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Injury to tooth buds from rigid fixation screws
T
01 OR
J Oral Maxillofac Surg 51:1410,1993
Is THE MANDIBULAR CONDYLE NECESSARY?
INJURY TO TOOTH BUDS FROM RIGID FIXATION SCREWS
To the Editor:-It seems to me that oral and maxillofacial surgery has become overly concerned with the replacement of missing or damaged temporomandibular joint (TMJ) structures with synthetic joints. This has undoubtedly been a reflex response to the placement of artificial hip or knee joints in orthopedics. There is a crucial difference between these joints and the TMJ. The TMJ is not a weight-bearing joint, and condyle-to-fossa contact is not necessary. One has only to consider the large number of displaced condylar neck fractures to appreciate that patients can and do function well with a pseudoarthrosis. Placing a prosthetic joint only duplicates the rotary function and carries with it the potential for surgical and medicolegal complications. In these days of cost effectiveness, it also involves a significant expense. This philosophy does not hold, of course, when treating a child. In these cases growth is desired, and a costochondral graft is indicated. Wouldn't it be simpler and more logical to do a condylectomy and thereby establish a pseudoarthrosis for patients with intractable pain than to embark on the placement of a prosthesis? A prosthesis does no more than replicate rotary function and, in the future, may produce a serious foreign body response and surgical failure.
To the Editor:-I read with great interest the recent article "Pediatric Facial Fractures: Evolving Patterns of Treatment" (J Oral Maxillofac Surg 51:836-844, 1993). I found that the prospective nature and insightful analysis of the data was very useful. However, I was deeply concerned that members of other specialties who involve themselves in the treatment of pediatric facial fractures might construe this article as a "green light" to plate all pediatric fractures. Posnick et al have the distinct advantage ofunderstanding dental development and the importance of avoiding trauma to the developing teeth. Unfortunately, in our community we have surgeons from other specialties who have undertaken open reduction with internal fixation using miniplate and microplate fixation who have totally disregarded the developing teeth when placing the internal fixation devices. I am' anxious to see Dr Posnick's follow-up on the effects of treatment on facial growth as this will be another important finding related to this topic and will provide additional guidance when using plating for internal fixation. STEVEN M. SULLIVAN, DDS Chairman, Oral and Maxillofacial Surgery Colleges of Dentistry and Medicine Oklahoma City, OK
ROBERT HIMMELFARB, DDS Garden City, New York
Reply:-I share Dr Sullivan's concerns about misadventures in the treatment of pediatric facial trauma. It is his belief that, within his geographic region (Oklahoma), the use of internal mini- and microplate and screw fixation by some surgeons may have resulted in injury to many developing teeth. The tools and techniques currently available to surgeons with a special interest in the head and neck region (ie, oral and maxillofacial surgeons, plastic and reconstructive surgeons, and otolaryngologic/head and neck surgeons) provide the potential to restore an injured face or damage it further. When treating a child or adult with a facial fracture, the well-trained surgeon makes treatment decisions and selects from specific fixation options for the management of each fracture. When considering the treatment of a maxillary or mandibular fracture, the immobilization technique selected: arch bars with maxillomandibular fixation; the use of an acrylic splint; direct intraosseous wires; miniplates or microplates, will vary in its potential for injury to the teeth and tooth buds. There is no excuse for the injudicious use of internal fixation when managing a fractured bone. However, when used effectively, it is a powerful technique to restore facial form and the quality of a patient's life, which would otherwise be unachievable. This is a fact that cannot be disputed. The knowledge of when the benefits outweigh the potential risks and complications is a matter of experience. In our sophisticated society, there is very little excuse for a surgeon trying to gain expertise by the old adage, "see one, do one, teach one." By following the golden rule of treating each patient as you would a member of your own family, you may not always make the best decision, but you will rarely make an irrevocable one.
KUDOS FROM CANADA
To the Editor:-It is' said that consistency fosters stability and stability is the mother ofprogress. This is certainly true of the Journal ofOral and Maxillofacial Surgery. This publication has faithfully served the specialty of oral and maxillofacial surgery over the past half century. The JOMS has continued to excel with each year of publication and your personal contribution has been outstanding. It has and continues to provide us with a medium for education, thought and opinion. It is with great pleasure, on behalf of the Canadian Association of Oral and Maxillofacial Surgeons, its Executive Council, members and affiliates, that I congratulate the Journal of Oral and Maxillofacial Surgery and all those responsible for its publication on the occasion of its 50th anniversary. We wish you every success in the years to follow. TR STEVENSON, BSc, DDS, MS President. CAOMS Edmonton, Alberta, Canada
Letters to the Editorare considered for publication (subject to editingand abridgment), provided that they are submitted in duplicate, signed byallauthors, typewritten in double spacing, and do not exceed 40 typewritten linesof manuscript text (excluding references). Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal articlemust be received within 6 weeks of the article's publication. Receipt ofletters is not acknowledged; correspondents will be notified whena decision is made.
