Airway status in civilian maxillofacial gunshot injuries in Johannesburg, South Africa.

BACKGROUND: Airway management of the maxillofacial gunshot injury constitutes a critical decision and an area that requires review in the context of civilian injuries. Most of our knowledge is extrapolated from military experience, which constitutes a different trauma patient group. This paper reports a retrospective survey of airway status in relation to maxillofacial gunshot injuries. The objective is to correlate clinical findings with treatment decisions. METHODS: A survey was done of 11,622 archived maxillofacial surgery records (1987-1992) in the three academic hospitals in Johannesburg. RESULTS: There were 211 maxillofacial gunshot injuries, for which 92 patient records had sufficient detail for inclusion in the analysis. The typical patient was a black male aged 20-29 years, shot with a low-velocity bullet of 0.38 calibre, admitted to hospital the day of the injury, operated on within 4 days, and discharged 4 days later. The airway was threatened in 20/92 cases at admission; 12/20 cases were treated with oro-or nasotracheal intubation, and 9/12 later had elective tracheostomies; 8/20 needed immediate surgical airways, 5 tracheostomies and 3 cricothyroldotomies (all later converted to tracheostomies). Three of thirty-seven patients with normal airways on admission later required emergency tracheostomy. CONCLUSIONS: An abnormal airway was significantly more likely after a high-velocity injury, and when the tongue, floor of mouth, midline or bilateral facial skeletal bones were involved.

Curriculum 2001: a proposal for a new, integrated, dental curriculum at the University of the Witwatersrand.

Recent technological advances and an escalation of knowledge in dentistry have highlighted the need to revise the current undergraduate dental curriculum at the University of the Witwatersrand. This imperative is reinforced on one hand by manifest problems in content, structure and sequencing of the existing curriculum, and on the other hand by the need to urgently address contemporary South African issues. Revision will also offer the opportunity to incorporate modern educational practice and philosophy. This paper proposes that the contents, sequence and duration of the curriculum must be determined by the knowledge demands of dentistry (global issues) as well as by local constraints. It suggests early clinical contact and changes in syllabus content, pedagogy and assessment practices in an undergraduate course of slightly reduced duration.

Vascularity of the dental pulp after segmental osteotomy in the chacma baboon (Papio ursinus).

OBJECTIVE: To assess the vascularity of the dental pulp after segmental operations with and without interpositional autogenous bone grafting. DESIGN: Experimental study. SETTING: University Department, South Africa. ANIMALS: 26 chacma baboons. INTERVENTIONS: Maxillary and mandibular posterior segmental osteotomies were perfused with barium sulphate 3, 6, 12 and 18 months postoperatively. The animals were killed at 3, 6, 12 and 18 months after surgery and perfused with barium sulphate. Barium-filled vessels were counted in histological sections from 189 control and experimental teeth. MAIN OUTCOME MEASURE: Number of blood vessels. RESULTS: Blood vessel counts in mandibular teeth in osteotomy segments ranged from 0 to 1.15 compared with 2.27 to 4.58 in control teeth, while in maxillary teeth counts ranged from 0.54 to 2.22 for experimental teeth and 3.3 to 4.65 for controls. For both jaws, the numbers of vessels in experimental teeth gradually increased between 3 and 18 months but remained less than those in control teeth. Numbers of blood vessels were similar in graft and no-graft groups but both were less than half the counts in control teeth. CONCLUSION: Blood flow is present in the teeth at all times after posterior segmental osteotomy but there is a risk of ischaemia.

Multi-planar and cross-sectional oblique scanning (CT) in implant surgery.

A comprehensive clinical examination followed by a radiographic assessment of the edentulous areas is a prerequisite to placing dental implants. Although radiographic assessment of the mandible is accurate using plain film radiography this is not so for the maxilla for which computed tomography is often necessary. In this study patients requiring the placement of maxillary implants were referred for multi-planar cross-sectional oblique and panoramic computed tomography (CT scan) in addition to standard radiographic views. After interpretation of the CT scans patients could be categorized into two groups. One group comprised those patients who could be treated with a standard protocol for implant placement; the second group required augmentation procedures to supplement bone volume. After implant placement, a minimum healing period of 24 weeks was adhered to prior to placing healing abutments. By 27 months 95.5 per cent of Brånemark System fixtures were osseo-integrated.

