex RH19 3DZ mark.cutler@qvh.nhs.uk
Tel: +44 (0)20 3299 9000 ext 2524
E: muhanad.hatamleh@nhs.net
Subscriptions Membership of the IMPT is required to view the journal on the IMPT website. The contents page and abstracts will be accessible to non members and, should access to the Journal or individual articles be requested, these can be supplied for a fee of £3.00 per article or £20.00 for the complete Journal. Requests should be made directly to the Editor at the address below.
6 WINTER 2014 IMPT
Peter Ward Booth FDS FRCS
Maxillofacial Surgeon, Howbourne Oast, Buxted TN22 4QD
Jason Watson MIMPT, BmeD, Sci
Consultant MPT Healthcare Scientist, Maxillofacial Laboratory, Nottingham University Hospitals Trust, West Block B Floor, Derby Road, Nottingham NG7 2UH
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Editorial Board Cont.
Council Members
Naimesha Patel MIMPT, MSc
Floor 20 Guys Tower Wing Facial Prosthetic Rehabilitation Great Maze Pond London SE1 9RT
Caroline Reed MIMPT, BSc (Hons), DPS
Floor 20 Guys Tower Wing Facial Prosthetic Rehabilitation Great Maze Pond London SE1 9RT
Editorial Advisory Board
President
Kavin Andi FCRS (OMFS) FRCSEd FDSRCEng FHEA Pg Cert Med Ed MBBS BDS
President Elect
Steven Dover FDSRCS (Eng) FRCS (Eng)
Chair
Sarah Parkinson FIMPT, BSc (Hons)
Secretary
Fraser Walker FIMPT, MSc, LCGI
Minutes Secretary
Naimesha Patel MIMPT, MSc
Treasurer
Richard Eggleton FIMPT
Newsletter Editor
Adrian Kearns MIMPT, DPS
Regulatory Lead
Mark Cutler FIMPT, MBE
Journal Editor
Barry Edwards MIMPT, MSc
Dr Richard Bibb
Leicester, UK
Dr Harry Reintsema
Groningen, NL
Steve Worrolo
Birmingham, UK
Chris Maryan
Manchester, UK
Peter Evans
Wales, UK
Mark Cutler MBE
East Grinstead, UK
Colin Haylock MBE
London, UK
Ken Sneddon
East Grinstead, UK
Fraser Walker
Glasgow, UK
Steven Dover
Birmingham, UK
Website Editor and Communications Officer
Hitesh Koria MIMPT BSc (Hons)
Philip Federspiell
Germany
Registrar
Andrew Brown
East Grinstead, UK
Mark Cutler FIMPT, MBE
Mohit Kheur
India
Council Member
Dr Mohamed Bamber FIMPT, PhD
Dr Trevor Coward
London, UK
Joern Brom
Germany
Co-opted Council Member
Heidi Silk MIMPT
K.F. Moos OBE
Scotland
Co-opted Council Member
Edward Malton MIMPT
K. Thomas
Southend, UK
J. Collyer
East Grinstead, UK
Education Officer
Jason Watson MIMPT,BmeD,Sci
AIB Officer
Stefan Edmonson MIMPT, BSc (Hons), DPS
Company Solicitor
Fraser Macnamara MIMPT (Hons)
Student Representative
Amy Myers AIMPT, BSc (Hons)
Contacting the IMPT All correspondence to the IMPT should be sent via our website or email: info@impt.co.uk www.impt.co.uk
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IMPT WINTER 2014 7
Hollow prosthetic eyes Dr Emma Worrell PhD, MIMPT Maxillofacial Prosthetist, Maxillofacial Laboratory, Queen Victoria Hospital Foundation Trust, Holtye Road, East Grinstead West Sussex, RH19 3DZ Keywords: ocular prosthesis, prosthetic eye, ocular obturator, rehabilitation, hollow
Abstract The following article describes a new technique to produce a hollow eye prosthesis for one patient, followed by a series of case studies. Following the loss of an eye, ocular prosthetic rehabilitation proved difficult for these long-term anophthalmic patients. This paper describes the fabrication of hollow ocular prostheses and documents the results of the case studies.
Introduction A 72-year-old lady presented in clinic following a penetrating wound to the eyeball with a foreign body when she was 5-years old. The duty of care in the longstanding treatment after a childhood injury necessitates frequent remakes and remodelling for ocular patients. Immediately after the accident, enucleation of the eye was performed and a hydroxyapatite implant inserted. Rehabilitation in this patient became complicated by migrational implant issues, recently requiring a change to a high-density porous polyethylene, MEDPOR, implant only three years ago.1 Upper eyelid ptosis and lower eyelid sagging further complicated a good cosmetic result. Ageing produces a descent and sagging of the tissues, accompanied by gravitational descent.2-4 Her existing prosthesis had alterations made, by means of a ptosis shelf, however even with this prosthetic ‘cure’ the eyelid ptosis remained. The ptosis shelf increased the original weight creating a bulky, heavy ocular prosthesis, further exacerbating the pressure, irritation and reddening to the lower eyelid, as seen in figure 1. Constant pressure and irritation to the eye socket caused daily mucous discharge.5-9 The patient reported a noticeable pressure within the socket whilst wearing her existing prosthesis and a ‘sinking’ feeling of the prosthesis. Noticeably the iris pupil unit on first insertion was correct. After ten minutes the pupil appeared to drop by 2mm, with the lower eyelid sagging and stretching, unable to sustain the weight of the prosthesis, accompanied by an unsatisfactory aesthetic appearance. Further surgery, an ipsilateral blepharoplasty
8 WINTER 2014 IMPT
with a tightening and elevation of the right lower eyelid was performed in February 2013 to aid with the prosthetic rehabilitation.
Figure 1: On presentation
“The patient reported a noticeable pressure within the socket whilst wearing her existing prosthesis and a ‘sinking’ feeling of the prosthesis.” Method and materials Fabrication Post surgery the patient presented with a noticeably smaller eyelid aperture. Assessment of the socket revealed a large defect behind a markedly reduced opening. An alginate impression in a custom made ocular impression tray of the patient’s right eye socket was taken. From
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
“Tests demonstrated a mouldable substance, hard when set, able to be packed around with acrylic, and revealed a clean void when removed.”
this impression a stone cast was poured. An ocular wax pattern was sculpted, finished and tried into the socket. The iris pupil (IP) unit was then positioned accurately onto the wax pattern, ensuring that the pupil unit maintained the correct gaze position both during movement and at rest. In the maxillofacial laboratory the wax pattern was sterilised and a two-part mould in dental stone was made in the traditional manner (Figure 2). To fabricate the hollow eye the wax was removed and a sheet 0.5mm wax relief placed on both sides of the flask. The IP unit was then repositioned into the superior part of the flask (Figure 3).
Figure 2: Traditional mould
Figure 3: Mould with wax relief in-situ
To make the hollow within the eye, fabrication of a mould matrix was required. The matrix properties needed to be a substance that was hard when set, able to take the pressure of the acrylic being packed around it under the bench press and easy to remove once cured. The full evacuation and removal of the matrix through a tiny pin hole was required to leave a clean, light void within the eye. Initially a mix of 25% plaster and 75% pumice was used as a matrix. Removal of this proved time-consuming and a surface residue remained within the eye. After experimentation by the author, a sugar mixture of water and caster sugar, in a ratio of 1:5 was used, as this met the required matrix properties. Tests demonstrated a mouldable substance, hard when set, able to be packed around with acrylic, and revealed a clean void when removed.
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Separating film was then applied to both sides of the mould and the dry, mouldable sugar solution placed in the mould and placed under the bench press. After 10 minutes, the film was removed which allowed the sugar matrix to set overnight at room temperature. Once set, the sugar matrix was repositioned onto the fit surface relief wax (Figure 4). The wax was boiled off from around the IP unit and separated in the usual manner. Scleral acrylic was packed around the IP unit, a separating film placed over the sugar matrix and replaced under the bench press (Figure 5). Once packed the mould was opened, the film removed and the sugar matrix placed into the scleral acrylic section. The fit surface half of the mould was boiled off and separated and the remaining scleral acrylic packed into the mould. The acrylic was cured overnight in the usual manner to eliminate as much free monomer as possible.
Figure 4: Sugar Matrix
Figure 5: Polythene sheet in-situ
The eye flask was carefully opened, the eye removed and mould maintained as this same mould would be used for the clear cornea component. The surface area of the scleral acrylic was trimmed to reveal the IP unit. The space within the mould allowed for the scleral characterisation and clear corneal covering of the ocular prosthesis. Finally, a small pilot hole was drilled and the eye placed in boiling water for 10 minutes, causing
IMPT WINTER 2014 9
the sugar to dissolve revealing the fully evacuated void (Figure 6). A small addition of sclera self-cure acrylic sealed the pinhole. Characterisation stains and veining were added (Figure 7). The prosthesis was sealed with superclear heat cure acrylic (which covers the self-cure acrylic pinhole plug) and put on a long cure overnight. Standard manufacturing methods were used to trim and polish the hollow eye (Figure 8) and conventional disinfection and sterilisation methods could be performed.
Figure 6: Cavity within eye
hollow prosthesis was fabricated and the void within the eye had reduced the prosthesis weight by a third (Figure 10). Aesthetically the iris pupil unit remained in alignment and no ‘sinking’ feeling of the prosthesis was reported. The patient had gone from only being able to wear her prosthesis ‘for best’ to constant wear, experiencing no problems and markedly reduced mucous build up and discharge.
“She reported a significant improvement with aesthetics, increased comfort, increased wear time of prosthesis and an improvement in mucous discharge.”
Figure 7: Characterisation stains and veining
Figure 8: Finished hollow eye
Results
Figure 10: Solid vs hollow eye weight
The patient was asked to fill in a questionnaire comparing the solid prosthesis with the new hollow prosthesis. She reported a significant improvement with aesthetics, increased comfort, increased wear time of prosthesis and an improvement in mucous discharge (Figure 9). The
Following the successful outcome of the first patient, a small case series will now be presented.
Solid
Hollow Figure 9: Improved aesthetics of the hollow eye
10 WINTER 2014 IMPT
Table 1: Solid vs Hollow weight Patient no
Solid
Hollow
% Lighter
1
2.9g
1.9g
34.5%
2
5.9g
3.4g
42.4%
3
4.3g
2.7g
37.2%
4
3.3g
2.1g
36.4%
5
6.9g
4.0g
42.0%
6
2.8g
1.9g
32.1%
7
3.6g
2.2g
38.9%
8
4.6g
3.1g
32.6%
9
3.6g
2.4g
33.3%
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Table 2: Questionnaire results - Overall experience (see Legend guide) 3 2 1 0
1
2
3
4
5
6
7
8
9
-1
Table 3: Questionnaire results - Individual factors (see Legend guide) 3
2
1
solid prostheses versus their hollow eyes demonstrates a significant reduction in weight, mean = 36.6%, as shown in Table 1. The patient questionnaires reported marked improvement in their overall prosthesis experience, shown in Table 2. In addition improvement in prosthesis use, lessened mucous discharge, increased comfort and better aesthetics was reported, as illustrated in Table 3. Increased movement of the prostheses was also reported. In every category their hollow eye scored higher, reporting improvements compared to their experiences with their existing solid eye prosthesis. The patients’ described their solid prostheses as overburdening the lower eyelids, causing discomfort, irritation and reddening, whereas the new lightweight prostheses are unobtrusive, comfortable and much improved aesthetically. Figure 11 shows the typical sunken appearance of these complex patients’ solid eyes (above) and below the improved aesthetics, comfort and function with their hollow eye.
