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Re: Wake MJC. Descriptive titles: primary and secondary cleft surgeons. Br J Oral Maxillofac Surg 2001; 39:160
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doi: 10.1054/bjom.2001.0668, available online at http://www.idealibrary.com on
Re: Care in the placement of bicortical intermaxillary fixation screws Sir, Messrs Holmes and Hutchison1 highlighted the problem of intermaxillary bicortical bone screws shearing at bone level during placement. In Morriston, we have placed over 400 intermaxillary fixation (IMF) screws during the last 3 years
and by far the commonest problem encountered during placement is caused by inaccurate alignment of the screw. With such a wide variation in root morphology, postoperative radiographic views regularly show grooving of adjacent teeth (Fig. 1) with occasional exposure of the root canal. These areas generally heal with good bony regeneration and few long-term clinical problems have resulted. Nevertheless, if the pulp is traumatized, the tooth may become non-vital and subsequent root canal therapy may prove difficult (Fig. 2). From our experiences, we would recommend a thorough clinical and radiographic assessment of the teeth adjacent to the site for IMF screw placement. The alignment of the teeth in 3-dimensions should be fully appreciated. If any resistance is encountered whilst drilling beyond the outer cortical bony plate, then the IMF screw hole should be resited. The use of bicortical bone screws is an invaluable technique that greatly shortens the operative time to achieve intermaxillary fixation but care must be taken to avoid damage to adjacent teeth. Steven Key FDSRCPS, FRCS Locum Staff Grade in Oral and Maxillofacial Surgery Andrew Gibbons MA (Cantab) FDSRCS, FRCS Specialist Registrar in Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery Morriston Hospital Swansea SA6 6NL, UK
Fig. 1 Postoperative radiograph demonstrating upper and lower teeth damaged by careless IMF screw placement.
REFERENCES 1. Holmes S, Hutchison I. Letter: Caution in use of bicortical intermaxillary fixation screws. Br J Oral Maxillofac Surg 2000; 38: 574. 2. Jones DC. The intermaxillary screw: a dedicated bicortical bone screw for temporary intermaxillary fixation. Br J Oral Maxillofac Surg 1999; 37: 115–116.
doi: 10.1054/bjom.2000.0699, available online at http://www.idealibrary.com on
Re: Wake MJC. Descriptive titles: primary and secondary cleft surgeons. Br J Oral Maxillofac Surg 2001; 39: 160
Fig. 2 Extracted tooth with exposed root canal.
Sir, I agree with Michael Wake that the distinction between primary and secondary cleft surgery is imprecisely defined. As one of a small but significant number of cleft surgeons who have been comprehensively trained and undertake the full spectrum of cleft surgery, I consider the distinction between primary and secondary cleft surgery to be artificial and illogical. All aspects of cleft surgery are interrelated and impact on each other. Any attempt to divorce primary from secondary cleft surgery (whichever way you choose to define it) may result in inadequate treatment determined by the limits of a particular surgeon’s expertise. Multidisciplinary clinics are designed to minimize this problem, but should be supported wherever possible by comprehensively trained surgeons who understand and manage all aspects of cleft surgery. I am reassured to see that members of the Cleft Implementation Group (CIG) support the concept of a ‘cleft surgeon’.1 I hope that CIG will encourage
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the assimilation into the new arrangements of that small group of surgeons who have had a broad training and already provide the whole range of cleft care. With regard to the appointment of staff at newly designated cleft centres it is still not clear as to what will happen in the interim before the new generation of cleft surgeons have been comprehensively trained. The proposal to remove the apparently demeaning primary or secondary prefix from the title cleft surgeon may be unhelpful and misleading. The proposed title of cleft surgeon with a particular interest implies a broad training and expertise in the field of cleft surgery, which may not be the case. Until the new generation of cleft surgeons have been trained and appointed, the old familiar titles still best describe the range of expertise of the vast majority of surgeons involved in cleft care in the UK. Newly designated units should be staffed with the best surgeons available and preferably those trained and dedicated to undertake the full spectrum of cleft surgery. This is not going to be achieved by simply renaming existing surgeons already appointed to designated cleft centres. If, as Michael Wake claims, we really are going to start out as we mean to continue, multidisciplinary teams at newly designated cleft centres should be reappointed through open competition. There will, understandably, be some resistance to this from clinicians who happen to be on the spot in designated centres, especially those who have made significant contributions to cleft care in the past. The re-appointment process should, however, be open, fair and transparent and performed according to nationally agreed protocols guided by the Cleft Lip and Palate Interface Group established by the Joint Committee for Higher Surgical Training. If the whole process can be managed sensitively and sympathetically, without specialty bias, then it has the potential to produce harmonious, high quality cleft teams. Anything less would be a betrayal of the principles that underpinned the whole venture initiated by the Clinical Standards Advisory Group’s Report published in 1998.
