Temporomandibular joint dysfunction (TMD) can lead to jaw hypomobility and trismus. There are several treatment options depending on diagnosis, however, where possible, conservative measures are preferred to surgical intervention. This paper investigates the safety and efficacy of using RestorabiteTM (Integrated Prosthetics & Reconstruction, Chris O'Brien Lifehouse), a new jaw-stretching device with regulated and incremental levels of force, to treat trismus in patients with chronic closed lock of the temporomandibular joint. Fifteen consecutively recruited participants used RestorabiteTM as their primary treatment modality. Maximum incisal opening and trismus, swallowing, and speech-related quality of life outcome measures were measured at baseline (time of diagnosis), after 10 weeks of therapy, and at 6 and 12-month follow up. At completion of the intervention mouth opening improved on average by 15.1 mm (p < 0.001). This was maintained at 6 months (average gain of 16.7 mm, p < 0.001) and 12 months (15.5 mm, p < 0.001). Trismus-related quality-of-life scores also significantly improved by 23.6 (p = 0.01). There were no treatment-related adverse events. RestorabiteTM is a safe option for the conservative management of TMD-related trismus. Restorabite™ offers a safe and effective treatment for trismus resulting from chronic TMJ closed lock in patients with TMD.

Background/Objectives: Cadaveric models have traditionally been a mainstay of dental and medical education worldwide since their inception. In Australia, educators at dental schools were among the first to use cadaveric porcine heads in formal teaching in oral surgery. This practice has since fallen out of favour in most modern dental curricula. The aim of this pilot study was to determine the utility of cadaveric porcine models for oral surgery training from a student perspective (Griffith University, Gold Coast, Australia). Methods: Thirty participants who were all third-year dental students attended a two-hour session comprising a 30 min lecture followed by a 90 min practical workshop. The lecture outlined the steps and supervision of students during the practical and was provided by a consultant maxillofacial surgeon. At the conclusion of the workshop, participants were asked to anonymously complete a printed questionnaire with eight questions related to their experience. Results: Prior to the workshop, two-thirds (61%) of participants felt that they had been taught the surgical procedure for raising mucoperiosteal flaps adequately in their dental school curriculum during their third year, although only 43% of students had assisted specialty residents in raising a mucoperiosteal flap and 14% reported having performed the procedure themselves. Almost all students (96%) agreed that the porcine model was useful for their dental education and that they would practice the exercise using the model again if provided with the opportunity. The questionnaire had a 93.33% completion rate. Conclusions: This pilot study indicates that porcine heads present a useful, low-cost adjunct in the learning of basic oral surgical procedures.

Study design: Case report. Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. The progression of ORN can lead to loss of bone, teeth, soft tissue necrosis, pathologic fracture, and oro-cutaneous fistula. Reconstructive surgery has mostly been reserved for late-stage disease where segmental resections are frequently necessary. Evidence is emerging to support earlier treatment in the form of debridement in combination with soft tissue free flaps for intermediate-stage ORN. The authors present a case of a 76-year-old male with persistent Notani 2 ORN of the mandible, treated with surgical removal of all remaining mandibular teeth, transoral debridement of all necrotic mandibular bone, and bone coverage with a left medial femoral condyle (MFC) periosteal free flap based on the descending genicular artery. Treatment was uneventful both intraoperatively and postoperatively. Since surgery (15 mo) the patient has remained free from clinical and radiologic signs of ORN. The MFP periosteal free flap provided an excellent result with minimal surgical complexity and morbidity in this case. Such treatment at an intermediate stage likely results in a reduction in segmental resections, less donor site morbidity, less operative time, less overall treatment time, and possibly fewer postoperative complications compared with the status quo.