Conclusion
Huge difference
Good improvement
Some improvement
No difference
Aesthetics
Comfort
Mucous discharge
-1
Prosthesis usage
Cleaning regime
Lubrication
0
Worse than solid eye
Solid
The advantage of a hollow prosthesis is that it replicates the exact size, shape and volume of the patient’s existing solid prosthesis. Creating a hollow medical device enhancing aesthetics, comfort, added functionality, utilising traditional fabrication methods is both innovative and cost effective as a treatment option. A hollow prosthesis can increase patient satisfaction by reducing irritation and discharge, increase of wear time and produce significantly lighter prostheses.
“The advantage of a hollow prosthesis is that it replicates the exact size, shape and volume of the patient’s existing solid prosthesis.” Acknowledgements
Hollow Figure 11: Improved Aesthetics
Discussion This small case series incorporates patients with large empty sockets due to disease, trauma, penetrating wounds, gunshots, insufficient implant volume or with no orbital implant. Direct comparison of these patients’
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I would like to thank Mr Raman Malhotra for his input into this paper and the photographic department at the Queen Victoria Hospital for the provision of the images used in this paper. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. There were no competing interests whilst making this medical device. All medical devices have to be compliant with EU directive 93/42/EEC (hospital medical device number:CA000530).
IMPT WINTER 2014 11
References 1. MEDPOR Oculoplastic Implants, Michigan,USA. http://www.stryker.com/en-us/products/ Craniomaxillofacial/MEDPOR/MEDPOROculoplasticImplants 2. Garg A, Alio JL. Surgical techniques in Ophthalmology: Oculoplasty and reconstructive surgery. Jaypee Brothers Medical Publishers (P) Ltd First Edition 2010 ISBN 978-81-8448-817-3 3. Spinelli HM. Atlas of Aesthetic Eyelid and Periocular surgery. Saunders, Elsevier Inc.2004 ISBN 0-7216-8633-8 4. Worrell E. What factors affect Maxillofacial Prosthetists in the rehabilitation of the anophthalmic socket. Part 3 of 3 in an ocular prosthetic series for the maxillofacial prosthetist. The Journal of Maxillofacial Prosthetics & Technology Summer 2013.12.Issue 1. pg33-36 ISSN 1366-4697 5. Pine K, Sloan B, Stewart J, Jacobs RJ. Concerns of anophthalmic patients wearing prosthetic eyes. Clin Experiment Ophthalmol. 2011Jan;39(1):47–52.doi: 10.1111/j.1442-9071.2010.02381.x. 6. Evaluation of lubricants for the prosthetic eye wearer. Fett DR, Scott R, Putterman AM. Ophthal Plast Reconstr Surg. 1986;2(1):29–31. doi: 10.1016/j.optm.2009.11.003. 7. Osborn KL, Hettler D. A survey of recommendations on the care of ocular prostheses. Optometry. 2010Mar;81(3):142-5. 8. Features and management of an acute allergic response to acrylic ocular prostheses. Patel V, Allen D, Morley AM, Frcophth RM. Orbit. 2009;28(6):pg339-41. doi:10.3109/01676830903104660. 9. Lee A, Elsie MB. Artificial eyes and tear measurements 1. J Am Soc Ocularists.1981a:26-28.
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THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Post-burns splint therapy for the treatment of hypertrophic scarring Miss Sian Hayward BSc Dr Emma Worrell PhD, MIMPT STP in Reconstructive Science, Maxillofacial Prosthetics Laboratory, Queen Victoria Hospital Foundation Trust, Holtye Road, East Grinstead, West Sussex, RH19 3DZ
Abstract The following article describes the treatment of a patient with hypertrophic scarring as a result of third degree burns following an industrial accident. After several skin grafts to his upper body, head and neck, the patient presented with hypertrophic scarring that was both disfiguring and movement limiting. The fabrication of the post-burn splint and subsequent follow up is discussed.
Introduction Hypertrophic scars are red, raised, firm, nodular bundles of predominantly collagenous tissue.1 The scars can be dry, irritable and itchy while being both disfiguring and disabling for the patient. Clinically, hypertrophic scarring slowly becomes pale, flat and smooth as it matures but this can take years.2 The use of splint therapy utilizes the application of pressure to re-model the hypertrophic scar tissue and accelerate the normal tissue maturation process.2 Furthermore, the facial splint forms a physical barrier to dirt and bacteria and in addition prevents patient’s emollients, i.e. creams and ointments, from being wiped away or evaporating into the atmosphere.2
Case History This patient, a 28-year-old male, suffered third degree burns to his complete upper body, arms, hands, head and neck whilst at work. This was the result of paint thinners becoming ignited at his car-spraying workshop. Multiple skin grafts to his forearms, upper body, head and neck have been successful. The patient on initial assessment is shown in Figure 1. Post-burn splint rehabilitation commenced approximately one year ago. He maintains a strict regime of physiotherapy and a comprehensive massage programme. Currently, he is on his fourth burns splint and awaiting further surgery. A forthcoming commissure operation to improve mouth opening is planned.
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“The use of splint therapy utilizes the application of pressure to re-model the hypertrophic scar tissue and accelerate the normal tissue maturation process.” Presentation On examination of the patient notes and pathology reports, it was noted that this patient was not MeticillinResistant Staphylococcus Aureus (MRSA) or MultiResistant Acinetobacter Baumannii (MRAB) positive.3,4 A high percentage of burns patients do present with a raised infection status due to the nature of the typically open, oozing wounds and multiple skin graft sites.5 The general condition and mobility of the skin is documented in the patient’s medical records. The fibrous nature of the remaining hypertrophic scarring was clinically assessed by touch, assessing the sensitivity to pressure and blanching of tissues. Clinical assessment identified areas that had responded well to treatment with pressure therapy. These areas had become less erythemic and appeared to have flattened and softened on palpation. Further examination revealed more areas that required pressure treatment. Any areas of contracting and contorting hypertrophic scarring affecting the facial tissues were prioritized.
IMPT WINTER 2014 13
Evidence of previous splint therapy had improved the webbing at the inner canthus of the patient’s eyes, the overall shape of his nose, and the profile of his lips as shown in Figure 2.
Firstly, to further reduce the webbing at the inner canthus, to counteract the contraction of scar tissue which, if left, could become painful, obstruct vision and ultimately could damage his eyesight. Secondly, prevention of Simian deformity, the deformation of nasal tissues as a result of hypertrophic scarring contracting, causing a pulling effect on the nasal tissues, flattening and widening the nose.2 Thirdly, mouth opening had progressively become constricted due to the contraction of the obicularis muscles and associated scar tissue bands. A Therabite® (Platon Medical, Eastbourne, BN21 2HZ) device had been prescribed and this use was ongoing.6
Figure 1: Presentation prior to treatment
The patient has responded well to previous post-burn splint therapy. A marked difference in skin tone, texture and softening of features is evident in pre and post-burn therapy photographs (Figures 6 and 7). A noticeable demarcation line can be clearly seen, highlighting the patient’s commitment to wearing the burn splint and the maintenance of a strict physiotherapy regime, in combination with a comprehensive massage programme.
Figure 2: Patient wearing the splint
Figure 3: Presentation after six months of splint therapy
Figure 4: Presentation after twelve months of splint therapy
Case History Three main focus areas were identified, illustrated in figure 5. Figure 6: Pre pressure therapy
1 3
3
Figure 7: Post pressure therapy
“The patient has responded well to previous post-burn splint therapy. A marked difference in skin tone, texture and softening of features is evident in pre and post-burn therapy photographs”
Figure 5: Target areas identified
14 WINTER 2014 IMPT
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Materials and methods To fabricate the splint, a full-face impression of the patient was taken to produce a working stone model, Figures 8-11. Petroleum Jelly was applied to the patient’s eyebrows, eyelashes, hairline and granulated skin areas. This is to prevent trauma to the tissues on removal of the impression material. Alginate impression material was selected as it is straightforward to use, has adequate working time, is cost effective, water-based and readily available. When undertaking a full–face impression, it is essential that the patient is informed of the impression procedure at the outset. Reassurance of maintaining the airway throughout the impression technique was given. Initially alginate was applied to the nostrils and mouth. A backing strip of gauze applied with a dual purpose of binding the alginate for support and as a mechanical bond, in readiness for the plaster of paris backing at the next stage. Carefully and methodically, the treatment area was covered in alginate and backed with gauze. Communication and constant reassurance was given throughout the procedure. Prior to applying the plaster of paris backing, a description of the added weight and exothermic reaction was again reiterated to the patient. Once the alginate was adequately supported by the stone backing, the impression was gently eased away.
“When undertaking a full–face impression, it is essential that the patient is informed of the impression procedure at the outset. Reassurance of maintaining the airway throughout the impression technique was given.” The impression was then disinfected by submerging in Disfin®(Bracon Dental Laboratory Products, Ethingham, TN19 7AL) solution for ten minutes before pouring the model, using a type IV dental stone strong enough to withstand the subsequent manufacturing processes.7 The dental stone was applied to all areas of the impression and built up to a thickness of roughly 15mm to reduce unnecessary weight of the resultant model and prevent distortion of the large alginate facial impression, Figure 9. Once the stone had set, tools were used to carefully prize the impression plaster and alginate from the model. Areas where pressure was to be applied was identified and marked on to the model using a pencil, (Figure 10).
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A plaster knife was used to remove 1-2mm from these areas in order for the final splint to generate the desired amount of pressure. The scarred surfaces of the model were then smoothed with sandpaper, reducing any uneven textures, and holes drilled in the deepest parts of the model where extra suction would be required at the vacuum forming stage, as shown in Figure 11.2
Figure 8: Full face impression
Figure 9: Dental stone mould
Figure 10:Target areas identified
Figure 11: Prepared model
The model was coated with two layers of Unifol® (Bracon Dental Laboratory Products, Ethingham, TN19 7AL) separating medium and left to dry.8 It was then placed into the vacuum forming machine and heaters were switched on and left for thirty minutes to reach the correct temperature. A 2mm thick thermoplastic sheet (North Sea Plastics, 2-5 Campsie Road, G66 1SH) was clamped into place and heaters drawn across. After thirty seconds the heaters were pushed away, the sheet rotated and re-clamped in position and the heaters repositioned. This process was repeated for two to three cycles until the sheet was sufficiently heated on both sides. The heaters were finally pushed away and the sheet was vacuum drawn onto the model. However, in certain cases it may be necessary to manually apply extra pressure in areas such as the inner canthus to ensure the splint is close fitting in these areas. All facial splints at Queen Victoria Hospital are adapted from 2mm thick thermoplastic sheets, in comparison to neck splints,
IMPT WINTER 2014 15
which are 3mm thick. The model and splint were left to cool for five minutes before removing from the vacuum forming machine. Using a tri-cutter burr, the splint was removed from the model and cut to a rough extension with preliminary holes for the patient’s eyes mouth and nose. At this stage, only the model can be used as a guide. Edges were smoothed and at the patient’s next appointment the splint was offered up to the patient and necessary adjustments made to avoid the patient’s eyelashes or lips being caught, and to ensure the patient had a full range of movement while wearing the splint. Once the extensions were correct and the patient expressed no discomfort, traction hooks were secured to the splint. Traction hooks were adapted from 0.8mm wire and were then heated in a flame in order to secure them into the splint. (Figure 12) They were further secured in place with the use of auto-polymersing polymethyl methacrylate (PMMA) applied to the surface, while manually applying pressure until polymerised. Traction hooks allowed elastic straps to be attached by the patient in order to apply therapeutic pressure, as showing in Figure 13. These must be secured in a suitable position and angled in order to exert traction force in the right direction and to ensure that the elastic straps sit comfortably on the patient and do not displace over the top of their head.2 Alternatively Velcro straps are available, however they do not have the ability to exert the same amount of traction force.
“Using a tri-cutter burr, the splint was removed from the model and cut to a rough extension with preliminary holes for the patient’s eyes mouth and nose.”