485
flap to reconstruct the orbital floor following its resection in the surgical treatment of malignancy. This is a technique that we have used for some years now and we feel that it provides a useful and easy means of reconstruction of a critical area in selected cases. The approach was described by Curioni and Fioretti in 19781 and subsequently published in 1983.2 We are not aware of earlier workers describing this technique but would certainly appreciate being informed by the authors or others if we are mistaken. In our experience the length of the coronoid and temporalis muscle varies between individuals and as a result difficulty may be experienced in achieving bone-to-bone contact between the coronoid process and the medial resection margin, particularly if the latter is closer to the lacrimal fossa than in the case illustrated by the authors in Fig. 2. Any attempt to ‘stretch’ the flap results in alteration of globe position. The length of the composite flap can be increased if the coronoid is sectioned further inferiorly than the sigmoid notch – if necessary taken down to the retromolar trigone or beyond as suggested by Curioni et al.2,3 The authors quite rightly highlighted a useful technique. We felt that it was appropriate to bring to colleagues’ attention the work of Curioni and his co-workers, who to our knowledge initially described it. Yours faithfully I. P. Downie FRCS (OMFS), FDSRCS(Ed) Specialist Registrar B. T. Evans FRCS, FDSRCS, FFDRCSI Consultant Department of Oral and Maxillofacial Surgery Southampton University Hospitals, UK REFERENCES
Yours faithfully C. Penfold Consultant Oral and Maxillofacial Surgeon Glan Clwyd Hospital Bodelwyddan Denbighshire LL18 5UJ, UK
1. Curioni C, Fioretti C. Nouvelle technique de reconstruction du plancher orbitaire (utilisant un lambreau osteomusculaire). Abstract 4th Congress EAMFS Venice 24–27 September 1978. 2. Curioni C, Toscana P, Fioretti C, Salerno G. Reconstruction of the orbital floor with the muscle-bone flap (temporal muscle with coronoid process). J Maxillofac Surg 1983; 11: 263–268. 3. Curioni C, Toscana P, Clause L, Padula E. Facial and craniofacial reconstruction techniques for tumours involving the orbital walls. Chirugia della testa e del collo 1984; 1: 15–35.
REFERENCE 1. Report of a Clinical Standards Advisory Group Committee. Cleft Lip and/or Palate. London: The Stationary Office, 1998.
doi: 10.1054/bjom.2001.0679, available online at http://www.idealibrary.com on
Re: Holmes S, Hutchison I. Reconstruction of the orbital floor after its removal for malignancy. Br J Oral Maxillofac Surg 2001; 39: 158–159 Sir, We read with interest the paper describing the use of the coronoid process and the temporalis muscle as a pedicled composite
doi: 10.1054/bjom.2001.0678, available online at http://www.idealibrary.com on
Re: Holmes S, Ali N, Bradley PF. A true craniomaxillary fracture. Br J Oral Maxillofac Surg 2001; 39: 160–161 Sir, As a response to a letter from Holmes et al. I would like to mention that although the fracture in point might not have been reported in the literature before, I do not think that it represents a very unusual condition. I would like to prove my point by describing a very similar condition.
