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REDUCING THE FAILURE RATE OF OCULAR PROSTHESIS

​

AT HOSPITAL SULTANAH AMINAH, �JOHOR BAHRU

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Group Members

Dr Muhamad Imran Abdullah

Dental Officer UG48

OMFS HSA JB

Dr Mohd Ikmal Abdul Hakim

Dental Officer UG44

OMFS HSA JB

Dr Rolzilah Rohani

Dental Officer UG54

Oral Health District Office JB

Puan Rosni Amin

Dental Technician U38

OMFS HSA JB

Dr Noraziyah Abdul Aziz

Chief Assistant Director

Oral Health Division, Johor State Heath Department

Dr Muhd Hisyam Zainal Abidin

Assistant Director

Oral Health Division, Johor State Health Department

Dr Rosliza Binti Parumo

OMFS Specialist UG56

OMFS HSA JB

FACILITATOR

2

Oral Maxillofacial Surgery (OMFS)

Hospital Sultanah Aminah (HSA)

Johor Bahru (JB)

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SELECTION OF OPPORTUNITIES FOR IMPROVEMENT

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Problem Identification

No

Problem Statement

Magnitude of problem

1

Long waiting time for issue dentures to patient in Hospital Sultanah Aminah

(Standard : 20%)

​

30%

2

Increasing number of Failure Rate of ocular prosthesis in Hospital Sultanah Aminah

(Standard : 0%)

44%

3

Long waiting time for dental treatment in Hospital Sultanah Aminah

(Standard : 0%)

20%

4

Increasing amount of patient with post extraction dry socket after horizontal third molar surgery in Hospital Sultanah Aminah

(Standard : <5%)

10%

4

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Problem Prioritization – ‘SMART’ Criteria

No

Problem Statement

S

M

A

R

T

Total

marks

1

Long waiting time for issue dentures to patient in Hospital Sultanah Aminah

12

9

7

8

7

43

2

Increasing number of Failure Rate of ocular prosthesis in Hospital Sultanah Aminah

18

9

12

9

9

​

3

Long waiting time for dental treatment in Hospital Sultanah Aminah

9

8

7

9

7

40

4

Increasing amount of patient with post extraction dry socket after horizontal third molar surgery in Hospital Sultanah Aminah

9

7

8

7

7

38

NGT (Nominal Group Technique) based on SMART criteria

57

6 Group members

Mark Awarded

1

2

3

Rating

Low

Average

High

5

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Reasons for Selections

SERIOUSNESS

  • The number of failed ocular prosthesis increased.
  • Failed ocular prosthesis leads to dissatisfied patients which could affect their social life and psychological wellbeing.
  • Increased cost due to repairing/ redoing the ocular prosthesis.

S

M

A

R

MEASURABLE

  • Data on failed ocular prosthesis easily retrievable from Dental Records at HSA, JB.

APPROPRIATENESS

  • No proper guidelines.
  • Contribute to patient dissatisfactions.
  • Continuation of care.

REMEDIAL

  • Multidisciplinary approach.

TIMELINESS

  • This study can be conducted and completed within recommended time frame.

T

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Terms and Definitions

Role of post basic OMFS dental technician

Ocular Prosthesis

Failed Ocular Prosthesis

Maxillofacial dental technician are in great demand in hospital by oral surgery, ophthalmic, burns and cancer units, where they help to reconstruct faces damaged by disease or trauma.

An ocular prosthesis or also known as artificial eye is a type of craniofacial prosthesis that replaces an absent natural eye following an enucleation, evisceration, or orbital exenteration.

A failed case of ocular prosthesis issued is defined when an ocular prosthesis does not pass the issue stage of the prosthesis and the whole clinical and lab process must be repeated in order to re-issue the ocular prosthesis.

