771
LETTERS TO THE EDITOR
1
ies, no evidence exists that apnea improves or worsens; therefore, our patients underwent postoperative studies at 6 weeks. In addition, most of our patients underwent surgery because they did not respond to, or refused to wear, nasal CPAP. Therefore, 6 months of nasal CPAP while awaiting surgery is unreasonable. Pressures necessary to correct apnea prior to surgery often change postoperatively and, therefore, it is not in the patient’s best interest to continue nasal CPAP without reevaluation. The article stated that multiple sites of upper airway obstruction may contribute to the overall syndrome, and therefore, all of our patients were studied the same way as Dr Riley’s group, by physical examination, cephalometric analysis, and fiberoptic pharyngoscopy. Finally, the discussion claimed that we failed to include the patients’ weight as part of their objective analysis. This is not true, and weight loss was carefully studied. As stated in the article, weight loss occurred in all cases and the difference between the failure group and the successful group was insignificant. The point is that weight loss was not responsible for our successful results. In conclusion, I appreciate the research, development, and support of Drs Riley and Powell in the area of surgical treatment for obstructive sleep apnea. I hope many other members of our specialty become actively involved with research in this area. PETER D. WAITE, MPH, DDS, MD VIRGIL WOOTEN, MD Birmingham, Alabama ALLOGENEIC BONE OR HYDROXYLAPATITE FOR THE SINUS LIFT PROCEDURE? To the Editor:-This letter concerns the discussion by Dr Thomas Golec of the article by Jensen et al entitled “Reconstruction of the Severely Resorbed Maxilla With Bone Grafting and Osseointegrated Implants: A Preliminary Report” (J Oral Maxillofac Surg 4833, 1990). Reconstruction of the severely resorbed maxilla is best accomplished by placing a preformed iliac graft with immediate implant placement. ‘*’ This is the best way to get retention of the graft as well as integration of implants. With this technique 5-year survival of implants has been reported at above 90% in some centers. The key to successful retention of an implant in this setting is that it engages native bone, which in some cases is essentially absent. I have described the site selection for the highly resorbed jaw (class D site) as having less than 3 mm of bone available so that an implant can not mechanically engage the site. Autogenous grafting of a jaw area is required in these cases before an implant can be placed.3 In my experience, implants that are lost early are not integrated because of the lack of this initial mechanical stabilization into native bone. To overcome this difficulty, Dr Golec advises using hydroxylapatite in the sinus and as an onlay augmentation material to provide additional mechanical, though minimal osseointegrative, support to the subsequently placed implant.4 Indeed, the implant longevity and success may be in proportion to the osseointegrating capacity of the native bone and to a very limited extent to osseo-conducted bone in the areas of the hydroxylapatite implant. It has been my experience that an HA particulate implant is
never totally ossified, but has fibrous encapsulation present throughout much of the implant. Biopsies of sinus grafts have shown this as well.’ When the HA graft is placed into the sinus fist and surgical implantation is done later, should perforation of the sinus occur any nonintegrated HA could support a chronic infection that may not be possible to clear without secondary surgical intervention. This could also lead to loss of implants that are placed. When matured HA grafts are drilled into, especially in the mandible, HA particles generate increased heat in the drilling procedure and this can impair primary osseous repair. This is much less likely in the maxilla, but should be a consideration. I would recommend, therefore, in the elderly where an iliac bone graft is proscribed that a sinus lift or nasal mucosal lift be used with allograft augmentation and immediate placement of implants. This has proven highly successful over the past 2 years that I have used the technique. I do not attempt immediate placement of implants if there is not at least 3 mm of bone available to engage the implant. All trephine biopsies done (6 months after implant and sinus graft placement) under these conditions have shown formation of bone in the sinus. Implants have consistently integrated. Up to 15 mm of bone has been formed in the first molar area and has been confirmed histologically. Augmented sinus bone has proven to be clinically denser than adjacent bone at the biopsy stage. This technique appears to me to have several advantages over the ceramic implants as well as the iliac bone grafts where implant placement is delayed for a few months after grafting. The allograft solution should not be overlooked for the class C implant sites (3-7 mm vertical bone). It has been much more predictable than with the use of the ceramic in my hands and may be a preferred technique from a biological standpoint. OLE T. JENSEN, DDS, MS Denver, Colorado
