Letters to the Editor

CLEFT LIP AND PALATE SURGERY IN INDIA

MIDDLE

THIRD

Sir,
May I, through your correspondence
column, bring to the
attention of higher trainees the exceptional training which
can be obtained
in Mangalore,
India in cleft lip and
palate surgery.
I have just returned, having spent 2 weeks at a workshop
there. In a total of 8 days operating we performed
42
operations,
most of which were primary cleft repairs, I
myself completing
15 primary lip repairs and 3 primary
palate repairs. There are still over 140 cleft cases requiring
primary surgery on the waiting list and the only limitation
on the number of cases that can be treated, is the time
taken to complete the surgery.
Unlike other units in which it may be only possible to
observe, or the report of a previous course in India in
which there was said to be little teaching, this unit provides
hands-on training which is closely supervised and instructed
by a very experienced maxillofacial
cleft surgeon, the surgery being performed to a very high standard using principles
developed
by
Delaire.2-4
A
fundamental
understanding
of these concepts is essential though, before
visiting this unit if the trainee is to obtain the most from a
visit. Further workshops can be arranged on an individual
basis for interested trainees (or consultants) who wish to
increase their experience. It would also be possible to
arrange workshops in the management of oral.malignancy
or aesthetic facial surgery, tailored to the training requirements of individual
surgeons.
If any trainees who are interested in travelling
to
Mangalore will contact me, I can initiate the arrangements
for them.

Sir,
As part of audit all the records and radigraphs of a 5-yearold child who was hit in face by a playground
swing, and
who subsequently
died of neurosurgical
injuries were
reviewed. The CT scan revealed a complex, cornminuted
maxillary fracture, which had been suspected clinically, but
due to the severity of the neurosurgical
injury had not been
referred for specialist opinion.
Further scrutiny of the cases transferred for neurosurgical
care revealed a 9-year-old child with a complex middle third
injury sustained as the result of a road traffic accident 4
months prior to this case.
This finding of two cases of complex middle third injuries
occurring in children in a hospital which has few cases of
trauma in 4 months is surprising.
This is because the
reported incidence of these injuries in the UK is very low,
and this confirms earlier studies in the USA2 and Australia.3
However, it is well recognised that when these complex
middle third injuries are present in children, it is often in
association with cranial, and more rarely, visceral injuries.
This unexpected cluster of cases suggests that the true
incidence of these injuries may be higher than the current
published studies suggests, but because of the severity of
the associated injuries they are not seen by maxillofacial
surgeons.
P. J. Anderson
Fellow in Craniofacial

INJURIES

Surgery

W.J. Harkness F.R.C.S.

Consultant Neurosurgeon
Hospital for Sick Children
Ormond Street
London

Andrew Fordyce
Senior Registrar
Oral and Maxillofacial
Unit
Middlesbrough
General Hospital
Ayresome Green Lane
Middlesbrough
Cleveland
TS5 5AZ

References
1. Anderson PJ. Fractures of the facial skeleton in Children.
Injury 1995; 26: 47-50.
2. Kaban LB, Mulliken JB, Murray JB. Facial fractures in
Children. Plas Reconstructr Surg 1977; 59: 15-21.
3. Hall RK. Injuries to the face and Jaws in Children. Int J Oral
Surg 1972; 1: 65-82.

References
1. Smith WP. Clinical attachment to the Dharwad Cleft Unit,
SCM College of Dental Sciences and Hospital, Dhanvad, India
November-December 1993. Supplement to Ann R Co11 Surg
Engll994; 76: 296-297.
2. Markus AF, Smith WP, Delaire J. Primary closure of cleft
palate: a functional approach. Br J Oral Maxillofac Surg 1993;
31: 71-77.
3. Markus AF, Delaire J. Functional primary closure of cleft lip.
Br J Oral Maxillofac Surg; 1993; 31: 281-291.
4. Smith WP, Markus AF, Delaire J. Primary closure of the cleft
alveolus: a functional approach. Br J Oral Maxillofac Surg;
1995; 33: 156-165.

