James R. Hupp

Use of porous hydroxylapatite blocks for augmentation of atrophic mandibles

A clinical study of the use of porous blocks of hydroxylapatite (Interpore 200) for augmentation of atrophic residual mandibular ridges was performed. Fifteen patients each had three preoperatively customized blocks placed. They were then examined clinically and radiographically for at least 2 years. Six patients had skin-graft vestibuloplasties performed over the blocks 3 months after implantation; dentures were made for 11 of the patients. No clinical or radiographic evidence of migration or resorption of the blocks was found; however, all 15 patients suffered complications. Eleven developed ulcerations over the blocks with persistent exposure, six had suture line dehiscence leading to exposure, two infections occurred, and two patients developed chronic pain in the area of block insertion. The skin graft took only partially in all patients undergoing subsequent vestibuloplasties. To date, 37 of the original 45 blocks have required complete removal. Histologic examination of removed blocks has revealed partial filling of the pores with lamellar bone. The use of blocks of porous hydroxylapatite to reconstruct atrophic residual mandibular ridges was found to have an unacceptably high rate of failure and the ability to sustain an overlying split-thickness skin graft was unpredictable.

A review of Burkitt's lymphoma. Importance of radiographic diagnosis.

Burkitts lymphoma is a malignant proliferation of undifferentiated B lymphocytes that most often affects children. In endemic areas of Africa, the jaws are the sites most frequently involved. In non-endemic areas of North America, the jaws are involved in only 15-18 per cent of the cases. The oral and maxillofacial surgeon can play an important role in the early diagnosis of Burkitts lymphoma by recognizing the clinical signs of multiple loose teeth and jaw tenderness coupled with the radiographic signs of generalized destruction of tooth crypts and diffuse disruption of jaw trabeculation. Successful treatment results from a combination of early diagnosis and controlled chemotherapy.

The melanotic neuroectodermal tumor of infancy: Report of two cases and review of the literature

Abstract The melanotic neuroectodermal tumor of infancy (MNTI) is a rare childhood neoplasm with an alarming but classical clinical presentation. It appears as a rapidly enlarging mass in the jaws or skull of infants and unless MNTI is considered in the differential diagnosis, the lesion can easily be mistaken for a malignant neoplasm. Although possessing an aggressive growth rate and radiographic appearance, the MNTI almost always behaves in a benign fashion and can be treated with local excision. However, recent reports of malignant behavior as well as of occasional recurrences make close follow-up important. Approximately 139 cases of the MNTI have been reviewed and tabulated with respect to age at discovery, sex, tumor location, length of follow-up, and whether recurrence occurred. 2 additional cases, 1 of which was in the mandible, are presented along with theories of origin and recommended therapy.

Changing methods of preventing infective endocarditis following dental procedures: 1943 to 1993.

The report by Northrop and Crowley in the inaugural issue of the Journal of Oral Surgery heralded the appearance of studies designed to confirm both the relationship between dental procedure-induced bacteremia and infective endocarditis and the best methods to interrupt this chain of causation. Their discovery that antibiotics can modulate bacteremias produced by dental procedures eventually led to the universal adoption of the prophylactic regimens to prevent cases of infective endocarditis following dental procedures. Advances since their work have involved a greater understanding of the role of adherence in the mechanism of action of prophylactic antibiotics, an appreciation of the ability to limit antibiotic administration to only the immediate preoperative period, the need to keep prophylactic regimens as uncomplicated as is safe, and greater knowledge about the interaction between dental procedures and bacteremias. Whether the widespread use of prophylactic antibiotics during dental procedures significantly decreases the incidence of endocarditis remains open to future investigation.

Superselective angiography with digital subtraction and embolization of a maxillary hemangioma in a patient with Eisenmenger's syndrome

Central maxillofacial hemangiomas can represent diagnostic and therapeutic problems. The concurrent existence of Eisenmengers complex in the presented case added an anesthetic challenge. The development of superselective arterial catheterization and digital subtraction angiography has been instrumental in improving the ability of clinicians to diagnose and effectively manage vascular lesions, especially in the maxillofacial region. Embolization remains an excellent adjunctive therapy for vascular processes.