References 1. Breine U, Branemark PI: Reconstruction of alveolar ,jaw bone. Stand J Plast Reconstr Surg 14:23, 1980 2. Branemark PI: Personal communication, April 1988 3. Jensen OT: Site classification for the osseointegrated implant. J Prosthet Dent 61:228, 1989 4. Smiler DG, Holmes RE: Sinus lit procedure using porous HA: A preiiminary report. J Oral Implants 13:42, 1986 5. Kirsch A: Personal communication, October 1989 REDISCOVERY OF THE TEMPORALIS MUSCLE. FLAP FOR ANKYLOSIS To the Editor:-1 read with interest the article by Pogrel and Kaban, “The Role of a Temporalis Fascia and Muscle Flap in Temporomandibular Joint Surgery” (J Oral Maxillofac Surg 48: 14, 1990). I commend the authors on their article and partially on their review of the literature. J.B. Murphy in Chicago, as far as I have been able to determine, and as they noted in their bibliography, was the first to use the temporal muscle for correction of a temporomandibular joint ankylosis. The procedure, however, fell into oblivion until it was repopularized by Dr Paul Tessier, who showed a movie of this operation at an Educational Foundation meeting of the American Society of Plastic and Reconstructive Surgeons in Dal-
772
LETTERS TO THE EDITOR
las which took place in 1972. Dr Tessier’s movie was very clear and explicit, and I am sure Dr Kaban, particularly because of his association with Dr Tessier in Boston, would agree about adding this citation to his bibliography. S. ANTHONYWOLFE, MD, FACS Miami, Florida DIVISION OF THE SPECIALTY To rhe E&or:-It is with interestthat I note the recent advertisementfor the American Board of Cosmetic Surgery in the January 1990 issue of Journal of Oral and
Maxiiiofacial Surgery: Although many of us are performing procedures that would qualify us for admittance into any subspecialty that can be deemed “cosmetic surgery,” The American Board of Cosmetic Surgery has taken upon itself to segmentalize our specialty into those who have obtained a dual MD-DDS degree and those who have not. I have read the protests of many oral and maxillofacial surgeons over the past few months in regard to the double degree situation and their expressed interest in maintaining a lack of duality within our specialty. It is obvious that this segmentalization has already occurred as recognized by the American Board of Cosmetic Surgery. I am afraid that what we are seeing is just the beginning of the further disjointing of our specialty; it is becoming a two-tiered specialty as has been feared by numerous members of our association. I would, therefore, hope that the powers that be within our organization (the members themselves) reconsider the proposed changes, for they have created a “can of worms” that has just been opened.
JOELS. TEE, DMD Brentwood, New York LOSING DENTOALVEOLAR SURGERY TO THE GENERAL DENTIST To rhe Editor:-The article on specialist-generalist relations in the last issue of the AAOMS Digest is overdue by about 20 years. I had personally approached the AAOMS people about this very thing at least 20 years ago and I was shrugged off. I also confronted AAOMS at that time about the concept of offering “how to” programs to the generalist, and the reaction was arrogant and smug. In this part of the world in today’s marketplace, prying patients away from the generalist is like pulling teeth. With the advocacy of the double-degree oral and maxillofacial surgeon, advanced training of the generalist in general practice residencies, and the continuation of “how to” programs offered to dentists by oral and maxillofacial surgeons, I see the demise of the dentoalveolar oral and maxillofacial surgeon in a very few years. ROBERTJ. BLUM, DMD Wayne, New Jersey THE PROPERWAY TO OBTAIN MEDICAL AND SURGICAL TRAINING
To the Editor:-Your editorial “A Second Look at the Double Degree” in the June 1989 issue was timely but, regrettably, stresses some of the lesser reasons for the program rather than the more substantial ones. The essential reason for advocacy of becoming medically qual-
ified was to remedy the medical education deficit of dental graduates. This is particularly important for oral and maxillofacial surgeons who cannot provide optimal patient care without sound basic medical knowledge and surgical skills. Our specialty has, indeed, broadened even without the four areas of future expansion you mentioned, although some of our colleagues do operate in those specific areas even now. McCallum’s article,’ in the same issue of the Journal as your editorial, lends support to this. He wrote, “My first question is whether our scope has changed? To this I would give a resounding yes.” In fact, if one overlooks the present burgeoning interest in cosmetic surgery, trauma, orthognathic, temporomandibular joint, and jaw reconstructive surgery, which constitute a significant portion of the present oral and maxillofacial surgeon’s work, are all complex procedures that demand knowledgeable pre- and postoperative care, as well as