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Re: Newton J. P. et al. Masseteric hypertrophy?: preliminary report. Br J Oral Maxillofac Surg 1999; 37: 405–408
Letters 2.
Yamamoto K, Uchiyama T. Title in only Japanese. Infection and Immunity in Childhood (Shoni Kansen Meneki) 1998; 10: 163.
doi: 10.1054/bjom.2000.0512
THIRD MOLAR SURGERY The study of lingual nerve injury tends to favour the buccal approach to third molar surgery. The lingual approach has many advantages and shouldn’t be abandoned too readily. The strong ridge running buccally to the third molar is minimally disturbed, reducing the risk of jaw fracture at operation or subsequently. Avoiding extensive reflection of soft tissue on the buccal aspect will reduce the postoperative pain, swelling, trismus and risk of infection. The avoidance of sutures will help still further (Winstanley RP. Br Oral Maxillofac Surg 1985; 23: 381–385). The general trend in surgery is towards closed or semiclosed procedures and in maxillofacial work minimal intervention techniques may offer the best protection to the lingual nerve. Using a narrow chisel touching the tooth and reversing the bevel as required, sufficient distal and lingual bone (and buccal bone if necessary) can be pared away with the minimum of soft tissue reflection. Retractors are seldom needed. The use of broad lingual flap retractors together with a tongue depressor could well put the lingual nerve at risk of being crushed; the combined retractor of Hovell may reduce this hazard (cf. Moss CE, Wake MJC. Br J Oral Maxillofac Surg 1999; 37: 255–258.). The chisel needs no cooling, so washing and suction which can be traumatic are reduced to a minimum. Impacted third molars may support the dental arch and so, being functional, promote the health of the surrounding bone. In the report of the survey on oral surgeons (presented at the BAOMS autumn meeting in 1985) many of the older Fellows had impacted teeth that had remained symptomless for many years. Many younger ones had third molars removed, mainly with little inconvenience but some had significant complications. Perhaps our prayer for help in the discernment of the clinical findings and advising on operation or not should be that of Solomon who was granted a heart full of wisdom. Ronald P. Winstanley Consultant Maxillofacial Surgeon 1 Pine Road Manchester M20 6UY, UK doi: 10.1054/bjom.2000.0449
Re: Newton J. P. et al. Masseteric hypertrophy?: preliminary report. Br J Oral Maxillofac Surg 1999; 37: 405–408 Sir, We note with interest Newton et al.’s1 effort to relate computerized tomographic (CT) findings of masseteric muscle enlargement to histological studies of normal and abnormal masseter muscle. We were however surprised to see CT being used for the assessment of masseteric enlargement. Magnetic resonance imaging (MRI), as well as being less invasive than CT, provides a more defined illustration of soft tissue features2 and delineates medial and lateral layers of the masseter muscle. MRI differentially shows localized enlargements of masseter, thereby aiding in planning surgery.3
573
Measuring volume of different parts of the muscle might be more relevant than cross-sectional area (CSA) as this can be helpful in estimation of the amount of tissue to be removed when surgical reduction is carried out. This would also be helpful when monitoring the progress and outcome in patients treated surgically or otherwise. Shaukat Mahmood FRCS, FDSRCS, FFDRCSI David Conway FDSRCS Regional Oral & Maxillofacial Surgery Service, South East Scotland St John’s Hospital Livingston West Lothian EH54 6PP, UK References 1. 2.
3. 4. 5.
Newton JP, Cowpe JG, McClure IJ, Delday MI, Martin CA. Masseteric hypertrophy?: preliminary report. Br J Oral Maxillofac Surg. 1999; 37: 405–408. Sano K, Ninomiya H, Selkine J, Pe MB, Inokuchi T. Application of magnetic resonance imaging and ultrasonography to preoperative evaluation of masseteric hypertrophy. J Cranio-Maxillofac Surg 1991; 19: 223–226. Fyfe EC, Kabala J, Guest PG. Magnetic resonance imaging in the diagnosis of asymmetrical bilateral masseteric hypertrophy. Dento-Maxillo-Facial Rad 1999; 28: 52–54. Yonetsu K, Nakayama E, Yuasa K, Kanda S, Ozeki S, Shinohara M. Imaging findings of some buccomasseteric masses. Oral Surg Oral Med Oral Pathol 1998; 86: 755–759. Braun IF, Torres WE, Landman JA, Davies PC, Hoffman JC Jr. Computed tomography of benign masseteric hypertrophy. J Comput Assist Tomogr 1985; 9: 167–170.
doi: 1054/bjom.2000.0452
Re: Kerawala CJ. Oral cancer, smoking and alcohol: the patients’ perspective. Br J Oral Maxillofac Surg 1999; 37: 374–376 Sir, We read with interest the results of the study by Kerawala1 regarding the knowledge of patients about oral cancer, smoking and alcohol. Those patients who had been treated for oral malignancy appeared to have no greater knowledge of the risk factors for the disease than the control group. The article does not state whether the head and neck clinic used in the study had a policy of routinely giving advice regarding the risk factors, in the pre-operative work-up and/or post-operative monitoring of these patients. If they did, then the apparent lack of knowledge was presumably due to denial or memory loss by the patient. If advice was not given by the clinicians, then it is a cause for concern. In our own clinical practice of managing patients with oral pre-malignant dysplastic conditions, we regard it as a fundamental part of the treatment to give advice regarding alcohol and tobacco cessation, and document this in the case notes. There is clear evidence to show that cessation is associated with a reduced risk of the development of epithelial dysplasia2, and it would surely seem sensible that repeated reiteration of such cessation advice should be a routine process in the management of all patients with oral squamous cell carcinoma or associated pre-malignant lesions. Should the patient be unable to follow the advice then at least the provision of this information will have allowed them the autonomy to have made their own informed choice.
