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®

Issue 62 / July 2020

Editor-in-Chief Javier González Lagunas

Assistant Editor Deepak Krishnan

Graphic Designer María Montesinos

Executive Committee 2020-2021 Board of Directors

Gabriele Millesi, President Alexis Olsson, Past President Alejandro Martinez, Vice President Sanjiv Nair, Vice President-Elect Arthur Jee, Treasurer Larry Nissen, IAOMS Foundation Chair Mitchell Dvorak, Executive Director

Members-at-Large Piero Cascone Rui Fernandes Fred Rozema

Regional Representatives

Imad Elimairi, Africa Tetsu Takahaski, Asia Nick Kalavrezos, Europe Leopoldo Victor Meneses Rivadeneira, Latin America Ian Ross, North America Jocelyn Shand, Oceania Nabil Samman, Editor-in-Chief, IJOMS

Committee Chairs G.E. Ghali, Education Alejandro Martinez, Governance and Ethics Alfred Lau, Membership and Communications Sean Edwards, Research Paul Sambrook, IBCSOMS Representative David Koppel, 25th ICOMS-2021, Glasgow Ed Dore, 26th ICOMS-2023, Vancouver FACE TO FACE Registered in U.S. Patent and Trademark Office. ©Copyright 2018. International Association of Oral and Maxillofacial Surgeons. Chicago, Illinois, USA. All rights reserved under international and Pan American copyright conventions. Cover image Adobe Stock

CONTACT US

International Association of Oral and Maxillofacial Surgeons IAOMS Foundation 200 E. Randolph St., Suite 5100 Chicago, IL 60601 USA / communications@iaoms.org


Letter from the Editor AS I SEE IT SUMMER has started at last. After a gloomy spring splashed by COVID-19, many of us thought that the ordeal was over. Unfortunately, the epicenter of the tragedy is now moving to America and some parts of Africa. The aftereffects will last a few months, leaving significant challenges especially to public health. I do not want to focus the magazine only in the virus, but we will pay some attention to COVID 19: to its present impact in Africa, but also to an interesting precedent during the Greek ancient times. Face to face number sixty-two goes to Eastern Europe, a melting pot of countries and cultures. As it is only fair that a magazine with a global scope should dedicate some space to Eastern Europe, we will catch a glimpse of the reality of Oral and Maxillofacial Surgery in that part of the world. I look forward to welcome new authors and contributions from that corner of the planet. We also have our usual sections with authors from all around the globe. We pay attention to publishing, foreseeing the future with the editor of our magazine IJOMS. But we also receive inputs from the President of the Panafrican association. From Sydney, Australia Dr Paul Coceancig answers our Proust questionnaire, while Women´s corner is written by a Romanian professor. Italy is well represented not only with a clinical case from Rome, but also with Udine´s contribution to The New New Thing. Nextgen is coming from Eastern Africa. Dr Merks in his paper on the Tanzania missions pays a tribute to Paul Stoelinga, former president of IAOMS. Congratulations on his 80th anniversary! As always, all of us have devoted all our enthusiasm to prepare this new issue of Face to Face. So we will appreciate it if you read it, and share it with your colleagues and friends. But what we would very much like is that you enjoy it! AGAIN, TAKE CARE AND STAY HEALTHY

Javier González Lagunas EDITOR IN CHIEF


CONTENTS July 2020 10 SPECIAL REPORT Eastern Europe.

PUBLISHING 20

Medical Journals: is change a risk for quality?

22 THE GREAT PLAGUE OF ATHENS

Lessons from the first reported epidemic in the world, in the COVID-19 era.

WOMEN IN IAOMS 25

My experience as a female maxillofacial surgeon in Romania.

26 NEXTGEN

Covid -19 and the practice of maxillofacial surgery in Africa.

HOW I DO IT 30

Slice Functional Condylectomy in Condylar Hyperplasia.

36 FROM PROUST TO PIVOT Paul Coceancig.

OMS ON MISSION 40 Tanzania.

43 PUBLISHING PAPERS IN SCIENTIFIC PAPERS: AN AFRICAN PERSPECTIVE

BEYOND THE O.R. 45 Twenty-five.


ADAPTING TO CHANGE DURING these unprecedented times IAOMS is bringing OMF surgeons together in the only way possible – through digital and virtual connection. As we all adapt to these changes, IAOMS continues to meet the needs of OMF surgeons by providing online education and networking opportunities to stay connected as a community. Although we may not be able to meet in person, we continue to expand our library of e-learning resources to better meet the needs of our OMF community.

DIGITAL TRANSFORMATION & EDUCATION The IAOMS staff team is working closely with our Education Committee to build a comprehensive calendar of Scientific Webinars, micro-Learning videos, all new episodes of the IAOMS Podcast Series and more. With record breaking attendance for our e-learning offerings, we would like to thank our speakers, participants, and partners once again for assisting IAOMS in the execution of these successful programs. IAOMS Stay Connected Series: As the global pandemic swiftly changed the landscape of education, IAOMS worked diligently with a team of experts within the specialty to bring this limited series to surgeons everywhere. This series connected IAOMS members and leading OMF surgeons from around the globe for brief lectures, case studies and live question & answer opportunities. Designed for surgeons – by surgeons – this well-attended program helped us to continue learning as a community through face to face interaction. All lectures are available on www.iaoms.org under e-learning. IAOMS Virtual Conference: In collaboration with the Osteo Science Foundation, IAOMS hosted our second Virtual Conference on June 5, 2020. Through the generous support of Osteo Science Foundation, IAOMS was able to offer complimentary registration to all OMF

surgeons. This dynamic program featured keynote speaker Dr. Sean P. Edwards, followed by three breakout sessions from Dr. Nardy Casap, Dr. Shahram Ghanaati and Dr. James C. Melville. Thank you to all of those that attended, and we look forward to developing future virtual conferences. Unable to attend? Access the 2019 and 2020 IAOMS Virtual Conference on www.iaoms.org under e-learning.

NETWORKING & EDUCATION OPPORTUNITIES ICOMS Glasgow 2021: Planning for the 25th International Conference on Oral and Maxillofacial Surgery is well underway. If you haven’t attended an ICOMS in the past or you are curious about our upcoming meeting in Glasgow, please visit www.iaoms. org/icoms2021 for more information on our signature, biennial event. Take a moment to review the 2019 highlight video from the 24th ICOMS in beautiful Rio de Janeiro, and preview what’s to come in Glasgow with our “Looking Ahead to 2021” promotional clip. We encourage you to make the most of your trip to Scotland. You’ll find general information, information on tourist activities in Glasgow and more on the ICOMS website. Save the Date:

Mitchell Dvorak EXECUTIVE DIRECTOR, IAOMS


Letter from the President

Dear Colleagues, Friends & IAOMS Members, I would first like to address the health and wellbeing of our community. I hope our members, our friends, and your families are safe and healthy during these challenging and uncertain times. Is there any other topic today to discuss other than Covid-19 global pandemic? Unfortunately, it is at the forefront of most of our daily lives. We are have become familiar with seeing our friends around the world either dressed up or locked up at home, in a squared frame on a display, using virtual platforms as our source of communication. All of us are struggling with our new private and working conditions, and coping with the remarkable psychological and personal pressure that comes with our new normal. In these unusual times, you may be finding yourself participating in unconventional activities or routines. I came across this picture of “Endurance”, the ship of Sir Ernest Shackleton (1874-1922), an Irish Antarctic explorer who led three British expeditions. Looking at this ship jammed in the ice, I could not help but think of a comparison with our daily lives and our association, the IAOMS. The expedition to the Antartic in 1914 was challenging and limited by unbearable conditions. However, despite these insuperable hurdles, Sir Shackleton, as captain, was able to save the lives of his crew! This was a miracle due to the incredible and wise leadership. Do not get me

wrong, Sir Ernest Shackleton was an undisputed hero, unprecedented for centuries, but he was only so successful because he was side by side with his crew, and able to strengthen his men morally through leading by example. As president of the IAOMS, I am feeling the unfortunate results of being home. My primary


form of communication engage with our members is by recording video messages, rather than having the chance to be with you and participate in your national, regional or local conferences. Nevertheless, I can assure you that we, the Board of Directors of the IAOMS and the IAOMS Chicago Headquarters, are strongly working together to further support our members in under these new circustmances. As an international community, we are aware that it is impossible to come up with recommendations on how to cope with this pandemic in every single situation across the globe. Nations and regions are affected by the Covid-19 threat in waves and with diverse

We would like to remind the OMF community that IAOMS is here to accompany you through these unpredictable times, by offering you educational resources and programs to help you continue your education (and work!)... intensity, with a variety of restrictions and regulations by their governing bodies. We would like to remind the OMF community that IAOMS is here to accompany you through these unpredictable times, by offering you educational resources and programs to help you continue your education (and work!) while in the comfort of your home. We are continuously developing content based on your needs, with an increased effort to develop virtual learning opportunities using the IAOMS e-learning platform, Zoom.com, and social media to stay connected.