Discussion The progress the patient has made as a result of the pressure therapy that was provided for him at Queen Victoria Hospital is demonstrated in Figure 14. During treatment, patient compliance was an important factor. Each patient must wear the splint for 18-23 hours a day in order to see the benefits of treatment.1,2,6,7,8 Patient non-compliance is common and is usually because of the appearance of the splint or discomfort during wear as a result of heat or ulceration. Ulceration or tissue breakdown can also be a result of excess pressure and this should be closely monitored and treatment modified or suspended if necessary.9 This particular patient, as well as others, finds the splints claustrophobic and uncomfortable when wearing at night and requires sleeping tablets to be prescribed in order for him to be able to sleep while wearing it.
Figure 14: Patient Progress
Due to the constant application of pressure, the patients’ mouth is kept in a relatively static position. To prevent permanent restriction in movement (ankylosis), it is important that a simple exercise regime is adopted, whereby several times a day he exercises his mouth using appliances such as a Therabite.® Regular massaging of the skin was also recommended to reduce scarring and improve mobility. Anecdotally, this patient massages his face twice a day with a Jade roller. There is no hard evidence for the use of this stone but he has found that since applying this cold pressure regularly he has seen beneficial results. Additional splinting and surgery has subsequently been planned to further improve mouth opening.
General considerations with splint therapy
Figure 12: Traction hook
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Figure 13: Splint positioned on the patient
In addition to the mutual understanding of the required motivation of the patient, a cleaning regime must also be agreed between the Maxillofacial Prosthetist and the patient. The patient should remove the splint every two hours to wash and dry both the splint and his face. Soap and water is sufficient, as harsher cleaning products may alter the mechanical properties causing crazing or cracks to develop. The patient should then apply any emollient creams or ointments they may be using before reapplying the splint.
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It is also important to consider the psychological wellbeing of the patient. Burns patients with significant hypertrophic scaring, such as this case, are likely to have a significant emotional response to their permanent disfigurement, and may need psychological support alongside their physical rehabilitation.10 Patients are reviewed approximately at one month intervals but each splint should last 8-10 weeks. At each review appointment patients’ progress is clinically assessed as described earlier and recorded in the medical records. As the hypertrophic scar tissue changes, new impressions and models will need to be produced to manufacture new and effective splints. Noticeable results can be achieved between 18 months and two years, after this time aesthetic improvements may be minimal.
“Burns patients with significant hypertrophic scaring, such as this case, are likely to have a significant emotional response to their permanent disfigurement.”
References 1. Atiyeh, B.S. (2007) ‘Nonsurgical management of hypertrophic scars: Evidence-based therapies, standard practices, and emerging methods.’ Aesthetic plastic surgery, 31 pp. 468-492 2. Cutler, M. (1991) The Brasier Award Dissertation 1987, Fellowship by Thesis. Institute of Maxillofacial Prosthetics 3. Public Health England’s national health protection service (2013) MRAB guidelines http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Acinetobacter/Guidelines/ 4. Public Health England’s national health protection service (2014) MRSA Staphylococcus Aureus http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/StaphylococcusAureus/ 5. Branski, L.K. Al-Mousawi, A. Rivero, H. Jeschke, M.G. Sanford, A.P. Herndon, D.N. (2009) ‘Emerging infections in burns.’ Surg Infect, 10(5) pp. 389-397 6. Shons, A.R. Rivers, E.A. Solem, L.D. (1980) ‘A rigid transparent face mask for control of scar hypertrophy’ Annals of Plastic Surgery, 6 (3) pp. 245-258 7. Mustoe, T.A. Cooter, R.D. Gold, M.H. Hobbs, R. Ramelet, A.A. Shakespear, P.G. Stella, M. Teot, L. Wood, F.M Zeigler, U.E. International Clinical Recommendations on Scar Management 8. Alster, T.S. Tanzi, E.L. (2003) ‘Hypertrohpic scars and keloid: etiology and management.’ American Journal of clinical dermatology, 4 (4) pp. 235-243 9. Leung, K.S. Cheng, J.C. Clark, J.A. Leung, P.C. (1984) ‘Complications of pressure therapy for post-burn hypertrophic scars. Biomechanical analysis base on 5 patients.’ Burns Including Thermal Injury, 10 (6) pp. 434-438 10. Blakeneya, P.E. Rosenberga, L. Rosenberga, M. Faberb, A.W. (2008) ‘Pychosocial care of persons with severe burns.’ Burns, 34 (4) pp. 433-440
Conclusion This paper has described the process of manufacturing a vacuum formed thermoplastic face splint for the treatment of a burns patient. The improvements that can be achieved by prosthetic splint therapy are demonstrated in the multiple images of this particular case but it is stressed that results rely on the motivation and commitment of the individual.
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IMPT WINTER 2014 17
A unique orofacial “bottle opener” prosthesis Mrs H Silk MIMPT, Mr M Townend FIMPT, Mr A Kusanale, Prof Ilankovan, Mr SGS Ellis. Poole Hospital NHS Foundation Trust heidi.silk@poole.nhs.uk
Abstract This case study describes the complete rehabilitation of a patient with a left-sided extended hemimaxillectomy with orbital exenteration. This unique and complex orofacial prosthesis combines both implant and magnetic retentive components within it. A removable implant retained support structure sustains both the obturator and the orbital prosthesis. Magnetic retention provides a quick, self-locating and inter-locking fit to the various components. The prosthesis removal is straight forward and allows easy access for the patient or carer to maintain hygiene and debridement of the cavity.
Introduction A 79-year-old caucasian male underwent a left-sided extended hemi-maxillectomy and orbital exenteration for T4 N0 M0 poorly differentiated squamous cell carcinoma of the left maxillary antrum in 2003.1 The patient subsequently had further surgery, left-sided elective neck dissection for nodal disease and chemo radiotherapy. Whilst overall the patient and his wife/carer were coping well, the hygiene of the orbital cavity was challenging and the constant use of an eye patch caused drying and crusting of the secretions, occasionally causing trauma to the tissues on debridement.2 Retention of the existing obturator was poor, and there was progressive dental deterioration with expected tooth loss of both upper canines. To address both issues, extra retention prior to rehabilitation was required. Consequently orbital rim implants were proposed to support and retain a bar to extend down into the oral cavity to assist with retention of both the obturator component but also retain the orbital prosthesis. It was hoped that the use of an orbital prosthesis would seal the orbital defect, keeping it both moist and to prevent any mucous secretions from hardening, which would facilitate easier maintenance of the defect area.
Method and materials After discussion, four, 10mm Nobel Bio care intra-oral implants were placed peri-orbitally, two superiorly and two in the lateral border of the supra-orbital ridge.3
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“Whilst overall the patient and his wife/carer were coping well, the hygiene of the orbital cavity was challenging.” On initial assessment a treatment plan incorporating a semi-permanent gold or titanium bar structure soldered onto the orbital implant abutments was considered. However, this could be problematic working in the confined space within the orbital defect, bearing in mind the patient and his carer’s manual dexterity. Furthermore, the metal semi-permanent substructure could limit access to the accumulation of mucous within the cavity, exacerbating the current cleaning difficulties especially cleaning around the new implant abutments. An alternative method of retention was designed and fabricated to overcome the multiple hygiene issues. The design of the connector had to extend from the implants down into the oral cavity to communicate with the intraoral dental component (Figure 1). The masticatory forces were significant in the stabilisation of the device and were assessed and evaluated to prevent displacement of the connector when in function. The shape, depth and contour of the connector pattern were considered carefully. The design would need to allow optimum space for the iris pupil unit and sculpting of the orbital component part of the orofacial prosthesis (Figure 2).
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Once fabricated the connector was positioned onto the patient, see Figure 3. The patient fondly refers to the connector component part as his “bottle opener”.
positioning of the iris pupil unit and the anatomical sculpting of the orbital prosthesis. The connector extended down to communicate with the oral cavity, shown in figure 2. This communication enabled connection to the superior aspect of the obturator via a multi-purpose magnet. The multi-purpose magnet was incorporated into the base of the connector which was then processed in clear heat cure polymethylmethacrylate (PMMA).
“The shape was contoured to allow for the positioning of the iris pupil unit and the anatomical sculpting of the orbital prosthesis.” Figure 1: Orbital connector with dental device
Figure 2: Communication with oral cavity
The opposing section of the connector magnet was then secured accurately onto the superior aspect of the dental obturator. The connector was then positioned onto the orbital implants, the opposing magnet attached and Epiform Flex impression material was then applied around the magnet.5 The patient was instructed to bite together throughout the duration of the impression stage. The wash impression of the superior aspect of the obturator, incorporated the communication with the orbital cavity of the bottle opener connector, ensured a peripheral seal and provided lateral stability see Figure 4.
Figure 3: Connector in-situ
The innovative connector design incorporated a large multi-purpose magnet for the connection to, and retention of, the dental obturator.4 The connector also encompassed four maxi S-range magnets to locate to the four implants and housed the magnet keepers for the retention of the orbital prosthesis.4 The whole concept of the bottle opener connector is that it allows for easy, self-locating placement onto the orbital rim positioned implants followed by insertion of the obturator and lastly the orbital prosthesis.
Fabrication Initially an accurate impression of implant fixtures and surrounding soft tissue was taken.5,6 A wax prototype of the connector was fabricated incorporating four maxi S-range magnets to retain the structure to the magnaabutments. The shape was contoured to allow for the
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Figure 4: Impression of oral communication with the bottle opener connector.
On completion of the connector and the dental obturator component parts the sculpting of the soft tissues and eye positioning was carried out. The orbital prosthesis carving incorporated an acrylic substructure (PMMA)
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which housed a further three maxi size magnets. Magnet keepers were then positioned onto the connector to directly correspond with the magnets within the wax carving. The optimum position for the retention magnets was established to enable an even pressure onto the patient’s soft tissue to maintain a peripheral seal around the orbit. Again magnets were chosen due to the selflocation ability, the ease of use and of cleaning. The silicone M511 was colour matched to the patient, a dental stone mould was fabricated and the silicone cured in the usual manner (Figure 5).4 Figure 9: Worms eye view
Figure 5: Silicone colour swatches and dental stone mould Figure 10: Complete Orofacial
Extrinsic colour was added at the fitting of the prosthesis and the sewing of eyelashes and eyebrows finalized the fabrication (Figures 6-10).
A custom-made tool was supplied to patient and carer to help preserve the delicate edges of the prosthesis, to increase the prosthesis lifespan and also to aid removal. During treatment the upper canines required removal as predicted and these were later added to the obturator (Figures 9,10).
Discussion The unique multi-part orofacial prosthesis described in this paper has several advantages specifically designed for this patient’s particular requirements.
Figure 6: Bottle opener in-situ
Figure 7: Prosthesis in-situ
This innovative design overcomes the manual dexterity issues allowing simple insertion, removal and maintenance of all the component parts, implants and the defect cavity itself. Both the retention and stability of the obturator and the orofacial prosthesis have been greatly improved. Hygiene of the orbital cavity has been enhanced and the peripheral seal of the orbital defect now prevents the previous problems caused by drying and crusting of the secretions. To the author’s knowledge this modification is unique and has not been published before.
Figure 8: Superior view
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Conclusion This case study demonstrated a unique removable connector in the complete rehabilitation of a patient with a left-sided extended hemi-maxillectomy with orbital exenteration. The challenge to design and create this innovative approach to retain and support this complex modular removable orofacial prosthesis was stimulating and highly successful. Acknowledgements: We would like to thank Becky Ward, Medical Photography at Poole Hospital for production of images in this article.
