- Email: [email protected]
80 Initial evaluation of a novel total TMJ replacement
Oral presentations / British Journal of Oral and Maxillofacial Surgery 48 (2010) S1–S24
specificity 0.45 & 1.00 and 0.42 & 0.93 respectively). TMF gave no statistically significant difference between benign and malignant tumours. Conclusions and Clinical relevance: Our analysis confirms p16 promoter hypermethylation in malignant progression of PA to CXPA. In addition methylation across several gene promoters gives weight to the development of a diagnostic biomarker for malignant progression. As genomic analysis becomes the routine, promoter methylation may offer a diagnostic biomarker for malignant progression superior to present cytological assessment. 78 Prospective 5 year outcome of custom made total TMJ replacement A. Sidebottom. Queens Medical Centre, Nottingham University NHS Trust, UK The TMJ Concepts is a custom-made prosthesis with titanium body and cobalt-chrome condylar head on high molecular weight polyethylene fossa articulating surfaces. This prosthesis has outcomes up to 17 years and is currently the favoured prosthesis in the UK. This review analyses the outcome of the authors first 5 years of cases using this prosthesis. Results: Indications: 43 patients (64 joints), 36 left, 28 right • age 27–70 (mean 47) • main diagnoses – degenerative disease 11 – rheumatoid 6 – post-trauma 9 – post multiple surgery 6 – ankylosis 6 – psoriatic 3 • revision cases 11 Pain (10 cm analogue): • pre-op 83 (45–100) • 6/52 post-op 28 (0–69) • 6/12 post-op 17 (0–70) • 1 year post-op 9 (0–60) [47 joints] All patients improved. Opening (mm): • Pre-op 24 (3–44) mm • 6/52 post-op [42 patients] 27 (15–41) mm • 6 months [35 patients] 31 (15–43) mm • 1 year post-op [31 patients] 32 (15–45) mm All patients with reduced opening showed improvement. Dietary scores (10 cm analogue liquid to solid): • Pre-op 41 (1–100) • Post-op 1 year 93 (25–100) All patients improved. Revisions: Case 1. Acute dental infection 3 days post-op. Dentist delayed treatment for 6 weeks. Biofilm infection of the prosthesis required joint removal and placement of gentamicin impregnated acrylic spacer for 3 months. Now 3 years post revision prosthesis with no ongoing problems. Case 2. 6 weeks post-op developed otitis externa with secondary cellulitis of face and secondary joint infection. Joint removed, awaiting replacement. Conclusion: TMJ replacement provides an excellent mode of reconstruction of the irreparably damaged TMJ.
S21
79 Evaluation of conformity between clinical and pathological TNM staging for oral and oropharyngeal squamous cell cancer S. Anderson, J. Zhao, J. Ubhi, V. Bhatt, K. Webster. University Hospital Birmingham, UK Background: Clinical staging of oral and oropharyngeal squamous cell cancer using the TNM staging system can be difficult to ascertain accurately with current methods, particularly nodal involvement. Imaging assisted clinical staging is perhaps more accurate and informs the clinician of locoregional and distant metastases. Conformity of clinical TNM stage (cTNM) to pathgological TNM stage (pTNM) is an indicator of accurate assessment and provides a basis for prognostication. Underestimation of staging clinically may lead to lesser treatment and overestimation conversely leads to aggressive treatment where not required. Patients and Methods: In this retrospective study we looked at the clinical and pathological TNM staging of all operated cases of oral and oropharyngeal squamous cell cancer between 1st January 2008 and 31st December 2009 from case records, online pathology reports imaging reports and documentation on the Somerset Cancer Database within our Unit. Results: The principal manifestation of the staging inconsistency was that the pTNM stage was more advanced than cTNM stage in upto 15% of cases. The principal influencing cause was that N stage was not well evaluated by cTNM. In very few cases there was downstaging of T stage on pathological examination. Conclusion: Current clinical methods of evaluating cTNM stage are not accurate. pTNM staging is generally considered more accurate where nodal status is concerned. There is room for error in the reporting of the pathological T stage. 80 Initial evaluation of a novel total TMJ replacement E.W. Abel, P. McLoughlin, F. Stewart, S. Huang. University of Dundee, UK Introduction and Aims: A new custom made total TMJ replacement has been designed in Dundee. The prosthesis is metal on metal and the design concept allows a minimalist design. The only bone removal is the diseased condylar bone. The remaining condylar head and neck provide structural support for the prosthesis, allowing a small mandibular ramus plate to be used, secured with only four screws. As part of the design and development process, the prosthesis is being subjected to an engineering analysis, in order to assess the structure for stresses under loading and to consider, if necessary, design changes to the device. Material and Methods: A computer based stress analysis using finite element analysis. The prostheses are fabricated in the Department of OMFS, Dundee, from which a 3D scan of a typical prosthesis was used for the computer model. The model was tested under simulated physiological loading conditions for strength in the main structure and at the points of screw fixation. An initial study of the contact stresses at the articulating surfaces was also undertaken. Results: The stresses were in all cases well below the failure stress of the cobalt chrome material. Even with a loss of bone-prosthesis contact at the interface between the resected condylar head and the prosthesis, the local stresses did not exceed 10% under normal loading conditions. There were similarly low levels of stress in the screw hole regions.