The radial forearm free flap (RFFF) is widely used for oral reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap is an increasingly utilized alternative. The cases of 165 patients who received either an RFFF or SCIP flap for oral reconstruction at Chris O'Brien Lifehouse, Sydney were reviewed. The aim was to report on patient, pathology, treatment, and outcome variables and to compare these between the two flap groups. A RFFF was used in 126 patients and a SCIP flap in 39 patients. SCIP flap patients were younger (P < 0.001) and had shorter operative times (P < 0.001), shorter anaesthetic times (P < 0.001), and more frequent recipient site dehiscence (P = 0.005) when compared to RFFF patients. The SCIP flap was significantly less frequently used for composite resections including bone when compared to the RFFF (P < 0.001). The primary site distribution was more even for RFFF patients (P < 0.001). There were no SCIP flap failures; three RFFF failures occurred. SCIP flaps performed comparably in terms of operative and clinical outcomes. Most SCIP flaps were utilized in younger patients with partial glossectomy defects.

Objective: To describe and assess two cases of a delayed post-traumatic recontouring of the frontal bone using a novel technique.Materials and methods: Using rapid prototyping, patient specific sterilisable moulds were constructed from mirrored intact contralateral anatomy. The moulds were used intraoperatively to contour calcium phosphate cement at the bone defect. The accuracy of reconstruction was evaluated post operatively through comparisons of planned and actual reconstruction data from a three-dimensional optical scanner.Results: The contour of both defects was well restored clinically and there was no significant difference between the computer planned reconstructions and the actual reconstructions, with a mean difference of 0.4 cm3.Conclusion: Supraorbital rim disruption, commonly associated with fracture of the frontal bone, can be difficult to reconstruct aesthetically. This technique is a time-efficient and accurate way to reconstruct three-dimensional facial anatomy.

BACKGROUND:The zygomatic implant perforated (ZIP) flap is a novel approach to the challenge of reconstructing the maxilla. We report on our experience using the ZIP flap technique for patients undergoing infrastructure maxillectomy at Chris O'Brien Lifehouse, Sydney, Australia. METHODS:Thirteen patients who underwent a ZIP flap reconstruction between August 2019 and August 2021 were identified. Demographic, surgical, and histopathological information was collected. Health Related Quality of Life (HRQOL) was assessed using the FACE-Q Head and Neck Cancer module, the M.D. Anderson Dysphagia Inventory, and the Speech Handicap Index. RESULTS:A total of 44 zygomatic implants were placed, of which 42 (95%) survived. The median time from surgery to dental rehabilitation was 35 days. HRQOL data was available for nine patients over 24 months, demonstrating improved speech and swallowing outcomes over the follow up period. CONCLUSIONS:The ZIP flap is a reproducible surgical technique that facilitates rapid dental rehabilitation post infrastructure maxillectomy.

Anterolateral thigh (ALT) and Radial forearm free flaps (RFFF) are historically the most common methods of oral reconstruction. The Superficial circumflex iliac artery perforator flap (SCIP) is an alternative providing a donor site that can be readily closed primarily with improved cosmesis in younger patients, due to its concealability.

Objectives. Osteoradionecrosis (ORN) of the jaw is a potentially devastating consequence of head and neck irradiation. Despite recent advances, there are patients who fail to respond to conventional therapies. Historically, free flaps were reserved for advanced cases requiring segmental resection and composite reconstruction, with early and intermediate disease treated more conservatively. We have adopted a more active surgical approach in selected intermediate cases. Study Design. A retrospective review of patients with intermediate stage ORN who received debridement and either fascio-cuta-neous or fascio-periosteal free flap reconstruction was performed. Demographic data, ORN severity, treatment, and outcomes are described. Results. From 2019, 9 cases in 7 patients were identified. All cases were Notani grade II. There were 6 Epstein stage IIa and 3 Epstein stage IIIa. The mandible was the most common site (n = 8). Of the 7 patients, 2 had oropharyngeal primaries treated with chemoradiation, and 5 had oral cavity primaries treated with surgery and adjuvant radiation therapy. Three patients had prior hyperbaric oxygen therapy, and 2 had pentoxifylline/tocopherol therapy. After debridement, the radial forearm, ulnar artery per-forator, and antero-lateral thigh fascio-cutaneous free flaps were each used in 1 case and the temporoparietal fascio-periosteal free flap was used in 6 cases. There was no recurrence or progression of ORN at the site of surgery, but 2 patients developed addi-tional sites of ORN. Conclusions. For patients with unresponsive intermediate ORN, debridement and soft tissue free flap reconstruction is an alterna-tive to ongoing conservative management or composite resection and reconstruction. (Oral Surg Oral Med Oral Pathol Oral Radiol 2023;136:128-135)