References 1. Campbell WJ et al; Head and Neck Cancer - Squamous Cell Carcinoma, eMedicine, Dec 2010 2. Ward Booth P. Maxillofacial Surgery. 2nd ed. Churchill Livingstone. Management of orofacial Infections. Chap.80.1550.2007 3. Williams & Warwick Grays Anatomy. 36th ed. Churchill Livingstone. Osteology. Chap.3.296-9.1980 4. Technovent Ltd, info@technovent.com 5. Epiform flex impression material www.institut-schilling.com UK supplier Claude Hill Dental, Tel 01384 262121 6. M518 Coform Hard impression material, Technovent Ltd. info@technovent.com
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Compartment Syndrome: Complications & Rehabilitation Dr Emma Worrell PhD, MIMPT Maxillofacial Prosthetist, Maxillofacial Laboratory, Queen Victoria Hospital Foundation Trust, Holtye Road, East Grinstead West Sussex, RH19 3DZ
Abstract Following a life-threatening overdose in 2010 this patient suffered rhabdomyolysis, compartment syndrome, diabetes and renal failure. She has been attending the Queen Victoria Hospital (QVH) for the last four years as part of her rehabilitation. This article describes the methods, materials and techniques used in rehabilitating a severely disfigured young woman. The medical complications of rhabdomyolysis, compartment syndrome and the full rehabilitation emotionally, physically and aesthetically with a custom-made calf implant is described.
Introduction
in May 2012. This is rarely performed to establish the diagnosis of this condition, however acute compartment Compartment syndrome is a painful and potentially syndrome in an extremity is a limb-threatening surgical serious condition caused by bleeding or swelling within emergency.2 Diagnosis of the condition based on clinical an enclosed bundle of muscles (a muscle ‘compartment’).1 information is paramount and urgent fasciotomy is usually The seriousness of her long-lasting muscle compression required. The cause of compartment syndrome is due to through lying unconscious on a hard surface during her increased pressure in a limited myofascial space, leading suicide attempt, lead to rhabdomyolysis and compartment to compromised microcirculation of nerves and muscular syndrome of right lower leg requiring multiple operations tissues with irreversible ischemic damage. and skin grafts. A custom-made silicone calf implant was prescribed to restored the defect site in volume, contour Multiple fasciectomies were performed in mid to late 2010 and aesthetics. to relieve both tension and pressure and the resultant
loss of circulation to her lower leg. A fasciotomy is a limb-saving procedure used to treat acute compartment Case History syndrome. The procedure has a very high success rate in regard to saving limbs, however, accidental damage to a Rhabdomyolysis is a serious syndrome due to a direct nearby nerve occurred requiring a tibialis posterior transfer or indirect muscle injury and early complications for foot drop with another lower leg fasciectomy which include high levels of potassium in the blood. Later, rhabdomyolysis can also lead, in about 15% of patients, to was performed in October 2012. kidney failure. A condition called compartment syndrome may also occur, through maintained compression of Assessment on presentation nerves, blood vessels, and muscles which causes tissue damage and problems with blood flow. Magnetic This patient attended her first appointment in the resonance imaging (MRI) with Gadolinium was performed maxillofacial clinic in a wheelchair unable to weight bear
“Rhabdomyolysis is a serious syndrome due to a direct or indirect muscle injury and early complications include high levels of potassium in the blood.” 22 WINTER 2014 IMPT
on her right leg. On clinical examination the anterior surface of her right lower limb was painful the slightest touch. The loss of bulk in the posterior compartments of the leg, in addition to the numerous split skin grafts required to cover the anterior compartment for her original fasciectomies, has caused significant disfigurement both physically and aesthetically. To assess
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“The foot drop operation was performed to help her keep her foot in a more dorsiflex position, to aid movement and to hopefully allow walking without an orthotic splint.”
the deformity and be able to discuss in detail the shape, weight and aesthetics of treatment options available models of both legs were required. Firstly, alginate impressions of both legs were taken in the clinic chair as she could not stand, however this process was long and painful for the patient (Figure 1).
The corrective tendon transfer to correct foot drop prior to reconstruction of her calf proved a success. The patient adhered to a strict physiotherapy regime which consisted of no weight bearing for the first week after tendon transfer then increasingly more weight bearing for three Figure 1: Alginate impression weeks whilst wearing an orthotic splint. The patient is The impressions were cast in dental stone and fabrication now very pleased with the changes to her gait. of two wax templates replicating the silicone implants were sculpted. In the laboratory sash clamps were used to orientate the models and enable a 3D view of the bulk Method and materials required for the calf muscle in relation to the opposing Fabrication leg (Figure 2). From these models the loss of bulk and Post surgery the patient presented un-aided in the clinic shape of the lower leg muscles could be seen. The and without an orthotic splint to support her gait. Calf templates were held in place with Tubigrip to illustrate muscle asymmetry remained due to the secondary the final implant location and aesthetic outcome. compartment syndrome on the right leg (Figure 3). Fabrication of a right calf custom-made silicone implant started. Due to the time, cost of materials and discomfort caused by the weight of the original alginate impression material, a 3D computer photo scan (Vectra X3 New Jersey, USA) of the patient’s legs was taken. The data was then manipulated into a stereolithographic file (STL), the file format that CAD software machines use for printing three-dimensional rapid prototyping models.
Figure 1: Wax Templates in-situ
A joint consultation with both the plastic surgeon and patient revealed that the anterior fascia required a further skin graft to reduce its nerve sensitivity in association with a tendon transfer to correct foot drop. The foot drop operation was performed to help her keep her foot in a more dorsiflex position, to aid movement and to hopefully allow walking without an orthotic splint. After the tibialis posterior transfer operation she would then be ready for reconstruction of her calf. The final procedure for insertion of the calf implant would not fully restore the volume of the leg but would improve the aesthetics and the overall appearance.
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Figure 3: Post tendon transfer for foot drop
After joint discussion with the consultant, the initial double implant design was changed to a one-piece device due to the size and positioning of the implant. The wax profile was sculpted on the 3D model and after a further
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“Care was taken to line the mould to ensure no contamination of the implant silicone by the porous plaster of paris.”
joint consultation the shape, size and position of the calf implant was agreed. (Figure 4)
are manufactured and processed under strictly controlled conditions and are completely traceable. The MED-4805 silicone was cured as per manufacturer’s instructions, six hours at 140ºC degrees, allowed to cool, removed from the mould and the implant was post-cured for an hour at 140ºC (Figure 5). The silicone was then sterilised ready for theatre (Figure 7).
Figure 4: Wax Template
Figure 5: Implant in situ
Figure 6: Silicone injection into foil lined mould
Figure 7: Sterilised implant in theatre
The wax pattern was placed in a mould and flasked in the usual manner. Once boiled out and dry, the surface of the mould was lined with tin foil. Care was taken to line the mould to ensure no contamination of the implant silicone by the porous plaster of paris. Once both sides of the flask were fully lined the tin foil was washed with detergent to remove any traces of grease or dirt prior to the injection of the implant silicone into the mould (Figure 6). Nusil MED-4805 injection moulding elastomer is considered a long-term, implantable medical device silicone (greater than 29 days).3 Nusil products are all ISO 9001-certified, which ensures that all Nusil materials
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The right calf custom-made silicone implant was inserted in a capsule cavity (figure 8). The patient stayed in hospital for eight days.
Figure 8: In surgery
Complications after surgery The surgical wound was re-explored to evacuate haematoma and re-position two vacuum drains. Once the initial healing dressings were removed a double layer of Tubigrip was worn to support the weight of the implant. Initially there appeared to be some lifting of the inferior edge of the implant, which might have needed more fascia lata (muscle graft) for support however, continued use of the double Tubigrip bolstering support of the implant enabled the inferior edge to settle. The patient attended the hospital for regular draining of serous fluid for the first eight weeks. Approximately 1000mls was drained from the site and Adcortyl was administered by
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Conclusion
injection to reduce the rate of seroma production. The patient was advised to restrict strenuous activity but to keep mobile.
This paper outlined the methods, materials and techniques used in rehabilitating this patient. The difficulties experienced and the full rehabilitation emotionally, physically and aesthetically, by way of a custom-made silicone calf implant, restored the defect site in volume, contour and aesthetics.
References 1. Compartment Syndrome http://www.nhs.uk/conditions/compartment-syndrome 2. K-H Weng, W-S Tzeng, GH.F Shu, C W Lo, C K-H Chen. Magnetic Resonance Imaging of Compartment Syndrome: report of three cases. J Radiol Sci June 2013 Vol.38 No.2
Figure 9: Implant insitu and opposing calf
3. Nusil, implantable elastomer - MED 4805 http://www.nusil.com/products/healthcare/unrestricted/index.aspx
Discussion Since the suicide attempt in 2010, which led to rhabdomyolysis and compartment syndrome of the right lower leg requiring multiple operations and skin grafting, the patient now has renal failure and is diabetic. Unfortunately a previous history of rhabdomyolysis increases the risk of rhabodomyolysis in the future. The road to full rehabilitation in this patient has been over three years, however, with each operation she has gained more movement, less pain and ultimately a very presentable aesthetic outcome with which she remains delighted.(Figure 9). During the construction of this prosthesis, patient compliance was an important factor throughout the treatment plan. Multidisciplinary discussions were vital in planning the best outcome for this patient. Factors such as patient motivation, age, health and dexterity are paramount in understanding patient needs and achieving the best possible prosthetic rehabilitation. Custom-made implants are implanted life-long and as such every care and attention to detail must be considered.
“Factors such as patient motivation, age, health and dexterity are paramount in understanding patient needs and achieving the best possible prosthetic rehabilitation.” www.impt.co.uk
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Use of PEEK in maxillofacial reconstruction: a 6-year review of cases S. Madhavarajan FRCSEd (OMFS), A. Abdullakutty BDS, MBBS, MRCS, J. Collyer FRCS, OMFS, K. Sneddon FRCS, OMFS, Specialty Registrar, Oral & Maxillofacial Unit, Queen Victoria Hospital Foundation Trust, Holtye Road, East Grinstead West Sussex, RH19 3DZ satish.madhavarajan@qvh.nhs.uk
Abstract This paper describes the use of Polyetheretherketone (PEEK) implants at the Queen Victoria Hospital, East Grinstead, over a six-year period and assess whether this implant material is a good option in the reconstruction of various maxillofacial defects.
Introduction Polyetheretherketone (PEEK) is a well-established material, which has been used in aerospace, electrical and automotive industries for more than 20 years. PEEK is an alloplastic material possessing ideal properties for surgical reconstruction. It was originally used for cervical disc fusion then subsequently for cranial defects.1 The use in maxillofacial defects has increased recently. PEEK implants are reported to be safe, reliable and biocompatible. The semi-crystalline polyaromatic linear polymer exhibits an excellent combination of strength, durability, biocompatibility and environmental resistance. 2,3,4,5
“PEEK is an alloplastic material possessing ideal properties for surgical reconstruction.” Methods The Queen Victoria Hospital has used PEEK as a patient specific implant (PSI) for maxillofacial reconstruction for 6 years (2006-2012). Ten patients were identified from hospital records, 6 females and 4 males (age range 2160 years) having had PEEK implants in this period. The custom-made PEEK implants were used to reconstruct maxillofacial defects by two consultants (JC/KJS). Various indications for reconstruction included post-oncological surgery, post-orthognathic surgery and aesthetic considerations. PEEK implants were manufactured as a PSI. Each patient underwent a 3D CT scan and the facial
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“PEEK implants were used to reconstruct maxillofacial defects by two consultants (JC/KJS). Various indications for reconstruction included post-oncological surgery, post-orthognathic surgery and aesthetic considerations” bony defects were reconstructed on the digital image. From this data the implant and bony structures are fabricated. The implants were inserted and fixed using standard methods of surgical access and internal fixation.
Case aetiology This series includes post-oncological surgical defects, orthognathic surgery residual defects and facial asymmetry, see Tables 1 & 2. Table 1: PEEK implant sites Facial bone reconstructed
No. of cases
Fronto-orbital
1
Orbital
1
Mid-face
2
Mandible
6
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Table 2: Patient data Case No
Indication for implant
Implant site
1
Post-oncology surgical defect
Left fronto-orbital
2
No of 9Year implants
Complications
Comments Navigational surgery used. Original PEEK implant removed to improve result. Replacement PEEK poor fit , 3rd implant constructed and fixed.