I want to thank each of you for your strong and regular participation in our online activities. It has been such a wonderful opportunity to connect, learn and laugh with our community over webcams and online platforms, face to face in the only way currently possible. Wearing masks and hiding our faces reduces our very personal interaction, and is in conflict with the aimed outcomes of our profession as Oral and Maxillofacial Surgeons: creating smiles. However, we are finding ways to adapt to these changes together! I would like to reassure our community that we strongly believe that this is not our future, and that COVID -19 will be defeated. With that in mind, we are actively planning ahead for our 2020-2021 year of programming. We are collaborating with the British Association of OMS and their Organizing Committee on the success of our next ICOMS in Glasgow in September 2021. By then, we will be all infected by Zoom and webcam fatigue, and a face to face meeting like our unique ICOMS will be an unforgettable (and refreshing!) experience again. We may have tough months ahead, but I want to encourage you to stay strong, stay optimistic and stay connected with IAOMS!

Wishing you health and stay safe!

Gabriele Millesi IAOMS PRESIDENT 2020-2021


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01

RUSSIAN Oral and Maxillofacial Surgery in 2020 By Alexander Ivanov Moscow, RU

THE TREATMENT practice in Russia was historically divided between two groups of therapists – the healer-herbalists and the doctors invited from Europe for treating tsar families. It was under Peter the Great that the big reform of “Europeanisation” was initiated leading to the creation of the Russian Academy of Science in 1724 and the Faculty of Medicine in the Moscow State University in 1758. Many famous professors graduated from these institutions. At the same time the dentistry schools appeared as a separate specialization taught by European doctors. The First and the Second World Wars in the 20th century pushed the development of maxillo-facial surgery to the next level. The Central Institute of Traumatology and Orthopedy (CITO) was created where the soldiers with facial injuries were treated as well. In 1962 the CITO maxillafacial surgery department was transformed into the Central Research Institute of Stomatology. And this is the place the Russian maxillo-facial surgery school originates from.

The National Association of Maxillo-Facial Surgery (an association of specialists in maxillofacial surgery) in Russia was founded in 2017. The affiliation with IAOMS was fulfilled in 2017. We expect the rise of international activity among Russian colleagues. Many of most advanced surgeons and scientists find interest in international congresses and fellowship programs.

During the Soviet period scientific contact with foreign colleagues was restricted. Only in 1990 Russian specialists were invited for the first time to the Congress of the European Association of Maxillofacial Surgery, which took place in Brussels. At that time Professor Plotnikov presented on the subject of transplanting lyophilized grafts in mandibular defects reconstruction, which impressed the founder of the association. Professor Hugo Obwegeser. The Russian Dental Association was created in 1992 and included the Maxillo-Facial Surgery Section. July 2020

Board of the Association of specialists in maxillofacial surgery Moscow 2018. iaoms.org 11


Buildings of the Central research Institute of dentistry and maxillofacial surgery, Moscow.

Modern equipped operating room of the pediatric clinic of the Central research Institute of dentistry and maxillofacial surgery.

Now there are 77 Medical Schools in Russia. The higher education in medicine lasts 6 years for general medicine and 5 years for dentistry. Both general doctors and dentists can continue their education to become maxillofacial surgeons in 16 post-graduation schools. The residency lasts 2 years for general doctors and 3 years for dentists. The number of postgraduate students in maxillo-facial surgery is 275. Every year 100+ specialists get their qualification in MFS and continue their professional activity in state or private hospitals and dentistry clinics. The double qualification is not necessary now in Russia. The discussions about this continue. 12 iaoms.org

There have been no uniform protocols developed up till now in pediatric maxillo-facial surgery in Russia. Thus, one of the goals of the national association is to stimulate the research on effective treatment protocols. July 2020


I wish for Russia to be incorporated into the international education system in health care. The exchange of trainees, and doctors` visits, could be organized in Russia. The low infrastructure costs are a good reason to make Russia one of the most attractive places in Europe for organizing events like scientific congresses... In Russia we do not have an official division between pediatric and adult maxillo-facial surgery. Nevertheless, around 50 pediatric maxillo-facial divisions exist. There is state financial support for complex surgeries, as well as the public insurance system. The surgeries can also be performed in private practice. I think the Russian school of maxillo-facial surgery During craniofacial surgery in the operating room of the is forming now by a combination of national Burdenko Institute of neurosurgery, Moscow, 2020. techniques and our most advanced international experience. This might be considered an advantage. Our priorities in congenital malformations medical care here. So, the number of rare patients treatment are complete rehabilitation at the earliest permits us to do research in this field as well. Our age possible, and minimal morbidity. In hospitals health system allows us to admit patients from abroad. the cleft treatment protocol includes a functional The administrative routine is moderate, and costs are approach for primary cheilorhinoplasty and a onevery competitive. stage palatoplasty at the age of less than 20 months, followed by bone grafting at 7 years of age. I consider Looking to our future I wish for Russia to be the alveolar bone grafting the most important stage in incorporated into the international education cleft patients’ rehabilitation. Thus, this surgery must system in health care. The exchange of trainees, and be done by an experienced and skilled team. doctors` visits, could be organized in Russia. The low infrastructure costs are a good reason to make There have been no uniform protocols developed up Russia one of the most attractive places in Europe till now in pediatric maxillo-facial surgery in Russia. for organizing events like scientific congresses, Thus, one of the goals of the national association international visiting scholarships, leading specialists’ is to stimulate the research on effective treatment workshops and masterclasses. protocols. In recent years the professional standards and clinical recommendations have been elaborated on I think Russia is continuing to integrate into European to reduce the risk of inappropriate surgical treatment. standards of health care. This is a historic tradition since the reform under Peter the Great. During Craniofacial surgery is also developing in Russia. the last 100 years the image of Russia has been There are a few craniofacial surgery divisions based in compromised by different political events. And maxillo-facial surgery or neurosurgery departments. probably it is right now that the winds of change have Taking care of rare congenital diseases is also a started to blow. My dream is to see the world safe significant part of CMF surgery. We have a population and predictable with uniform life quality standards. of approximately 146 million in Russia and traditionally I am glad to contribute as a councilor of Russia in many patients from ex-soviet territories come to get IAOMS. ■ July 2020

iaoms.org 13


02

The rise of Orthognathic Surgery in LITHUANIA By Simonas Gybrauskas Lithuania

LITHUANIA, a Baltic country with a population of just 2.8 million, has an amazing history, and quite a few interesting places and traditions have survived to see modern times. The Lithuanian language is one of the oldest living languages in Europe and is the closest one to the ancient Sanskrit. Lithuania‘s predominant religion is Christianity, but to be honest, the dominant religion has been basketball for many decades. Known as the largest country in Europe in 14th century, the Grand Duchy of Lithuania fell at the end of 18th century when the Commonwealth was terminated, and Lithuania was effectively split between Prussia’s and Russia’s empires. The first time independence was reestablished in 1918, but this did not last for long. Lithuania reemerged on the modern world map as an independent country for the second time after the breakdown of the Soviet Union in 1990, and celebrated 30 years of independence recently.

14 iaoms.org

The first known teaching facility of maxillofacial surgery is known to be the Lithuanian University which was founded in 1922. Currently maxillofacial surgery training occurs at the Lithuanian University of Health Sciences and at Vilnius University. Medical doctors may choose five years of training in maxillofacial surgery whereas dentists are eligible for a three-year training program in oral surgery. The main surgery centers are the at the two university hospitals in Kaunas and Vilnius as well the Klaipeda University hospital. The Lithuanian Association of Oral and Maxillofacial surgeons was established in 1995 and has 154 members. Unfortunately, the country was negatively affected by the Soviet occupation in many different ways, including the effect on the healthcare system. Stagnation and bureaucracy are still the most powerful catalysts for young doctors to decide to choose emigration over the work within the country, since Lithuanian doctors are highly valued across Europe for their education, knowledge and dedicated work.

July 2020


Great surgeons and teachers from Brazil: Dr. Lucas Esteves and Dr. Vanessa Castro conducting the 5th BSCOSO facial planning course in Vilnius in 2018.

Since I had the opportunity and luck to establish a successful orthognathic surgery practice in my country, I will limit the overview of maxillofacial surgery through this particular lens. ORTHOGNATHIC SURGERY - THE ROOTS In early years of Lithuanian independence orthognathic surgery was performed sporadically at Lithuanian hospitals. Surgery often involved single jaw osteotomy only and was seldom coordinated with perioperative orthodontic treatment. The place where I first learned contemporary orthognathic surgery as a team play between surgeon and orthodontists was in Riga Stradins University (Latvia) during my early residency years in 2001. I need to give credit to the kindness and generosity of Prof. Andrejs Skagers and Prof. Ilga Urtane for allowing me to return to their Institute over the years and also to Drs. Girts Šalms, Andris Bigestans and Gunars Lauskis for teaching me and helping me to perform the first bimaxillary orthognathic surgery with perioperative orthodontic

treatment in Lithuania in 2003. Their kindness and professionality inspired me to continue my orthognathic surgery journey up till now being aware that the learning process is endless. A special thanks goes to chief of department Dr. Renaldas Vaičiūnas for his trust in me. WHEN THE STUDENT IS READY, THE TEACHER IS JUST AROUND THE CORNER Prof. Andrejs Skagers kindly shared his contacts and arranged fellowships at Dept. of Maxillofacial Surgery at Helsinki University Hospital (chair: Prof. Ch. Lindqvist) where I had the chance to observe the work of Pekka Laine, Risto Kontio, Patricia Stoor, Hanna Thoren, and Karri Mesimäki. From there I continued to Morriston Hospital at the Welsh Centre for Burns, Plastic Surgery and Maxillofacial Surgery in Swansea, UK, where Dr. Adrian Sugar made the biggest impact on my professional career. Unfortunately, Lithuania was not a member of EU at that time and I was not eligible for numerous

S’OS clinic staff at Prof. Haakman’s two-days course in the Netherlands.