JEFFREY C. POSNICK, DMD, MD, FRCS(C) Chief, Craniomaxillofacial Surgery Director, Georgetown. Craniofacial Center Washington, DC
1410
01 OR
J Oral Maxillofac Surg 51:1410,1993
Is THE MANDIBULAR CONDYLE NECESSARY?
INJURY TO TOOTH BUDS FROM RIGID FIXATION SCREWS
To the Editor:-It seems to me that oral and maxillofacial surgery has become overly concerned with the replacement of missing or damaged temporomandibular joint (TMJ) structures with synthetic joints. This has undoubtedly been a reflex response to the placement of artificial hip or knee joints in orthopedics. There is a crucial difference between these joints and the TMJ. The TMJ is not a weight-bearing joint, and condyle-to-fossa contact is not necessary. One has only to consider the large number of displaced condylar neck fractures to appreciate that patients can and do function well with a pseudoarthrosis. Placing a prosthetic joint only duplicates the rotary function and carries with it the potential for surgical and medicolegal complications. In these days of cost effectiveness, it also involves a significant expense. This philosophy does not hold, of course, when treating a child. In these cases growth is desired, and a costochondral graft is indicated. Wouldn't it be simpler and more logical to do a condylectomy and thereby establish a pseudoarthrosis for patients with intractable pain than to embark on the placement of a prosthesis? A prosthesis does no more than replicate rotary function and, in the future, may produce a serious foreign body response and surgical failure.
To the Editor:-I read with great interest the recent article "Pediatric Facial Fractures: Evolving Patterns of Treatment" (J Oral Maxillofac Surg 51:836-844, 1993). I found that the prospective nature and insightful analysis of the data was very useful. However, I was deeply concerned that members of other specialties who involve themselves in the treatment of pediatric facial fractures might construe this article as a "green light" to plate all pediatric fractures. Posnick et al have the distinct advantage ofunderstanding dental development and the importance of avoiding trauma to the developing teeth. Unfortunately, in our community we have surgeons from other specialties who have undertaken open reduction with internal fixation using miniplate and microplate fixation who have totally disregarded the developing teeth when placing the internal fixation devices. I am' anxious to see Dr Posnick's follow-up on the effects of treatment on facial growth as this will be another important finding related to this topic and will provide additional guidance when using plating for internal fixation. STEVEN M. SULLIVAN, DDS Chairman, Oral and Maxillofacial Surgery Colleges of Dentistry and Medicine Oklahoma City, OK
ROBERT HIMMELFARB, DDS Garden City, New York
Reply:-I share Dr Sullivan's concerns about misadventures in the treatment of pediatric facial trauma. It is his belief that, within his geographic region (Oklahoma), the use of internal mini- and microplate and screw fixation by some surgeons may have resulted in injury to many developing teeth. The tools and techniques currently available to surgeons with a special interest in the head and neck region (ie, oral and maxillofacial surgeons, plastic and reconstructive surgeons, and otolaryngologic/head and neck surgeons) provide the potential to restore an injured face or damage it further. When treating a child or adult with a facial fracture, the well-trained surgeon makes treatment decisions and selects from specific fixation options for the management of each fracture. When considering the treatment of a maxillary or mandibular fracture, the immobilization technique selected: arch bars with maxillomandibular fixation; the use of an acrylic splint; direct intraosseous wires; miniplates or microplates, will vary in its potential for injury to the teeth and tooth buds. There is no excuse for the injudicious use of internal fixation when managing a fractured bone. However, when used effectively, it is a powerful technique to restore facial form and the quality of a patient's life, which would otherwise be unachievable. This is a fact that cannot be disputed. The knowledge of when the benefits outweigh the potential risks and complications is a matter of experience. In our sophisticated society, there is very little excuse for a surgeon trying to gain expertise by the old adage, "see one, do one, teach one." By following the golden rule of treating each patient as you would a member of your own family, you may not always make the best decision, but you will rarely make an irrevocable one.
KUDOS FROM CANADA
To the Editor:-It is' said that consistency fosters stability and stability is the mother ofprogress. This is certainly true of the Journal ofOral and Maxillofacial Surgery. This publication has faithfully served the specialty of oral and maxillofacial surgery over the past half century. The JOMS has continued to excel with each year of publication and your personal contribution has been outstanding. It has and continues to provide us with a medium for education, thought and opinion. It is with great pleasure, on behalf of the Canadian Association of Oral and Maxillofacial Surgeons, its Executive Council, members and affiliates, that I congratulate the Journal of Oral and Maxillofacial Surgery and all those responsible for its publication on the occasion of its 50th anniversary. We wish you every success in the years to follow. TR STEVENSON, BSc, DDS, MS President. CAOMS Edmonton, Alberta, Canada
Letters to the Editorare considered for publication (subject to editingand abridgment), provided that they are submitted in duplicate, signed byallauthors, typewritten in double spacing, and do not exceed 40 typewritten linesof manuscript text (excluding references). Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal articlemust be received within 6 weeks of the article's publication. Receipt ofletters is not acknowledged; correspondents will be notified whena decision is made.
JEFFREY C. POSNICK, DMD, MD, FRCS(C) Chief, Craniomaxillofacial Surgery Director, Georgetown. Craniofacial Center Washington, DC
1410