3
2008
Nil
Post-oncology surgical Left inferior orbital rim defect
1
2007
Nil
3
Post-oncology surgical defect
Right malar and orbital rim
1
2009
Nil
4
Post-orthognathic surgery residual deformity
Mandible
1
2009
Nil
5
Post-orthognathic surgery - improve mandibular contour
Mandible
3
2011
Nil
6
Post-orthognathic surgery - improve mandibule contour
Either side of chin
2
2008
Nil
7
Left mandibular hypertrophy (stable)
Right lower mandible border onlay
1
2009
Infection 1/52 post op
8
Left hemi-facial microsomia
Left mandibular onlay implant
1
2010
Nil
9
Left hemi-facial microsomia (Goldenhar Syndrome)
Left mandibular onlay implant
1
2010
Nil
10
Post-trauma defect
Zygoma
1
2009
Nil
Navigational surgery used
Antibiotics. Implant left in-situ. No further problems Free flap provided bulk over implant
Navigational surgery used
Post-oncological surgical defects Two patients had complex multi-dimensional hard tissue and soft tissue defects around the orbit following oncological resection of cancer. Case 1 (Figure 1), had a complex fronto-orbital defect, including bony and soft tissue defects as a result of surgical resection of a childhood rhabdomyosarcoma of the orbital region.
The patient had post-operative radiotherapy. The initial PEEK implant reconstructed the bony orbital and zygomatic defect, in addition to a deep inferior epigastric perforator (DIEP) free flap to reconstruct the soft tissue defect. Subsequent corrective surgical procedures were performed to improve the facial profile. The insufficient volume of the original PEEK implant was replaced to improve aesthetics. A first PEEK implant was inaccurate, ill-fitting and therefore was not implanted.
Pre op Post op Figure 1: Case 1 Left fronto-orbital reconstruction.
CT scan
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Figure 1 contd.
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The subsequent new PEEK implant was constructed and placed with navigation assistance. Further soft tissue sculpting with liposuction, dermal fat graft addition to the left eyebrow and eyebrow lift improved soft tissue appearance. Case 3 had presented with right orbital socket contraction following enucleation of right eye and radiotherapy for childhood retinoblastoma (Figure 2). A PEEK onlay implant was placed via a hemi-coronal approach to augment the right cheek bone and infra-orbital rim. Further soft tissue augmentation with dermal grafts and lower conjunctival fornix reconstruction by ophthalmic surgeons resulted in a successful augmentation which further improved her facial appearance. Figure 3 contd. Pre op
Pre op
Post op
Figure 2: Case 3 Right malar and orbital rim augmentation
Post-orthognathic surgery defects Three patients (case numbers 4, 5 & 6) had onlay PEEK implants to improve mandibular symmetry and facial appearance following orthognathic surgery. Excellent post-implant facial profiles were observed, as shown in figure 3.
Pre op
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Pre op
Figure 3 contd. Post op
Figure 3: Case 5 Mandibular angles and chin augmentation
Post op
Post op
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Post-orthognathic surgery defects Three patients presented with congenital facial asymmetry (case numbers 7, 8 & 9) and PEEK implants were placed to improve facial appearance. PEEK onlay implants were used on the lower border of the unaffected mandible, mirror-imaging the affected side (hypertrophic side) and resulted in good facial symmetry.
Pre op
Post op
Figure 5: Case 8 Mandibular PEEK augmentation with antero-lateral thigh (ALT) soft tissue free flap reconstruction Figure 4 contd. Pre op
Figure 4 contd. Post op
Pre op
Post op
Another patient presented with hemifacial microsomia and Goldenhar syndrome, and had a PEEK onlay to the left angle and ramus of the mandible through a previous neck scar (Figure 6). She had undergone multiple surgical procedures since childhood to correct facial asymmetry.
Figure 4: Case 7 Right lower mandible onlay
Pre op
Post op
Figure 6: Case 9 Left mandibular PEEK augmentation
Figure 4 contd. Post op
Facial asymmetry A further patient had a PEEK onlay implant via the left submandibular approach to augment the left angle and lower border of mandible (Figure 5). He had an antero-lateral thigh flap placed over the PEEK implant to improve soft tissue contour.
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One older patient (case number 10) had a malar implant placed as onlay over the cheek bone to conceal a post traumatic defect following a delayed presentation of a missed zygomatic fracture. A corrective osteotomy was not performed as the patient did not wish to undergo complex reconstructive surgery. A malar onlay PEEK implant placed via an intraoral approach effectively masked the underlying defect.
Results This study reports the implantation of fifteen PEEK implants in ten patients over a six-year period.
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Complications No implants in this study have been lost due to implant failure or infection. Some patients suffered minor complications which were more related to access surgery than to the implant. There was a single infective complication (Case 7) in the first post-operative week with a patient’s mandibular onlay implant. This was managed conservatively with a combination of intravenous and oral antibiotics. The PEEK implant was left in-situ and after 3 years follow-up the implant is still in place. There were minor complications as a result of the surgical access to the various implant sites. A patient with hemifacial microsomia experienced temporary weakness of the marginal mandibular nerve due to the submandibular surgical approach. In addition two patients reported temporary mental nerve paresthesia post mandibular implant placement. These minor complications resolved in time.
Discussion Polyetheretherketone (PEEK) is being increasingly used in oral and maxillofacial reconstruction of hard tissue defects.7,8 Its application in orthopaedic procedures and cervical spine fusion has given satisfactory results.1 PEEK has generally been used in reconstruction of complex skull and skull-base defects following tumour resection and trauma. According to a recent UK neurosurgical survey in 2011 by Broughton et al, PEEK was used in 4.2% of cranioplasties.8 There are few reports in the literature regarding PEEK usage in the reconstruction of facial bones. The first case where a PEEK implant was successfully used as a PSI was to reconstruct a complex orbito-fronto-temporal defect.9 Also reported was a series of 4 patients where they used PEEK to reconstruct orbitomaxillary defects following surgical resection and trauma.10 They report no implant related complications and felt that this material showed great promise in the reconstructive armamentarium due to its physical properties and the ability to customize.10 A two-piece PEEK implant was used as combined orbital floor and orbital rim implant.11 No complications were found in another case series of 7 patients, with complex skull base and facial post-surgical defects. PEEK implants were used as a PSI to reconstruct the defects, however they reported a variance in cosmetic results due to the difficulty in accurately predicting the surgical defect.12 However, the authors concluded that PSI reconstruction is a reliable and safe method of reconstruction.12
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“Its application in orthopaedic procedures and cervical spine fusion has given satisfactory results.” To date this paper presents the largest (with ten patients) and most varied in usage of PEEK implants. PEEK has been used to reconstruct the malar bone, orbit and mandible. Intra-operative navigational surgery was used for accurate placement of implants in complex orbital reconstruction in some of the patients. Our indications for PEEK implant use were: 1. Reconstruction of post-oncological surgery complex facial defects 2. Post-orthognathic surgery contour defects 3. Congenital facial asymmetry 4. Post-traumatic bony defects In patients with complex maxillofacial defects, the production and material cost of these PSIs may be offset in real terms by reduction in operating time, hospital stay and complications associated with complex reconstructive options, including bony free flaps. However, this would be applicable to only a small subset of such patients. A near normal “bony” result maybe accurately be achieved with mirror-imaging the normal side to design these implants and the use of navigational surgery to implant them. Additionally, it is possible to achieve soft tissue reconstruction over the implant to enhance facial appearance, and possible improvement in function is a secondary benefit of using PEEK implants.
“A near normal ‘bony’ result maybe accurately be achieved with mirror-imaging the normal side to design these implants and the use of navigational surgery to implant them.” PSI’s may also be a simpler option to use in patients who have undergone previous orthognathic surgery but have residual contour defects. These defects may be extremely difficult to treat but can be easier to mask. Again, reduction in operating time, reduction in surgical complications including risk to the inferior dental nerve and reduced hospital stay, in this particular subset of patients who have had prolonged orthodontic treatment
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
and multiple corrective surgeries, make the PEEK PSI an attractive reconstructive option. Masking bony post-traumatic facial defects is another indication for PEEK. PEEK may again be useful to mask defects to avoid complex secondary osteotomies, especially in a previously severely traumatised patient. The three commonly used implants in maxillofacial reconstruction are compared in table 3.
The cost of manufacturing PEEK PSI varies and in this series the outlay per implant ranged between £1750 to £3500. The complexity of the defect was reflected in the manufacturing cost.
Table 3: Implant material compared Implant Material
Advantages
Disadvantages
• • Medpor • (Porous Polyethylene) •
Biocompatible Easy to contour Strong but flexible Vascularisation and tissue ingrowth into implant pores • Positional stability of implant
Titanium
PEEK
• • • • • •
Biocompatible Osseointegrates Resistant to heat, ionizing radiation Easy to sterilise Higher yield, mechanically stable Can withstand 45.8KN of force
• • • • • •
Biocompatible Resistant to heat, ionizing radiation Easy to sterilise Flexible, resemblance to bone Can withstand 24.5KN of force PEEK absorbs traumatic forces, flexible structure
• • • •
Risk of extrusion Risk of exposure Infection Gas sterilisation (limits sterilisation choice)
• Does not osseointegrate • Implants have to be coated in collagenous fibrous tissue with no direct bone – implant interface • Instability implant placement may vary, lack of osseointegration
Conclusion Compared to other implantable materials, PEEK has three distinct advantages: 1. Radiolucency (no artefacts or image scatter on CT/ MRI images) which is important for monitor in oncology patients.13 2. PEEK implants are lightweight, which adds to patient comfort (important for reconstructing the small facial bones) 3. PEEK is not thermo-conductive and therefore does not conduct thermal changes (important in cranioplasties but may also be important in the facial region). 9
PEEK is being increasingly used as a PSI in patients with complex maxillofacial bony defects as a result of oncological surgery and trauma. In addition to the above categories, PEEK implants have been used in patients with congenital facial asymmetry to improve facial appearance and this indication may become more popular in this surgically difficult subset of patients. PEEK can also be used to aesthetically refine post-surgical bony contour defects and thus avoid more complex procedures. PEEK has been found to be a safe implant material in our experience and infective complications appear to be mild despite being placed through a challenging environment, namely the oral cavity. Minimal morbidity in the placement of these implants is reported and patients are satisfied with the aesthetic results. PEEK may be used in the future to replace metals, ceramics and plastics in a variety of medical applications.
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IMPT WINTER 2014 31
References 1. Mastronardi L, Ducati A, Ferrante L. Anterior cervical fusion with polyetheretherketone (PEEK) cages in the treatment of degenerative disc disease: preliminary observations in 36 consecutive cases with a minimum 12-month follow-up. Acta Neurochir (Wien). 2006;148(3): 307-312 2. Schelgel J, Green S. Medical Plastics 2000. Vol 14, 12.1-12.10 3. Jockisch KA, Brown SA, Bauer TW, Merritt K. Biological response to chopped carbon-fiber– reinforced PEEK. J Biomed Mater Res. 1992;26(2):133-146. 4. Morrison C, Macnair R, MacDonald C, Wykman A, Goldie I, Grant MH. In vitro biocompatibility testing of polymers for orthopaedic implants using cultured fibroblasts and osteoblasts. Biomaterials. 1995;16(13):987-992. 5. Wenz LM, Merritt K, Brown SA, Moet A, Steffee AD. In vitro biocompatibility of polyetheretherketone and polysulfone composites. J Biomed Mater Res. 1990; 24(2):207-215. 6. PSI–Patient Specific Implants. West Chester, PA: Synthes Inc; 2004. (Reprinted) Arch Facial Plast Surg/Vol 11 (No.1), Jan/Feb 2009 www.archfcial.com 57 ©2009 7. Kim MM, Boahene KDO, Byrne PJ. Use of customized polyetheretherketone (PEEK) implants in the reconstruction of complex maxillofacial defects. Archives of Facial Plastic Surgery 2009;11(1):53-57. 8. Broughton E, Bhatia R, Ellamushi H. The UK national cranioplasty survey. Br J Neurosurg 2011;25(5):577-578. 9. Scolozzi P, Martinez A, Jaques B. Complex orbito-fronto-temporal reconstruction using computer-designed PEEK implant. J Craniofac Surg. 2007 Jan;18(1):224-8. 10.Kim MM, Boahene KD, Byrne PJ. Use of customized polyetheretherketone (PEEK) implants in the reconstruction of complex maxillofacial defects. Arch Facial Plast Surg. 2009 Jan Feb;11(1):53-7. 11.Goodson ML, Farr D, Keith D, Banks RJ. Use of two-piece polyetheretherketone (PEEK) implants in orbitozygomatic reconstruction. Br J Oral Maxillofac Surg. 2012 Apr;50(3):268-9. 12.Campbell AAE, Evans B, Sharma S, Lang D, Shenouda E. Patient Specific Implants (PSI) in complex skull base defects. British Journal of Oral and Maxillofacial Surgery 2011;49:S38. 13.Hanasono, M.M., Goel, N., and DeMonte, F. (2009). Calvarial reconstruction with polyetheretherketone implants. Ann. Plast. Surg. 62, 653–655.