THIRD

MOLAR

SURGERY

Sir,
In response to the letter in your journal of August 1995 by
J V Townend concerning our paper on third molar surgery
from earlier in the year, I would like to thank Mr Townend
for his obvious careful appraisal of the paper. However, I
feel he has failed to appreciate the key points of the
publication.
The thrust of this paper was to highlight the fact that
5 1% of patients who actually underwent third molar surgery
had no clinical indication
for this. The authors consider
this to be the most important take home message from this
paper, whereas the data relating to nerve injury probably
only reflects a minor contribution
to the already vast literature on this subject.
395

396

British

Journal

of Oral

and Maxillofacial

Surgery

To address some of his points further, Mr Townend

requests that the precise stage at which data were recorded
should be stated. I feel that our phrase within 10 days of
surgery is probably more appropriate than his suggested
at the first postoperative visit.
Our statements about the total incidence of nerve injury
were placed under the major heading of patient complaints.
Therefore once again the authors feel it appropriate to have
ignored the four patients who in fact were unaware of their
sensory deficit.
I cannot emphasise too strongly that the main thrust of
this paper was directed towards issuesof quality. Therefore
precise breakdowns as to whether more than one nerve was
affected or not, and use of the rather macho expression of
hit rate per wisdom tooth, were entirely inappropriate for
this publication.
I think Mr Townend has made a purposeful attempt to
confuse the reader by suggesting minor changes in the use
of the English language repeatedly in his letter, thus actually
clouding the issue of the need to thoroughly and accurately
appraise the need for third molar surgery, particularly as
regard the indications for removal. The authors felt that
little further comment was required on the various incidences of nerve damage above and beyond those made in
the paper as the rate appeared to be roughly the same as
those seen in the general literature on these subjects. In fact
what was of greater importance was the fact that patients
were sustaining any nerve damage at all: an issue of quality
as far as the patient is concerned.
Finally, the authors of our paper do whole heartedly
support Mr Townends requests to improve the literature
surrounding nerve injuries related to third molar surgery.
However, surely preventing the damage by not operating
on inappropriate cases is better than making elaborate
records of the results of our surgical morbidity.

A MODIFIED
ARTICULATOR
INCISAL PIN
FOR ORTHOGNATHIC
SURGERY WORK-UP
Sir,
The usual way to measure the antero-posterior movements
of the maxillary cast, during model surgery work-up, is to
measure the distance from the maxillary central incisors to
the articulator incisal pinm5 The measurements are taken
by simply looking across the pin and reading the ruler
calibrations. However the Denar articulator incisal pin is a
6 mm round rod that does not provide an ideal surface
reference point. Variations in the angle one looks from, can
give up to 2 mm variation in the readings. To overcome
this inaccuracy following simple modification of the Denar
articulator incisal pin is suggested.
10 mm short of both ends, the posterior surface of the
pin is cut flat to a 1.5 mm depth (Fig. 1). This provides a
definitive edge to measure against, and a slit 0.55 mm wide
is also cut, which allows the metal ruler to pass through
the pin (Fig. 2). This slit provides a frictional fit to the
metal ruler. The distance to the maxillary teeth from the
pin is measured in a direct line before and after the model
surgery and the difference readily calculated, providing an
accurate antero-posterior movement of the maxillary cast.
Besides measuring the antero-posterior maxillary and

v. Lopes

Moseley
Birmingham
West Midlands
INCISIONAL

BIOPSY: REDUCING

ARTEFACT

Sir,
I read with interest the recent article by Moule, Parsons
and Irvine (Br J Oral Maxillofac Surg 1995; 33: 245-247)
advocating the use of punch biopsy in the removal of oral
tissue for diagnostic purposes. Whilst admiting that such
biopsies obtained specimens of smaller width than conventional incisional biopsies, they concluded that the former
produced fewer artefacts.
Many of the artefacts obtained in the incisional biopsy
group may reflect the standard technique adopted for
harvesting the samples, namely grasping the specimen with
toothed tissue forceps. An alternative which permits less
tissue handling is to pass a suture through the centre of the
lesion to be removed. This can then be used to provide
traction and allows delivery of the specimen without
resorting to tissue handling forceps. By adopting such a
technique a biopsy of any size may be taken with a minimum of artefactual disturbance. Both cost and additional
training of junior staff are thus avoided.

Fig. 1 - The posterior

surface of the incisal pin is flattened to a
depth of 1.5 mm that provides
a definite surface to measure
against. The ruler is passed through
the centre of the pin.

C.J. Kerawala

Higher Surgical Trainee

Middlesbrough General Hospital
Ayresome Green Lane
Middlesbrough
Cleveland

Fig. 2 - A slit of 0.55 mm is machined

through
the pin. It provides
a frictional
fit to the metal ruler for precise antero-posterior
measurements.
The anterior
view of the pin showing the ruler
passing through
the modified pin.