Cutaneous squamous cell carcinoma of the head and neck (HNcSCC) is one of the commonest malignancies. When patients present with regional metastatic disease, treatment escalation results in considerable morbidity and survival is markedly reduced. Owing to the high incidence, Australian institutions have been at the forefront of advocating for reliable, accurate, and clinically useful staging systems that recognise the distinct biological characteristics of HNcSCC. As a result, an extensive body of literature has been produced over the past two decades, which has defined critical prognostic factors, critiqued existing staging systems, and proposed alternative staging models. Notwithstanding, a suitable staging system has proved elusive. The goal of cancer staging is to group patients according to cancer characteristics for which survival differs between groups (distinctiveness), consistently decreases with increasing stage (monotonicity), and is similar within a group (homogeneity). Despite implementing major changes based on published data, the latest edition of the American Joint Committee on Cancer (AJCC) staging manual fails to satisfy these fundamental requirements. This review chronologically explores and summarises the Australian contribution to prognostication and nodal staging of HNcSCC and highlights the ongoing challenges.

The oculocardiac reflex (OCR) is a well-recognised phenomenon characterised by cardiac arrhythmia precipitated by various electrical, physical or chemical stimuli to branches of the trigeminal nerve. The reported incidence rate varies widely and specifically following post-trauma orbital reconstruction in the adult population has not been clearly defined. We reviewed a continuous case series of 100 patients who underwent post-traumatic orbital reconstruction to investigate the incidence of OCR in this population. Variables recorded included age, gender, American Society of Anaesthesiologists physical status (ASA), regular medications of relevance, fracture subtype, number of intraoperative OCR events, intraoperative medical management, and primary surgeon experience level. The overall incidence of OCR in this cohort was 48.4%. Increasing fracture complexity was associated with an increased risk of OCR (OR 4.378, 95% CI: 1.023 to 18.730, p = 0.046). Age, gender, ASA, regular medications of relevance and primary surgeon experience did not have a statistically significant effect on the incidence of an OCR. Our study indicates that the OCR is a common phenomenon during post-trauma orbital reconstruction. Further studies may be warranted to further recognise at-risk patients, to identify ideal management strategies.

BACKGROUND:The order of significance of clinicopathologic characteristics for the prognosis of patients with regional metastases from head and neck cutaneous squamous cell carcinoma (HNcSCC) is not well characterized. This study aimed to understand the impact of the known characteristics, including the presence of immunosuppression, number of deposits, largest deposit size, location and laterality of deposits, and presence of extranodal extension (ENE) on overall survival (OS) and disease-specific survival (DSS).METHODS:A retrospective study of 366 patients treated with curative intent for HNcSCC with regional metastatic disease was undertaken using recursive partitioning analysis (RPA).RESULTS:Using RPA modeling, the study determined that number of metastatic deposits carried the highest impact for both OS and DSS, followed by largest deposit size. The presence of ENE and immunosuppression was less significant.CONCLUSIONS:The results from this study provide new evidence for identifying and stratifying high-risk patients with metastatic HNcSCC. This information will be valuable in determining future HNcSCC staging systems.

STUDY DESIGN:Letter to the Editor.OBJECTIVE:Disarticulation may be considered during segmental mandibulectomy where margins necessitate high condylar neck osteotomy. Although a number of techniques have been reported for reconstruction of the condyle, successful preservation of normal joint anatomy, where possible, should be considered as a superior alternative. This report demonstrates a safe and predictable approach to condylar head preservation with high condylar neck osteotomy.METHODS:We present two cases of native TMJ preservation with a very short salvageable condylar component utilising 3D-printed patient specific cutting guides and implants.RESULTS:The condyle preserving reconstructive technique described successfully preserves the capsule of the TMJ, and with careful execution can preserve the intra-articular components of the joint and their relationships to each other. Both patients have experienced excellent outcomes to date.CONCLUSIONS:As opposed to disarticulation reconstructions, this technique is more likely to achieve long-term normal occlusion, maintain normal alignment of reconstructed segments, and preserve condylar translation as opposed to simple hinging, in addition to avoiding the potential pitfalls of alternative techniques.

