P21 / British Journal of Oral and Maxillofacial Surgery 52 (2014) e75–e127 e123

ranula. We present a series of cases treated with a novelmodification to this technique.

Method: The modified technique involves: initial needledecompression of the ranula, then 48 to 72 hours later, underlocal anaesthetic, 2-3 interrupted silk sutures are placed in theranula dome, into the floor-of-mouth and out of the ranuladome again. This technique was designed to compress theranula sac and cause maximal fibrosis of the duct drainingthe associated gland. Retrospective review of 8 cases wasperformed.

Results: Eight patients underwent the procedure. Mediantime to follow-up was 5 months (range 4-14). Of 8 cases, 7were successfully treated. Of the successful cases, 3 requireda second procedure, either due to early suture loss or ranularecurrence. No complications were encountered.

Conclusion: With a success rate approaching 90%, wepropose that modified micro-marsupialisation may be asimple, cost-effective and clinically favourable first-linealternative to gland excision in the treatment of oral ranula.

http://dx.doi.org/10.1016/j.bjoms.2014.07.241

P140

Submandibular Gland Excision as a Day Case Procedure:A Feasibility Study

Sajid Sainuddin ∗, Jennifer L. Thompson, Nadeem R. Saeed

John Radcliffe Hospital, Oxford

Introduction: The aim of this study was to ascertain thefeasibility of carrying out submandibular gland excision as asafe day case procedure, with the potential to carry out suchsurgery on peripheral day case lists.

Materials/Methods: A prospective study involving a sin-gle surgeon performing submandibular gland excision wascarried out. 25 consecutive patients underwent surgery overa five-year period. All patients were treated to a specific studyprotocol.

Results: After exclusion, 22 patients were included in thestudy. 21 patients (95.4%) had their drain removed on thesame day. One brittle diabetic had the drain left in until thenext day as he had to be on a sliding scale and a decision wasmade to leave the drain in. However, this patient had drainedless than 10mls at the time of removal the next day. Eighteenpatients (81.8%) were successfully discharged the same day,with the remaining three patients having to stay in due tosocial reasons. Two patients (9%) with no drainage into thedrains were found to have a small haematoma in the regionat two-week follow-up. Five patients (22.7%) had mild tem-porary facial nerve weakness which resolved early, with oneexception which resolved at 12 months. One patient (4.5%)also had weakness of the hypoglossal nerve that settled withina period of 6 months.

Conclusion: This study confirms that submandibulargland excision can be carried out as a safe day case procedure,

thereby reducing hospital costs and allowing surgery atperipheral sites.

http://dx.doi.org/10.1016/j.bjoms.2014.07.242

P141

Treatment of iatrogenic salivary fistulas associated withsialoceles with Botulinum Toxin A

David Tighe ∗, M.D. Williams, D. Howlett

Eastbourne District General Hospital

The use of Botulinum Toxin A to treat many salivarydisorders is established.

We present two cases of iatrogenic injury to the parotidcapsule secondary to retro-mandibular trans-parotid surgi-cal access for open reduction and internal fixation of themandibular condyle. We demonstrate clinical photographsand ultrasonic images of the sialoceles the technique of intraglandular injection of Botulinum Toxin A.

The first case, a 45yr male presented one week after openreduction and internal fixation of a unilateral condyle frac-ture with a salivary fistula through the healing skin incision.He was treated with ultrasound guided transcutaneous intra-parotid injections of 50units Botulinum A toxin. The fistulastopped discharging and healed within 5 days.

The second case, a 23yr male with unstable epilepsyman, sustained bilateral condylar fractures and an anglefracture of the mandible. On Day 3 post-operatively hedeveloped painful tense sialoceles bilaterally. On Day 5 ultra-sound demonstrated bilateral sialoceles with no extracapsularextravastation of saliva. Ultrasound guided aspiration ofsaliva was followed with immediate intra-parotid infiltrationof 50units Botulinum A toxin each side. One side reaccumu-lated and fistulated through the surgical incision wound. Onday 13 a repeat infiltration of 100units Botulinum Toxin Aachieved a sustained resolution which was demonstrated onultrasound after 2 weeks.

Traditional measures to treat salivary fistulas and sialoce-les are discussed. Blind intra fistula or peri-fistula infiltrationof botox is possible but we prefer the reassurance of visu-ally targeting the parotid tissue in close association with thesialocele.

http://dx.doi.org/10.1016/j.bjoms.2014.07.243

P142

Reducing joint failure in total tempormandibular jointreplacement: A survey of UK surgeons and preliminarydata for national guidelines

Sophia Richardson ∗, Nad Saeed

Oxford Hospitals Trust

Introduction: Total temporomandibular joint replace-ment (TMJR) has been conducted in the United Kingdom

e124 P21 / British Journal of Oral and Maxillofacial Surgery 52 (2014) e75–e127

(UK) since 1987, and is now a well-established technique.With increased regulations on reporting of surgical outcomesand a general move towards protocol driven treatment, it isan ideal time to develop a national protocol to reduce TMJRfailure rates. We surveyed all current UK TMJR surgeonsto establish individual practices implemented to reduce thisrisk. In particular, we assessed the different methods adoptedduring the surgeon’s pre-operative planning and peri-/post-operative management.