July 2020

iaoms.org 15


A group of Brazilian surgeons led by Dr. Carlos Saiki taking part in the 3rd International Fellowship program at S’OS clinic.

trainee funding programs that are available now. Short breaks in the program allowed me to return home and earn for future studies abroad. I was very lucky to meet Dr. William Arnett (USA), Prof. Mirco Raffaini (Italy) and Prof. Chi Yang (China) and learn both from their educational activities and by observing surgeries. With every new teacher I was able to augment new orthognathic surgery protocols with new techniques and philosophies: multi-segmental LeFort I surgery, CCW rotation of the occlusal plane and mandible-first sequence in surgery. Some of them were game changers and eyeopeners requiring critical rethinking of previously used techniques. Other important objective to achieve was to increase the accuracy of planning and transfer to the surgery room. This is where my computer skills came to practice about a decade ago. At that time there were few good software packages and most of them looked more like engineering tools rather than clinically driven solutions for a surgeon. Implementation of 3D planning by utilizing a combination of different medical and engineering software packages was the only way to boost the accuracy of planning. FROM LEARNING TO TEACHING Together with my colleagues Carlos Saiki and Octavio Cintra we developed the mid-sagittal plane based head orientation and calibration technique called the Sagitta technique which was a milestone in our entire 3D planning protocol. Another useful protocol, the so called “Forced symmetry“ simulation for asymmetric faces, is also based on the same concept of accurate determination of the mid-sagittal plane as one of the 16 iaoms.org

most important determinants of successful planning and surgery. In our opinion, these small details were the missing link between the clinicians and the software, due to which inadequate control of sophisticated software packages can result in less than ideal results. The bottom line is that virtual planning is not a panacea and does not guarantee good results if it is not calibrated with clinical planning. Since 10 years ago, clinically driven virtual planning and precision surgery earned our team a name in orthognathic surgery. At that point I decided to subspecialize and limit my practice to orthognathic surgery only and established a private practice S‘OS Orthognathic Surgery. Cooperation with more than a hundred orthodontists from within and outside the country allowed our practice to reach a constant volume of 120 cases per year, the maximum we can handle with high precision with the help of two junior associate surgeons. This is about 85-90% of the entire orthognathic surgery volume performed in the country, although the demand is at least triple that. In order to run the busy service we grew to have 27 staff members on board, among them having 3 surgeons, an orthodontist, periodontologists, dentists, anesthesiologists, medical engineers, assistants, front office and back office. We work hard and we grow together by learning and travelling. On top of that we launched an international research group for virtual planning, 3D analysis and superimposition of medical images under the name of Eurosplint. Since 2009, we have been effectively running an educational program under the name Baltic Sea Courses on Orthognathic Surgery and Orthodontics (BSCOSO), that has served for more than 50,000 specialists worldwide till date and created a real community of specialists. July 2020


THE PROTOCOL Our routine protocol for every orthognathic patient is: two visits one hour each for repetitive clinical examination on different days. Asymmetric patients are scheduled for a third clinical check too. Facial planes, cants, yaws, midlines and anticipated surgical repositioning movements are recorded and will be used for head orientation and planning in the virtual setup. The latter is done in 2D and 3D environments and the last checkup is splint check and patient counseling. Ninety percent of orthognathic surgery is multi-segmental bimaxillary osteotomies and it usually lasts 5 to 6 hours since a lot of attention is placed on details. Our aim is to perform the most accurate planning and surgery and avoid any re-do or additional retouching surgery that may be needed to correct a less than ideal outcome in the later stage. The long hours pay back as patients do not need to wear elastics after surgery due to well established occlusal contact; postoperative follow-up visits are usually a piece of cake and last 5 to 10 minutes. High accuracy of work allows us to see more patients in the same time. There are more than 14 reasons not to take a “surgery-first” approach and we try to educate our patients not to be seduced by this approach as it usually will not provide results of the same quality as the conventional approach does. Our protocol of planning and surgery gained worldwide interest and during the last 2 years our team was happy to accept more than 80 international visiting doctors from 25 countries at S‘OS Orthognathic Surgery center free of charge. What I like most about the fellowship program is that it is not just about teaching or learning we exchange our experience bi-directionally, therefore every visitor makes me a better surgeon too. Visitors are welcome back again. We also had three exceptional one-week fellowship programs successfully completed with visiting doctors from Brazil. Many visitors ask if it is worth coming for a 3-6 months fellowship program, July 2020

my usual advice is rather to limit the visit to 2-4 weeks and to return to us later, each time with new questions following from the experience of putting our protocols to practice. Longer visits are welcome too, but in my understanding they are not as efficient as multiple returning visits since visitors are allowed to observe only. THE FUTURE I see the future of orthognathic surgery in synergy with artificial intelligence. Data mining will help us understand some hidden etiological factors of TMJ pathology and predict the risk of condylar resorption after surgery. Beyond robotics, AI may help us automate our work: from data segmentation to automatic osteotomies and facial planning and splints. I believe we will see automated workflow in no more than 3 years.

For now, I am extremely happy that technology and software available in the present day provide us with all the possibilities to perform accurate planning and surgery and promise predictable results to our patients, something which was scarcely possible a couple of decades ago. However, we should not stop here and should move forward every single day with new ideas and achievements. I truly hope that this success story will inspire young colleagues to create and establish innovative surgery centers in their countries worldwide. Meanwhile, we will do our best to serve our patients and the maximum number of specialists from worldwide who show interest in our work and are dedicated to learn. ■ iaoms.org 17


03

Maxillofacial Surgery in SERBIA Past, present and future

By Vitomir Konstatinovic, Drago Jelovac Belgrade. Serbia

MORE THAN a hundred years ago, during the Balkan wars of 1912-1913 a young volunteer joined the Serbian military ambulance forces as a military war surgeon. Doctor Atanasije Puljo was treating gunshot injuries, mutilations, and infections of the face and jaws. He was the pioneer of the “surgery of jaws” in Serbia. In the battlefield ambulance conditions, Dr Puljo had early recognized and emphasized the importance of a tight teamwork between dentists and general surgeons in the treatment of jaw and facial injuries. He asserted that the most difficult cases of jaw trauma should be referred to dentists, underscoring the importance of additional surgical training and skills. Thanks to Dr Puljo’s firm beliefs and unequivocal expertise in war post-traumatic injuries of the face and jaws, those conflict years contributed to the emergence and development of Maxillofacial Surgery in Serbia. He quickly took over the lead in thought and treatment by presenting a brilliant idea for jaws and face injuries: the “inside out” algorithm. Before Kazanjian, Dr Puljo promoted a revolutionary approach in the treatment of facial mutilations. He proceeded by establishing the occlusion as the primary core in the reconstruction of the jaws, and then taking care of the soft tissues’ 18 iaoms.org

injuries. His method of treatment of the upper jaw neglected fractures, the so-called “Balkan method”, was recognized worldwide. The specialty of Maxillofacial Surgery in Serbia was developed firstly through the Faculty of Stomatology at the University of Belgrade, since its founding in 1948, as “Stomato-surgery” in the Military Medical Academy. The first specialist in Maxillofacial Surgery (1962) was Professor Aleksa Piščević (who introduced bimaxillary surgery after training in Zurich with Professor Obwegeser. Together with Professor

fessor Miodra Professor Aleksa Piščević, Pro July 2020

g Karapandžić.


Miodrag Karapandžić (who described the technique of lip reconstruction “Karapandzic flap”, also known as neurovascular fan flap), they established modern Maxillofacial Surgery in Serbia based on the “Double Qualification”, similar to the German-Austrian-Swiss model.

Complex procedures as craniofacial and orthognathic surgical cases are mainly performed in the university centers and the Military Medical academy. Most patients who need pre-prosthetic surgery are treated in the Maxillofacial University clinic at the School of Dental Medicine in Belgrade.

Maxillofacial Surgery is a postgraduate speciality level of education for both dental doctors (DMD) and medical doctors (MD). The five-year curriculum and training program, with multidisciplinary residencies is somewhat different for dentists and medical doctors. National Association of Maxillofacial Surgery recommendations are that the doctors should obtain both graduate degrees in dentistry and medicine before continuing their studies in specialty.