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Oral presentations / British Journal of Oral and Maxillofacial Surgery 48 (2010) S1–S24
Conclusions: These encouraging findings support the design concept and feed back into the design process, which is continuing to evolve. 81 Post-treatment pain in disease free head and neck cancer patients L.M. Hanu-Cernat, T. Martin, S. Parmar, A.M.S. Brown, K. Webster, D.E. Hanu-Cernat. University Hospital Birmingham, UK Pain is an important symptom in post-treatment head and neck cancer patients with a significant impact on their quality of life that may even have prognostic value for recurrence and survival. An observational study to investigate post-treatment pain in disease-free head and neck cancer patients was initiated, focusing on the assessment of prevalence, distribution, character and severity of pain, and correlation with patient’s demographics, tumour site and stage, treatment modality, pre-treatment pain and co-morbidity, depression and quality of life. Three relatively homogenous groups of patients were identified in accordance with the treatment modalities adopted. The first group consisted of patients who received tumour resection, reconstruction and neck dissection only, the second group of those who received additional radiotherapy and the third group of those who underwent primary (chemo)radiotherapy. Further stratification within groups was applied for bilateral cases and extent of neck dissection. Donor site related pain was assessed separately. All patients during first year after treatment, those with suspected or overt recurrent disease or on-going osteoradionecrosis were excluded. The McGill’s pain questionnaire, British pain inventory short form and the visual analogue scale were used assess pain and its intensity and the interference sleep scale, the hospital anxiety and depression scale and the short form 12 were used to determine the impact of pain on sleep, mood and quality of life. The subjective reports were correlated with the examination findings. The results of the pilot study on the first eligible 50 consecutive patients who presented in the review clinic are presented. 82 The use of steroid injections for the treatment of tempero-mandibular joint capsulitis following arthroscopy. A prospective outcome assessment A. Khan, A. Sidebottom. Queens Medical Centre, Nottingham University Hospitals, UK Patients with TMJ related pain and restriction associated with post arthroscopy TMJ capsulitis and who have failed to respond to routine conservative measures may be submitted to intracapsular steroid injections, which has been associated with significant therapeutic improvement in 74% or more patients. There is no current data on the use of steroid injections for the treatment of TMJ capsulitis. This prospective audit presents 45 patients treated between 2008–2009 from one surgeon’s practice. The majority of patients with TMJ capsulitis presented with pain and restriction of mouth opening. They were assessed for mouth opening, left and right lateral excursions and protrusion in mm measured with calipers and pain scores were recorded using a 10cm analogue scale. Once a diagnosis for capsulitis was confirmed and the steroid injections administered the patients were followed up at 6 weeks and the assessments repeated.