484
11/22/01 2:04 PM
Page 484
British Journal of Oral and Maxillofacial Surgery
doi: 10.1054/bjom.2001.0668, available online at http://www.idealibrary.com on
Re: Care in the placement of bicortical intermaxillary fixation screws Sir, Messrs Holmes and Hutchison1 highlighted the problem of intermaxillary bicortical bone screws shearing at bone level during placement. In Morriston, we have placed over 400 intermaxillary fixation (IMF) screws during the last 3 years
and by far the commonest problem encountered during placement is caused by inaccurate alignment of the screw. With such a wide variation in root morphology, postoperative radiographic views regularly show grooving of adjacent teeth (Fig. 1) with occasional exposure of the root canal. These areas generally heal with good bony regeneration and few long-term clinical problems have resulted. Nevertheless, if the pulp is traumatized, the tooth may become non-vital and subsequent root canal therapy may prove difficult (Fig. 2). From our experiences, we would recommend a thorough clinical and radiographic assessment of the teeth adjacent to the site for IMF screw placement. The alignment of the teeth in 3-dimensions should be fully appreciated. If any resistance is encountered whilst drilling beyond the outer cortical bony plate, then the IMF screw hole should be resited. The use of bicortical bone screws is an invaluable technique that greatly shortens the operative time to achieve intermaxillary fixation but care must be taken to avoid damage to adjacent teeth. Steven Key FDSRCPS, FRCS Locum Staff Grade in Oral and Maxillofacial Surgery Andrew Gibbons MA (Cantab) FDSRCS, FRCS Specialist Registrar in Oral and Maxillofacial Surgery Department of Oral and Maxillofacial Surgery Morriston Hospital Swansea SA6 6NL, UK
Fig. 1 Postoperative radiograph demonstrating upper and lower teeth damaged by careless IMF screw placement.
REFERENCES 1. Holmes S, Hutchison I. Letter: Caution in use of bicortical intermaxillary fixation screws. Br J Oral Maxillofac Surg 2000; 38: 574. 2. Jones DC. The intermaxillary screw: a dedicated bicortical bone screw for temporary intermaxillary fixation. Br J Oral Maxillofac Surg 1999; 37: 115–116.
doi: 10.1054/bjom.2000.0699, available online at http://www.idealibrary.com on
Re: Wake MJC. Descriptive titles: primary and secondary cleft surgeons. Br J Oral Maxillofac Surg 2001; 39: 160
Fig. 2 Extracted tooth with exposed root canal.
Sir, I agree with Michael Wake that the distinction between primary and secondary cleft surgery is imprecisely defined. As one of a small but significant number of cleft surgeons who have been comprehensively trained and undertake the full spectrum of cleft surgery, I consider the distinction between primary and secondary cleft surgery to be artificial and illogical. All aspects of cleft surgery are interrelated and impact on each other. Any attempt to divorce primary from secondary cleft surgery (whichever way you choose to define it) may result in inadequate treatment determined by the limits of a particular surgeon’s expertise. Multidisciplinary clinics are designed to minimize this problem, but should be supported wherever possible by comprehensively trained surgeons who understand and manage all aspects of cleft surgery. I am reassured to see that members of the Cleft Implementation Group (CIG) support the concept of a ‘cleft surgeon’.1 I hope that CIG will encourage
Bjom-Lett.qxd
11/22/01 2:04 PM
Page 485
Letters
the assimilation into the new arrangements of that small group of surgeons who have had a broad training and already provide the whole range of cleft care. With regard to the appointment of staff at newly designated cleft centres it is still not clear as to what will happen in the interim before the new generation of cleft surgeons have been comprehensively trained. The proposal to remove the apparently demeaning primary or secondary prefix from the title cleft surgeon may be unhelpful and misleading. The proposed title of cleft surgeon with a particular interest implies a broad training and expertise in the field of cleft surgery, which may not be the case. Until the new generation of cleft surgeons have been trained and appointed, the old familiar titles still best describe the range of expertise of the vast majority of surgeons involved in cleft care in the UK. Newly designated units should be staffed with the best surgeons available and preferably those trained and dedicated to undertake the full spectrum of cleft surgery. This is not going to be achieved by simply renaming existing surgeons already appointed to designated cleft centres. If, as Michael Wake claims, we really are going to start out as we mean to continue, multidisciplinary teams at newly designated cleft centres should be reappointed through open competition. There will, understandably, be some resistance to this from clinicians who happen to be on the spot in designated centres, especially those who have made significant contributions to cleft care in the past. The re-appointment process should, however, be open, fair and transparent and performed according to nationally agreed protocols guided by the Cleft Lip and Palate Interface Group established by the Joint Committee for Higher Surgical Training. If the whole process can be managed sensitively and sympathetically, without specialty bias, then it has the potential to produce harmonious, high quality cleft teams. Anything less would be a betrayal of the principles that underpinned the whole venture initiated by the Clinical Standards Advisory Group’s Report published in 1998.
