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Re: Hodder et al. SPECT bone scintigraphy in the diagnosis and management of mandibular condylar hyperplasia. Br J Oral Maxillofac Surg 2000; 38: 87–93
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less than impressive outcomes reported by Maier et al., it is unfortunate that they did not follow their own advice. D. Clarke Palmetto Richland Memorial Hospital Columbia, South Carolina, USA REFERENCE 1. Maier A, Gaggl A, Klemen H et al. Review of severe osteoradionecrosis treated by surgery alone or surgery with postoperative hyperbaric oxygenation. Br J Oral Maxillofac Surg 2000; 38: 167–246. doi: 10.1054/bjom.2000.0528, available online at http://www.idealibrary.com on
Re: Hodder et al. SPECT bone scintigraphy in the diagnosis and management of mandibular condylar hyperplasia. Br J Oral Maxillofac Surg 2000; 38: 87–93 Sir, The educative paper by Mr S. C. Hodder and his co-workers on the use of nuclear scintigraphy with SPECT in the diagnosis and management of mandibular condylar hyperplasia was read to advantage, and with much interest. It was pleasing to see that others also believed the technique had proved to be of value. The nuclear physicians with whom I have worked over the last 20 years were interested that the summary included the comment, ‘Previous studies have, however, relied only on planar images’, and it was appreciated that this was, on the balance of probability, a remark that the authors may have intended for emendation, particularly as they had quoted the report by Stephen Allwright et al. from 1987.1,2 The writer and his colleagues in nuclear medicine have utilized SPECT using the same radiotracer (Tc-99MDP or HDP) for approximately 15 years.3 The technique of SPECT scanning represents the nuclear physician’s version of the computerized tomographic scan and, when combined with a numeric and graphic representation of the pixel count, we have found it to be of great value in the assessment of the progress and staging of condylar hyperactivity and hyperplasia, particularly in the teenager and young adult. It may be the principal deciding factor in the decision made by the surgeon and orthodontist as to the timing of an operation. There is no dubiety that the SPECT scan is superior to planar imaging, and the writer and his coworkers had recognized this by 1986. It has been a personal quest always to insist on the pixel count in numeric and graphic form when requesting the scan.4 Nuclear scintigraphy with SPECT is valuable in the assessment of suppurative temporomandibular (TM) arthritis, osteoarthritis, primary and secondary neoplasms, fibrous dysplasia, aneurysmal bone cyst (ABC), synovial osteochondromatosis and TM ganglion. We have found the gallium scan valuable in the assessment of inflammatory and neoplastic conditions. The writer has found over the years, in the course of conduct of a facial and jaw deformity clinic, that explaining a minified axial or coronal scan to a patient and his or her parents is a little difficult at times, and how much easier it is to show the SPECT scan and the graph, and in the case an adult with
mandibular condylar hyperplasia with a pixel count of 316 on the left and 98 on the right. The letters section of this journal of excellence is not the appropriate forum to reflect on the writer’s experience and philosophy of the management of condylar hyperplasia, and some of the opinions expressed 20 years earlier and representing, inter alia, an analysis of only 12 patients, have been advanced considerably. It has been the writer’s practice to invite the consultant pathologist examining the condylar specimen to carry out mensuration with the ocular micrometer and indicate the depth of penetration of the cartilage cells in the overactive condyle, in the same manner as one would with malignant melanoma or squamous carcinoma. It would be interesting to learn from Mr Adrian Sugar and his colleagues precisely the depth (in millimetres) of cartilage downgrowth in those patients who underwent condylar surgery. It is, incidentally, rarely necessary to resect the entire condyle. There is one group of patients in whom one is reluctant to recommend condylar surgery, and that is the patient who has completed 2 years of fixed band orthodontic treatment, is aged between 19 and 23, and still has residual growth and an active unilateral scan. Rather than operate on the mandibular condyle, it has been our practice to strip the condylar neck widely at the time of the sagittal splitting osteotomy. The advantages and disadvantages of this are discussed with the patient, and her or his parents (the majority of our patients have