Marketing—Preparing the Soil for Success

f d p i f h s p n i January represents different things to different people. For many, it is a time for new beginnings, full of New Year’s resolutions to try new things or to stop doing unwanted things. Those in cooler climates who are employed to tend swimming pools during summer may find January a prosperous time to clear snow. Individuals in northern hemispheric subtropical climates enjoy January as a time to enjoy outdoor activities during less hot and humid days. I am an avid gardener. To some, this might suggest that January has little to offer someone with that avocation. However, the dedicated gardener will use the winter months to set the stage for his/her garden. It is a time of planning and laying the groundwork for the coming growing season. At the San Diego American Academy of Oral and Maxillofacial Surgeons meeting, the House of Delegates voted to move forward with a new marketing initiative. To me, this represents the association’s wish to start a new time of planning and laying the groundwork for a new season of better educated consumers seeking our care. This is our chance to reinforce to the public and our health care profession colleagues our knowledge and skills in complex exodontia and advanced forms of ambulatory anesthesia; hopefully, this will be expanded in the future to educate them to the many other capabilities of the members of our specialty. Gardeners know that the success of their garden hinges on proper preseason preparation. Garden preparation is an art and a science. Different plants require different soil types and nutrients, amounts of sunlight and water, and spacing between plants. As opposed to farmers who grow large plots of the same plant, gardeners usually have different plants growing in a relatively small area. Therefore, the gardeners’ artistic side is called on to blend the growth elements of their planned plantings to optimize growth across their garden. Marketing requires a similar balance of art and science. The science aspects typically use focus groups of potential consumers who are asked to react to various marketing messages. The art comes into play when creating possible messages for focus groups. Art and science combine when determining the composition of focus groups and interpreting the results. Overall, our specialty markets itself well. In general, we are portrayed as caring professionals providing high-quality care. We are known as the discipline on w

Surgical Training: Is Dabbling Enough?

The education and training of a future surgeon is a complex process. The educational component involves the delivery of a (hopefully) well-designed curriculum to impart knowledge. The training aspect builds upon the educational foundation and provides the clinical skills, manual and otherwise. Training also should give the trainee experience in making sound judgments, such as when to and when not to operate, and what procedure to perform. Ideally, the educational training of a surgeon covers all aspects of clinical scope that the surgeon will be privileged to perform, recognizing that in most cases the trainee does not know where their career may take them. Therefore, for an oral and maxillofacial surgery (OMS) resident, his or her education and training are expected to cover most aspects of our traditional scope of practice (the definition of that awaits another editorial). The decision of what areas of surgery are minimally required for the fully prepared graduating oral and maxillofacial surgeon is not left to individual programs. Instead, they are dictated by 2 organizations. The first is the Commission on Dental Accreditation (CDA) of the American Dental Association. The second is the American Board of Oral and Maxillofacial Surgeons (ABOMS). Now, some will dispute whether the ABOMS does or should set the scope of training for OMS or simply test what others determine is required to be fully prepared (that too must be put off to a future editorial). Nevertheless, although the AAOMS has a major voice in what occurs in OMS residency programs, it is the CDA and, to a lesser degree, the ABOMS who dictate the basic education and training of oral-maxillofacial surgeons. More about this a bit later. There are a couple of fundamental facts that I believe guide the practice of most members of our specialty, and other surgical disciplines as well. The first is that the more comfortable you are doing a procedure, the more likely you are to keep doing it. Therefore, if you did very few or no cases of a certain type, say a sagittal split osteotomy, in your residency program the odds are high that it will not be a part of your personal practice. Obviously, there are exceptions to this, but in general, it is true. The second fundamental truth with surgery is that the more you do a certain procedure the better (more skilled, faster, better judgment) you get. (See my editorial “Mastery Through Repetition.”) Furthermore, the better you

Cone-Beam Computed Tomography Incidental Findings—A Cause for Worry?