sophisticated surgical expertise. You posed the question of whether the present expanded training curriculum can provide the medical knowledge and core surgical training that oral and maxillofacial surgeons need. I would suggest that formal education, in the medical school context, is a more certain way of learning what we all declare to be necessary than an “apprentice” system integrated within a training program. Furthermore, all other surgical core specialties have recognized (and require) at least a year of basic surgical training. Despite that, our specialty assumes that if a resident spends 1 of 4 years rotating through various surgical departments, an equivalent surgical core will be acquired. In this litigious era, that seems particularly questionable. Being the responsible surgeon of record, for general surgery, requires medical licensure, and assuming responsibility is essential to the maturation of a surgeon in training. I agree with your last sentence, “The question of whether it is necessary for everyone in our specialty to have such training, however, still remains to be answered.” There are, however, a few suggestions I would make. One is that those who disagree with the double-degree concept be as tolerant of its advocates as they are of its adversaries. Time will, in fact, settle the issue and there is no need of confrontation. Secondly, the fear that our specialty will lose its identity as medically qualified members defect to “medicine” is not borne out by the record to date. A review of the San Francisco annual meeting program, with its numbers of presentations by double-degree colleagues, should hearten those who doubt their allegiance. WALTERGURALNICK,DMD Boston, Massachusetts
Reference 1. McCallum CA: The future of oral and maxillofacial surgery. J Oral Maxillofac Surg 1989 PROPERTRAINING FOR ORAL AND MAXILLOFACIAL SURGERY
To the E&or:-1 read with dismay the December editorial entitled “Maintaining the Unity of Oral and Maxillofacial Surgery” (48:1247, 1990). It implied that those residents finishing oral and maxillofacial surgery programs with a medical degree have somehow mysteriously expanded the scope of their training, and therefore the scope of their expected hospital credentials. As
LETTERS TO THE EDITOR
1
ies, no evidence exists that apnea improves or worsens; therefore, our patients underwent postoperative studies at 6 weeks. In addition, most of our patients underwent surgery because they did not respond to, or refused to wear, nasal CPAP. Therefore, 6 months of nasal CPAP while awaiting surgery is unreasonable. Pressures necessary to correct apnea prior to surgery often change postoperatively and, therefore, it is not in the patient’s best interest to continue nasal CPAP without reevaluation. The article stated that multiple sites of upper airway obstruction may contribute to the overall syndrome, and therefore, all of our patients were studied the same way as Dr Riley’s group, by physical examination, cephalometric analysis, and fiberoptic pharyngoscopy. Finally, the discussion claimed that we failed to include the patients’ weight as part of their objective analysis. This is not true, and weight loss was carefully studied. As stated in the article, weight loss occurred in all cases and the difference between the failure group and the successful group was insignificant. The point is that weight loss was not responsible for our successful results. In conclusion, I appreciate the research, development, and support of Drs Riley and Powell in the area of surgical treatment for obstructive sleep apnea. I hope many other members of our specialty become actively involved with research in this area. PETER D. WAITE, MPH, DDS, MD VIRGIL WOOTEN, MD Birmingham, Alabama ALLOGENEIC BONE OR HYDROXYLAPATITE FOR THE SINUS LIFT PROCEDURE? To the Editor:-This letter concerns the discussion by Dr Thomas Golec of the article by Jensen et al entitled “Reconstruction of the Severely Resorbed Maxilla With Bone Grafting and Osseointegrated Implants: A Preliminary Report” (J Oral Maxillofac Surg 4833, 1990). Reconstruction of the severely resorbed maxilla is best accomplished by placing a preformed iliac graft with immediate implant placement. ‘*’ This is the best way to get retention of the graft as well as integration of implants. With this technique 5-year survival of implants has been reported at above 90% in some centers. The key to successful retention of an implant in this setting is that it engages native bone, which in some cases is essentially absent. I have described the site selection for the highly resorbed jaw (class D site) as having less than 3 mm of bone available so that an implant can not mechanically engage the site. Autogenous grafting of a jaw area is required in these cases before an implant can be placed.3 In my experience, implants that are lost early are not integrated because of the lack of this initial mechanical stabilization into native bone. To overcome this difficulty, Dr Golec advises using hydroxylapatite in the sinus and as an onlay augmentation material to provide additional mechanical, though minimal osseointegrative, support to the subsequently placed implant.4 Indeed, the implant longevity and success may be in proportion to the osseointegrating capacity of the native bone and to a very limited extent to osseo-conducted bone in the areas of the hydroxylapatite implant. It has been my experience that an HA particulate implant is