Source: Kelley JJ. History of ocular prosthesis. Int Ophthalmol Clin 1970;10:713–9

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Literature Review

  • The mutilated face can be a stigma for the patient and relatives. This may affect the individual’s self-esteem due to difficulty in establishing emotional ties, new life style, insecurity and rejection. An average of 60% of patients suffering from eye loss exhibit such symptoms. (M. C. Goiato, 2012)

​

  • Ocular prosthetic aims to restore aesthetics, protect tissues and rehabilitate the patient for social reintegration. (M. C. Goiato, 2012)

​

  • A study done by Song et al reports an overall satisfaction with initial artificial eyes of 71.8% (Song et al, 2006)

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  • On a study by LostEye, U.S. patients report ,costs for a custom ocular prosthesis is $2,500-$6,000 (RM11,000 – RM26,415).
  • If a patient’s ocular prosthesis fails and have to be redo, the cost is doubled amounting to $5,000-$12,000 (RM20,500.00 – RM49,200.00).
  • In Hospital Sultanah Aminah (HSA), the cost of constructing one ocular prosthesis amounts up to RM 5000 while we do not charge any fee according to Perintah Fi (Perubatan) (Pindaan) 2017.

( Based on $1= RM 4.10)

Cost

RM5000 / unit

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Instruments and material used in ocular prosthesis fabrication

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Flow Chart Of Ocular Prosthesis Construction

Impression Stage

Cast model

Iris Process

Try-in stage

Issue and post op instructions

1st Stage trimming

Detailing

Second packing

Finishing

Flasking

Pupil/Iris Colouring

CLINICAL STAGE

LAB STAGE

Duration of whole lab process: 1 month

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STATEMENT OF THE PROBLEM

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​

  • Increasing number of Failure Rate of ocular prosthesis in Hospital Sultanah Aminah

​

Problem

Effect

  • Failed ocular prosthesis leads to dissatisfied patients.
  • Increased cost due to repairing/redoing the ocular prosthesis

​

Possible Cause

​

  • Improper screening of referred patient from Ophthalmology Department
  • Insufficient skill/ experience in taking impression for ocular prosthesis
  • Lack of knowledge /skill in construction of ocular prosthesis

Aim of Study

Statement of the problem

  • To reduce the failure rate of ocular prosthesis at Hospital Sultanah Aminah, Johor Bahru

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Chart 1 : Failure Rate of Ocular Prosthesis at HSA, JB from 2013 - 2015

Year

2013

2014

2015

No. of issue

7

10

9

No of failure

2

4

4

Failure rate

28.6%

40%

44.4%

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KEY MEASURES FOR IMPROVEMENT

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Indicator & Standard

Failure rate of ocular prosthesis at Hospital Sultanah Aminah, Johor Bahru

No. of failed cases of ocular prosthesis for a particular year x 100%

Total Number of issued ocular prosthesis for that particular year

​

​

​

​

​

​

​

​

STANDARD : ZERO percent (Consensus with Oral Maxillofacial Surgery (OMFS) specialist Head of Department)

Hospital Sultanah Aminah specific approach

Indicator

Standard

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Study Objectives

To take remedial actions towards those contributing factors

3

To evaluate the remedial actions

4

To determine the percentage of failure rate of ocular prosthesis

1

To identify contributing factors towards failed ocular prosthesis

2

To reduce the failure rate ocular prosthesis at

Hospital Sultanah Aminah, Johor Bahru

General Objective

Specific Objectives

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CAUSE EFFECT AND ANALYSIS

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Cause – Effect Analysis Chart

Improper orbital anatomy

INCREASED FAILURE RATE OF OCULAR PROSTHESIS AT HSA, JB

Improper screening process

Insufficient skill and experience in taking impression for ocular prosthesis

Lack of knowledge and skill in construction of ocular prosthesis

High Patient’s expectations

Inexperienced new Dental lab technician

No CDE on procedure for construction of ocular prosthesis

Inexperienced new Dental Officers

Poor psychological & behavior condition of patient

Immature post-operative referral

No CDE on screening/ guideline

Complicated lab procedure

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Process Of Care

20

Referral from Ophthalmology Department

Registration

Impression stage

Consultation

Satisfactory

Lab (cast, iris process, iris & pupil colouring)

Satisfactory

Try-in stage

Satisfactory

Lab (flasking, trimming, detailing, second packing & finishing )

Issue stage

Review

End

Satisfactory

Satisfactory

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

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Model Of Good Care

21

No

Process

Criteria

Verification

Standard

1.

Registration

Ensure the correct patient is referred to the OMFS department

100%

100%

Ensure the details of the patients are properly registered and documented

100%

100%

2.

Consultation

To see the general condition of the patient

50%

100%

To examine the condition of the eye socket prior to treatment

50%

100%

3.

