In Reply to a Letter to the Editor

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References 1. Tompach P, Dodson TB, Kaban LB: Autogenous temporomandibular joint replacement, in Fonseca, RJ, Bays, RA, Quinn, PD (eds): Oral and Maxillofacial Surgery (vol 4). Philadelphia, Saunders, 2009, pp 301-315 2. Guyuron B, Lasa Cl, Jr: Unpredictable growth pattern of costochondral graft. Plast Reconstr Surg 90:880, 1992 3. Schwartz HC, Relle RJ: Distraction osteogenesis for temporomandibular joint reconstruction. J Oral Maxillofac Surg 66:718, 2008 4. Eski M, Deveci M, Zor F, et al: Treatment of temporomandibular joint ankylosis and facial asymmetry with bidirectional transport distraction technique. J Craniofac Surg 19:732, 2008 5. Bell WH, Guerrero CA: Distraction Osteogenesis of the Facial Skeleton. Hamilton, BC Decker, 2007, pp 461-466

thism and open bite, multidirectional or curvilinear distraction is indicated. The advantages of using DO for this indication include absence of a donor site with the accompanying morbidity and the ability to start mobilization of the jaw with physical therapy immediately after the operation. Because there is less pain and only 1 operative site, the recovery is quicker and easier. However, because a growth center is not transplanted when using DO, asymmetry may continue to develop over time, in growing children, despite good motion.10 We agree with the authors of the letter that this modification is an excellent concept and an important addition to the protocol. We caution, however, that more research is required to document the long-term maintenance of jaw motion. In addition, the subsequent growth pattern in pediatric patients must be established with valid outcomes data.

doi:10.1016/j.joms.2009.09.115

In reply:—I welcome the opportunity to comment on the above letter regarding the protocol for management of temporomandibular joint (TMJ) ankylosis first published in the Journal in 1990.1 In this 7-step protocol, Kaban et al1 emphasized a conceptual approach for surgical management of ankylosis that included 1) complete excision of the ankylotic mass; 2) ipsilateral coronoidectomy; 3) contralateral coronoidectomy when necessary to achieve complete mobility; 4) lining of the TMJ with native disc, when possible, or a temporalis myofascial flap; 5) reconstruction of the ramus/condyle unit with a costochondral graft; 6) early mobilization of the jaw; and 7) aggressive physical therapy. I would like to make 2 general points in commenting on the letter. First, the lesson of the original protocol was that the key elements for successful ankylosis release are excision of the ankylotic mass and ipsilateral or bilateral coronoidectomy to completely mobilize the joint(s). Lining of the joint and reconstruction of the ramus/condyle unit (steps 4 and 5) are important, but success can never be achieved if steps 1 through 3 are not adequately executed. Second, the question raised in the letter is actually answered in detail in a subsequent publication,2 which was probably in press and not accessible to the authors when their letter was submitted. In this latest publication, step 5 is modified to include the use of either costochondral graft or distraction osteogenesis (DO). The concept of using DO in the setting of TMJ ankylosis is not new and has been described by other authors.3-9 Our technique2 is slightly different from that described in the letter. We do more reshaping of the transport disc to make it more “condyle-like,” and we use a unidirectional distraction device. In children with recent onset of unilateral ankylosis, the mandibular asymmetry is almost completely limited to the affected ankylosed ramus/condyle unit. In those with longstanding ankylosis, the asymmetry becomes more complex and often involves the contralateral mandible and the midface.10 In the former situation, a unidirectional device to lengthen the affected ramus is adequate. In the latter scenario, the asymmetry is complex and often requires bilateral mandibular osteotomies and possibly maxillary surgery. An operation on the affected mandible regardless of the type of distractor will not be adequate. Therefore we concentrate on correcting the ankylosis and restoring the affected ramus/condyle unit length. We deal with residual asymmetry when growth is completed. In cases of bilateral ankylosis with retrogna-

LEONARD B. KABAN, DMD, MD Boston, MA

References 1. Kaban LB, Perrott DH, Fisher K: A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 48: 1145, 1990 2. Kaban LB, Bouchard C, Troulis MJ: A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 67:1966, 2009 3. Kaban LB, Troulis MJ: Pediatric Oral and Maxillofacial Surgery. Philadelphia, PA, Saunders, 2004, p 469 4. Stucki-McCormick SU: Reconstruction of the mandibular condyle using transport distraction osteogenesis. J Craniofac Surg 8:48, 1997 5. Dean A, Alamillos F: Mandibular distraction in temporomandibular joint ankylosis. Plast Reconstr Surg 104:2021, 1999 6. Piero C, Alessandro A, Giorgio S, et al: Combined surgical therapy of temporomandibular joint ankylosis and secondary deformity using intraoral distraction. J Craniofac Surg 13:401, 2002 7. Pelo S, Quagliero A, Mosca R, et al: The use of osteodistraction in treatment of ankylosis of the temporomandibular joint. A case report. Minerva Stomatol 51:87, 2002 8. Papageorge MB, Apostolidis C: Simultaneous mandibular distraction and arthroplasty in a patient with temporomandibular joint ankylosis and mandibular hypoplasia. J Oral Maxillofac Surg 57:328, 1999 9. Hikiji H, Takato T, Matsumoto S, et al: Experimental study of reconstruction of the temporomandibular joint using a bone transport technique. J Oral Maxillofac Surg 58:1270, 2000 10. Kaban LB: Mandibular asymmetry and the fourth dimension. J Craniofac Surg 20:622, 2009 (suppl 1)

doi:10.1016/j.joms.2009.10.025

IN REPLY TO A LETTER TO THE EDITOR To the Editor:—I mainly agree with the comments made in the letter to the editor1 in terms of using the buccal fat pad in the irradiated maxilla. Whenever radio-osteonecrosis is suspected, it would probably be better to plan for a larger surgical procedure and a different pedicled or free flap to achieve safe closure of the defect. I would recommend the use of the buccal fat pad in irradiated patients only for the closure of small oroantral communications if the presence of radio-osteonecrosis can be precluded by diagnostic methods before surgery. From my experience, I am not sure