Yamamoto K, Uchiyama T. Title in only Japanese. Infection and Immunity in Childhood (Shoni Kansen Meneki) 1998; 10: 163.
doi: 10.1054/bjom.2000.0512
THIRD MOLAR SURGERY The study of lingual nerve injury tends to favour the buccal approach to third molar surgery. The lingual approach has many advantages and shouldn’t be abandoned too readily. The strong ridge running buccally to the third molar is minimally disturbed, reducing the risk of jaw fracture at operation or subsequently. Avoiding extensive reflection of soft tissue on the buccal aspect will reduce the postoperative pain, swelling, trismus and risk of infection. The avoidance of sutures will help still further (Winstanley RP. Br Oral Maxillofac Surg 1985; 23: 381–385). The general trend in surgery is towards closed or semiclosed procedures and in maxillofacial work minimal intervention techniques may offer the best protection to the lingual nerve. Using a narrow chisel touching the tooth and reversing the bevel as required, sufficient distal and lingual bone (and buccal bone if necessary) can be pared away with the minimum of soft tissue reflection. Retractors are seldom needed. The use of broad lingual flap retractors together with a tongue depressor could well put the lingual nerve at risk of being crushed; the combined retractor of Hovell may reduce this hazard (cf. Moss CE, Wake MJC. Br J Oral Maxillofac Surg 1999; 37: 255–258.). The chisel needs no cooling, so washing and suction which can be traumatic are reduced to a minimum. Impacted third molars may support the dental arch and so, being functional, promote the health of the surrounding bone. In the report of the survey on oral surgeons (presented at the BAOMS autumn meeting in 1985) many of the older Fellows had impacted teeth that had remained symptomless for many years. Many younger ones had third molars removed, mainly with little inconvenience but some had significant complications. Perhaps our prayer for help in the discernment of the clinical findings and advising on operation or not should be that of Solomon who was granted a heart full of wisdom. Ronald P. Winstanley Consultant Maxillofacial Surgeon 1 Pine Road Manchester M20 6UY, UK doi: 10.1054/bjom.2000.0449
Re: Newton J. P. et al. Masseteric hypertrophy?: preliminary report. Br J Oral Maxillofac Surg 1999; 37: 405–408 Sir, We note with interest Newton et al.’s1 effort to relate computerized tomographic (CT) findings of masseteric muscle enlargement to histological studies of normal and abnormal masseter muscle. We were however surprised to see CT being used for the assessment of masseteric enlargement. Magnetic resonance imaging (MRI), as well as being less invasive than CT, provides a more defined illustration of soft tissue features2 and delineates medial and lateral layers of the masseter muscle. MRI differentially shows localized enlargements of masseter, thereby aiding in planning surgery.3
573
Measuring volume of different parts of the muscle might be more relevant than cross-sectional area (CSA) as this can be helpful in estimation of the amount of tissue to be removed when surgical reduction is carried out. This would also be helpful when monitoring the progress and outcome in patients treated surgically or otherwise. Shaukat Mahmood FRCS, FDSRCS, FFDRCSI David Conway FDSRCS Regional Oral & Maxillofacial Surgery Service, South East Scotland St John’s Hospital Livingston West Lothian EH54 6PP, UK References 1. 2.
3. 4. 5.
Newton JP, Cowpe JG, McClure IJ, Delday MI, Martin CA. Masseteric hypertrophy?: preliminary report. Br J Oral Maxillofac Surg. 1999; 37: 405–408. Sano K, Ninomiya H, Selkine J, Pe MB, Inokuchi T. Application of magnetic resonance imaging and ultrasonography to preoperative evaluation of masseteric hypertrophy. J Cranio-Maxillofac Surg 1991; 19: 223–226. Fyfe EC, Kabala J, Guest PG. Magnetic resonance imaging in the diagnosis of asymmetrical bilateral masseteric hypertrophy. Dento-Maxillo-Facial Rad 1999; 28: 52–54. Yonetsu K, Nakayama E, Yuasa K, Kanda S, Ozeki S, Shinohara M. Imaging findings of some buccomasseteric masses. Oral Surg Oral Med Oral Pathol 1998; 86: 755–759. Braun IF, Torres WE, Landman JA, Davies PC, Hoffman JC Jr. Computed tomography of benign masseteric hypertrophy. J Comput Assist Tomogr 1985; 9: 167–170.
doi: 1054/bjom.2000.0452
Re: Kerawala CJ. Oral cancer, smoking and alcohol: the patients’ perspective. Br J Oral Maxillofac Surg 1999; 37: 374–376 Sir, We read with interest the results of the study by Kerawala1 regarding the knowledge of patients about oral cancer, smoking and alcohol. Those patients who had been treated for oral malignancy appeared to have no greater knowledge of the risk factors for the disease than the control group. The article does not state whether the head and neck clinic used in the study had a policy of routinely giving advice regarding the risk factors, in the pre-operative work-up and/or post-operative monitoring of these patients. If they did, then the apparent lack of knowledge was presumably due to denial or memory loss by the patient. If advice was not given by the clinicians, then it is a cause for concern. In our own clinical practice of managing patients with oral pre-malignant dysplastic conditions, we regard it as a fundamental part of the treatment to give advice regarding alcohol and tobacco cessation, and document this in the case notes. There is clear evidence to show that cessation is associated with a reduced risk of the development of epithelial dysplasia2, and it would surely seem sensible that repeated reiteration of such cessation advice should be a routine process in the management of all patients with oral squamous cell carcinoma or associated pre-malignant lesions. Should the patient be unable to follow the advice then at least the provision of this information will have allowed them the autonomy to have made their own informed choice.