Our colleagues and peers are maintaining high standards in training and delivering the best individualized treatment to each patient. We keep an open mind to all new and advanced treatment options and our patients in Serbia are able to benefit from state-of-the-art maxillofacial treatment plans. Patients in Serbia enjoy benefits of all advanced and novel procedures.

Young doctors are encouraged to participate in various international meetings and congresses, where they can meet and learn, be seen and heard. Serbia has three universities in Belgrade, Novi Sad, Niš, and the Military Medical Academy, with postgraduate programs in maxillofacial specialty. Currently, some 20 residents pursuing their specialty training are enrolled in the programs. Curriculums in all university centers are coordinated and provide courses in craniofacial traumatology, infections, benign and malignant tumors, reconstructive and orthognathic surgery. Serbian Association of Maxillofacial Surgeons has more than seventy members. Most of them are employed by public or University hospitals. There are also maxillofacial surgeons who are working in private sector and are performing mainly dentoalveolar surgery procedures. In Serbia, following into the steps of famous predecessors in maxillofacial surgery, our scope of procedures and surgical attempts today are covering the entire landscape of the specialty. We are Head and Neck surgeons treating daily the full scope of the speciality, from trauma and infections to different types of malignancies in the head and neck region. Also, we are managing an important number of parotid glands tumors. July 2020

Drago Jelovac, Vitomir Konstatinovic.

Continuing education and consistent share of knowledge worldwide are priorities for Serbian Association of Maxillofacial surgeons. Young doctors are encouraged to participate in various international meetings and congresses, where they can meet and learn, be seen and heard. That represents a very good head start in a complex specialty of maxillofacial surgery. ■ iaoms.org 19


Publishing

MEDICAL JOURNALS: IS CHANGE A RISK FOR QUALITY? By Nabil Samman Hong Kong

High quality journals are important for members and readers because what is published is: a. Current and at the forefront of the topic. b. Supported and endorsed by a high-level peer scrutiny. c. At any given time represents a snapshot of current knowledge in OMS. WHETHER THE IMPACT FACTOR (IF) SYSTEM IS TO REMAIN

QUALITY in the context of a scientific journal refers to a number of different areas within the material submitted and published in that journal. In relation to submissions: a. Triage of submissions for relevance and usefulness to readers. b. Honest appraisal with high level of scrutiny. In relation to what is ultimately published: a. Novelty and Significance. b. Timeliness and Relevance of Studies and Topics. c. Robust methodology, reliable findings and valid conclusions. 20 iaoms.org

IF is one of a number of metrics used to quantify the performance of a journal. IF is far from perfect (and not relevant to many non-academic readers) but is the most commonly considered metric for both journal and author. Its strength traditionally lies in providing an objective calculation of a citation index for articles within a two-year period. Its main weakness is that it is open to manipulation because of its dependence on citations by authors. One attempt at diminishing this weakness is by separate calculation and possible exclusion of “self citations”, self being author and journal. Other metrics are already in place but it is not known if the IF will ever become completely obsolete. Already critical evaluation of authors’ academic performance takes in multiple parameters only one of which is the IF. New alternative metrics “Altimetrics” record “mentions” of an article in social and other media outlets like Facebook, Twitter, Google+, Wikipedia, Reddit, blogs, online videos, and patents. These are harnessed through an algorithm to calculate “impact”. It is fair to say that altimetrics are far from being accepted as an alternative scoring system at this stage. But things can change. FULL OPEN ACCESS TO JOURNAL ARTICLES AND VIDEOS There is a certain monetary cost to publishing. The current system involves subscription payments by readers and institutions for access to articles and journals while authors do not pay for submissions and ultimately published articles. July 2020


Open access assumes no payment by readers and institutions, leaving the cost of publishing unaccounted for. Currently the cost of publishing open access is borne by authors or sponsors. In Full Open Access, there is a simple substitution of payment between readers and authors which is a choice that can be made. However, scientific articles paid for by industry sponsors are by definition risky due to the resulting conflict of interest that might jeopardize the quality of the articles published. This is currently one reason for flagship professional journals not to shift completely to open access, bearing in mind the option is available for authors. CHANGE THE MODEL OF MEDICAL JOURNALS? The current model relies on volunteer peer review by experts selected by editors for their perceived ability to judge a submission concerning a particular subject within their area of expertise. The model is

indicative of the prevailing standard that is being observed by the review process which either rejects submissions falling below the standard or oversees a raising of the quality of the submission to the required standard after revision. By its nature, this system is “labor intensive” for the busy specialists and scientists volunteering, and thus vulnerable to delays and inaccuracies due to inevitable subjectivity at certain times and settings. The latter drawback is balanced by the availability of submission to alternative journals and a fresh peer review by other reviewers. Alternatives involving non-existent peer review are fraught with risk of lower standards and even dissemination of false science. The internet is brimming with information that has no assurance of validity or truth. The lure of short submissionto-publication intervals and open access must be balanced against the robustness of the review process to assure a quality article. ■

The

NEW NEW THING IN OMFS Massimo Robiony. Udine, Italy IN THIS VIDEO, Professor Massimo Robiony presents the key role that a simulation center providing 3D technology plays in a modern Maxillofacial Surgery department, and discusses with his resident a clinical case of a combined orbital and cranial resection and reconstruction. They have realized a dream envisioned two years ago, founding a laboratory for virtual surgical planning and 3D Printing, showing that technology has allowed us to redesign paradigms in surgery and it is only the first step in a true revolution in medicine. Virtual surgical planning and 3D printing have deeply changed the way surgeons approach complex problems. Having in the eyes the virtual result of procedures preliminarily and safely performed in an entirely digital environment, surgeons are given the power

to predict surgical outcomes and design optimal osteotomies. The anatomical resemblance provided by the graphical capabilities of modern software is exponentially growing, and the simultaneous development of 3D printing has allowed us to turn such images into material models. When such technology is conjugated with design skills and clinical intuition, it is possible to self-fabricate models which are useful for surgery - not just anatomical replicas, but also surgical templates and molds. Notably, molds are a valuable strategy to model existing surgical materials, including polymethilmetacrylate (PMMA), July 2020anatomical iaoms.orgparts 21 into accurate

which can be used to shape cranial prostheses with unprecedented accuracy and at low cost. Moreover, the best of technology is achieved when different devices dialogue with each other; therefore a file used for printing can also be used for a surgical navigation plan or augmented reality. ■


THE GREAT PLAGUE OF ATHENS

LESSONS FROM THE FIRST REPORTED EPIDEMIC IN THE WORLD, IN THE COVID-19 ERA By Evangelos Kilipiris

Greece

IT IS WIDELY accepted that history likes to repeat itself throughout the centuries, and to give meaningful lessons. From AIDS to Ebola, and from SARS to MERS, previous epidemics served both as a reminder and a forewarning of our vulnerability to infectious outbreaks. However, when we were speaking about the future of infectious diseases, the most likely picture was drawn by an unexplained underestimation of the real problems that could arise from this extraordinarily diverse group of diseases. And now the COVID-19 pandemic arrives reminding us that as infectious diseases continue

to emerge, and re-emerge, we will require an unprecedented effort to lift their burden. As the quote “if a picture is worth a thousands words, a good story is worth many columns of statistics” suggests, it is worth travelling back to 430 B.C., and more precisely to the Classic Greece. The city-states of Athens and Sparta, the biggest rivals in ancient Greece enter the second year of the Peloponnesian War, we are just at the beginning of this intense, long-lasting war, but suddenly, an invisible enemy, a rapidly spreading infection hits the Athenian population, greatly altering the course of the war. This deadly epidemic, denominated as the Great Plague of Athens, is considered the first epidemic. Though Athens appears very well prepared to fight against Sparta, at the same time it looks very weak in handling the epidemic.

“My work is intended to be a possession forever.”

Thucydides


The primary source of information comes from Thucydides (460 B.C.-399 B.C.), the father of political realism and scientific history whose work is monumental. Although Thucydides was not a physician, but a careful observer and recorder of events, his description of the epidemic appears very accurate. He also fell victim of the disease since he got the infection but he recovered, so he had a firsthand knowledge of its signs and symptoms. The Athenian society at the beginning of this highly contagious and potentially lethal epidemic is portrayed by novel pictures, unfamiliar for an advanced city of that period. Thucydides narrates, “the crowding along with inadequate housing, sanitation and poor personal and domestic hygiene measures helped the uncontrolled spread of the disease”. The onset of the infection was sudden, and the transmission rate very high. Doctors were struggling to cope with the new epidemic, because never in the past had they met something similar and they were unable to understand the exact nature of it. The infectious disease that caused the

This deadly epidemic, denominated as the Great Plague of Athens, is considered the first epidemic.

he points out, “People recovered from the disease were behaving with more solidarity to other victims, because they had already passed through the painful experience, and also were feeling more safe. However, some started thinking themselves as immortal, and they created perfunctory hopes that in the future they will not catch any other disease.” The disease arrived first in Pireaus, the main harbor of Athens, and then spread across the city. The first disinformation comes very fast: “The Spartans threw poisons in the wells of Pireaus.” One of the worst components of the epidemic was the depression and dispair, together with loss of the feeling of safety. Because of the magnitude of the disaster, people stopped paying attention to sacred rituals. The funeral ceremonies were strongly violated, and dead bodies were buried in any possible way. Thucydides highlights, “A city that was paying high respect for the dead with strict burial rites, now is unable to bury them.” The citizens experienced a rapid transformation and their behavior changed radically. The epidemic introduced a breakdown in traditional social values. Thucydides underlines, “Nobody was able to concentrate and focus more on something useful in the long-term, because of the sense that it would take too long to accomplish it.” Nothing seemed to ameliorate the crisis. The elderly Athenians recalled an oracle from the past, given to Spartans, that replied highlighting “only if they will fight united with all of their power they will win.”