Impression Stage

Impression taken using alginate

70%

100%

To ensure all borders of the eye socket taken properly

70%

100%

4.

Lab (cast, iris process, iris & pupil colouring)

To cast impression with methacrylate resin

53%

100%

To fabricate iris & pupil with taking into account the appearance of the adjacent eye

50%

100%

5.

Try-in stage

To ensure the wax try-in fits properly in the eye socket and does not displaced

70%

100%

To ensure position, colour and shape of iris is the same as the adjacent eye

70%

100%

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No

Process

Criteria

Verification

Standard

6.

Lab (flasking, trimming, detailing, second packing & finishing )

To invest, cure , detailing, second invest process and finishing of prosthesis

55%

100%

To ensure anatomical characterization was done using acrylic paints to simulate the veins and follow the actual colour of adjacent eye

60%

100%

7.

Issue stage

Ensure the ocular prosthesis fits well in the eye socket and appear natural

65%

100%

Ensure the colour, shape and position of the iris on the ocular prosthesis is similar to the adjacent eye

67%

100%

Does not cause irritation to patient

70%

100%

8.

Review stage

To review the patient’s compatibility with the ocular prosthesis

80%

100%

To see if any problems arise such as irritation, looseness of ocular prosthesis or others

80%

100%

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Model Of Good Care

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PROCESS OF GATHERING INFORMATION

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Methodology

Study design

Cross sectional study

Study location

Oral Maxillofacial Surgery (OMFS) Department, HSA

Data collections

  • Universal sampling – all Ocular Prosthesis cases
  • LP6 (Laboratory card)
  • LP8 (Clinical card)
  • Ocular prosthesis questionnaire

Data analysis

  • Microsoft Excel

​

  • Ocular prosthesis cases occurring in Hospital Sultanah Aminah, Johor Bahru which have already been issued and reviewed successfully

Inclusion Criteria

Exclusion Criteria

  • Orbital implants/ ocular implants cases occurring in Hospital Sultanah Aminah, Johor Bahru
  • Ocular prosthesis cases in which patient failed to attend during any stage of the treatment

​

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Methodology – Study period

Verification of problem and identification of contributing factors (June – December 2015)

Verification Study

  • Implementation and evaluation of remedial measures
  • January –December 2016
  • Implementation and evaluation of remedial measures
  • January –December 2017
  • Remedial measures still being carried out and monitored
  • 2018 - 2019

Cycle 1

Cycle 2

Re-evaluation

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Data collection for verification study

  • Dental records from OMFS department, Hospital Sultanah Aminah, Johor Bahru from 2013 to 2015.

​

  • Ocular Prosthesis Questionnaire Form was distributed among the specialist, officers and dental technicians at the OMFS Department, Hospital Sultanah Aminah. (20 sets)

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Dental Records

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Questionnaire

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DATA ANALYSIS AND INTERPRETATION (VERIFICATION STUDY)

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Chart 1 : Failure Rate of Ocular Prosthesis at HSA, JB from 2013 - 2015

Year

2013

2014

2015

No. of issue

7

10

9

No of failure

2

4

4

Failure rate

28.6%

40%

44.4%

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Table 1: Category of failed ocular prosthesis at HSA, JB 2013-2015

YEAR

MRN Patient

Age

Type of ocular prosthesis

Reason Of Failure

2013

P1220/13

8

Left eye prosthesis

Growth in eye socket

2013

P955/13

9

Left eye prosthesis

Too shallow eye socket

Total number of failed ocular prosthesis in 2013 : 2 Total issued : 7

2014

394/14

59

Right eye prosthesis

Socket not properly healed

2014

805/14

30

Right eye prosthesis

Too deep eye socket

2014

1085/14

64

Left eye prosthesis

Growth in eye socket

2014

P1414/14

10

Right eye prosthesis

Patient mentally ill

Total number of failed ocular prosthesis in 2014 : 4 Total issued : 10

2015

1751/15

35

Left eye prosthesis

Eye socket space too big

2015

P24/15

11

Left eye prosthesis

Sutured eye socket

2015

2837/15

44

Right eye prosthesis

Eyeball still present in socket

2015

2172/15

16

Right eye prosthesis

Too much eye discharged

Total number of failed ocular prosthesis in 2015 : 4 Total issued : 9

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Chart 3 : Reasons of failed ocular prosthesis cases 2013 - 2015

