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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 prac- tice. Hopefully, this will cause some thought and consider- ation 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 pro- duced 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 sur- geons” 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 render- ing 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 prac- titioners, 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, espe- cially 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 foun- dation 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 tra- dition of reviewing the current issue of the Journal of Oral and Maxillofacial Surgery monthly. Recently, an article by Hsu et al 1 entitled “Manual Reduction of Mandibular Frac- tures 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 sacri- ficing surgical outcomes. After reviewing the article by Hsu et al, 1 we immediately applied the stringent inclusion/ex- clusion 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 pa- tient was referred to us for management. Clinical examina- tion 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 frac- tures, 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 inci- sion with an anterior buccal vestibular release was per- formed, and the fracture was exposed. Intraoperative eval- uation 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

Putting Literature Into Clinical Practice

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Page 1: Putting Literature Into Clinical Practice

LETTERS TO THE EDITOR

J Oral Maxillofac Surg

70:2492-2493, 2012

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Yo8lfie

fyt

ro

WHO IS AT FAULT?

To the Editor:—This letter to the editor is strictly based onmy opinion; there is no scientific research to back this up.It is based on my personal observation and communicationswith my colleagues, both in academics and in private prac-tice. Hopefully, this will cause some thought and consider-ation by you, my fellow oral-maxillofacial surgeons.

Our young residents coming out of training today are thebest-trained oral-maxillofacial surgeons that we have pro-duced so far. Although their residencies may seem long tothem, I think it is remarkable that they have enough time toacquire all the knowledge and surgical expertise that arerequired of them. Some have taken the term “super sur-geons” to describe these young women and men.

There within lies the problem as I see it. I believe that anumber or even the majority of these well-trained doctorsare not adequately applying the vast amount of expertisethat they have acquired. They tend to be satisfied with anoffice practice only, performing advanced alveolar surgeryand implant procedures. They are abandoning the veryfoundation that our profession was built on, that is, facialtrauma. We are the most qualified professionals to treatfacial trauma. Facial trauma has been the foundation of ourprofession. It helped legitimize our rightful place in thehospital and led to us expanding our surgical horizons,including orthognathic surgery, reconstructive surgery, andcosmetic surgery. I have heard some say that they paid backsociety while treating facial trauma patients in training. Thisis exactly opposite of the truth. Society trained these youngresidents, and now they should pay back society by render-ing the best facial trauma care possible. I know that traumais not a money-maker, and many have educational debts topay back, but removing oneself from the active staff oremergency department call at a hospital is not the answer.We must do what is right and best for our patients and ourspecialty.

Now who is at fault? Is it the American Association of Oraland Maxillofacial Surgeons, the American Board of Oral andMaxillofacial Surgery, the training centers, the private prac-titioners, governmental regulations, the present economicconditions, or the unknown, better known as universalhealth care? We know that the American Board of Oral andMaxillofacial Surgery has begun to address this issue, but itcannot do it alone. I personally dislike regulations, espe-cially governmental regulations. We cannot regulate tomake our young colleagues stay on hospital staffs and takeactive emergency department calls. There must be a betterway. Maybe it is time for our leaders to address thissituation. 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

Letters to the Editor must be in reference to a specific article omust be submitted within 6 weeks of the article’s print publicatioit first appeared online. Letters must be submitted electronically vjoms. Letters are subject to editing and those exceeding 500 wophotograph may accompany the letter if it is essential to undermaterial or material published elsewhere. There is no guarantee tnot be provided. Submitting a Letter to the Editor constitutes tedition of the journal, in any form or medium.

2492

plan. I would also include oral-maxillofacial surgeonsfrom 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 foun-dation gives way and the building blocks of our specialtycome tumbling down upon us.

RONALD B. MARKS, DDSPast 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 LincolnMedical and Mental Health Center has a long-standing tra-dition of reviewing the current issue of the Journal of Oraland Maxillofacial Surgery monthly. Recently, an article byHsu et al1 entitled “Manual Reduction of Mandibular Frac-ures Before Internal Fixation Leads to Shorter Operativeuration and Equivalent Outcomes When Compared Witheduction With Intermaxillary Fixation,” published in the

uly 2012 edition, was reviewed.As a Level I Trauma Center in the South Bronx, New

ork, Lincoln Hospital provides the training program withver 200 operative trauma cases per year; approximately5% of these cases are mandible fractures. We are always

ooking for ways to decrease operative time, without sacri-cing surgical outcomes. After reviewing the article by Hsut al,1 we immediately applied the stringent inclusion/ex-

clusion criteria set forth in the article.An 18-year-old man with no significant medical history

was initially seen by his general dentist, complaining oftooth pain associated with the left mandibular third molar.A dental panoramic radiograph was taken and showed aminimally displaced left mandibular angle fracture. The pa-tient was referred to us for management. Clinical examina-tion showed stable and reproducible occlusion, with noinferior alveolar nerve paresthesia.

The proper inclusion/exclusion criteria were applied, asoutlined in the article.1 These include an isolated left angleracture, no involvement of the condyle, age greater than 16ears, no gross comminution, no concurrent facial frac-ures, and no history of previous facial fractures.

The patient was taken to the operating room for openeduction with manual reduction and internal fixation, asutlined in the article.1 A standard distal hockey-stick inci-

sion with an anterior buccal vestibular release was per-formed, and the fracture was exposed. Intraoperative eval-

uation showed that the associated tooth was not indicated

r editorial that has been published by the Journal. Lettersn or, for an online-only article, within 8 weeks of the dateia the Elsevier Editorial System at http://ees.elsevier.com/

rds may be shortened or not accepted due to length. Onestanding the subject. Letters should not duplicate similarhat any letter will be published. Prepublication proofs willhe author’s permission for its publication in any issue or

Page 2: Putting Literature Into Clinical Practice

tusiassto

f

al and

LETTERS TO THE EDITOR 2493

for immediate extraction. Centric occlusion was achievedwith only manual reduction, and maintained during fixationwith a Synthes (West Chester, PA) prebent Champy plate.The clinical and radiographic result of the procedureshowed stable, reproducible, pre-trauma occlusion (Fig 1).

By using the manual reduction technique, we were ableo reduce the operating time from our average of 72 min-tes to 21 minutes without any sacrifice of the desiredurgical outcome. We would, however, advocate additionalnclusion criteria: stable occlusion, favorable fracture, andnticipated satisfactory postoperative compliance with in-tructions. The knowledge of occlusion is what sets ourpecialty apart from others that treat mandibular trauma. Ifhe occlusion cannot be re-established through the methodsutlined in the article by Hsu et al,1 it is important that there

be no hesitation to use arch bars or another method ofintermaxillary fixation.

Obviously, there are a limited number of patients who fit

FIGURE 1. Pre- and post-reduction clinic

the inclusion criteria of this study; those who do, however,

may greatly benefit from this approach to treatment. It ishighly recommended that the technique described in thearticle by Hsu et al1 be used where indicated, and we lookorward to its continued use in the care of our patients.

BENJAMIN F. BUSH, DDSRAWLE F. PHILBERT, DDSMALCOLM B. ZOLA, DDS

New York, NY

Reference1. Hsu E, Crombie A, To P, et al: Manual reduction of mandibular

fractures before internal fixation leads to shorter operative durationand equivalent outcomes when compared with reduction withintermaxillary fixation. J Oral Maxillofac Surg 70:1622, 2012

radiologic views and occlusion attained.

http://dx.doi.org/10.1016/j.joms.2012.07.046