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THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Magnetic ocular prosthesis Dr Emma Worrell PhD, MIMPT, Mrs Susan Insole MIMPT Maxillofacial Prosthetist, Maxillofacial Laboratory, Queen Victoria Hospital Foundation Trust, Holtye Road, East Grinstead West Sussex, RH19 3DZ Keywords: ocular prosthesis, prosthetic eye, ocular obturator, rehabilitation, hollow
Abstract This paper describes an alternative method for ocular rehabilitation in the long-term management of an anophthalmic patient. It is a follow-up to the previously published paper ocular prosthesis for orbital exenteration with lid sparing.1,2
Introduction Following aggressive surgery to remove a squamous cell carcinoma the patient presented with a large empty eye socket requiring imaginative ocular rehabilitation. Due to the vastness of the socket defect post tumour removal a flexible substructure had to be fabricated to support an ocular prosthesis.1,2 Rehabilitation with a simple one-piece silicone obturator had been successful but difficulties with manual dexterity necessitated a replacement. This technical note describes an alternative design involving the use of a magnet to support her ocular prosthesis.
Method and materials Fabrication Due to the size of the anophthalmic socket behind very tight immobile eyelids a 5-piece sectional putty impression was taken in clinic (Figure 3).8 Vaseline was placed after each addition before adding the next section to ensure impression removal.
Case History The patient first presented for rehabilitation in July 1999 with an aetiology of squamous cell carcinoma (SCC) which was excised and reconstructed with a forehead flap (Figures 1&2).3 The supraorbital nerve was included in the biopsy specimen and subsequently no movement of the affected eyelids could be achieved. Augmentation of the supra-orbital rim with a split rib graft was utilised at the time of reconstruction and this remains as the lining for the brow and socket.
Figure 3: Sectional impression Figure 4: Lateral view
Figure 6: Working model
Figure 1: Squamous Cell Carcinoma
Figure 2: Anophthalmia
The socket has the appearance of mucosal lining and granulation tissue with patches of keratinisation.3 Due to the mixed nature of the skin in her socket, epithelium skin shedding exists, causing an environment for bacteria growth and a build-up of daily fluid and discharge.4-7
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Figure 5: Frontal view
Once the impression was completed the sections of putty were carefully removed, disinfected and then re-constructed in the laboratory prior to casting (Figures 4 & 5). A working model was poured in dental stone. Location grooves were carved in the base of the model and a plaster boat constructed to enable replacement of the model sections in the original position once the model had been sectioned (Figure 6).
IMPT WINTER 2014 33
“The epithelium within the socket exfoliates without any means of removal, therefore a vent was purposely introduced into the posterior of the obturator.”
Figure 13: Magnet and keeper in-situ
In the laboratory a simple one-piece silicone obturator for the socket was constructed (Figure 7). A neo magnet was incorporated into the silicone for ease of ocular location.9 Previous experiments with varying shore hardness of silicones revealed that a 20 shore silicone met all of the desired objectives, supportive, yet flexible so this was chosen to fabricate the definitive ocular one-piece obturator.10 The epithelium within the socket exfoliates without any means of removal, therefore a vent was purposely introduced into the posterior of the obturator. The obturator also acts as a collection point for exfoliants until removal and cleaning.
Figure 7: Magnet in-situ with silicone obturator
Figure 14: Customised tool
Simplicity was important, as the patient was required to insert and remove the prosthesis daily for cleaning. The lateral and frontal views illustrate how the ocular prosthesis locates onto the obturating silicone section (Figures 11,12 & 13). This illustrates the vastness of the anophthalmic socket to be obturated behind two tight immobile eyelids.
Discussion & Conclusion
The patient was happy with the new eye prosthesis, which can be easily inserted, removed and cleaned. A daily cleaning regime with saline, no strong detergent use, and complete inversion of the obturator was recommended.9,12 Patient motivation, age, health and dexterity are all factors which require careful consideration to achieve the best possible prosthetic rehabilitation.
References 1. Worrell E. Ocular prosthetic obturator - an innovative medical device Br J Ophthalmol bjophthalmol-2013-304457
Figure 8: Wax try in
Figure 9:Tool in-situ
Try in of the silicone section was easy as the patient was experienced in collapsing her previous prosthesis. A wax pattern for the ocular component incorporated a metal keeper. The eye was sculpted and the placement of the iris pupil unit performed (Figure 8). This simple magnetic design created the ability to secure the ocular prosthesis to the substructure. A customised tool was also fabricated to aid with insertion and removal of the obturator, with a magnet one end and a scoop the other. (Figures 9, 10 & 14).
2. Worrell, E. Ocular Prosthesis for orbital exenteration with lid sparing – An Update The Journal of Maxillofacial Prosthetics & Technology Summer 2013. Vol. 12 Issue 1 pg 16-19. ISSN1366-4697 3. Worrell, E. Management of the anophthalmic socket. The Journal of Maxillofacial Prosthetics & Technology Summer 2013. Vol.12. 4. Pine K, Sloan B, Stewart J, Jacobs RJ. Concerns of anophthalmic patients wearing prosthetic eyes. Clin Experiment Ophthalmol. 2011; 39(1):47–52. 5. Pine K, Sloan B, Stewart J, Jacobs RJ. A survey of prosthetic eye wearers to investigate mucoid discharge. Clin Ophthalmol. 2012;6:707-13. 6. Patel V, Allen D, Morley AM, Malhotra R Orbit. Features and management of an acute allergic response to acrylic ocular prostheses. 2009;28 (6): pg 339-41. 7. Fett DR, Scott R, Putterman AM. Evaluation of lubricants for the prosthetic eye wearer. Ophthal Plast Reconstr Surg. 1986;2(1):29–31. 8. Exafast vinyl polysiloxane impression material http://www.gceurope.com/products/detail.php?id=34 9. Neo magnets. MagDev http://www.magdev.co.uk 10.Nusil Silicone Products http://www.nusil.com/products/healthcare/index.aspx 11.Osborn KL, Hettler D. A survey of recommendations on the care of ocular prostheses. Optometry. 2010;81(3):142–145 12.Lee A, Elsie MB. Artificial eyes and tear measurements 1. J Am Soc Ocularists.1981a:26-28.
Figure 10: Removal tool
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Figure 11: Lateral view Figure 12: Frontal view
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Sports-related maxillofacial injuries; a critical review of the literature Muhanad M. Hatamleh, BSc, MPhil, MSc (Health Mgmt), Dip (MaxFac), MIMPT, PhD Senior Maxillofacial Prosthetist/Reconstructive Science, Cranio-Maxillofacial Prosthetics Unit, King’s College Hospital NHS Foundation Trust, London, SE5 9RS Tel: +44 (0)20 3299 9000 ext 2524 Email: muhanad.hatamleh@nhs.net Ahed M. AL-Wahadni, BDS, MDSc, PhD, FFD RCSI, CPM , Professor of Prosthodontics, Consultant, Faculty of Dentistry, Jordan University of Science & Technology, Irbid 22110, Po Box 3030 Jordan Email: ahed@just.edu.jo
Abstract This literature review is focused on maxillofacial injuries and in particular those occurring during sports activities. It aims to investigate the aetiology, incidence, prevention options and common treatment methods available for sports-related maxillofacial injuries and finally offers some recommendations in reducing further risk of injury when pursuing sports activities.
Introduction Maxillofacial fractures sustained during sports are increasing because of the large number of people who engage in sports activities.1-3 Sports-related maxillofacial injuries vary with sport type, the athlete’s gender and age, and the season the activity is participated in. High impact team sports (i.e. soccer, rugby and cricket) along with cycling and skiing have been associated with high incidence of such injuries. Also, young adult males in the age range of 20-30 years have had high percentages of sports-related maxillofacial injuries due to their high levels of physical activity.1,2 In the early months of seasonal tournaments there is a higher occurrence of sports-related fractures due to the low fitness levels of players. Also an increased injury incidence is seen in summer months due to an escalation in outdoor activities. Fracture sites in maxillofacial injuries may include zygomatic, nasal, mandibular or alveolar bone fractures depending on the nature of sports involved. Head and mouth guards effectively reduce the severity and incidence of fractures in specific sports, and there is a demand to make their wearing obligatory in some highimpact sports.
Aetiology of maxillofacial injuries Studies from several countries describe traffic accidents, assaults, falls, and sports as the most frequent causes of maxillofacial fractures.1 Work-related and traffic accidents are associated with more severe injuries than sportsrelated trauma. A ten-year review of over 9,000 craniomaxillofacial trauma patients reported that 19.6% of the patients had concomitant injuries, especially cerebral and
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cervical spine injuries.2 Road traffic accidents accounted for the most frequent cause of injury in these patients. However, the cost and the recovery period due to sportsrelated injuries could be less than those occurring due to road traffic and work-related accidents. Sports-related trauma seems to be increasingly implicated in causing maxillofacial injuries because of the large number of people who engage in sporting activities.1,3 The intense physical nature and growing popularity of sports are believed to be the key factors responsible for the increased prevalence of such trauma.4,5 Recent studies have reported the prevalence of sports-related facial fractures between 6-33%, in contrast to the 5-9% reported in studies published more than a decade ago.2,4,6-8 The frequency of the facial involvement in sporting injuries varies between studies, countries and sports. In Greece, soccer and basketball were the most hazardous sports with respect to maxillofacial fractures.9 In Australia and Ireland football was the sport responsible for most fractures followed by cricket.7,10 Whereas in Japanese and British studies rugby carried the highest risk of fractures.8,11 In Finland, France and Italy soccer was the sport most associated with facial fractures.12-14 Most of the sports-related fractures are observed in males aged between 21 and 30 years.7,8,12 This possibly reflects the high levels of physical activity or lower awareness of danger in this gender and age group. In addition, there may be the perception that female athletes are less aggressive and therefore possibly at reduced risk of injury.
