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Putting Literature Into Clinical Practice
LETTERS TO THE EDITOR J Oral Maxillofac Surg 70:2492-2493, 2012
WHO IS AT FAULT? To the Editor:—This letter to the editor is strictly based on my opinion; there is no scientific research to back this up. It is based on my personal observation and communications with my colleagues, both in academics and in private practice. Hopefully, this will cause some thought and consideration by you, my fellow oral-maxillofacial surgeons. Our young residents coming out of training today are the best-trained oral-maxillofacial surgeons that we have produced so far. Although their residencies may seem long to them, I think it is remarkable that they have enough time to acquire all the knowledge and surgical expertise that are required of them. Some have taken the term “super surgeons” to describe these young women and men. There within lies the problem as I see it. I believe that a number or even the majority of these well-trained doctors are not adequately applying the vast amount of expertise that they have acquired. They tend to be satisfied with an office practice only, performing advanced alveolar surgery and implant procedures. They are abandoning the very foundation that our profession was built on, that is, facial trauma. We are the most qualified professionals to treat facial trauma. Facial trauma has been the foundation of our profession. It helped legitimize our rightful place in the hospital and led to us expanding our surgical horizons, including orthognathic surgery, reconstructive surgery, and cosmetic surgery. I have heard some say that they paid back society while treating facial trauma patients in training. This is exactly opposite of the truth. Society trained these young residents, and now they should pay back society by rendering the best facial trauma care possible. I know that trauma is not a money-maker, and many have educational debts to pay back, but removing oneself from the active staff or emergency department call at a hospital is not the answer. We must do what is right and best for our patients and our specialty. Now who is at fault? Is it the American Association of Oral and Maxillofacial Surgeons, the American Board of Oral and Maxillofacial Surgery, the training centers, the private practitioners, governmental regulations, the present economic conditions, or the unknown, better known as universal health care? We know that the American Board of Oral and Maxillofacial Surgery has begun to address this issue, but it cannot do it alone. I personally dislike regulations, especially governmental regulations. We cannot regulate to make our young colleagues stay on hospital staffs and take active emergency department calls. There must be a better way. Maybe it is time for our leaders to address this situation. I believe the time has come for our leaders, associations, and private and academic oral-maxillofacial surgeons to meet and come up with suggestions for a
plan. I would also include oral-maxillofacial surgeons from other countries. So, are we at fault? Yes, we are all at fault to some degree. We have the talent to solve this problem before our foundation gives way and the building blocks of our specialty come tumbling down upon us. RONALD B. MARKS, DDS Past President, American Association of Oral and Maxillofacial Surgeons 1992-1993
http://dx.doi.org/10.1016/j.joms.2012.07.047
PUTTING LITERATURE INTO CLINICAL PRACTICE To the Editor:—The residency training program at Lincoln Medical and Mental Health Center has a long-standing tradition of reviewing the current issue of the Journal of Oral and Maxillofacial Surgery monthly. Recently, an article by Hsu et al1 entitled “Manual Reduction of Mandibular Fractures Before Internal Fixation Leads to Shorter Operative Duration and Equivalent Outcomes When Compared With Reduction With Intermaxillary Fixation,” published in the July 2012 edition, was reviewed. As a Level I Trauma Center in the South Bronx, New York, Lincoln Hospital provides the training program with over 200 operative trauma cases per year; approximately 85% of these cases are mandible fractures. We are always looking for ways to decrease operative time, without sacrificing surgical outcomes. After reviewing the article by Hsu et al,1 we immediately applied the stringent inclusion/exclusion criteria set forth in the article. An 18-year-old man with no significant medical history was initially seen by his general dentist, complaining of tooth pain associated with the left mandibular third molar. A dental panoramic radiograph was taken and showed a minimally displaced left mandibular angle fracture. The patient was referred to us for management. Clinical examination showed stable and reproducible occlusion, with no inferior alveolar nerve paresthesia. The proper inclusion/exclusion criteria were applied, as outlined in the article.1 These include an isolated left angle fracture, no involvement of the condyle, age greater than 16 years, no gross comminution, no concurrent facial fractures, and no history of previous facial fractures. The patient was taken to the operating room for open reduction with manual reduction and internal fixation, as outlined in the article.1 A standard distal hockey-stick incision with an anterior buccal vestibular release was performed, and the fracture was exposed. Intraoperative evaluation showed that the associated tooth was not indicated
Letters to the Editor must be in reference to a specific article or editorial that has been published by the Journal. Letters must be submitted within 6 weeks of the article’s print publication or, for an online-only article, within 8 weeks of the date it first appeared online. Letters must be submitted electronically via the Elsevier Editorial System at http://ees.elsevier.com/ joms. Letters are subject to editing and those exceeding 500 words may be shortened or not accepted due to length. One photograph may accompany the letter if it is essential to understanding the subject. Letters should not duplicate similar material or material published elsewhere. There is no guarantee that any letter will be published. Prepublication proofs will not be provided. Submitting a Letter to the Editor constitutes the author’s permission for its publication in any issue or edition of the journal, in any form or medium.