Materials and Methods: A structured questionnaire wassent out to all the UK maxillofacial surgeons (16) who arecurrently carrying out TMJR.

Results: There was a 100% response rate. With a smallnumber of active surgeons and a wide variation of practice;a descriptive analysis of the result will be presented. Thisincludes:

- pre-operative assessment: endogenous and exogenous fac-tors

- peri-operative management: reduction of contaminants,use of barriers, and theatre set-up

- post-operative management: drain, bandage, antibiotics,antibiotic prophylaxis

The results demonstrated a wide discrepancy in the man-agement of TMJR, including the treatment of smokers;pre-operative assessment of ear and dental infections; useof antibiotics; and allergy testing.

Conclusions: With increasing numbers of TMJR occur-ring in the UK, it is important to evaluate the different waysto reduce joint failure. An initial national protocol has nowbeen developed to ensure that we can reduce the incidence ofthis rare, but potentially serious, surgical complication.

http://dx.doi.org/10.1016/j.bjoms.2014.07.244

P143

The longevity of TMJ replacements over an 18 year period(1995-2013) in Liverpool

Jennifer Vesey ∗, M. Dodd

Aintree University Hospital

Introduction: Over the last 25 years temporomandibu-lar joint (TMJ) replacement has become a viable treatmentoption for patients with significant TMJ disease. However,there is limited data available on the longevity of these pros-theses, especially in the UK.

Method: A retrospective analysis of the case notes ofpatients who underwent TMJ replacement between 1995 and2013 was carried out (n = 58). 4 patients were excluded fromthe study due to unavailability of the case notes (n = 54).

Results: 54 patients were included in the study. Replace-ments were carried out by three experienced surgeons using;Christiansen, TMJ Concepts or Biomet prostheses. Therewere 63 joints in total; 9 bilateral, 45 unilateral. The meanage at time of placement was 46.2 years (IQR 37.9-52.1).

94.4% (n = 51) of patients were female. All had previoussurgical interventions (mean 4.6, IQR 3-6). Of the 63 pros-theses placed 17.4% were subsequently removed (n = 11) dueto; wear of prosthesis (n = 4), allergy (n = 3), foreign bodyreaction (n = 3) or infection (n = 1). The mean time fromplacement to removal was 6.1 years (range 0.5-14.8). Allbut one of the prostheses were placed pre-2007.

Conclusions: Due to the significant morbidity associ-ated with a failed prosthesis, patients should be advisedpre-operatively of the potential need for replacement, as percurrent NICE guidelines. Since 2008 it has been best practiceto patch test patients prior to joint replacement, which thisdata supports.

http://dx.doi.org/10.1016/j.bjoms.2014.07.245

P144

Delayed closure of lateral cantholysis post orbital floorrepair

Nabeel Bhatti ∗, Amar Kanzaria, Neil Huxham, ChristopherBridle, Simon Holmes

The Royal London Hospital

Introduction: A transconjunctival and lower lid swingapproach to the infra-orbital rim and orbital floor is a wellrecognised technique. It allows good access to the infraorbitalrim, the lateral rim and the orbital floor.

Repair of orbital fractures carry with them the risk ofpost-operative haemorrhage, which can have devastating con-sequences. A post-operative haemorrhage can lead to anorbital compartment syndrome with subsequent compromiseof the neurovascular structures supplying the globe and there-fore blindness.

Aim: In patients in whom this risk is increased- patientswith intra-operative hypertension, patients with clottingabnormalities, smokers in whom extubation may causecoughing and spasm and subsequent increases in orbitalpressures, the authors propose a technique of delayed closure.

Method:

1. The upper limb and lower limb of the lateral canthal ten-don are approximated and 5/0 Vicryl rapide suture passedbut not tied.

2. The grey line is the stiched with 6/0 V rapide as is theconjunctival incision.

3. The lateral relieving incision is then closed also with 6/0.4. Finally the loose canthal suture is secured loosely to the

patient using steristrips.5. After a period of observation- In this unit 6 hours, the

suture can be tied.

Conclusion: This technique means that the orbital com-partment remains decompressed while the patient is at riskfrom intra-orbital bleeding. In our experience there has beenno aesthetic compromise as a result of this delayed closure.