been female), and it is explained that it will be necessary to arrange a SPECT scan on an anniversary basis 12 months post-operation, and triennial follow-up is essential, and that there will be a minority of patients who, despite a satisfactory aesthetic and functional osteotomy result and wide stripping of the condylar neck, will continue with condylar growth and require subsequent excision of the condylar growth centre. Needless to say, these details are well documented in the notes, and an appropriate letter written to the patient. A patient operated on a month ago had undergone a bimaxillary procedure in another excellent centre, in 1985, by a most experienced colleague, and had been referred for an opinion in regard to an hyperactive condyle and emergent asymmetry, and it was apparent from the 3-D CT scans that she had an osteocartilaginous hamartoma. This was resected and the depth of the cartilage downgrowth was noted on the ocular micrometer to be 6 mm. It is to be hoped that those surgeons who have patients with condylar hyperplasia might be encouraged to invite their consultant pathologist to review the sections and carry out measurement of condylar downgrowth as laid out by Dr Dorothy Painter in her earlier contributions.5,6 Yours faithfully J. E. deB. Norman FRCS(Ed), FRACS Maxillofacial Surgeon 5 Brunswick Avenue Strathfield NSW 2135, Australia REFERENCES 1. Allwright J, Cooper RA, Shuter B, Painter DM, Henry RG, Norman JEdeB. SPECT in the diagnosis of hyperplasia of the mandibular condyle [Abstract]. Aust NZ J Med 1987; 17: 460.
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Letters to the Editor 2. Allwright J, Cooper RA, Shuter B, Painter DM, Henry RG, Norman JEdeB. SPECT in the diagnosis of hyperplasia of the mandibular condyle [Abstract]. J Nucl Med 1988; 29: 780. 3. Cooper RA. Bone scintigraphy. In: Norman JEdeB, Bramley P, eds. Textbook and Color Atlas of the Temporomandibular Joint: Diseases, Disorders, Surgery. London: Wolfe Medical Publications Ltd, 1990; 108–109. 4. Norman JEdeB, Mitchell RD, Shnier RC. Temporomandibular crepitus: imaging of the temporomandibular joint: radiology, CT scanning, MRI and arthrogram video, and nuclear scintigraphy with SPECT. Brunei Int Med J 2000; 2: 429–437. 5. Norman JEdeB, Painter DM. Hyperplasia of the mandibular condyle. A historical review of important early cases with a presentation and analysis of twelve patients. J Maxillofac Surg 1980; 8: 161–175. 6. Painter DM. Pathology. In: Norman JEdeB, Bramley P, eds. Textbook and Color Atlas of the Temporomandibular Joint: Diseases, Disorders, Surgery. London: Wolfe Medical Publications Ltd, 1990; 52–68. doi: 10.1054/bjom.2000.0542, available online at http://www.idealibrary.com on
doi: 10.1054/bjom.2000.0553, available online at http://www.idealibrary.com on
AUDIT ON IMPACTED WISDOM TEETH Sir, Such audits appear still both trendy and continuing. All wisdom teeth referrals to Whipps Cross Hospital throughout a threemonth period commencing on 1 February 2000 were recorded and examined individually by one oral & maxillofacial surgeon (B.L.). A total of 146 patients were referred specifically for removal of their impacted wisdom teeth. These could be categorized as follows:
Re: Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations. Br J Oral Maxillofac Surg 2000; 38: 124–126 Sir, We were interested to read the opinion of Webster and Wilde1 on the management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial surgery. They recommend the use of tranexamic acid mouthwash postoperatively for patients who have had minor oral surgery procedures. We would like to point out that at this time tranexamic acid does not have a licence for use as a mouthwash in the UK, despite its proven benefit.2 Webster and Wilde also refer to a publication by Souto et al.3 ‘… in which the dose of warfarin was not modified …’. The anticoagulant used by Souto et al. was, in fact, acenocoumarol and not warfarin. Yours faithfully Luc Evans Medical Student; previously Senior House Officer Adrian W. Sugar Consultant Oral and Maxillofacial Surgeon Morriston Hospital Morriston, Swansea SA6 6NL, UK REFERENCES 1. Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations. Br J Oral Maxillofac Surg 2000; 38:124–126. 2. Sindet-Pederson S, Ramstrom G, Bernvil S, Blomback M. Hemostatic effect of tranexamic acid mouthwash in anticoagulanttreated patients undergoing oral surgery. N Engl J Med 1989; 320: 840–843. 3. Souto JC, Oliver A, Zuazu-Jausoro, Vives A, Fontcuberta J. Oral surgery in anticoagulated patients without reducing the dose or oral anticoagulant: a prospective randomized Study. J Oral Maxillofac Surg 1996; 54: 27–32.