Pain scores improved significantly with intervention, from an average pain score of 45.4 to 15.05 (range 0–100). Mouth opening also improved for the majority of patients from 0–64%. Approximately 74% had sufficient improvement for discharge. This study shows the therapeutic benefits for the use of steroid injections for the treatment of TMJ capsulitis. 83 The patients’ perspective of the financial impact of treatment of head and neck cancer C. Harvey-Woodworth, S.N. Rogers, D. Lowe. University Hospital Aintree and Edge Hill University, UK The aim of this project was to gain a better understanding of the financial impact of head and neck cancer. In the 2009 annual survey of 762 patients, 466 responded of whom 46% (215/466) agreed to take part in a structured telephone interview on financial aspects. Quota sampling was performed on employment status (retired, unemployed, working full time, working part time) and whether their work status was affected by H&N cancer. 51 patients were interviewed, with an average age of 61 years (SD 8). 20 were retired, 11 unemployed, 13 worked full-time and 7 worked part-time. 24 had had their work status affected by head and neck cancer and 27 had not. 57% stated that they thought they had suffered financially since being diagnosed, particularly the retired (65%) and if work status affected by cancer (79%). 53% stated that their quality of life had decreased as a result of the financial impact of H&N cancer, especially the unemployed (64%), and if work status affected by cancer (83%). 75% felt that they had not received adequate help and information about finance and this affected the group as a whole with no notable factors apart from those in full time employment who reported less of a problem (61%). Patients and carers need to have better access to financial advice and an increased awareness of available financial support. It is suggested that each MDT has a designated benefits/financial advisor who can be readily available for patients in clinic and ward. 84 Electronic cross matching: Time to replace routine pre-operative crossmatching in major head and neck surgery? S.K. Chandran, I.H. Nasr, M.J. Fardy. University Hospital of Wales, Cardiff, UK Introduction: Routine preoperative crossmatching of blood for elective surgery often involves unnecessary crossmatching and consequently over-ordering of blood. This retrospective study assessed our blood ordering practice for major head and neck oncology surgery. We also look at the use of Electronic Cross Matching (ECM) as a method which can provide blood within minutes of request and avoid unnecessary preoperative crossmatching in eligible cases. Aims: To compare the number of units of blood crossmatched preoperatively to the number transfused in major head and neck oncological surgery. To look into ECM as a way of reducing the number of units of blood unnecessarily crossmatched thus reducing work and costs for transfusion services and to minimize wastage from outdating of blood products. Methods: Data for this retrospective study was collected from patients’ medical records and haematology and blood transfusion database.
specificity 0.45 & 1.00 and 0.42 & 0.93 respectively). TMF gave no statistically significant difference between benign and malignant tumours. Conclusions and Clinical relevance: Our analysis confirms p16 promoter hypermethylation in malignant progression of PA to CXPA. In addition methylation across several gene promoters gives weight to the development of a diagnostic biomarker for malignant progression. As genomic analysis becomes the routine, promoter methylation may offer a diagnostic biomarker for malignant progression superior to present cytological assessment. 78 Prospective 5 year outcome of custom made total TMJ replacement A. Sidebottom. Queens Medical Centre, Nottingham University NHS Trust, UK The TMJ Concepts is a custom-made prosthesis with titanium body and cobalt-chrome condylar head on high molecular weight polyethylene fossa articulating surfaces. This prosthesis has outcomes up to 17 years and is currently the favoured prosthesis in the UK. This review analyses the outcome of the authors first 5 years of cases using this prosthesis. Results: Indications: 43 patients (64 joints), 36 left, 28 right • age 27–70 (mean 47) • main diagnoses – degenerative disease 11 – rheumatoid 6 – post-trauma 9 – post multiple surgery 6 – ankylosis 6 – psoriatic 3 • revision cases 11 Pain (10 cm analogue): • pre-op 83 (45–100) • 6/52 post-op 28 (0–69) • 6/12 post-op 17 (0–70) • 1 year post-op 9 (0–60) [47 joints] All patients improved. Opening (mm): • Pre-op 24 (3–44) mm • 6/52 post-op [42 patients] 27 (15–41) mm • 6 months [35 patients] 31 (15–43) mm • 1 year post-op [31 patients] 32 (15–45) mm All patients with reduced opening showed improvement. Dietary scores (10 cm analogue liquid to solid): • Pre-op 41 (1–100) • Post-op 1 year 93 (25–100) All patients improved. Revisions: Case 1. Acute dental infection 3 days post-op. Dentist delayed treatment for 6 weeks. Biofilm infection of the prosthesis required joint removal and placement of gentamicin impregnated acrylic spacer for 3 months. Now 3 years post revision prosthesis with no ongoing problems. Case 2. 6 weeks post-op developed otitis externa with secondary cellulitis of face and secondary joint infection. Joint removed, awaiting replacement. Conclusion: TMJ replacement provides an excellent mode of reconstruction of the irreparably damaged TMJ.