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whether hyperbaric oxygenation would really help in these cases, but it surely is worth a try. Of course, we used antibiotics before and after surgery. Our regimen usually consists of amoxicillin and clavulanic acid for 7 to 10 days, beginning at least 3 days before surgery. If the patient is allergic to penicillin, we use clindamycin. The administration of antibiotics is a crucial point for success and is just as important as thoroughly rinsing the sinus preoperatively. Fortunately, it has never occurred that some uninformed colleague just cut away the buccal fat pad or parts of it because of the fear of tumor recurrence, but I agree that this technique should be popularized more among dentists, maxillofacial surgeons, and otorhinolaryngologists. I hope our article can contribute to that. PAUL W. POESCHL, MD, DMD Vienna, Austria

Reference

COST OF 3-DIMENSIONAL IMAGING-BASED SURGERY To the Editor:—I read the recent publication by Schendel et al1 with great interest. Schendel et al1 mentioned that 3dimensional (3D) imaging and computer simulation could be used effectively for planning office-based procedures, and this technique was helpful for treatment planning for correction of a facial deformity. In addition, Schendel et al1 also noted that “The end result is improved patient care and decreased expense.” It is acceptable that 3D imaging and simulation technology can help achieve a better plan for performing a procedure. However, the cost of the system is of concern. According to the study by Schendel et al,1 the cost identification was not done fully and no comparison was done between the new 3D imaging-based technology and the classic approach. Nevertheless, in assessing the cost of the 3D imaging-based system, one must also include the cost of implementing the system (ie, software, hardware, IT connection, place setting, personal training). I suggest the need for a complete assessment of the cost-effectiveness and cost utility of the new 3D-based approach compared with the classic approach.

1. Ngeow WC: The use of Bichat’s buccal fat pad to close oroantral communications in irradiated maxilla. J Oral Maxillofac Surg 68:229, 2010

VIROJ WIWANITKIT, MD Bangkok, Thailand

Reference doi:10.1016/j.joms.2009.11.011

1. Schendel SA, Jacobson R: Three-dimensional imaging and computer simulation for office-based surgery. J Oral Maxillofac Surg 67:2107, 2009

OUR SPECIALTY To the Editor:—I am perplexed why our specialty has not addressed a growing problem. Dentistry now has 2 specialties who are experts in oral surgery: oral and maxillofacial surgeons and the other specialty, well you know who it is. Oral surgeons have paid their dues for the privilege of doing what we do. How is a competing specialty now the expert on every oral surgical procedure? Why does our specialty legitimize the competing specialty by inviting them to lecture at national meetings? An oral surgeon has training as a resident with skin grafts and burn patients. Why does an oral surgeon need a lecture from a competing specialty about how to graft a piece of dead collagen? Oral surgeons fix complicated fractures with plates and screws but need a competing specialty to show us how to place an implant. Don’t think it’s a problem. My son completed dental school 2 years ago. He related a story. A classmate needed her 4 first bicuspid teeth removed. She was referred by the orthodontic clinic to the other specialty clinic because they were more gentle. I had a patient I saw for an examination visit for third molars. She returned 6 months later. She had seen the other specialist for another problem. The other specialist told her she could remove her third molars. To top it off, her fee was $700 more than mine. I believe in fairness to the public that we should inform the public that there is only one oral and maxillofacial surgery specialty, in whose hands the public is the safest. MICHAEL J. GRAU, DMD, PSC Cincinnati, OH

doi:10.1016/j.joms.2009.11.002

doi:10.1016/j.joms.2009.10.012

EDITORIAL RESPONSE To the Editor:—Thank you for your timely editorial (J Oral Maxillofac Surg 67:1789, 2009) in response to the new AAOS Information Statement. In view of the paucity of evidence to support antibiotic prophylaxis for joint replacement patients, not to mention the AHA’s positional change for SBE prophylaxis, I read your closing paragraph with great interest: “Until clinical scientific evidence is available, the reader should note that the AAOS paper is kindly subtitled: ‘An educational tool based on the opinions of the authors.’ That leaves oral and maxillofacial surgeons free to form their own opinions and to act based upon the levels of evidence available, and in the best interests of their patients.” While I wholeheartedly applaud the intent of this statement, it does nonetheless bring to bear 2 potential concerns. In a health care environment where insurance companies continuously look to reduce benefit payments and in an economic slowdown, I believe we must look more closely at the risk of liability with the potential situation in which an oral and maxillofacial surgeon (OMS), whether he/she be single or dual degreed, might exercise his/her “freedom to form his/her own opinions” and decide against prophylaxis, only then to have the patient develop an inadvertent joint infection, although the 2 events may have been only temporally associated. I believe we might not be shocked to find that litigation attorneys would literally fight