245
56 patients had sufficient clinical and radiographic evidence to justify an inpatient waiting list entry for surgical removal of the wisdom teeth; 20 patients had sufficient information for addition to the daystay waiting list; 3 patients had sufficient clinical and radiographic information to warrant removal of wisdom teeth under local anaesthesia.
In 54 of the patients, there was insufficient evidence to justify any surgical intervention at that time and the cases were placed ‘on probation’ this with clinical review six months later, followed by a further radiographic check at one year. Patients were advised to bring these review appointments forward, were there to be significant clinical deterioration. Also that if surgical intervention became unavoidable, then it would be appropriate to ‘backdate’ a waiting list entry. Forty-two patients had symptoms of temporomandibular joint pain dysfunction, the wisdom teeth were ‘red herrings’, therefore not requiring removal. In only five cases was it deemed appropriate to return the patient to the referring practitioner after their initial consultation, without any follow-up. In summary, over half of the patients referred for removal of their wisdom teeth was justified and correct. Where there is inadequate clinical information to make a valid judgement, then placing ‘on probation’ can be a useful tool. Finally, the third largest category referred to temporomandibular joint pain dysfunction symptoms to which the wisdom teeth were non-contributory. I would suggest that this possibility should always be considered before making a decision to surgically remove wisdom teeth which may merely be a chance finding on a rotational tomograph. Mr B. Littler MBBS, BDS, FDSRCS Consultant Oral & Maxillofacial Surgeon Whipps Cross Hospital Leytonstone London E11 1NR, UK
5/15/01 4:28 PM
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less than impressive outcomes reported by Maier et al., it is unfortunate that they did not follow their own advice. D. Clarke Palmetto Richland Memorial Hospital Columbia, South Carolina, USA REFERENCE 1. Maier A, Gaggl A, Klemen H et al. Review of severe osteoradionecrosis treated by surgery alone or surgery with postoperative hyperbaric oxygenation. Br J Oral Maxillofac Surg 2000; 38: 167–246. doi: 10.1054/bjom.2000.0528, available online at http://www.idealibrary.com on
Re: Hodder et al. SPECT bone scintigraphy in the diagnosis and management of mandibular condylar hyperplasia. Br J Oral Maxillofac Surg 2000; 38: 87–93 Sir, The educative paper by Mr S. C. Hodder and his co-workers on the use of nuclear scintigraphy with SPECT in the diagnosis and management of mandibular condylar hyperplasia was read to advantage, and with much interest. It was pleasing to see that others also believed the technique had proved to be of value. The nuclear physicians with whom I have worked over the last 20 years were interested that the summary included the comment, ‘Previous studies have, however, relied only on planar images’, and it was appreciated that this was, on the balance of probability, a remark that the authors may have intended for emendation, particularly as they had quoted the report by Stephen Allwright et al. from 1987.1,2 The writer and his colleagues in nuclear medicine have utilized SPECT using the same radiotracer (Tc-99MDP or HDP) for approximately 15 years.3 The technique of SPECT scanning represents the nuclear physician’s version of the computerized tomographic scan and, when combined with a numeric and graphic representation of the pixel count, we have found it to be of great value in the assessment of the progress and staging of condylar hyperactivity and hyperplasia, particularly in the teenager and young adult. It may be the principal deciding factor in the decision made by the surgeon and orthodontist as to the timing of an operation. There is no dubiety that the SPECT scan is superior to planar