2492
2493
LETTERS TO THE EDITOR
FIGURE 1. Pre- and post-reduction clinical and radiologic views and occlusion attained.
for immediate extraction. Centric occlusion was achieved with only manual reduction, and maintained during fixation with a Synthes (West Chester, PA) prebent Champy plate. The clinical and radiographic result of the procedure showed stable, reproducible, pre-trauma occlusion (Fig 1). By using the manual reduction technique, we were able to reduce the operating time from our average of 72 minutes to 21 minutes without any sacrifice of the desired surgical outcome. We would, however, advocate additional inclusion criteria: stable occlusion, favorable fracture, and anticipated satisfactory postoperative compliance with instructions. The knowledge of occlusion is what sets our specialty apart from others that treat mandibular trauma. If the occlusion cannot be re-established through the methods outlined in the article by Hsu et al,1 it is important that there be no hesitation to use arch bars or another method of intermaxillary fixation. Obviously, there are a limited number of patients who fit the inclusion criteria of this study; those who do, however,
may greatly benefit from this approach to treatment. It is highly recommended that the technique described in the article by Hsu et al1 be used where indicated, and we look forward to its continued use in the care of our patients. BENJAMIN F. BUSH, DDS RAWLE F. PHILBERT, DDS MALCOLM B. ZOLA, DDS New York, NY
Reference 1. Hsu E, Crombie A, To P, et al: Manual reduction of mandibular fractures before internal fixation leads to shorter operative duration and equivalent outcomes when compared with reduction with intermaxillary fixation. J Oral Maxillofac Surg 70:1622, 2012
http://dx.doi.org/10.1016/j.joms.2012.07.046
WHO IS AT FAULT? To the Editor:—This letter to the editor is strictly based on my opinion; there is no scientific research to back this up. It is based on my personal observation and communications with my colleagues, both in academics and in private practice. Hopefully, this will cause some thought and consideration by you, my fellow oral-maxillofacial surgeons. Our young residents coming out of training today are the best-trained oral-maxillofacial surgeons that we have produced so far. Although their residencies may seem long to them, I think it is remarkable that they have enough time to acquire all the knowledge and surgical expertise that are required of them. Some have taken the term “super surgeons” to describe these young women and men. There within lies the problem as I see it. I believe that a number or even the majority of these well-trained doctors are not adequately applying the vast amount of expertise that they have acquired. They tend to be satisfied with an office practice only, performing advanced alveolar surgery and implant procedures. They are abandoning the very foundation that our profession was built on, that is, facial trauma. We are the most qualified professionals to treat facial trauma. Facial trauma has been the foundation of our profession. It helped legitimize our rightful place in the hospital and led to us expanding our surgical horizons, including orthognathic surgery, reconstructive surgery, and cosmetic surgery. I have heard some say that they paid back society while treating facial trauma patients in training. This is exactly opposite of the truth. Society trained these young residents, and now they should pay back society by rendering the best facial trauma care possible. I know that trauma is not a money-maker, and many have educational debts to pay back, but removing oneself from the active staff or emergency department call at a hospital is not the answer. We must do what is right and best for our patients and our specialty. Now who is at fault? Is it the American Association of Oral and Maxillofacial Surgeons, the American Board of Oral and Maxillofacial Surgery, the training centers, the private practitioners, governmental regulations, the present economic conditions, or the unknown, better known as universal health care? We know that the American Board of Oral and Maxillofacial Surgery has begun to address this issue, but it cannot do it alone. I personally dislike regulations, especially governmental regulations. We cannot regulate to make our young colleagues stay on hospital staffs and take active emergency department calls. There must be a better way. Maybe it is time for our leaders to address this situation. I believe the time has come for our leaders, associations, and private and academic oral-maxillofacial surgeons to meet and come up with suggestions for a
plan. I would also include oral-maxillofacial surgeons from other countries. So, are we at fault? Yes, we are all at fault to some degree. We have the talent to solve this problem before our foundation gives way and the building blocks of our specialty come tumbling down upon us. RONALD B. MARKS, DDS Past President, American Association of Oral and Maxillofacial Surgeons 1992-1993