Plague of Athens has been a topic of debate among classical scholars and physicians for centuries, and still continues up to recent years. Various infectious diseases have been proposed as the cause of the epidemic, with typhoid fever, influenza, smallpox and measles mentioned among them. Thucydides describes, “They were not able to cure the patients, and many of them died as well, because they constantly were coming in contact with many infected people. Many citizens died, some because of lack of medical care, but also others who had great care. Effective therapy was not found. Everyone, doctor or ignorant of the health situation, was able to say whatever they were thinking in relation to the disease.” It was a disaster of epic proportions. Approximately one third of the total population of Athens perished as a result of the plague. For those who survived July 2020

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After the end of the Peloponnesian War, Athens surrendered, and an oligarchic group took control of the city. The city-state was dominated by aggressive figures and populist demagogues. Athenian democracy would never recover.

identification of our role as an individual clinician, a hospital department, an entire hospital, a community, a nation, and the whole globe itself, if we don’t want to follow the response of people in ancient Athens, who clearly failed.

Today, as we run the marathon of a new pandemic with different personal, local and national experiences and strategies, and from different positions, we see this story from a different perspective. It is also characteristic of Thucydides, that he never tells us what to learn, where to pay attention. He just describes important events critically, rationally and impartially, to allow future generations to identify similar events in the present and future. Although ancient, some notions expressed in Thucydides’ work are still applicable today.

The COVID-19 crisis has multiple dimensions (medical, economic, social, logistic) that exist simultaneously. The only way to arrive successfully at the finish line of this marathon, is with a coordinated approach.

The evolution and great impact of epidemics has not changed over the course of millennia. In the highly interconnected world we live in, it is critical to execute our scientific and technological advances, and to reconstruct and rebuild partnerships among physicians, researchers, industries and governments. However, achievement of that goal requires a thoughtful and systematic 24 iaoms.org

As resilient runners with a shared aspiration, and empowered by solidarity and the compelling purpose of serving humanity we should receive the energy to run further and cover a long distance in this crisis response marathon. As compassionate professionals, it is our universal responsibility to engage with our communities, to implement an agile and highly adaptive strategy, trusted actions, an expertise-driven response, transparent communication, and a capability to learn and change. By following this strategy, we follow the winning oracle given to Spartans… ■ July 2020


Women in IAOMS

My experience as a Female Maxillofacial Surgeon in ROMANIA By Lidia Stefanescu Ploiesti, Romania

IN MY FIRST YEAR of college, all my colleagues said they wanted to become Buccal and Maxillofacial surgeons, so I was convinced that I would choose any specialty except that one. And so I thought until I graduated from college in 1993, when I started my internship / boarding year. That year I worked for a term on each specialty and I found that Buccal and Maxillofacial surgery was my love - “it’s Bucal and Maxillofacial surgery or nothing”. The residency followed. There were some impediments related to gender, as in any surgical specialty at that time, and I received more and more tasks to convince me to give up. After a few more difficult months, when everyone was convinced that they still wanted to continue despite the difficulties, I no longer had any limitations and was unequivocally seen as a surgeon. After finishing my residency, I was employed (only in 2004) in SJUP (Spitalul Judetean de Urgenta Ploiesti.),

That year I worked for a term on each specialty and I found that Buccal and Maxillofacial surgery was my love - “it’s Bucal and Maxillofacial surgery or nothing”. where I am still working. At the beginning it was hard, not due to gender discrimination but because of my surgical limitations after about 6 years of not working in Oral and Maxillofacial surgery. Subsequently, the trust came step by step and I eventually managed to far exceed the level of residency. Because my doctoral thesis was focused on oncology and because of the increased prevalence of malignant pathology in the country, most of my activity was dedicated to oncological interventions, that with time led to more and more satisfying cases. Currently I have a fairly large file for patients who have been declared free of disease, after 5 years of follow-up. I did not neglect other aspects of Oral and Maxillofacial Surgery, my only weak point being Orthognathic Surgery, which I did not address at all. I hope to perform this type of intervention in the future (after I manage to specialize in the field) to consider myself fulfilled in my profession. I am currently the head of the Buccal and Maxillofacial surgery Department at SJUP, coordinating with 2 other doctors, and 15 nurses, the department operating with a number of 20 beds. ■

July 2020

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NextGen

COVID -19 AND THE PRACTICE OF MAXILLOFACIAL SURGERY IN AFRICA By James Kirimi

Kenya. Africa

THE WORLD HEALTH ORGANISATION declared the novel coronavirus disease 2019 (COVID-19) a global pandemic on 11th March 2020 following an unprecedented global spread of the disease after its initial outbreak in Wuhan, China. Since then the disease has spread to all continents and over 200 countries in the world. At the time of writing this article there are over 6 mliion confirmed cases globally, with over 370,000 reported deaths; Africa has over 150,000 confirmed cases. There has been an enormous negative impact on the world economy, global public health systems, and the livelihoods of millions across the globe. The practice of surgery has been greatly affected and will likely change forever. The ministries of Health in various African countries have had to immediately come up with a raft of guidelines on the management of surgical patients during the COVID-19 crisis. Nearly all countries cancelled and postponed all nonemergency surgical operations, suspended all elective outpatient clinics, and declined all elective admissions. In Kenya, Nigeria, and South Africa this was advised as early as mid-March 2020 well before any cases were confirmed in Africa. The national surgical associations 26 iaoms.org

Map of the 2019-20 COVID-19 pandemic in Africa as of 2 June 2020. ■ 100,000 + Confirmed cases ■ 10,000–99,999 Confirmed cases ■ 1000–9999 Confirmed cases ■ 100–999 Confirmed cases ■ 10–99 Confirmed cases ■ 1–9 Confirmed cases Map of africa showing countries with confirmed cases. (Source: Wikipedia). July 2020


Local factory manufacturing surgical masks in kitui, kenya. (Source: Washington post 2020).

in various disciplines then immediately took the lead and came up with guidelines specific to their specialty. The initial reaction to cancel all non-emergency surgeries had to be reviewed due to the obvious negative effect it was going to have on patients awaiting elective surgery. In the initial weeks there was a lot of concern regarding safety of surgeons across all disciplines. This was quickly followed by concern about the deliberate neglect of the surgical patient with urgent but not necessarily emergency surgical needs. Therefore, national associations had to rapidly come up with guidelines on the scope of surgical practice in the COVID-19 period. There was immediate need to continue offering essential surgical procedures while keeping the surgical team completely safe from coronavirus.

Before COVID-19 nearly all PPEs ranging from surgical masks to Hazmat suits were imported into Africa. With local innovation now numerous small cottage industries and village technical colleges are now producing these PPEs. July 2020

Then came concern about the preparedness of public health hospitals to handle the pandemic. Were facilities suitably prepared to continue providing surgical services without compromising the health of staff and of other patients? Were public facilities, especially, well equipped with ventilators for example? Was there a risk of turning hospitals into a nidus of COVID-19 transmission? This was largely informed by the fear of transmission to health workers and other patients in view of limited resources, hence fears of an undersupply of PPEs. The entire definition and classification of PPEs had to be rethought. It soon became apparent that the need for PPEs extends beyond frontline health workers. The disciplines of OMFS, ENT, Head and Neck surgery and Anesthesiology had to be seen as “frontline� with respect to provision of adequate and appropriate PPEs. National Associations immediately had to look elsewhere for input on what had worked and what had not. The protection of health workers involved in surgical procedures then became paramount even as surgeons were encouraged to resume non-emergency services and to re-open outpatient clinics. The Nigeria OMFS association (NAOMS), the Kenya OMFS Association (AOMSK), the South African association (SASMFOS) and other chapters in sub Saharan Africa had to collaborate with other wider surgical associations so as to have a single voice on the guidelines to be employed. The national OMFS iaoms.org 27


The IAOMS has taken the lead in Africa with online webinars that have been aired from Nairobi, Lagos, Cairo and other African cities. had to work with the national Medical and Dental Associations to give guidance and direction to surgeons and to all other medical/dental disciplines.

as potentially positive and to apply protection accordingly. Due to limited resources questions are always arising on the availability of these PPEs in the public hospitals for example. However so far the supply levels have largely been acceptable, mainly buoyed by numerous innovations by manufacturers.