10%

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Chart 4 : Contributing Factors of Failed Ocular Prosthesis 2013 - 2015

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STRATEGY FOR CHANGE

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REMEDIAL MEASURES:

CYCLE 1

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Cause – Effect Analysis Chart

Improper orbital anatomy

INCREASED FAILURE RATE OF OCULAR PROSTHESIS AT HSA, JB

Improper screening process

Insufficient skill and experience in taking impression for ocular prosthesis

Lack of knowledge and skill in construction of ocular prosthesis

Patient’s expectations

Inexperienced new Dental lab technician

No CDE on procedure for construction of ocular prosthesis

Inexperienced new Dental Officers

Poor psychological & behavior condition of patient

Immature post-operative referral

No CDE on screening/ guideline

Complicated lab procedure

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Factor 1:

Improper screening process

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Attachments

Invitation Letter for CDE

OPCA Enforcement letter

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Attachments

Ocular Prosthesis Criteria Assessment (OPCA)

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Factor 2:

Lack of knowledge /skill in construction of ocular prosthesis

40

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Mentoring and Supervising New Staff

41

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CDE on construction of ocular prosthesis

42

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EFFECT OF CHANGE : CYCLE 1

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Process Of Care : Cycle 1

44

Referral from Ophthalmology Department

Registration

Impression stage

Consultation

Satisfactory

Lab (cast, iris process, iris & pupil colouring)

Satisfactory

Try-in stage

Satisfactory

Lab (flasking, trimming, detailing, second packing & finishing )

Issue stage

Review

End

Satisfactory

Satisfactory

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

OPCA screening

Other treatment modalities

Fail

Pass

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Chart 4 : Failure rate of ocular prosthesis at HSA, JB 2013 - 2016

Year

2013

2014

2015

2016

No. of issue

7

10

9

15

No of failure

2

4

4

3

Failure rate

28.6%

40%

44.4%

20%

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Chart 5 : Failure Rate differences between 2015 and 2016

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Table 2: Category of failed ocular prosthesis at Hospital Sultanah Aminah in 2016

YEAR

MRN Patient

Age

Type of ocular prosthesis

Reason Of Failure

2016

2568/16

45

Right eye prosthesis

Improper size of iris

2016

3156/16

51

Right eye prosthesis

Shallow eye socket

2016

3893/16

50

Left eye prosthesis

Shallow eye socket

Total number of failed ocular prosthesis in 2016 : 3 Total issued : 15

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REMEDIAL MEASURES: CYCLE 2

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Cause – Effect Analysis Chart

Improper orbital anatomy

INCREASED FAILURE RATE OF OCULAR PROSTHESIS AT HSA, JB

Improper screening process

Insufficient skill and experience in taking impression for ocular prosthesis

Lack of knowledge and skill in construction of ocular prosthesis

Patient’s expectations

Inexperienced new Dental lab technician

No CDE on procedure for construction of ocular prosthesis

Inexperienced new Dental Officers

Poor psychological & behavior condition of patient

Immature post-operative referral

No CDE on screening/ guideline

Complicated lab procedure

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Factor 1:

Improper screening process

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Factor 2:

Lack of knowledge /skill in construction of ocular prosthesis

51

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Mentoring and Supervising New Staff

52

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Factor 3:

Improper orbital anatomy

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Variable conformer sizes

54

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Factor 4:

Complicated lab procedure

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​

Akrilikdimasukkan kedalam Iris yang dikeluarkan dari Iris yang telad digilap

Fabricated Iris Mould Fabricated Iris Mould

FIM

Mixing of Acrylic

Insertion of Acrylic in FIM

Removal of Acrylic Iris from FIM

Polished Iris

Invested wax pole

Innovation : Fabricated Iris Mould (FIM)

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Flow Chart Of Ocular Prosthesis Construction

Impression Stage

Cast model

Iris Process

Try-in stage

Issue and post op instructions

1st Stage trimming

Detailing

Second packing

Finishing

Flasking

Pupil/Iris Colouring

CLINICAL STAGE

LAB STAGE

FIM

FIM

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Table 3: Before and After Innovation FIM

Before FIM

After FIM

Limited iris size

Variable iris size

High risk of iris post breakage

Eliminate risk of iris post breakage

Difficulty in iris removal from mould

Simplified iris removal from mould (less technique sensitive)