S21
79 Evaluation of conformity between clinical and pathological TNM staging for oral and oropharyngeal squamous cell cancer S. Anderson, J. Zhao, J. Ubhi, V. Bhatt, K. Webster. University Hospital Birmingham, UK Background: Clinical staging of oral and oropharyngeal squamous cell cancer using the TNM staging system can be difficult to ascertain accurately with current methods, particularly nodal involvement. Imaging assisted clinical staging is perhaps more accurate and informs the clinician of locoregional and distant metastases. Conformity of clinical TNM stage (cTNM) to pathgological TNM stage (pTNM) is an indicator of accurate assessment and provides a basis for prognostication. Underestimation of staging clinically may lead to lesser treatment and overestimation conversely leads to aggressive treatment where not required. Patients and Methods: In this retrospective study we looked at the clinical and pathological TNM staging of all operated cases of oral and oropharyngeal squamous cell cancer between 1st January 2008 and 31st December 2009 from case records, online pathology reports imaging reports and documentation on the Somerset Cancer Database within our Unit. Results: The principal manifestation of the staging inconsistency was that the pTNM stage was more advanced than cTNM stage in upto 15% of cases. The principal influencing cause was that N stage was not well evaluated by cTNM. In very few cases there was downstaging of T stage on pathological examination. Conclusion: Current clinical methods of evaluating cTNM stage are not accurate. pTNM staging is generally considered more accurate where nodal status is concerned. There is room for error in the reporting of the pathological T stage. 80 Initial evaluation of a novel total TMJ replacement E.W. Abel, P. McLoughlin, F. Stewart, S. Huang. University of Dundee, UK Introduction and Aims: A new custom made total TMJ replacement has been designed in Dundee. The prosthesis is metal on metal and the design concept allows a minimalist design. The only bone removal is the diseased condylar bone. The remaining condylar head and neck provide structural support for the prosthesis, allowing a small mandibular ramus plate to be used, secured with only four screws. As part of the design and development process, the prosthesis is being subjected to an engineering analysis, in order to assess the structure for stresses under loading and to consider, if necessary, design changes to the device. Material and Methods: A computer based stress analysis using finite element analysis. The prostheses are fabricated in the Department of OMFS, Dundee, from which a 3D scan of a typical prosthesis was used for the computer model. The model was tested under simulated physiological loading conditions for strength in the main structure and at the points of screw fixation. An initial study of the contact stresses at the articulating surfaces was also undertaken. Results: The stresses were in all cases well below the failure stress of the cobalt chrome material. Even with a loss of bone-prosthesis contact at the interface between the resected condylar head and the prosthesis, the local stresses did not exceed 10% under normal loading conditions. There were similarly low levels of stress in the screw hole regions.