This saw a very deliberate and coordinated approach to the handling of surgical cases in hospitals across the continent. It was immediately apparent that the OMFS and other allied workers must be protected when handling any cases. This led to the adoption of clear guidelines in multiple countries across the African continent as to, for example, which patients fall under urgent as opposed to emergency categorization. It was evident very early on that we had to continue with our ethical duty of providing timely and appropriate surgical care to our patients while keeping surgeons safe and maintaining stewardship for scarce resources. A locally designed mask for use by the public. David

Before COVID-19 nearly all PPEs ranging from surgical masks to Hazmat suits were imported into Africa. With local innovation now numerous small cottage industries and village technical colleges are now producing these PPEs. It is now very possible to get surgical masks produced by tailors in Accra, Lagos, Nairobi and Harare. The r designe bigger factories are own Avido, a Kenyan designer wearing his 2020). also manufacturing In Kenya for example, face mask (Source: VOGUE 3-ply surgical masks it was agreed that and Hazmat suits and OMFS would continue this has greatly improved the supply levels of PPEs to operate as much as was possible within the across the continent. Numerous local designers guidelines issued by the government as well as by have quickly converted their design workshops the national association (AOMSK). Whereas the into spaces for producing face masks for use by recommendation is to test all pre-operative patients the public. With the numerous prints and designs this is the case only in a few select hospitals in available the face mask is slowly becoming a fashion Kenya and in Africa as a whole. In the initial days statement in many African cities. after the outbreak of COVID-19 test kits were largely unavailable and testing was therefore largely limited OMFS surgeons across the globe have embraced to citizens returning home from abroad. This has online learning during this COVID-19 period. The since changed - to a large extent testing kits are same has happened across Africa with numerous readily available in most African countries and some online platforms for online learning now available surgeons are now able to test their patients prior to for the OMFS. The IAOMS has taken the lead in surgery. However, testing of patients prior to surgery Africa with online webinars that have been aired is not routinely done in most public facilities across from Nairobi, Lagos, Cairo and other African cities. the continent. These webinars have been a big boost to many OMFS surgeons in the continent during this period. The guidelines have advised on limiting any aerosol The exchange of ideas has been mutually beneficial generating procedures as much as possible. This to all participants and has encouraged surgeons to of course is difficult to avoid in trauma patients continue operating in the background of COVI-19. â– undergoing ORIF. The advice is to treat all patients 28 iaoms.org

July 2020


The IAOMS Foundation: A Message from the Chairman

DURING these unprecedented times, we are thankful for the strength of the global oral and maxillofacial community as we continue moving forward, adapting to the changes brought on by this global pandemic. IAOMS and IAOMS Foundation are extremely proud of its members and remain by your side as you navigate this uncertain situation. Although we have placed the solicitation part of the Global Impact Campaign on pause, we are working diligently to provide continued educational opportunities through web-based programs, As we continue to expand our global reach with our fellowship programs, scholarships and the Gift of Knowledge Program, we wanted to remind our members that our goal always remains the same; continuing to develop and foster educational opportunities, and empowering our members to become stewards of the OMF specialty, the IAOMS and the IAOMS Foundation. We look forward to the day that this pandemic will be resolved, and we can return to our normal activities, including our solicitation for the Global Impact Campaign. Once again, thank you for your continuous commitment and support of the IAOMS and IAOMS Foundation. We ask that you visit www.iaoms.org/foundation to be stay informed about the latest announcements regarding application periods, resources, and more. If you have any questions regarding IAOMS Foundation Programs, the IAOMS Foundation Global Impact Campaign, or want to get involved with the Foundation, please contact foundation@iaoms.org. Stay healthy and safe!

Dr. Larry W. Nissen IAOMS Foundation Chair

July 2020

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How I do it SLICE FUNCTIONAL CONDYLECTOMY IN CONDYLAR HYPERPLASIA

DR. PIERO CASCONE, DR. MICHELE RUNCI ANASTASI. Rome, Italy

Condylar Hyperplasia (CH) is a temporomandibular joint progressive disease characterized by mandibular condyle overgrowth. It represents one of the most common causes of facial asymmetry in early adulthood. Condylectomy is the most commonly used technique to remove the excess of the condylar head. During the years, many different surgical approaches have been developed, reporting different heights of condylar cut: High Condylectomy, Low Condylectomy, and Proportional Condylectomy. Most of the time condylectomy is the only surgical procedure for condylar hyperplasia. In selected cases, the Condylectomy can also be accompanied by orthognathic surgery, aiming to achieve the best aesthetical and functional result. We use the proportional condylectomy adapted to the three main goals of the therapy: TMJ function, facial symmetry, and good occlusion. The condyle is removed in progressive slices not only to avoid an excessive mechanical stress, but also to evaluate the exact amount of bone removal necessary to achieve the desired occlusion and facial symmetry. The disk is carefully repositioned with an anchor screw to the condyle. The disk preservation and the condyle disc unit reconstruction represent the core of the restored functionality. This technique requires a meticulous knowledge of anatomy as well as specific and advanced instrumentation. Here we present a case of Slice Functional Condylectomy with its main steps.

Surgical steps

1. Incision 2. Deep temporal fascia exposure 3. Vessels ligature 4. Temporomandibular joint capsule exposure 5. Lateral ligament incision 6. Retractor placement 7. Sliced osteotomies 8. Lateral ligament identification 9. Anchor screw discopexy 10. Arthrocentesis of the upper compartment 11. Final sutures 30 iaoms.org

July 2020


1

Incision T h e p a t i e n t s h o u l d u n d e rgo ge n e ra l nasotracheal anesthesia. This allows the surgeon to check for? the correct occlusion during surgery. The patient’s dressing must leave uncovered the ipsilateral temporal area to keep under control the possible contractions of the facial nerve, as well as part of the patient’s mouth, previously decontaminated, in order to check the occlusion. Pretragal preauricular incision is performed with a cold blade, extended by 1-2 centimeters in the temporal region with an arched course of 30° from back to front and from bottom to top, in order to increase surgical exposure of this region.

2

Deep temporal fascia exposure The dissection will start to expose the superficial temporalis fascia. Then we identify the deep temporalis fascia and the zygomatic arch. This is a safe procedure, while the frontal branch of the facial nerve runs over the superficial fascia, right in correspondence of the zygomatic arch.

3

Vessels ligature Now the goal is to detach the parotid gland from the perichondrium that covers the cartilage of tragus and the external auditory canal in all its depth, and to detach the parotid from the temporomandibular joint capsule. Moving the mandible of the patient, the motility of the mandibular condyle is appraised?. In this region the superficial temporal artery and vein are identified, carefully tied and interrupted.

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Temporomandibular joint capsule exposure

4

The vascular structures are protected and preserved in the posterior part of the parotid region. Once the vascular structures have been interrupted we can carry on the dissection by dlving deeper to detach the parotid gland. Now the surgeon diseects bluntly to find the joint capsule.

Lateral ligament incision

5

The lateral ligament’s insertion is identified on the lateral pole of the condylar head. With a cold blade the insertion is cut and the disk is softly moved upward, exposing the inferior compartment of the temporomandibular joint. The superior compartment of the temporomandibular joint should never be incised during this surgical procedure.

Retractor placement

6

Dunn-Dautrey temporomandibular joint condyle retractors are now inserted to carefully protect the disk and the structures medial to the condyle.

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7

Sliced osteotomies The discrepancy between the two condyles has been previously measured by acquiring the CT cone beam of the maxillo-facial structures with specific programs, and the surgical planning is replicated on a stereolithographic 3D model. To minimize the exposition and to carefully preserve all the functional temporomandibular joint structures, we perform a slice condylectomy with piezosurgery. The amount? of the condylectomy is continuously checked and compared with the results in the occlusion. The goal will be a proportional condylectomy adapted to occlusion and to aesthetic results.

8

Lateral ligament identification During the surgery the lateral ligament attached to the disc is moved antero-medially, Now it is necessary to identify it and to firmly hold it, to allow the anchor screw discopexy.

9

An invitation hole is then performed on the postero-lateral face of the condyle. The discopexy of the articular disc is now performed with the lateral ligament by means of a resorbable anchor screw. In this way, a large part of the contiguity of the joint capsule will be reconstituted. July 2020

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Anchor screw discopexy


Arthrocentesis of the upper compartment

10

At the end of these procedures, arthrocentesis of the upper compartment of the temporomandibular joint is performed. Washing of the upper chamber of the joint is performed with lactate ringer 20Â ml.

11 Final sutures

The deeper sutures are performed with resorbable material, while we use 5/0 nylon stitches for the skin.

KEY POINTS 1. During the dissection it is important not damage the perichondrium that covers the tragal cartilage. 2. Keeping the tissues retracted with hooks rather than with other retractors is safer for the facial nerve. 3. Yellow fat is an important landmark to understand when the deep temporalis fascia has been reached during the dissection. 4. The auriculotemporal nerve, which frequently runs parallel and contiguously to the superficial temporal vein, is preserved. 5. The lateral ligament must be preserved to allow the anchor screw discopexy.