never totally ossified, but has fibrous encapsulation present throughout much of the implant. Biopsies of sinus grafts have shown this as well.’ When the HA graft is placed into the sinus fist and surgical implantation is done later, should perforation of the sinus occur any nonintegrated HA could support a chronic infection that may not be possible to clear without secondary surgical intervention. This could also lead to loss of implants that are placed. When matured HA grafts are drilled into, especially in the mandible, HA particles generate increased heat in the drilling procedure and this can impair primary osseous repair. This is much less likely in the maxilla, but should be a consideration. I would recommend, therefore, in the elderly where an iliac bone graft is proscribed that a sinus lift or nasal mucosal lift be used with allograft augmentation and immediate placement of implants. This has proven highly successful over the past 2 years that I have used the technique. I do not attempt immediate placement of implants if there is not at least 3 mm of bone available to engage the implant. All trephine biopsies done (6 months after implant and sinus graft placement) under these conditions have shown formation of bone in the sinus. Implants have consistently integrated. Up to 15 mm of bone has been formed in the first molar area and has been confirmed histologically. Augmented sinus bone has proven to be clinically denser than adjacent bone at the biopsy stage. This technique appears to me to have several advantages over the ceramic implants as well as the iliac bone grafts where implant placement is delayed for a few months after grafting. The allograft solution should not be overlooked for the class C implant sites (3-7 mm vertical bone). It has been much more predictable than with the use of the ceramic in my hands and may be a preferred technique from a biological standpoint. OLE T. JENSEN, DDS, MS Denver, Colorado
References 1. Breine U, Branemark PI: Reconstruction of alveolar ,jaw bone. Stand J Plast Reconstr Surg 14:23, 1980 2. Branemark PI: Personal communication, April 1988 3. Jensen OT: Site classification for the osseointegrated implant. J Prosthet Dent 61:228, 1989 4. Smiler DG, Holmes RE: Sinus lit procedure using porous HA: A preiiminary report. J Oral Implants 13:42, 1986 5. Kirsch A: Personal communication, October 1989 REDISCOVERY OF THE TEMPORALIS MUSCLE. FLAP FOR ANKYLOSIS To the Editor:-1 read with interest the article by Pogrel and Kaban, “The Role of a Temporalis Fascia and Muscle Flap in Temporomandibular Joint Surgery” (J Oral Maxillofac Surg 48: 14, 1990). I commend the authors on their article and partially on their review of the literature. J.B. Murphy in Chicago, as far as I have been able to determine, and as they noted in their bibliography, was the first to use the temporal muscle for correction of a temporomandibular joint ankylosis. The procedure, however, fell into oblivion until it was repopularized by Dr Paul Tessier, who showed a movie of this operation at an Educational Foundation meeting of the American Society of Plastic and Reconstructive Surgeons in Dal-
772
LETTERS TO THE EDITOR
las which took place in 1972. Dr Tessier’s movie was very clear and explicit, and I am sure Dr Kaban, particularly because of his association with Dr Tessier in Boston, would agree about adding this citation to his bibliography. S. ANTHONYWOLFE, MD, FACS Miami, Florida DIVISION OF THE SPECIALTY To rhe E&or:-It is with interestthat I note the recent advertisementfor the American Board of Cosmetic Surgery in the January 1990 issue of Journal of Oral and
Maxiiiofacial Surgery: Although many of us are performing procedures that would qualify us for admittance into any subspecialty that can be deemed “cosmetic surgery,” The American Board of Cosmetic Surgery has taken upon itself to segmentalize our specialty into those who have obtained a dual MD-DDS degree and those who have not. I have read the protests of many oral and maxillofacial surgeons over the past few months in regard to the double degree situation and their expressed interest in maintaining a lack of duality within our specialty. It is obvious that this segmentalization has already occurred as recognized by the American Board of Cosmetic Surgery. I am afraid that what we are seeing is just the beginning of the further disjointing of our specialty; it is becoming a two-tiered specialty as has been feared by numerous members of our association. I would, therefore, hope that the powers that be within our organization (the members themselves) reconsider the proposed changes, for they have created a “can of worms” that has just been opened.