Chondroid tenosynovial giant cell tumour (TGCT) is an extremely rare disease affecting the temporomandibular joint (TMJ). This report details the peri-operative findings and treatment with custom TMJ replacement of an initially misdiagnosed chondroid TGCT involving the TMJ.

Complications related to lateral pterygoid muscle (LPM) botulinum toxin A (BtA) injection for recurrent temporomandibular joint dislocation are uncommon. No cases of velopharyngeal dysfunction (VPD) following LPM BtA injection have been reported to date. This report details the perioperative and follow-up findings for a patient developing VPD following LPM BtA injection.

Maxillofacial osteochondromas are considered benign neoplasms, and compared with their extracranial variant are relatively rare. When they involve the mandibular condyle they can induce significant facial deformity, malocclusion and various temporomandibular joint symptoms. Complete excision is considered the standard of care, but can lead to a reduction in the height of the ipsilateral mandible with resultant complications. In such cases, reconstruction is usually warranted and may be approached in various ways. This case report demonstrates a straightforward, accurate and reproducible approach to reconstructing the TMJ, facial profile and occlusion following resection of a large TMJ osteochondroma, without the need for concomitant orthodontics.

Zygomaticomaxillary complex (ZMC) and zygomatic arch (ZA) fractures are common injuries resulting from facial trauma and frequently require surgical management (Huang et al., Craniomaxillofac Trauma Reconstr 8(4):271-6, 2015). A substantial number of post-operative functional and cosmetic complications can arise from the surgical management of these fractures. These include scarring, inadequate facial profile restoration, facial asymmetries and diplopia (Ellis et al. J Oral Maxillofac Surg 54(4):386-400, 1996; Yang et al. Oral Maxillofac Surg Clin North Am 23(1):31-45, 2011; Kloss et al. Int J Oral Maxillofac Surg 40(1):33-7, 2011). Intuitively, most of these aforementioned complications arise as a result of inadequate fracture reduction; however, current standard practice is to assess reduction post-operatively through plain radiographs or computed tomography (CT) scans. The role of intra-operative CT scanning to assess the reduction of ZMC/ZA fractures and the potential impact on complications, has thus far not been established. This is a prospective randomised controlled trial currently being undertaken at the Royal Brisbane and Women’s Hospital. All patients who require operative management of their ZMC or ZA fractures are offered enrollment in the trial. The patients are randomised into two groups: interventional (intra-operative CT) and control (no intra-operative CT). All patients in each group will have post-operative radiographs taken. From these radiographs, the reduction of the ZMC and/or ZA fracture is graded by a blinded assessor. Patients will be reviewed in clinic at 1 week and 6 weeks post-surgery. During these consultations, all patients will be assessed for scarring, diplopia, facial profile restoration and need for revision surgery. Many complications associated with surgical management of ZMC and ZA fractures involve poor aesthetic results as a direct consequence of inadequate fracture reduction. Inadequate fracture reduction is predictable given that small incisions are used and only limited visualisation of the fractures is possible during the procedure. This is due to a desire to limit scarring and reduce the risk of damage to vital structures in an aesthetically sensitive region of the body. It follows that an intraoperative adjunctive tool such as a CT scan, which can assist in visualisation of the fractures and the subsequent reduction, could potentially improve reduction and reduce complications. Australian New Zealand Clinical Trials Registry, ACTRN12616000693426 . Registered on 26 May 2016.

Fractures of the facial skeleton place a burden on healthcare systems at the individual and population level. It is suggested that a high proportion of such patients are non-compliant with various aspects of their care. It stands to reason that non-compliance would contribute to adverse outcomes and increased costs in general. The intent of this study was two-fold: to determine factors associated with poor compliance in the studied population of 215 patients with 359 mandible fractures, and to determine whether poor compliance is associated with an increased incidence of treatment complications. Being male, an illicit drug user, non-employed, and living furthest from care were the factors associated with non-compliance in the studied population. Compliance with soft diet, mouthwash, oral antibiotics, cigarette cessation, and review appointment attendance was 74%, 96%, 96%, 16%, and 58%, respectively. Global compliance scores of low, medium, and high were assigned to 27%, 59%, and 14% of participants, respectively. None of the individual postoperative compliance variables was found to be significantly associated with outcomes of treatment at the 5% level. Borderline associations were found. Globally non-compliant patients were significantly more likely to experience wound dehiscence. The utility of the current postoperative regimen should be further elicited.