Nerve degeneration within the dental pulp after segmental osteotomies in the baboon (Papio ursinus).

Following dentofacial surgical procedures, teeth in segments often do not sense thermal or electric stimuli. This study was undertaken to assess changes in the neural component of the dental pulp after posterior maxillary and mandibular segmental osteotomies, with or without interpositional autogenous bone grafting, in 26 Chacma baboons. Innervation was assessed histologically immediately after operation, and at 3, 6, 12 and 18 months. Statistically significant differences were present between the experimental and control groups. Even after 18 months no nerves were present in any of the mandibular teeth. In maxillary teeth, 50 per cent had demonstrable nerves in the graft group and 40 per cent in the no graft group. As nerve degeneration was present in the experimental teeth, patients should be warned of possible change in tooth sensibility, following these operations. Careful post-operative follow up for long periods in humans following dentofacial surgical procedures is thus essential.

Experience with the Brånemark implant system: 1985-1995.

The osseo-integrated dental implant programme started at the University of the Witwatersrand, Johannesburg in 1985. This retrospective study describes the experience gained in the Division of Maxillofacial and Oral Surgery and the Department of Prosthetic Dentistry with the Brånemark implant system. The numbers of fixtures placed, the types of prostheses prescribed and the surgical and prosthodontic successes and problems are described. The results of implant treatment have improved, and follow a marked learning curve.

Maxillofacial injuries in a group of South Africans under 18 years of age.

OBJECTIVE: To find out the incidence of maxillofacial injuries in South African children aged 18 years or less. DESIGN: Retrospective study of casenotes. SETTING: Six teaching hospitals affiliated to the University of Witwatersrand, Johannesburg, serving a population of about 5 million people. SUBJECTS: All 326 children treated for facial injuries in the maxillofacial and oral departments of the six hospitals between 1 January 1989 and 30 June 1992. MAIN OUTCOME MEASURES: Classification of the types of injury, associated injuries, cause of the injury, and methods of diagnosis. RESULTS: Of the total of 4192 patients of all ages treated for facial injuries, 326 (8%) were within the age range of the study. The female:male ratio was 1:2.3. Most of the injuries (227, 70%) occurred in the 13-18 age group, and assaults, fights and gunshot wounds accounted for 155 injuries (48%). Of the 326 children, 173 (53%) had single injuries and 153 (47%) had multiple injuries. Mandibular fractures were the most common (64%) followed by maxillomandibular fractures (25%). Violence was the most common cause of injury, as in the USA and Zimbabwe, but unlike the rest of the world in which it is motor vehicle accidents. Soft tissue injuries were the most common associated injuries, and conventional plain radiography was the usual investigation. CONCLUSION: The incidence of 8% compares favourably with those in other countries, but far too many injuries are the result of violence.

Comparison of the safety and efficacy of a combination analgesic Myprodol and Ponstan in the treatment of dental pain.

A comparison of the efficacy of Myprodol, a combination analgesic (Ibuprofen, Paracetamol and Codeine phosphate) and Ponstan (Mefenamic acid) was undertaken in a randomised double blind trial of 52 patients who underwent surgical removal of impacted or unerupted teeth. Pain scores were measured for patients pre- and post operatively by means of a visual analogue scale and data was analysed using the BMPD package on the ISM main frame computer at the Medical Research Council. The results indicated that although Myprodol and Ponstan were equally adequate and well tolerated in the control of post operative dental pain, Myprodol exceeded Ponstan in duration of analgesia and in the degree of pain intensity control experienced by the patient.

Autotransplantation of maxillary canine teeth. A follow-up of 35 cases up to 4 years.

35 cases of autotransplantation of nonendodontically treated maxillary canines were followed for up to 4 years and were assessed according to loss of the transplanted tooth, onset of sensibility, mobility, intact lamina dura and presence of tooth resorption. The results of this study compare favourably with other studies and favour the hypothesis that little is to be gained by not endodontically treating autotransplanted teeth immediately after splint removal. It is also suggested that immobilization by means of a rigid splint, removing the tooth from occlusal forces, may account for the relatively low incidence of resorption in this series.