JOELS. TEE, DMD Brentwood, New York LOSING DENTOALVEOLAR SURGERY TO THE GENERAL DENTIST To rhe Editor:-The article on specialist-generalist relations in the last issue of the AAOMS Digest is overdue by about 20 years. I had personally approached the AAOMS people about this very thing at least 20 years ago and I was shrugged off. I also confronted AAOMS at that time about the concept of offering “how to” programs to the generalist, and the reaction was arrogant and smug. In this part of the world in today’s marketplace, prying patients away from the generalist is like pulling teeth. With the advocacy of the double-degree oral and maxillofacial surgeon, advanced training of the generalist in general practice residencies, and the continuation of “how to” programs offered to dentists by oral and maxillofacial surgeons, I see the demise of the dentoalveolar oral and maxillofacial surgeon in a very few years. ROBERTJ. BLUM, DMD Wayne, New Jersey THE PROPERWAY TO OBTAIN MEDICAL AND SURGICAL TRAINING
To the Editor:-Your editorial “A Second Look at the Double Degree” in the June 1989 issue was timely but, regrettably, stresses some of the lesser reasons for the program rather than the more substantial ones. The essential reason for advocacy of becoming medically qual-
ified was to remedy the medical education deficit of dental graduates. This is particularly important for oral and maxillofacial surgeons who cannot provide optimal patient care without sound basic medical knowledge and surgical skills. Our specialty has, indeed, broadened even without the four areas of future expansion you mentioned, although some of our colleagues do operate in those specific areas even now. McCallum’s article,’ in the same issue of the Journal as your editorial, lends support to this. He wrote, “My first question is whether our scope has changed? To this I would give a resounding yes.” In fact, if one overlooks the present burgeoning interest in cosmetic surgery, trauma, orthognathic, temporomandibular joint, and jaw reconstructive surgery, which constitute a significant portion of the present oral and maxillofacial surgeon’s work, are all complex procedures that demand knowledgeable pre- and postoperative care, as well as sophisticated surgical expertise. You posed the question of whether the present expanded training curriculum can provide the medical knowledge and core surgical training that oral and maxillofacial surgeons need. I would suggest that formal education, in the medical school context, is a more certain way of learning what we all declare to be necessary than an “apprentice” system integrated within a training program. Furthermore, all other surgical core specialties have recognized (and require) at least a year of basic surgical training. Despite that, our specialty assumes that if a resident spends 1 of 4 years rotating through various surgical departments, an equivalent surgical core will be acquired. In this litigious era, that seems particularly questionable. Being the responsible surgeon of record, for general surgery, requires medical licensure, and assuming responsibility is essential to the maturation of a surgeon in training. I agree with your last sentence, “The question of whether it is necessary for everyone in our specialty to have such training, however, still remains to be answered.” There are, however, a few suggestions I would make. One is that those who disagree with the double-degree concept be as tolerant of its advocates as they are of its adversaries. Time will, in fact, settle the issue and there is no need of confrontation. Secondly, the fear that our specialty will lose its identity as medically qualified members defect to “medicine” is not borne out by the record to date. A review of the San Francisco annual meeting program, with its numbers of presentations by double-degree colleagues, should hearten those who doubt their allegiance. WALTERGURALNICK,DMD Boston, Massachusetts
Reference 1. McCallum CA: The future of oral and maxillofacial surgery. J Oral Maxillofac Surg 1989 PROPERTRAINING FOR ORAL AND MAXILLOFACIAL SURGERY
To the E&or:-1 read with dismay the December editorial entitled “Maintaining the Unity of Oral and Maxillofacial Surgery” (48:1247, 1990). It implied that those residents finishing oral and maxillofacial surgery programs with a medical degree have somehow mysteriously expanded the scope of their training, and therefore the scope of their expected hospital credentials. As