Whole process of iris construction cost

RM 3007.60

Whole process of iris construction cost RM 5.70

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Table 2: Category of failed ocular prosthesis at Hospital Sultanah Aminah in 2016

YEAR

MRN Patient

Age

Type of ocular prosthesis

Reason Of Failure

2016

2568/16

45

Right eye prosthesis

Improper size of iris

2016

3156/16

51

Right eye prosthesis

Shallow eye socket

2016

3893/16

50

Left eye prosthesis

Shallow eye socket

Total number of failed ocular prosthesis in 2016 : 3 Total issued : 15

FIM

Conformer

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EFFECT OF CHANGE : CYCLE 2

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Process Of Care

61

Referral from Ophthalmology Department

Registration

Impression stage

Consultation

Satisfactory

Lab (cast, iris process, iris & pupil colouring)

Satisfactory

Try-in stage

Satisfactory

Lab (flasking, trimming, detailing, second packing & finishing )

Issue stage

Review

End

Satisfactory

Satisfactory

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

OPCA screening

Other treatment modalities

Fail

Pass

Process Of Care : Cycle 2

FIM

FIM

Conformer

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Chart 6 : Failure rate of ocular prosthesis at HSA, JB 2013 - 2017

Year

2013

2014

2015

2016

2017

No. of issue

7

10

9

15

8

No of failure

2

4

4

3

0

Failure rate

28.6%

40%

44.4%

20%

0%

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Chart 7 : Failure Rate differences between 2015, 2016 and 2017

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RE-EVALUTION

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​

​

Maintenance of Remedial Measures

​

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Chart 8 : Failure rate of ocular prosthesis at HSA, JB 2013 - 2019

Year

2013

2014

2015

2016

2017

2018

2019 (Jan – June)

No. of issue

7

10

9

15

8

11

7

No of failure

2

4

4

3

0

0

0

Failure rate

28.6%

40%

44.4%

20%

0%

0%

0%

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Model Of Good Care

67

No

Process

Criteria

Verification

Standard

Cycle 1

Cycle 2

1.

Registration

Ensure the correct patient is referred to the OMFS department

100%

100%

100%

100%

Ensure the details of the patients are properly registered and documented

100%

100%

100%

​

100%

2.

Consultation

To see the general condition of the patient

50%

100%

100%

100%

To examine the condition of the eye socket prior to treatment.

50%

100%

70%

100%

3.

Impression Stage

Impression taken using alginate

70%

100%

70%

100%

To ensure all borders of the eye socket taken properly

70%

100%

70%

100%

4.

Lab (cast, iris process, iris & pupil colouring)

To cast impression with methacrylate resin

53%

100%

53%

100%

To fabricate iris & pupil with taking into account the appearance of the adjacent eye

50%

100%

50%

100%

5.

Try-in stage

To ensure the wax try-in fits properly in the eye socket and does not displaced

70%

100%

70%

100%

To ensure position, colour and shape of iris is the same as the adjacent eye

70%

100%

70%

100%

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No

Process

Criteria

Verification

Standard

Cycle 1

Cycle 2

6.

Lab (flasking, trimming, detailing, second packing & finishing )

​

To Invest, cure , detailing, second invest process and finishing of prosthesis

55%

100%

60%

100%

To ensure anatomical characterization was done using acrylic paints to simulate the veins and follow the actual colour of adjacent eye

60%

100%

70%

100%

7.

Issue stage

Ensure the ocular prosthesis fits well in the eye socket and appear natural

65%

100%

75%

100%

Ensure the colour, shape and position of the iris on the ocular prosthesis is similar to the adjacent eye

67%

100%

75%

100%

Does not cause irritation to patient

70%

100%

80%

100%

8.