The ideal timing for treatment of mandible fractures has not been well established. The objective of this study was to analyse the effects of treatment timing in the surgical management of mandible fractures. A prospective evaluation of 215 continuous patients with a total of 359 mandible fractures was undertaken. Nine outcome variables were analysed in relation to treatment delay by logistic regression modelling: wound dehiscence, hardware exposure, local postoperative infection, malocclusion, trismus, nerve damage, fracture non-union, return to theatre, and radiographic outcome. Nineteen additional variables were included in the analysis to adjust for potential confounding. Delay was measured in days and ranged from 0 to 41days, with a mean delay of 4.6days. The incidence of wound dehiscence, hardware exposure, local postoperative infection, trismus, nerve damage, fracture non-union and return to theatre was 6%, 4%, 11%, 8.5%, 47%, 2% and 8%, respectively. Objective malocclusion and poor radiographic outcomes were evident in 13% and 4.5% of cases, respectively. No statistically significant association was found between treatment delay and treatment outcomes. The findings of this study suggest it may be safe to delay the definitive treatment of mandible fractures. Treatment delay may allow for improved resource distribution and prioritization of more time-dependent interventions.

Background: The ideal timing for treatment of mandible fractures has not been well established. Objectives: The objective of this study was to analyse the effects of definitive treatment timing in the management of all mandible fractures. Methods: A prospective case series of 215 continuous patients with a total of 360 mandible fractures was undertaken. Nine outcome measures were analysed in relation to treatment delay by logistic regression modelling: wound dehiscence, hardware exposure, local postoperative infection, malocclusion, trismus, nerve damage, fracture non-union, return to theatre, and radiographic reduction adequacy. 19 additional covariates were included in the analysis to adjust for potential confounding: age, gender, fracture aetiology, dental status, ASA, alcohol use, cigarette use, illicit drug use, prior mandible fracture, number of fractures, location of fractures, fracture comminution, tooth in line of fracture, local preoperative infection, associated maxillofacial injury, significant other injury, operation type, length of surgery, operator experience. Delay was measured in days and ranged from 0–41 days, with a mean delay of 4.6 days. Findings: A statistically significant association was only found between delay and trismus. For each additional day of delay, the odds of trismus being present, compared to absent, increased by 9% (odds ratio [OR], 1.10; 95% CI, 1.02–1.16). Conclusions: Definitive treatment of mandible fractures can be safely delayed. Treatment delay may allow for improved resource distribution and prioritisation of more time dependant interventions. Where practical, mandible fractures should be treated promptly to minimise trismus and other unstudied consequences of injury, such as pain and delayed return to work.

Odontoameloblastoma (OA) is a very rare and unusual ondotogenic neoplasm comprised of both odontoma and ameloblastoma tissue. It is thought that the lesions arise via proliferating ameloblastic epithelium that induces neighbouring mesenchymal tissue to form mineralised dental tissue. The clinical behaviour of OA is said to resemble the more sinister ameloblastic component, and aggressive treatment has typically been prescribed. To date, the published literature is limited to a small number of case reports, with lesions limited to people below 50 years of age. This case report likely presents the first case of OA in an elderly man, who presented with a painless lump beneath the mucosa of the right cheek. The case satisfies the three requisite histologic criteria set out by Kaugars and Zussmann for such a diagnosis; unequivocal ameloblastoma, connective tissue with a mature, homogeneous appearance, and fragments of malformed calcified dental structures.1Kaugars G.E. Zussmann H.W. Ameloblastic odontoma (odonto-ameloblastoma).Oral Surg Oral Med Oral Pathol. 1991; 71: 371-373Abstract Full Text PDF PubMed Scopus (11) Google Scholar