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icoms2021glasgow.com


From Proust to Pivot

AN APPARENTLY INNOCENT QUESTIONNAIRE FOR ORAL AND MAXILLOFACIAL SURGEONS

Paul Coceancig CEO and Medical Director of Profilo Australia

What is your favorite word? Bloviating. It perfectly describes me. Bizarrely... It is not found in the second edition of the long Oxford English Dictionary... but it is in the short edition... I think because it is an American word. 36 iaoms.org

What is your least favorite word? Not a word as such, but a phrase... said almost as a single word... It’s an Australianism. “No-worries-mate”. I literally hate it, because every millennial uses it when I ring a call centre about something that doesn’t work. July 2020


What is your favorite drug? Air. At sea level or at 3000 m...  What sound or noise do you love? Rain hitting the corrugated steel of the alcove outside my bedroom. That mixed with the smell of ozone from a summer thunderstorm. Instant sleep. What sound or noise do you hate? Gossip... usually amongst my secretaries and receptionists and nurses when the phones aren’t ringing. What is your favorite curse word? Fuckity I say it all the time. I shouldn’t. But I do. It’s my word. No one else uses it. I made it up. Who would you like to see on a new banknote? From Australia? Me. What profession other than your own would you not like to attempt? Chiropractic... no, wait... astrology.... ummmm no... bloodletting. If you were reincarnated as some other plant or animal, what would it be? A blue whale. I’d just swim everywhere and eat and squeal, and not give a fuckity. If Heaven exists, what would you like to hear God say when you arrive at the Pearly Gates? Anything but no-worries... if he says that I swear to god I’ll scream. What is your idea of perfect happiness? Driving a 4x4 unimog -fully kitted out as an exploration truck - across the Simpson desert and the Kimberley towards Ningaloo reef with my two sons. What is your greatest fear? My kids getting hurt. July 2020

What is the trait you most deplore in yourself? I have a complete inability to resign myself to blind luck. What is the trait you most deplore in others? I deplore that most people aspire to win lotto. Which living person do you most admire? Neil Degrasse Tyson... mostly because he knows more than me and everyone else and makes you feel good about it.  What is your greatest extravagance? I bought a very expensive apartment on a beach where I can go and sleep alone for one night a month to escape my wife, kids, friends, neighbours and staff. It helps.  What is your current state of mind? I am really frightened about COVID. More because I fear losing people I love. It has made me think that work really isn’t that important. Particularly as the government so easily prints money making the whole economy thing obviously a construction of pure imagination.  iaoms.org 37


What do you consider the most overrated virtue? Charity. I really think if a person is truly charitable, they do it themselves, anonymously, without making a big hooha about it. On what occasion do you lie? When my children say they are sick to me - I say I can fix it - and I ask them to help me find something sharp to cut it out... and to trust me that it will not hurt... and that I’m a surgeon and I know what I’m doing. It is always an instant cure. And my only lie. What do you most dislike about your appearance? Oh God... the dad bod. It has to go. I’m working hard on it. Which living person do you most despise? I despise no one personally. It’s really a negative thing to hate a person. I avoid plenty of people. But only not

to get into trouble myself. I can literally say I despise no one.  What is the quality you most like in a man? I think someone who makes decisions based on optimism and a fundamental intrinsic knowledge, but without obvious prejudice or bias. I call it leadership.  What is the quality you most like in a woman? The same. There is no difference.  Which words or phrases do you most overuse? Fuckity. Argggggghhhhh Hmmmmmmm What or who is the greatest love of your life? I love and think about and admire my five children... but my wife gave them to me because I love her best... but I think maybe my father I love above all things. As he originally taught me everything about love. When and where were you happiest? This morning. In my garden. And this evening too... when I was cooking.  Which talent would you most like to have? To be a pianist... or guitarist... or simply to be able to read music... all of that is a complete mystery to me. All of it. If you could change one thing about yourself, what would it be? I’d be younger... so I could live longer doing the same things. What do you consider your greatest achievement? Well... professionally I just submitted my book to Quintessence USA... it took me five years to write and draw. It is called 6 Ways to Design a Face. Rather lofty title.

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Personally... I don’t care about that at all. My greatest personal achievement is the family I have and love and adore. If you were to die and come back as a person or a thing, what would it be? I’d like to be my grandson. Or granddaughter. The child of one of my children.  Where would you most like to live? Oh that’s easy... on a beach in Sydney. But I already do. One day a month. What is your most treasured possession? I don’t have any possessions... just experiences. What do you regard as the lowest depth of misery? The flu... definitely having the flu.  What is your favorite occupation? Ok... well I have two... and I’ve done both. The first is military training... I did that when I was a navy officer. The other is flying helicopters... I did that for a few years...  Both weren’t really things I could continue because I had to grow up. But when I was young, and single... so much fun.

Who is your hero of fiction? Atticus Finch. Which historical figure do you most identify with? Galileo Galilei. Who are your heroes in real life? My father Bruno. He emigrated from Italy in 1956... with a suitcase and a Diploma written in Italian. In Sydney he had to reinvent himself, learn English, and raise three children with a very Australian wife. He literally left everything and everyone he knew - and just... achieved. He didn’t run a country, he wasn’t a surgeon, he didn’t invent anything. He was just simply... exceptional. What are your favorite names? I remember finding out my name was Paul. I was a very impressed 2 year old. I love this name. But even better are Kaleb and Massimiliano... my sons’ names. And Bruno is such a powerful name too. I named my daughters Alessandra, Mia and Gigi... I love these names.  What is it that you most dislike? Laziness. And complaining.  Hahaha... technically, I just complained. 

What is your most marked characteristic? I’m sort of... opinionated. It’s a terrible trait. I form an opinion on something, and for some reason I always think it’s true.

What is your greatest regret? Not working in more countries and manning bars in multiple cities when I was 18. I went to uni and studied dentistry instead.

What do you most value in your friends? Honesty and accessibility.

How would you like to die? Holding my wife’s hand. If she doesn’t mind.

Who are your favorite writers? Alastiar Reynolds. Jostein Gaarder. Mitch Albom. Galileo Galilei. Leon Uris.

What is your motto? Pliny the Elder said it best.  Nessun prophetas in patrias sua. ■

July 2020

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OMS on mission

By Matthias Merkx

Nijmegen. The Netherlands

In honor of the 80th birthday of Prof Dr Paul JW Stoelinga, former president of the EACMFS (1992-1994) and IAOMS (2001-2003), Editor in Chief of the IJOMS (1988-2000) and former Chair of the Department OMF surgery at the Radboudumc, Nijmegen, The Netherlands (1999-2005).

HISTORY IN 2002 Paul Stoelinga initiated (supported by MAWM) the foundation “Oral and Maxillo-Facial Surgery Tanzania” (www.mka-tanzania.nl), to promote OMFS in Tanzania in its most extensive form, to promote self-sufficiency of the Tanzanian OMF surgeons adapted to the local environment, to improve the quality of OMF Surgery in Tanzania and to make it available to more people. More local OMF surgeons should be trained and equipped. To achieve this, we sought support from the Tanzanian government, the board of the regional hospitals, the IAOMS foundation and the Leibinger Company. 40 iaoms.org

Tanzania has an area of about 945.087 km² (587.000 square miles) with approximately 53 million citizens. Dar es Salaam, the main city, is located on the east coast, which for most of the citizens of Tanzania means several days of traveling from their own community. In 2002 the Oral and Maxillofacial Surgery Department in the Muhimbili University of Health and Allied Services (MUHAS) Hospital in Dar es Salaam was the only OMFS department in whole Tanzania, with fairly basic facilities. It was headed by two Moscow-trained dental surgeons assisted by two unofficial registered assistants, trainees from the Dental School and nursing staff. This University also had a Dental School with about 20 students currently graduating each year. The department at that moment could use two operating rooms days a week, dependent on sufficient electricity and (disposable) materials. The outdoor patient facilities were very limited; instruments, July 2020


Dar es Salaam, the main city, is located on the east coast, which for most of the citizens of Tanzania means several days of traveling from their own community.

usually stayed with family or friends in Dar es Salaam. Sometimes hospitalization was (and still is) extended because the patient has no shelter. Planned operations were often postponed for several weeks due to technical defects and logistical problems.

treatment units, lamps etc. were in need of renewal. Patients with diseases of the OMF region were initially referred via “nurse practitioners” and “witch doctors” to 1 of the 4 regional hospitals all over the country. In such local hospitals rudimentary dental departments were functioning for initial diagnoses such as infections, injuries and growths of tumors mostly of gigantic size. If the patient had the financial means to travel and pay for their treatment, they were referred to Dar es Salaam. The patient, with or without family,

Since 1999, a WHO project has been investigating the prevention of benign odontongenic tumors in Tanzania and their treatment. With this project in view we went to Dar es Salaam several times to make an inventory of the situation and to teach the ‘OMFsurgeons’ several operating techniques. This project resulted in a PhD thesis in 2005 of Dr Elison Simon’s, titled ‘Odontogenic tumours in Tanzania with emphasis on epidemiology, quality of life after treatment and mandibular reconstruction’.1-5 Dr Elison Simon became, after his PhD, head of the department of OMFS in Dar

July 2020

THE RADBOUD UNIVERSITY/RADBOUDUMC DAR ES SALAAM RELATIONSHIP

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Start 2008 of IAOMS fellowship program Tanzania. From right to left Prof Dr John LL Williams (President of the IAOMS 2005-2007), Prof Dr Paul JW Stoelinga, Dr Elison Simon, Prof Dr Julio Acero (Chair IAOMS fellowships program, Vice president IAOMS), Prof Dr MAW Merkx.

es Salaam and dean of the dental school of MUHAS. As result of the finished PhD, the facilities in the OMFS department in MUHAS improved due to a generous IAOMS donation for a new operation facility of its own, and outdoor patient equipment. Also, a generous gift from the Leibinger company provided the opportunity to resect large benign odontogenic tumours and restore mandible continuity by reconstruction plates.5 It is far too early in these circumstances to reconstruct mandibles with revascularized bone flaps. Knowledge was further improved through the IAOMS training program started in 2008.

the skills and knowledge of the local colleagues. Therefore, it is essential to ensure a sufficient number of well qualified specialists. Due to the IAOMS Foundation’s efforts and help there is currently enough expertise in the MUHAS Hospital in Dar es Salaam. They now also have the necessary equipment and on site we support their efforts to develop new, enhanced procedures.