A recent article in the Journal of the American Dental Association (JADA) caught my eye. It was out of the University of Alberta and reported the results of a systematic search of electronic databases. The study examined all published reports of ‘‘incidental findings’’ (IFs) on cone-beam computed tomography (CBCT) scans. As defined in the JADA article, an IF is ‘‘any abnormal or pathologic finding that is unrelated to the original purpose of the imaging test or tests being performed; it may be a variant that is normal or benign or is of pathological concern.’’ CBCT scanning is growing in popularity among dentists. Such imaging allows the clinician to easily visualize hard tissue anatomy 3-dimensionally. This permits the practitioner to determine where bone exists, note the precise location of structures one seeks to avoid, detect abnormalities, and document preprocedure anatomy. Some dentists have found CBCT scanning so useful that they purchased CBCT equipment for their office. This is particularly true for oralmaxillofacial surgeons. The findings of the recent JADA article are therefore relevant to our specialty. Like most members of our discipline, I have reviewed intraoral films and panoramic images since dental school. Similarly, during residency I regularly reviewed various plain film images of patients needing orthognathic, trauma, pathologic, and reconstructive surgery. In all instances, we were taught that it was our responsibility to view ‘‘all 4 corners’’ of every image, and this became ingrained in each of us. As residents, we also viewed other types of images of our hospitalized patients, including chest radiographs and CT scans. Although I think most of us believed we had a duty to look over all these images, I am not sure I felt compelled to look at each and every image of a CT scan for abnormalities. This was not expected of me andmade sense. Itwas because all the images in the hospital setting were, or would soon be, read by a radiologist. This, in a sense, relieved me of carefully scrutinizing every patient image, allowing me to focus on those areas related to the purpose of ordering the test. Office-based CBCT scanning typically differs from hospital-based imaging. The difference is that in most cases no mandate exists that the image be read by a radiologist. Certainly, anyone obtaining a CBCT scan in their office can ask a radiologist to do a reading.

Oral-Maxillofacial Surgery Residency Training—Practice Pattern Mismatch?

I received a letter from one of my attending surgeons who taught me in my residency program. His note had a melancholy tone, recalling his own career in which he had seen the blossoming of our specialty from being primarily exodontia and office-anesthesia based to the broad scope we enjoy today. He recollected about how steps such as lengthening our training requirements, offering education leading toward themedical degree, and expanding general surgery rotations helped many surgeons become involved in major hospital-based procedures, while still providing officebased care. Hewent on to share his disquietwith a trend hehas beenwitnessing; namely, newlyminted, expertly and broadly trained, oral-maxillofacial surgery (OMS) program graduates choosing to focus their careers almost entirely on office-based dentoalveolar surgery (including implant procedures).* He mused that this was related to the very comfortable lifestyle that commonly accompanies such a career path. However, it saddened him to see so many take this path. My former attending and now colleague is not alone in his observations and dismay. I regularly hear from other members of our specialty regarding their anxiety about this trend among younger surgeons. I wonder if any truth exists in these observations such as was put forth in a previous editorial about oral-maxillofacial surgeons ‘‘retreating to their cottages.’’ This movement in practice patterns comes at the same time as other significant changes in the healthcare landscape. Public and private healthcare insurers have been demanding ever-increasing accountability, efficiency, and value in the provision of healthcare services. The increasing practice of healthcare organizations such asmajormedical centers andevenmidsize community hospitals to employ health professionals, including surgeons, on a fulltime basis threatens to curtail or end the need for all members of our specialty to be available to perform facial trauma care or manage major jaw and facial pathologic entities and reconstructive procedures. The hospital will have a strong incentive to steer those cases to their in-house–employed surgeons. (However, this is a topic for another editorial.) The letter frommyattending reached the conclusion that continuing to train all oral-maxillofacial surgeons to be capable of providing both state of the art dentoal-

The empty sella syndrome

Oral and maxillofacial surgeons, in the course of patient evaluation, may incidentally discover abnormalities of the sella turcica. A large percentage of patients with sella deformities will be found to have the empty sella syndrome. The clinical and radiographic manifestations of this disorder, and the significance of this diagnosis, are discussed.