Review stage

To review the patient’s compatibility with the ocular prosthesis

80%

100%

90%

100%

To see if any problems arise such as irritation, looseness of ocular prosthesis or others

80%

100%

90%

100%

68

Model Of Good Care

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IMPACT OF THE REMEDIAL MEASURES

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Table 4: Impact of the remedial measures

Before QA project

After QA project

Cost of construction of 1 Ocular Prosthesis : RM5000/ unit

Cost of construction of 1 Ocular Prosthesis with innovation FIM= RM2000/ unit

(SAVE RM3000)

High failure rate, up to 44%

Zero failure rate on 2017-2019

Total cost used in 2013

= RM 45,000 (7 unit + 2 redo)

​

Total cost used in 2014

= RM 70,000 (10 unit + 4 redo)

​

Total cost used in 2015

= RM 65,000 (9 unit + 4 redo)

Total cost used in 2016

= RM 90,000 (15 unit + 3 redo)* (before innovation FIM) *

​

Total cost used in 2017

= RM 16,000 (8 unit)

Total cost used in 2018

= RM 22,000 (11 unit)

Total cost used in 2019

=RM 14,000 (7 unit)

Redo cases 2013 (2 cases), 2014 (4 cases), 2015 (4 cases) = RM50000

Redo cases reduce from 3 to 0

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The Next Step

  • In order to maintain zero failure rate for ocular prosthesis, the project is still being carried out and monitored.
  • Therefore, there must be ongoing efforts to further enforce and advocate preventive measures to maintain 0% failure rate of ocular prosthesis.
  • The project was presented to all the TPKN and Ketua Program at Mesyuarat Jawatankuasa Dasar dan Perancangan Kesihatan Pergigian on 1st April 2019 for suggestion of replication to the whole Johor state (other OMFS department).

​

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​

​

“Replikasi Tindakan Penambaikan Bagi Meningkatkan Kejayaan Penghasilan Prostesis Okular”

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​

​

“Replikasi Tindakan Penambaikan Bagi Meningkatkan Kejayaan Penghasilan Prostesis Okular”

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​

​

“Replikasi Tindakan Penambaikan Bagi Meningkatkan Kejayaan Penghasilan Prostesis Okular”

REPLIKASI PROJEK KE JABATAN KEPAKARAN BEDAH MULUT DAN MAKSILOSIAL JOHOR

  1. Oral and Maxillofacial Specialist Department, Hospital Sultan Ismail, Johor Bahru
  2. Oral and Maxillofacial Specialist Department, Hospital Sultanah Fatimah, Muar
  3. Oral and Maxillofacial Specialist Department, Hospital Sultanah Nora Ismail, Batu Pahat
  4. Oral and Maxillofacial Specialist Department, Hospital Enche Puan Besar Hajah Kalsom, Kluang

​

​

​

​

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CONCLUSION

  • After implementation of the remedial measures:

​

    • We manage to reduce the failure rate of ocular prosthesis from 44% (4/9) in 2015 to 20% (3/15) in 2016.

​

    • In 2017, 2018 and 2019 we manage to reduce and maintain the failure rate of ocular prosthesis to 0%.

​

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CONCLUSION

  • The contributing factors were:
    • Improper screening of referred patient from Ophthalmology Department
    • Insufficient skill/experience in taking impression for ocular prosthesis
    • Lack of knowledge /skill in construction of ocular prosthesis

​

  • Remedial measures:
    1. CDE on proper screening of patients for ocular prosthesis based on OPCA and CDE on construction of ocular prosthesis given every year
    2. Mentoring and supervising of new staff by incharged supervisor
    3. Early referral for insertion of eye conformer post evisceration of eye

4. Innovation of technique: Fabricated iris mold (FIM)

​

​

​

​

​

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Gantt Chart

Plan

Implementation

Steps

June-Nov/15

1-15 Dec/15

16-31 Dec/15

Jan-Dec/16

Jan-Dec/17

Jan-Dec/18

Jan-June/19

July 2019

August 2019

Identifying problem

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Data collection

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Data analysis

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Remedial action

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Re-evaluation of remedial measures

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Report writing

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

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Reference

  • Baino, F., Perero, S., Ferraris, S., Miola, M., Balagna, C., Verné, E., et al. (2014). Biomaterials for orbital implants and ocular prostheses: overview and future prospects. Acta Biomater. 10, 1064–1087
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We would like acknowledge our TPKN Pergigian, Dr Norizan Binti Othman and our SDO Dr Roslinda bte Abdul Samad for their support in carrying out this project. We would also like to acknowledge our OMFS HSA Head of Department Dr Ma Bee Chai for her support, guidance and technical advice. Special thanks to the staff and doctors from the OMFS department, HSA for all the support and co-operation.

ACKNOWLEDGEMENT

HOSPITAL SULTANAH AMINAH, JOHOR BAHRU, JOHOR

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