http://dx.doi.org/10.1016/j.joms.2012.07.047
PUTTING LITERATURE INTO CLINICAL PRACTICE To the Editor:—The residency training program at Lincoln Medical and Mental Health Center has a long-standing tradition of reviewing the current issue of the Journal of Oral and Maxillofacial Surgery monthly. Recently, an article by Hsu et al1 entitled “Manual Reduction of Mandibular Fractures Before Internal Fixation Leads to Shorter Operative Duration and Equivalent Outcomes When Compared With Reduction With Intermaxillary Fixation,” published in the July 2012 edition, was reviewed. As a Level I Trauma Center in the South Bronx, New York, Lincoln Hospital provides the training program with over 200 operative trauma cases per year; approximately 85% of these cases are mandible fractures. We are always looking for ways to decrease operative time, without sacrificing surgical outcomes. After reviewing the article by Hsu et al,1 we immediately applied the stringent inclusion/exclusion criteria set forth in the article. An 18-year-old man with no significant medical history was initially seen by his general dentist, complaining of tooth pain associated with the left mandibular third molar. A dental panoramic radiograph was taken and showed a minimally displaced left mandibular angle fracture. The patient was referred to us for management. Clinical examination showed stable and reproducible occlusion, with no inferior alveolar nerve paresthesia. The proper inclusion/exclusion criteria were applied, as outlined in the article.1 These include an isolated left angle fracture, no involvement of the condyle, age greater than 16 years, no gross comminution, no concurrent facial fractures, and no history of previous facial fractures. The patient was taken to the operating room for open reduction with manual reduction and internal fixation, as outlined in the article.1 A standard distal hockey-stick incision with an anterior buccal vestibular release was performed, and the fracture was exposed. Intraoperative evaluation showed that the associated tooth was not indicated
Letters to the Editor must be in reference to a specific article or editorial that has been published by the Journal. Letters must be submitted within 6 weeks of the article’s print publication or, for an online-only article, within 8 weeks of the date it first appeared online. Letters must be submitted electronically via the Elsevier Editorial System at http://ees.elsevier.com/ joms. Letters are subject to editing and those exceeding 500 words may be shortened or not accepted due to length. One photograph may accompany the letter if it is essential to understanding the subject. Letters should not duplicate similar material or material published elsewhere. There is no guarantee that any letter will be published. Prepublication proofs will not be provided. Submitting a Letter to the Editor constitutes the author’s permission for its publication in any issue or edition of the journal, in any form or medium.
2492
2493
LETTERS TO THE EDITOR
FIGURE 1. Pre- and post-reduction clinical and radiologic views and occlusion attained.
for immediate extraction. Centric occlusion was achieved with only manual reduction, and maintained during fixation with a Synthes (West Chester, PA) prebent Champy plate. The clinical and radiographic result of the procedure showed stable, reproducible, pre-trauma occlusion (Fig 1). By using the manual reduction technique, we were able to reduce the operating time from our average of 72 minutes to 21 minutes without any sacrifice of the desired surgical outcome. We would, however, advocate additional inclusion criteria: stable occlusion, favorable fracture, and anticipated satisfactory postoperative compliance with instructions. The knowledge of occlusion is what sets our specialty apart from others that treat mandibular trauma. If the occlusion cannot be re-established through the methods outlined in the article by Hsu et al,1 it is important that there be no hesitation to use arch bars or another method of intermaxillary fixation. Obviously, there are a limited number of patients who fit the inclusion criteria of this study; those who do, however,
may greatly benefit from this approach to treatment. It is highly recommended that the technique described in the article by Hsu et al1 be used where indicated, and we look forward to its continued use in the care of our patients. BENJAMIN F. BUSH, DDS RAWLE F. PHILBERT, DDS MALCOLM B. ZOLA, DDS New York, NY
Reference 1. Hsu E, Crombie A, To P, et al: Manual reduction of mandibular fractures before internal fixation leads to shorter operative duration and equivalent outcomes when compared with reduction with intermaxillary fixation. J Oral Maxillofac Surg 70:1622, 2012
http://dx.doi.org/10.1016/j.joms.2012.07.046