imaging, and the writer and his coworkers had recognized this by 1986. It has been a personal quest always to insist on the pixel count in numeric and graphic form when requesting the scan.4 Nuclear scintigraphy with SPECT is valuable in the assessment of suppurative temporomandibular (TM) arthritis, osteoarthritis, primary and secondary neoplasms, fibrous dysplasia, aneurysmal bone cyst (ABC), synovial osteochondromatosis and TM ganglion. We have found the gallium scan valuable in the assessment of inflammatory and neoplastic conditions. The writer has found over the years, in the course of conduct of a facial and jaw deformity clinic, that explaining a minified axial or coronal scan to a patient and his or her parents is a little difficult at times, and how much easier it is to show the SPECT scan and the graph, and in the case an adult with
mandibular condylar hyperplasia with a pixel count of 316 on the left and 98 on the right. The letters section of this journal of excellence is not the appropriate forum to reflect on the writer’s experience and philosophy of the management of condylar hyperplasia, and some of the opinions expressed 20 years earlier and representing, inter alia, an analysis of only 12 patients, have been advanced considerably. It has been the writer’s practice to invite the consultant pathologist examining the condylar specimen to carry out mensuration with the ocular micrometer and indicate the depth of penetration of the cartilage cells in the overactive condyle, in the same manner as one would with malignant melanoma or squamous carcinoma. It would be interesting to learn from Mr Adrian Sugar and his colleagues precisely the depth (in millimetres) of cartilage downgrowth in those patients who underwent condylar surgery. It is, incidentally, rarely necessary to resect the entire condyle. There is one group of patients in whom one is reluctant to recommend condylar surgery, and that is the patient who has completed 2 years of fixed band orthodontic treatment, is aged between 19 and 23, and still has residual growth and an active unilateral scan. Rather than operate on the mandibular condyle, it has been our practice to strip the condylar neck widely at the time of the sagittal splitting osteotomy. The advantages and disadvantages of this are discussed with the patient, and her or his parents (the majority of our patients have been female), and it is explained that it will be necessary to arrange a SPECT scan on an anniversary basis 12 months post-operation, and triennial follow-up is essential, and that there will be a minority of patients who, despite a satisfactory aesthetic and functional osteotomy result and wide stripping of the condylar neck, will continue with condylar growth and require subsequent excision of the condylar growth centre. Needless to say, these details are well documented in the notes, and an appropriate letter written to the patient. A patient operated on a month ago had undergone a bimaxillary procedure in another excellent centre, in 1985, by a most experienced colleague, and had been referred for an opinion in regard to an hyperactive condyle and emergent asymmetry, and it was apparent from the 3-D CT scans that she had an osteocartilaginous hamartoma. This was resected and the depth of the cartilage downgrowth was noted on the ocular micrometer to be 6 mm. It is to be hoped that those surgeons who have patients with condylar hyperplasia might be encouraged to invite their consultant pathologist to review the sections and carry out measurement of condylar downgrowth as laid out by Dr Dorothy Painter in her earlier contributions.5,6 Yours faithfully J. E. deB. Norman FRCS(Ed), FRACS Maxillofacial Surgeon 5 Brunswick Avenue Strathfield NSW 2135, Australia REFERENCES 1. Allwright J, Cooper RA, Shuter B, Painter DM, Henry RG, Norman JEdeB. SPECT in the diagnosis of hyperplasia of the mandibular condyle [Abstract]. Aust NZ J Med 1987; 17: 460.