485
flap to reconstruct the orbital floor following its resection in the surgical treatment of malignancy. This is a technique that we have used for some years now and we feel that it provides a useful and easy means of reconstruction of a critical area in selected cases. The approach was described by Curioni and Fioretti in 19781 and subsequently published in 1983.2 We are not aware of earlier workers describing this technique but would certainly appreciate being informed by the authors or others if we are mistaken. In our experience the length of the coronoid and temporalis muscle varies between individuals and as a result difficulty may be experienced in achieving bone-to-bone contact between the coronoid process and the medial resection margin, particularly if the latter is closer to the lacrimal fossa than in the case illustrated by the authors in Fig. 2. Any attempt to ‘stretch’ the flap results in alteration of globe position. The length of the composite flap can be increased if the coronoid is sectioned further inferiorly than the sigmoid notch – if necessary taken down to the retromolar trigone or beyond as suggested by Curioni et al.2,3 The authors quite rightly highlighted a useful technique. We felt that it was appropriate to bring to colleagues’ attention the work of Curioni and his co-workers, who to our knowledge initially described it. Yours faithfully I. P. Downie FRCS (OMFS), FDSRCS(Ed) Specialist Registrar B. T. Evans FRCS, FDSRCS, FFDRCSI Consultant Department of Oral and Maxillofacial Surgery Southampton University Hospitals, UK REFERENCES
Yours faithfully C. Penfold Consultant Oral and Maxillofacial Surgeon Glan Clwyd Hospital Bodelwyddan Denbighshire LL18 5UJ, UK
1. Curioni C, Fioretti C. Nouvelle technique de reconstruction du plancher orbitaire (utilisant un lambreau osteomusculaire). Abstract 4th Congress EAMFS Venice 24–27 September 1978. 2. Curioni C, Toscana P, Fioretti C, Salerno G. Reconstruction of the orbital floor with the muscle-bone flap (temporal muscle with coronoid process). J Maxillofac Surg 1983; 11: 263–268. 3. Curioni C, Toscana P, Clause L, Padula E. Facial and craniofacial reconstruction techniques for tumours involving the orbital walls. Chirugia della testa e del collo 1984; 1: 15–35.
REFERENCE 1. Report of a Clinical Standards Advisory Group Committee. Cleft Lip and/or Palate. London: The Stationary Office, 1998.
doi: 10.1054/bjom.2001.0679, available online at http://www.idealibrary.com on
Re: Holmes S, Hutchison I. Reconstruction of the orbital floor after its removal for malignancy. Br J Oral Maxillofac Surg 2001; 39: 158–159 Sir, We read with interest the paper describing the use of the coronoid process and the temporalis muscle as a pedicled composite
doi: 10.1054/bjom.2001.0678, available online at http://www.idealibrary.com on
Re: Holmes S, Ali N, Bradley PF. A true craniomaxillary fracture. Br J Oral Maxillofac Surg 2001; 39: 160–161 Sir, As a response to a letter from Holmes et al. I would like to mention that although the fracture in point might not have been reported in the literature before, I do not think that it represents a very unusual condition. I would like to prove my point by describing a very similar condition.