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Incidence In reporting sports-related maxillofacial injuries, it is important to mention: • country of study • age • gender of patients • time-period of study • type of sport involved • mechanism of the injury • fracture sites sustained An understanding of the cause, severity, and temporal distribution of maxillofacial trauma can assist in establishing clinical and research priorities for effective treatment and prevention of these injuries. The data analysis of recently published retrospective studies on sports-related maxillofacial injuries is shown in Tables 1 and 2. Table 1: Analysis of sport-related maxillofacial injuries among different countries. Year of publicaiton
Sports involved (No of cases per sport)
Country & period of study
Number of patients & [Age range (yrs)] [Mean]
M:F ratio
712 [4-75][24.5]
So
Ba
F
Ski
Jo
Gy
Cy
Bo
Ho
Hr
Cr
Mb
W
Ru
Sk
Other
2.5:1
64
-
-
391
-
-
180
-
-
-
-
-
-
-
-
-
27
-
37
-
-
206
-
91
11
-
-
-
21
12
1
-
-
-
-
10944
4
1
-
14
-
-
-
-
4
1997
15
Austria 1984-1993
1998
11
UK 1993-1994
790 [11-68][21]
7:1
109
-
-
55
-
-
189
-
2001
13
France 1998-2000
140 [15-57][28.5]
7.2:1
35
4
4
11
1
1
14
3
2003
2
Austria 1991-2000
2991 [20-29][24.5]
2:1
240
-
-
950
-
-
707
-
-
-
-
2004
17
Sweden 2000-2002
750 [15-88][33.8]
5:1
12
-
3
23
-
-
19
-
8
6
-
2005
9
Greece 1996-2006
125 [8-52] [24.2]
9:1
80
17
6
4
3
3
2
2
2
2
2008
18
New Zealand 1996-2006
561 [6-82][26.2]
9:1
27
-
-
18
-
-
86
-
21
-
40
-
-
292
-
69
2008
19
Italy 2001-2006
1214 [11-72][28.5]
8:1
86
1
1
20
-
-
2
-
9
-
2
-
3
-
14
So (Soccer) Ba (Basketball) Ski (Ice and snow Skiing) Sk (Skating) Cr (Cricket) Jo (Jogging)
Mb (Mountain biking) Ru (Rugby) Cy (Cycling) Gy (Gymnastic) W (Wrestling) Bo (Boxing)
Ho (Hockey) Hr (Horse riding) Di (Diving/Swimming) Others (Aerial, handball, golf, softball) F (Fighting sports, i.e.Tae kwon do, Karate, Judo)
Table 2: Analysis of fractures sites sustained in sport-related maxillofacial injuries among different countries. Site of fracture
Study no
Mandible
Le Fort (I-III)
Alveolar process
Zygomatic
43 (Le1)
8
60*
Orbital walls
Nasal
1997
15
712
1998
11
419
2003
2
2004
17
14
7
2005
9
68
2
14
62
4
9
2008
18
297
-
-
211
121
32
*2008
19
43
8
57
39
9
Skull and frontal bone
Maxilla
Other
76
Facial bone fractures 3578, Dentoalveolar trauma 4082, Soft tissue lesions 1733 27
18
13
11 13
-
44 2
4
* These figures indicate the location of fractures.
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THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
According to this analysis, the sporting activities can be classified into different types: • contact sports (team sports and combat sports) • non-contact sports (vehicular sports, sports with balls and other individual sports). Maxillofacial injuries can result from: (1) impact against the ground (2) impact against another player (3) impact against equipment (personal protection, ball, handlebars,) (4) impact against environment (tree, wall, car, etc) Impact with another player was the most common cause of contact sports-related fractures in two of the studies.9,13 In fracture cases caused by contact sports, including soccer, rugby, handball, boxing, karate and others, the main cause was a blow from another player such as a clash of heads or a strike by the elbow.8,11,12,20,21 In sports such mountain biking, roller skating, skiing and horse-riding, a fall to the ground was the most frequent cause of the sports-related accidents.15,22 However in golf, cricket and other non-contact sports, the ball or other implement may cause a ‘missile’ type of injury to the head. The impact type in some sports-related injuries underscores the importance of preventive measures to reduce the frequency of facial trauma in patients involved in sport accidents. Protective equipment has been reported to be useful in such cases. The differences may be due to the nature of the sports involved.9,13,18 Soccer has a high incidence of injuries, which is due to the popularity of this game and the fact that no head protection is worn. Unsurprisingly the mandible had the highest prevalence of fracture. Mandibular fracture sites included the body of the mandible, the angle, the ramus, the condylar neck, the symphysis, and the coronoid process.16 Furthermore, mandibular sports-related injuries vary greatly among different sports as shown in Figure 1.15
Figure 1: Mandibular fracture distribution through Skiing (A), Cycling (B) and Soccer accidents (C).
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“Impact with another player was the most common cause of contact sports-related fractures in two of the studies” In younger individuals, the angle of the mandible is susceptible due to the unerupted third molars, believed to weaken this region.23,24 Fractures of the zygoma are due to their prominent anatomic position and the lack of protective equipment designed for this region. Further reinforcement is needed for mid-face protection to guard against orbital wall fractures. Trends have been reported that correlate significantly with certain months of the year. December to March collectively accounted for the highest percentage (56.6%) of all mandibular fractures that occurred in Austria.15 Predictably, skiing was found to be the most common cause (90.9%), whereas cycling injuries were found to be prevalent cause during the period of May to October (73.8%). In New Zealand there was a marked increase in sportsrelated facial fractures between March and August, with the highest number of fractures occurred in May.16 May is the start of the winter season for many rugby club competitions. The start of the season reflects the time when players’ fitness levels are typically below optimum.16 There may be an association between the low fitness and the reported increase of injuries at this time.
Prevention One author suggests that a sports medicine specialty needs to be established in which preventive and therapeutic interventions for injuries resulting from participation in sports are investigated.13 However, it is not possible to eliminate head injuries altogether from sporting activities. Even in non-contact and recreational sports, accidents can happen. In high speed and combat sports, wearing protective head gear and equipment reduces the risk of facial injuries. Decreases in the number of maxillofacial trauma cases were noted after the introduction of facial and dental protection, especially in boxing and ice hockey. Recently, mouthguards and faceguards were shown to be effective. Garon et al reported a significant decrease in facial trauma when protective mouth gear was used in American football.24 Intra-oral mouth guards afford
IMPT WINTER 2014 37
partial protection to jaws, teeth and alveolar process.25 Mouthguards and faceguards have been mandatory for some soccer players in some countries. Sports involving ‘missiles’ like cricket and ice hockey have been using face masks but face masks have not be fully accepted in soccer or basketball.
important to allow the development and evaluation of preventative measures. References 1. Brook I.M. and Wood N. Aetiology and incidence of facial fractures in adults. Int J Oral Surg, 1983. 12: 293-8. 2. Gassner R., Tuli T., Hachl O., Rudisch A., and Ulmer H. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg, 2003. 31: 51-61.
Basic prevention should play a leading role in all sports along with changing health and safety guidelines, and improved training also means that the incidence of facial injuries can be reduced, some studies have suggested.26
Treatment Facial fractures occurring during sports pursuits may require initial hospitalisation and surgical procedures which vary with each case. The main treatment applied in patients with facial fractures is reduction and immobilization.9 The displaced fractures can be confronted surgically with internal fixation, while the undisplaced fractures can receive either conservative treatment (maxillo-mandibular fixation with elastic bands) or no treatment.9 Several methods of reduction and fixation can be used in the treatment of maxillofacial fractures, such as eyelet wiring, arch bars, and simple intermaxillary fixation.16,18
Recommendations 1- Some sports are very country-specific, for example, “football” is a different game in the United States, Europe, Australia, and New Zealand. Consequently, there is a need to identify the specific risks of maxillofacial injuries by sport and by country. The practical benefit of identifying associations between these various sports and specific fracture sites is the ability to develop sportspecific safety equipment.
3. Allan B.P. and Daly C.G. Fractures of the mandible. A 35-year retrospective study. Int J Oral Maxillofac Surg, 1990. 19: 268-71. 4. Telfer M.R., Jones G.M., and Shepherd J.P. Trends in the aetiology of maxillofacial fractures in the United Kingdom (1977-1987). Br J Oral Maxillofac Surg, 1991. 29: 250-5. 5. Olasoji H.O., Tahir A., and Arotiba G.T. Changing picture of facial fractures in northern Nigeria. Br J Oral Maxillofac Surg, 2002. 40: 140-3. 6. Carroll S.M. and O’Connor T.P. Trends in the aetiology of facial fractures in the south of Ireland (1975-1993). Ir Med J, 1996. 89: 188-9. 7. Carroll S.M., Jawad M.A., West M., and O’Connor T.P. One hundred and ten sports-related facial fractures. Br J Sports Med, 1995. 29: 194-5. 8. Tanaka N., Hayashi S., Amagasa T., and Kohama G. Maxillofacial fractures sustained during sports. J Oral Maxillofac Surg, 1996. 54: 715-9; discussion 719-20. 9. Mourouzis C. and Koumoura F. Sports-related maxillofacial fractures: a retrospective study of 125 patients. Int J Oral Maxillofac Surg, 2005. 34: 635-8. 10.Lim L.H., Moore M.H., Trott J.A., and David D.J. Sports-related facial fractures: a review of 137 patients. Aust N Z J Surg, 1993. 63: 784-9. 11.Hill C.M., Burford K., Martin A., and Thomas D.W. A one-year review of maxillofacial sports injuries treated at an accident and emergency department. Br J Oral Maxillofac Surg, 1998. 36: 44-7. 12.Sane J. and Ylipaavalniemi P. Maxillofacial and dental soccer injuries in Finland. Br J Oral Maxillofac Surg, 1987. 25: 383-90. 13.Maladiere E., Bado F., Meningaud J.P., Guilbert F., and Bertrand J.C. Aetiology and incidence of facial fractures sustained during sports: a prospective study of 140 patients. Int J Oral Maxillofac Surg, 2001. 30: 291-5. 14.Cerulli G., Carboni A., Mercurio A., Perugini M., and Becelli R. Soccer-related craniomaxillofacial injuries. J Craniofac Surg, 2002. 13: 627-30. 15.Emshoff R., Schoning H., Rothler G., and Waldhart E. Trends in the incidence and cause of sport-related mandibular fractures: a retrospective analysis. J Oral Maxillofac Surg, 1997. 55: 585-92. 16.Bataineh A.B. Etiology and incidence of maxillofacial fractures in the north of Jordan. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1998. 86: 31-5. 17.Exadaktylos A.K., Eggensperger N.M., Eggli S., Smolka K.M., Zimmermann H., and Iizuka T. Sports-related maxillofacial injuries: the first maxillofacial trauma database in Switzerland. Br J Sports Med, 2004. 38: 750-3. 18.Antoun J.S. and Lee K.H. Sports-related maxillofacial fractures over an 11-year period. J Oral Maxillofac Surg, 2008. 66: 504-8.
2- It would seem logical to encourage mouth guard use and provide midface protection for high contact sports, such as rugby, and high-speed sports, such as cycling.
19.Roccia F., Diaspro A., Nasi A., and Berrone S. Management of sport-related maxillofacial injuries. J Craniofac Surg, 2008. 19: 377-82.
3- Government-led institutions may help increase game safety awareness among players. For example, recent initiatives by the Accident Compensation Corporation (ACC), which monitors sport, traffic, and work injuries in New Zealand, have resulted in reduced spinal injury rates in rugby players.27
21.Hill C.M., Crosher R.F., and Mason D.A. Dental and facial injuries following sports accidents: a study of 130 patients. Br J Oral Maxillofac Surg, 1985. 23: 268-74.
4- An understanding of the cause, severity, and temporal distribution of maxillofacial trauma can assist in establishing clinical and research priorities for effective treatment and prevention of these injuries. Continuous long-term data collection on maxillofacial fractures is 38 WINTER 2014 IMPT
20.Gassner R., Tuli T., Emshoff R., and Waldhart E. Mountainbiking--a dangerous sport: comparison with bicycling on oral and maxillofacial trauma. Int J Oral Maxillofac Surg, 1999. 28: 188-91.