NOWADAYS Nowadays, an East African Society of OMF Surgery, launched 5 July 2002 in Nairobi (Kenya), supports the curriculum of OMF trainees in Dar es Salaam and the whole of east Africa. A second department of OMFS was recently started in the Kilimanjaro Christian Medical Centre (KCMC) hospital at Moshi, near the Kilimanjaro mountain in the north of Tanzania. In Tanzania there is still insufficient availability and knowledge to treat patients with OMF diseases or pathological conditions. Most of them have infections, facial traumas or tumours, sometimes of gigantic proportions. They are referred by “Dental Therapists” (people with limited dental training) to KCMC or one of the three other local hospitals, or directly to the MUHAS in Dar es Salaam. THE FUTURE: EDUCATION! Development aid is not just a matter of finance. The most important contribution we can make is to help improve the quality of treatment locally and enhance 42 iaoms.org

Fortunately, an officially recognized training program in East Africa is now located in the neighboring country of Kenya, in Nairobi. This training is supported by the International Association of Oral and Maxillofacial Surgery and lasts 4 years. In time, these trained new colleagues could also settle in the 4 regional hospitals, bringing care closer and therefore more affordable to the patient. It is also necessary to keep the instruments and other supplies more or less up to date in number and quality in Dar es Salaam so that operations can be performed. The quality is guaranteed as much as possible by the Radboud - Dar es Salaam liaison and it is the intention to maintain this relationship in the future. Our goals may be ambitious. On the other hand, the effects are immediately visible and the circumstances are sufficient for continuity to be guaranteed. ■ REFERENCES July 2020


Publishing

PUBLISHING PAPERS IN SCIENTIFIC PAPERS: AN AFRICAN PERSPECTIVE By Imad Elimairi, Amel Sami Khartoum, Sudan

AFRICA has always been prominent on the scientific writing platform, but in recent times, it has recorded a stentorious will to produce expertbacked, reliable, interesting and vital scientific literature that not only corresponds to the continent’s specific and proliferating research and clinical questions, but also fills crucial gaps in the global medical literature. Now more than ever, African authors have shed light on the many epidemiological, aetiopathological, diagnostic and therapeutic challenges that continue to present themselves, in Africa particularly, but also from around the world. Trends in African scientific writing have exhibited dedication to universal excellence and reproducible standards and many of these authors now share their pivotal results through various literature forms (randomised control clinical trials, systematic reviews, audits, case series, reports and much more), and via many platforms: broadly country, continental or international peer reviewed journals, many of which have earned respectful impact factors with many African authors now developing prominent H indices. July 2020

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One of the first bridges that African authors have successfully crossed, is reporting on how distinct economic, logistic, social, cultural and healthcare barriers have impacted African oral clinical health. There are many difficult clinical plights that Africa is facing such as traditional medicine and folklore to treat disease; the late presentations of many infections, facial fractures and tumours; and the long distances that many patients have to travel to find optimum care. These might hinder or modify various treatment strategies. More specific socio–cultural parameters discussed in the literature include the worrying infant oral mutilation habits in Uganda (which are also undertaken in many other African countries), witchcraft related craniomaxillofacial injuries in Rwanda and facial injuries following wild animal attacks in Ethiopia and other countries. Furthermore, the westernization of many African populations is reflected in consumption of sugary and processed foods and drinks, as well as uptake of new smoking modalities such as e-cigarettes, roll-ups and other new forms of nicotine consumption, all of which can have deleterious effects on African oral and systemic health and cascade poor prognostics of disease.

as a potential agent of odontogenic tumours in Uganda and mitochondrial mutations in oral cavity cancers in Senegal) as well as compelling new science flickerings on exclusive topics such as the microbiome and its connection with oral health.

African literature has also expanded knowledge on the many infectious endemic diseases of the continent that due to ‘global microbial traffic’, have forced all scientists and clinicians to become familiar with their presenting symptoms and unique features. Buruli Ulcer, Noma, Actinomycosis, Mycetoma, Hydatid disease, Schistosomiasis, Leishmaniasis, Trypanosomiasis, Aspergillosis, HIV and Ebola are just some of the infections that have been expanded upon in the literature by African authors, in order to help with the identification and rapid diagnosis of presenting cases in both an ‘in and out of normal location scenario’. There have also been exclusive reports on rare diseases and syndromes from African writers (Macrophage activation syndrome, Parry Romberg syndrome, Eagle and First Bite syndrome), cancer associated discoveries (oral paraneoplastic melanosis from Sudan, Arenavirus

Finally, it is important to leave the reader with the knowledge that an incredible magnitude of papers from Africa employ the most up to date technological advances associated with oral and maxillofacial surgery and dental science, from use of microvascular surgery to cone beam CT and multidetector CT, as well as deep brain stimulation to treat advanced pain and neurological disease.

44 iaoms.org

Mindful authors have also powerfully targeted the prevention of oral and maxillofacial disease in Africa such as caries, periodontal disease and lifethreatening odontogenic infections through public health science articles. Many epidemiological studies have also been undertaken to pinpoint important disease incidence, prevalence and mortality rates, through papers on cancer registries in Africa, while others have discussed the importance of clinical audits to serve better identification and diagnosis of many diseases. There have also been great developments in the analysis of healthcare provisions (analysis of cleft lip and palate care in South Africa) as well as pivotal moves to bring about the concept of multidisciplinary care in Africa, such as the integration of oral health with management of other chronic disease states, which, according to the WHO regional office in Africa, the continent is a pioneer in.

Africa is on the forefront and at full capacity to write the most powerful and influential scientific papers in the world. This however requires dedication, mentoring support and simple inspiration from all the hierarchy of service. From deans and supervisors, to trainees, research and postgraduate students, the message is clear – The power is in your pen or fingers that type!. ■

July 2020


Beyond O.R.

Twenty-five By Javier González Lagunas (follow me on

@golagunas)

TWENTY-FIVE is the sum of the first five odd natural numbers (1 3 5 7 9). It is the atomic number of manganese. It is the number of years in a marriage that are marked by a silver wedding. For numerology fans, number 25 denotes wisdom with a touch of diplomacy and curiosity. It is about intuition, selfawareness and an interest in nearly everything. It is composed of two digits and it is reduced to the single digit 7 (2+5). Twenty-five is the number of “Beyond O.R.” columns I have written for FACE TO FACE. During the last seven years we have traveled over a few topics, many of them unrelated to medicine or to our speciality. In this wide range of issues, I have tried to be diverse and pluralistic, provocative and respectful. But I have to admit that I have been selfish and that we have covered topics that I was interested in. I have always thought that everything must have a beginning and an end. The beginning was in October 2013 in ICOMS Barcelona, when Piet Haers made me an offer I could not refuse. The end is today. Organizations need fresh blood, new people and new ideas. A key requirement for the survival of any organization is the renewal of the visible heads of the group. You just cannot be there forever.

Organizations need fresh blood, new people and new ideas. Being involved with the development and growth of this magazine has been an extraordinary personal experience. Its success has only been possible because of the commitment, effort and good will of all the authors who shared their views, skills and experience with the global community of Maxillofacial Surgeons. I have worked under four broad-minded IAOMS Presidents from whom I received full support. Deepak Krishnan served in the shadow as a true cornerstone of our team. And of course, our graphic designer Maria, responsible for those brilliant and touching covers of FACE TO FACE. She readily understood what style of magazine we were looking for. From the first day, I stated that the goal of FACE TO FACE was to transmit the idea tha It is great to be a maxillofacial surgeon, but that it is even better when you are an IAOMS member. I hope that our readers will reach the same conclusion. From today, you have a new Editor-in-Chief and I am sure you will all be amazed by his drive. GOOD LUCK DEEPAK! ■


START FINISH

Editor-in-Chief Javier Gonzรกlez Lagunas

46 iaoms.org

July 2020

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