S22
Oral presentations / British Journal of Oral and Maxillofacial Surgery 48 (2010) S1–S24
Conclusions: These encouraging findings support the design concept and feed back into the design process, which is continuing to evolve. 81 Post-treatment pain in disease free head and neck cancer patients L.M. Hanu-Cernat, T. Martin, S. Parmar, A.M.S. Brown, K. Webster, D.E. Hanu-Cernat. University Hospital Birmingham, UK Pain is an important symptom in post-treatment head and neck cancer patients with a significant impact on their quality of life that may even have prognostic value for recurrence and survival. An observational study to investigate post-treatment pain in disease-free head and neck cancer patients was initiated, focusing on the assessment of prevalence, distribution, character and severity of pain, and correlation with patient’s demographics, tumour site and stage, treatment modality, pre-treatment pain and co-morbidity, depression and quality of life. Three relatively homogenous groups of patients were identified in accordance with the treatment modalities adopted. The first group consisted of patients who received tumour resection, reconstruction and neck dissection only, the second group of those who received additional radiotherapy and the third group of those who underwent primary (chemo)radiotherapy. Further stratification within groups was applied for bilateral cases and extent of neck dissection. Donor site related pain was assessed separately. All patients during first year after treatment, those with suspected or overt recurrent disease or on-going osteoradionecrosis were excluded. The McGill’s pain questionnaire, British pain inventory short form and the visual analogue scale were used assess pain and its intensity and the interference sleep scale, the hospital anxiety and depression scale and the short form 12 were used to determine the impact of pain on sleep, mood and quality of life. The subjective reports were correlated with the examination findings. The results of the pilot study on the first eligible 50 consecutive patients who presented in the review clinic are presented. 82 The use of steroid injections for the treatment of tempero-mandibular joint capsulitis following arthroscopy. A prospective outcome assessment A. Khan, A. Sidebottom. Queens Medical Centre, Nottingham University Hospitals, UK Patients with TMJ related pain and restriction associated with post arthroscopy TMJ capsulitis and who have failed to respond to routine conservative measures may be submitted to intracapsular steroid injections, which has been associated with significant therapeutic improvement in 74% or more patients. There is no current data on the use of steroid injections for the treatment of TMJ capsulitis. This prospective audit presents 45 patients treated between 2008–2009 from one surgeon’s practice. The majority of patients with TMJ capsulitis presented with pain and restriction of mouth opening. They were assessed for mouth opening, left and right lateral excursions and protrusion in mm measured with calipers and pain scores were recorded using a 10cm analogue scale. Once a diagnosis for capsulitis was confirmed and the steroid injections administered the patients were followed up at 6 weeks and the assessments repeated.
Pain scores improved significantly with intervention, from an average pain score of 45.4 to 15.05 (range 0–100). Mouth opening also improved for the majority of patients from 0–64%. Approximately 74% had sufficient improvement for discharge. This study shows the therapeutic benefits for the use of steroid injections for the treatment of TMJ capsulitis. 83 The patients’ perspective of the financial impact of treatment of head and neck cancer C. Harvey-Woodworth, S.N. Rogers, D. Lowe. University Hospital Aintree and Edge Hill University, UK The aim of this project was to gain a better understanding of the financial impact of head and neck cancer. In the 2009 annual survey of 762 patients, 466 responded of whom 46% (215/466) agreed to take part in a structured telephone interview on financial aspects. Quota sampling was performed on employment status (retired, unemployed, working full time, working part time) and whether their work status was affected by H&N cancer. 51 patients were interviewed, with an average age of 61 years (SD 8). 20 were retired, 11 unemployed, 13 worked full-time and 7 worked part-time. 24 had had their work status affected by head and neck cancer and 27 had not. 57% stated that they thought they had suffered financially since being diagnosed, particularly the retired (65%) and if work status affected by cancer (79%). 53% stated that their quality of life had decreased as a result of the financial impact of H&N cancer, especially the unemployed (64%), and if work status affected by cancer (83%). 75% felt that they had not received adequate help and information about finance and this affected the group as a whole with no notable factors apart from those in full time employment who reported less of a problem (61%). Patients and carers need to have better access to financial advice and an increased awareness of available financial support. It is suggested that each MDT has a designated benefits/financial advisor who can be readily available for patients in clinic and ward. 84 Electronic cross matching: Time to replace routine pre-operative crossmatching in major head and neck surgery? S.K. Chandran, I.H. Nasr, M.J. Fardy. University Hospital of Wales, Cardiff, UK Introduction: Routine preoperative crossmatching of blood for elective surgery often involves unnecessary crossmatching and consequently over-ordering of blood. This retrospective study assessed our blood ordering practice for major head and neck oncology surgery. We also look at the use of Electronic Cross Matching (ECM) as a method which can provide blood within minutes of request and avoid unnecessary preoperative crossmatching in eligible cases. Aims: To compare the number of units of blood crossmatched preoperatively to the number transfused in major head and neck oncological surgery. To look into ECM as a way of reducing the number of units of blood unnecessarily crossmatched thus reducing work and costs for transfusion services and to minimize wastage from outdating of blood products. Methods: Data for this retrospective study was collected from patients’ medical records and haematology and blood transfusion database.