22.Seguin P., Beziat J.L., Breton P., Freidel M., and Nicod C. [Sports and maxillofacial injuries: etiological and clinical aspects apropos of 46 cases. Preventive measures]. Rev Stomatol Chir Maxillofac, 1986. 87: 372-5. 23.Kingsmill V.J. and Boyde A. Variation in the apparent density of human mandibular bone with age and dental status. J Anat, 1998. 192 ( Pt 2): 233-44. 24.Garon M.W., Merkle A., and Wright J.T. Mouth protectors and oral trauma: a study of adolescent football players. J Am Dent Assoc, 1986. 112: 663-5. 25.Ranalli D.N. and Demas P.N. Orofacial injuries from sport: preventive measures for sports medicine. Sports Med, 2002. 32: 409-18. 26.Khan A.A. A retrospective study of injuries to the maxillofacial skeleton in Harare, Zimbabwe. Br J Oral Maxillofac Surg, 1988. 26: 435-9. 27.van Beek G.J. and Merkx C.A. Changes in the pattern of fractures of the maxillofacial skeleton. Int J Oral Maxillofac Surg, 1999. 28: 424-8.
THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Technical Note Custom-made cusp trimming guidance splint Mr Adrian Kearns MIMPT DPS Consultant Maxillofacial Prosthetist Department of Maxillofacial Prosthetics, Royal Surrey County Hospital, Guildford, Surrey, GU2 7XX, United Kingdom akearns@nhs.net
Abstract This technical note describes a method of tooth cusp trimming to improve accuracy of final osteotomy surgical splints.
Introduction Achieving perfect interdigitation of the teeth following orthognathic surgery requires highly specialised pre and post-surgical orthodontics, skilled surgical technique and exacting laboratory preparation. In a few cases, where the final occlusion can be enhanced, guidance splints should be prepared to allow the judicious trimming of one or two tooth cusps. This will result in the highly accurate transfer of information from the laboratory to the theatre, with the exact replication of the laboratory surgical plan, and improved patient outcome.
Method and Materials Model surgery is performed by the Maxillofacial Prosthetist in the normal way to the prescribed position1, incorporating adaption of the cusp to the optimal position following consultation with the orthognathic planning team. A 1mm thick plastic disc (Erkodur ‘freeze’ E.M. Natt, London) is pressure formed over the untrimmed model. The splint is then placed on the adapted model and trimmed to expose the area of removed cusp. The splint is then transferred to the operating theatre with the orthognathic surgical splints. It is cold sterilised and used to assist the surgeon, highlighting the exact amount of cusp to be removed to achieve the predetermined optimum occlusion. Figures 1 and 2 show the splint in-situ, and the exposed cusp requiring removal. The author has found that combining the blue splint material with black marking
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round the exposed area highlighted the area to be reduced making it easier to locate, which is favourable for the surgeon.
Figure 1: Close up view of splint in-situ
Figure 2: Palatal view of splint in-situ
Discussion The manufacture of a custom-made splint has improved the transfer accuracy between the laboratory plan and the surgical procedure in the few number of orthognathic cases that have required this intervention at The Royal Surrey County Hospital. This splint design can also be utilised for maxillary and/ or mandibular fracture cases which have localised tooth mobility and slight modification of a cusp will result in a more favourable position prior to the adaption and application of arch bars.
References 1. Lockwood H. The Key Spacer Planning System. Proc Insti Maxillofac Techno 1976; 67-83
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Articles of interest Compiled by Caroline Reed MIMPT Guys and St Thomas Hospital, London
Welcome this edition’s ‘articles of interest’ page, which aims to highlight recently published articles that may be of interest to maxillofacial prosthetists and students alike. Dural adhesion to a cranioplasty implant material is often considered an advantage, however, this article considers the implications of dural adhesion to a HTR-PMI implant that required removal eight years post-operatively.
Dural adhesion to porous cranioplastic implant: A potential safety concern. C.M. Sayama, M. Sorour, R.H. Schmidt. Surgical Neurology International. 2014:5:19
Next is a paper that discusses a surgery first approach to orthognathic surgery for certain patients that meet required criteria. In this article the authors give their findings from 45 cases of surgery first procedures.
Surgery first in orthognathic surgery: What have we learnt? A comprehensive workflow based on 45 consecutive cases. F. Hernandez-Alfaro, R. GuijarroMartinez, M. Peiro-Guijarro. Journal of Oral and Maxillofacial Surgery 2014:72:376-390
Prosthetic rehabilitation of partial ear loss with custom-made acrylic attachment and long-term soft liner. P.Chand, K. Agrawal, G. Bhalla, K. Singh, S. Jurel, P. Goel and S. Singh. Prosthetics and Orthotics International. 2013:37:6:477-480
This paper demonstrates the use of CAD/CAM technologies to produce moulds for fabrication of orbital prostheses.
A new method for fabricating orbital prostheses with a CAD/CAM negative mold. Y.Bi, S. Wu, Y.Zhao and S. Bai. Journal of Prosthetic Dentistry. 2013:110:424/428
The final article is an interesting look at biomaterials for orbital implants and ocular prostheses. It describes the evolution of orbital implants and ocular prostheses and highlights future research areas.
Biomaterials for orbital implants and ocular prostheses: Overview and future prospects. F. Baino, S. Perero, S. Ferraris, M. Miola, C. Balagna, E. Verne, C. Vitale-Brovarone, A. Coggiola, D. Dolcino and M. Ferraris. Acta Biomaterialia. 2014:10:1064-1087
The next paper proposes the idea of constructing a prosthesis using a soft lining material, which ensures a secure bond between the silicone and acrylic substructure. A custom-made acrylic substructure provides retention and the soft lining material provides robust thin edges that the author claims are more resilient to wear.
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THE JOURNAL OF MAXILLOFACIAL PROSTHETICS & TECHNOLOGY
Instructions for authors
Original articles and editorial correspondence should be emailed directly to the current editor, Barry Edwards, at barry.edwards@ qvh.nhs.uk Articles of interest should be emailed to Caroline Reed at creed1@nhs.net Authors are no longer required to send hard copies but are instructed to email the document directly to the editor. Please ensure images, tables and graphs are placed in the document in the order of the author’s preference, and please remember to compress documents and images prior to sending. Articles will be either full length papers or technical notes. Full length papers should aim for a 2500 maximum word count with a maximum of 30 references, and technical notes, 1500 words with a maximum of 10 references. Letters to the editor are also welcome but should not exceed 500 words. The editor cannot accept responsibility for lost documents. The editor will email the author to acknowledge receipt of the article. Articles are accepted on the understanding that they have not been published or submitted simultaneously to another journal in the English language. Rejected articles will be returned to the author/s by email. Returned articles will be accompanied by constructive comment for the author. Every effort will be made to help authors gain publication. The editor reserves the right to make editorial and literary corrections. Any opinions expressed or policies advocated do not necessarily reflect the opinions or policies of the editor. Ethics Papers that contain the results of human and/or animal studies will only be considered for publication if it is made clear that a high standard of ethics was applied in carrying out the investigations. Appropriate ethical approval should be gained from the relevant ethical committees related to the institution in which the study was carried out and that subjects gave informed consent to take part. Copyright In order for the Institute of Maxillofacial Prosthetists and Technologists (IMPT) to ensure maximum dissemination and copyright protection of material published in the Journal, copyright must be explicitly transferred from the author to the IMPT. The author/s may be assured that no limitation will be put on your freedom to use material contained in the paper without
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requesting permission, provided acknowledgment is made to this journal as the original source of publication. Presentation of articles Articles will only be accepted when presented in the format described below. These guidelines standardise the text and help the editorial board review articles more efficiently. Failure to follow these simple guidelines will result in the article being immediately returned for formatting. Articles should be typed in size 12 Times New Roman font, be double line spaced and include page numbers in the bottom right corner. The document should be set out as follows: Title page, abstract, key words, introduction, method and materials, results, discussion and conclusion. Images should be set into the text in the appropriate location. References are at the end of the article in the order they appear in the text. Title page This page should include: a succinct title of the article (in Bold and centered), name of the author/s with full addresses, positions held, e-mail address and contact phone number. The main author for any correspondence should be listed first. Sources of support in the form of grants should be included at the bottom of the title page. Abstract This should consist of between 100 to 150 (maximum) words summarising the contents of the article. Up to five key words should be included to accurately identify the subject of the paper. Headings Should be appropriate to the nature of the paper. It should be noted that headings enhance the readability of a paper. Headings should be typed in bold using lower case and start with a capital but not be capitals throughout. Headings should be set in the left hand margin. Sub-headings These should be set out in lower case to left hand side of the page in bold and italic. Introduction This should be a short preface introducing the reader to the subject matter, including background and aim of the paper. Method and materials The name of suppliers of materials, instruments etc. should be entered in brackets at an appropriate point in the text, using lower case with an initial capital letter, followed by the full address. Remember with research and technical papers, the purpose is often to allow the reader to perform the experiment or construct the device described in the article.
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Results These should be clearly set out. Tables are the most useful means of presenting data but other forms of presentation such as bar charts or pie charts are also acceptable. Discussion This is the section where the author should evaluate the results or methodology of the paper in a critical fashion and make reference to why the subject matter is relevant to the journal. Conclusion A brief summary of the paper and what it has achieved. References The accuracy of references is the responsibility of the author. References should be entered in the Vancouver style, superscripted after the appropriate text and in numerical order. For example: The method of using autogenous bone has a logic which appeals to many neurosurgeons but is not without complications.1,2 If there are more than two numbers cited in continuous sequence, connect the first and last with a hyphen: e.g.1-4, 5-9 otherwise use commas: e.g.1,2 The actual references are then placed at the end of the article in numerical order as they appear in the text for the reader’s convenience. References to journal articles should include the author’s surname and initials. List all authors when five or fewer. If six or more list the first three then “et al”. Follow this with the full title of the article, journal title abbreviated using index medicus abbreviations only e.g. Journal of Dental Research should be written as J Dent Res. Followed by the year of publication, edition and /or volume number and first and last page numbers.
Patient confidentiality Where images include recognisable individuals, care must be taken to ensure consent for publication has been given. It is vital to ensure that not only is consent gained but also that the patient is fully aware of the intended use of the image, i.e. for teaching or publication. If identity is not essential to the image then crop accordingly. Patient consent is the author’s responsibility and a copy of the consent gained should be included with the submission. This can be on your own photographic consent form signed by the patient or guardian. Borrowed images Permission to use borrowed images or tables/graphs must be obtained and it is the author’s responsibility to do so. This may be placed directly alongside the image or at the end of the paper within acknowledgements. Borrowed material must be acknowledged in the following style: “Reproduced by the kind permission of (insert publisher) from (reference author/s)”. A signed copy of consent from the original author must be included. Presentations If the author has presented the paper previously, please include details of where and when the paper was presented immediately following the abstract. Abbreviations and units Avoid abbreviations in the title and abstract. Abbreviations should be used in brackets after their first introduction in full: e.g. “The model is obtained from a computed tomography (CT) scan.” The abbreviation can then be used throughout the text from this point onwards without brackets. Units should be expressed in metric, although imperial is acceptable for contributions from the USA.
For example: 1. Kingsmill VJ, Boyde A, Davis GR, Howell PG, Rawlinson SC. Changes to bone mineral and matrix in response to a soft diet. J Dent Res. 2010, 89 (5): 510-4 References to books should be set out as follows: 1. Ward Booth P. Maxillofacial surgery. 2nd ed. Churchill Livingstone. Dover M. Advanced oral implantology. Chap 80. 1550. 2007 Editor’s note on referencing: Vancouver style referencing is the preferred system as it is less disruptive to the flow of text. If a publication has multiple references however, re-numbering and re-arrangements can be time consuming. For this reason the Editor strongly recommends authors consider using a reference management system, such as Reference Manager or Endnote, if a paper has multiple references, i.e. more than ten. All references must be referred to in the text. Tables, graphs and images Tables and graphs should have a short descriptive title below each one and any footnotes suitably identified. The axis should be clearly labeled and the information within the table clear. A guideline of up to eight images per article is suggested but the editor is open to further images if it aids the clarity of the paper. The author should insert images into the text in the preferred position, however this cannot be guaranteed in the final draft. Captions should appear directly below each image with Figure number and text. Avoid joining images together and if side by side then label a and b accordingly, e.g., Figure 1a, Figure 1b. Figures must be referred to in the text.
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