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Letters to the Editor 2. Allwright J, Cooper RA, Shuter B, Painter DM, Henry RG, Norman JEdeB. SPECT in the diagnosis of hyperplasia of the mandibular condyle [Abstract]. J Nucl Med 1988; 29: 780. 3. Cooper RA. Bone scintigraphy. In: Norman JEdeB, Bramley P, eds. Textbook and Color Atlas of the Temporomandibular Joint: Diseases, Disorders, Surgery. London: Wolfe Medical Publications Ltd, 1990; 108–109. 4. Norman JEdeB, Mitchell RD, Shnier RC. Temporomandibular crepitus: imaging of the temporomandibular joint: radiology, CT scanning, MRI and arthrogram video, and nuclear scintigraphy with SPECT. Brunei Int Med J 2000; 2: 429–437. 5. Norman JEdeB, Painter DM. Hyperplasia of the mandibular condyle. A historical review of important early cases with a presentation and analysis of twelve patients. J Maxillofac Surg 1980; 8: 161–175. 6. Painter DM. Pathology. In: Norman JEdeB, Bramley P, eds. Textbook and Color Atlas of the Temporomandibular Joint: Diseases, Disorders, Surgery. London: Wolfe Medical Publications Ltd, 1990; 52–68. doi: 10.1054/bjom.2000.0542, available online at http://www.idealibrary.com on
doi: 10.1054/bjom.2000.0553, available online at http://www.idealibrary.com on
AUDIT ON IMPACTED WISDOM TEETH Sir, Such audits appear still both trendy and continuing. All wisdom teeth referrals to Whipps Cross Hospital throughout a threemonth period commencing on 1 February 2000 were recorded and examined individually by one oral & maxillofacial surgeon (B.L.). A total of 146 patients were referred specifically for removal of their impacted wisdom teeth. These could be categorized as follows:
Re: Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations. Br J Oral Maxillofac Surg 2000; 38: 124–126 Sir, We were interested to read the opinion of Webster and Wilde1 on the management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial surgery. They recommend the use of tranexamic acid mouthwash postoperatively for patients who have had minor oral surgery procedures. We would like to point out that at this time tranexamic acid does not have a licence for use as a mouthwash in the UK, despite its proven benefit.2 Webster and Wilde also refer to a publication by Souto et al.3 ‘… in which the dose of warfarin was not modified …’. The anticoagulant used by Souto et al. was, in fact, acenocoumarol and not warfarin. Yours faithfully Luc Evans Medical Student; previously Senior House Officer Adrian W. Sugar Consultant Oral and Maxillofacial Surgeon Morriston Hospital Morriston, Swansea SA6 6NL, UK REFERENCES 1. Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and maxillofacial operations. Br J Oral Maxillofac Surg 2000; 38:124–126. 2. Sindet-Pederson S, Ramstrom G, Bernvil S, Blomback M. Hemostatic effect of tranexamic acid mouthwash in anticoagulanttreated patients undergoing oral surgery. N Engl J Med 1989; 320: 840–843. 3. Souto JC, Oliver A, Zuazu-Jausoro, Vives A, Fontcuberta J. Oral surgery in anticoagulated patients without reducing the dose or oral anticoagulant: a prospective randomized Study. J Oral Maxillofac Surg 1996; 54: 27–32.
245
56 patients had sufficient clinical and radiographic evidence to justify an inpatient waiting list entry for surgical removal of the wisdom teeth; 20 patients had sufficient information for addition to the daystay waiting list; 3 patients had sufficient clinical and radiographic information to warrant removal of wisdom teeth under local anaesthesia.
In 54 of the patients, there was insufficient evidence to justify any surgical intervention at that time and the cases were placed ‘on probation’ this with clinical review six months later, followed by a further radiographic check at one year. Patients were advised to bring these review appointments forward, were there to be significant clinical deterioration. Also that if surgical intervention became unavoidable, then it would be appropriate to ‘backdate’ a waiting list entry. Forty-two patients had symptoms of temporomandibular joint pain dysfunction, the wisdom teeth were ‘red herrings’, therefore not requiring removal. In only five cases was it deemed appropriate to return the patient to the referring practitioner after their initial consultation, without any follow-up. In summary, over half of the patients referred for removal of their wisdom teeth was justified and correct. Where there is inadequate clinical information to make a valid judgement, then placing ‘on probation’ can be a useful tool. Finally, the third largest category referred to temporomandibular joint pain dysfunction symptoms to which the wisdom teeth were non-contributory. I would suggest that this possibility should always be considered before making a decision to surgically remove wisdom teeth which may merely be a chance finding on a rotational tomograph. Mr B. Littler MBBS, BDS, FDSRCS Consultant Oral & Maxillofacial Surgeon Whipps Cross Hospital Leytonstone London E11 1NR, UK