OMFS case discussions

[cgscribe]

Hello all,

I'm a regular in the pre-med/med. forums, but I have a dental question for you all that I was hoping you could help me with: I'm scheduled to have orthognathic surgery this summer. First of all (please don't be offended, this is just my ignorance in the dental field), I had no clue that DDS could do residencies and then perform facial surgeries. But, the doctor handling my case is indeed a DDS. Anyways, my issue is a "Class III Malocclusion." Seeing as I'm not even an M1 yet, this means very little to me. I was just curious what standard protocol is on these procedures. I have orthdontics in place now, but how long is the surgery? Am I intubated for it? Is my jaw wired shut afterwards? For how long usually? How long are orthodontics kept on afterwards usually? My teeth are straight, it's just my jaw that is crooked. Any help you guys would provide would be very much appreciated, I yield to your wisdom. Feel free to PM me for anymore details. Thanks.

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[toofache32]

Hello all,

I'm a regular in the pre-med/med. forums, but I have a dental question for you all that I was hoping you could help me with: I'm scheduled to have orthognathic surgery this summer. First of all (please don't be offended, this is just my ignorance in the dental field), I had no clue that DDS could do residencies and then perform facial surgeries. But, the doctor handling my case is indeed a DDS. Anyways, my issue is a "Class III Malocclusion." Seeing as I'm not even an M1 yet, this means very little to me. I was just curious what standard protocol is on these procedures. I have orthdontics in place now, but how long is the surgery? Am I intubated for it? Is my jaw wired shut afterwards? For how long usually? How long are orthodontics kept on afterwards usually? My teeth are straight, it's just my jaw that is crooked. Any help you guys would provide would be very much appreciated, I yield to your wisdom. Feel free to PM me for anymore details. Thanks.

This question should probably have it's own thread, but I'll give it a shot. These are all questions that your surgeon will answer for you. The surgery can be from 2 to maybe 6-7 hours depending on if they operate only one jaw or both, and if they have to cut the upper jaw into pieces, and if they're doing your chin, if they're doing your nose, and other factors. You will most likely be intubated (usually through the nose). The braces are usually kept on for several more months, depending on the surgical results. Sometimes you have to wire the jaws shut, sometimes you don't.....that's a question for your surgeon.

As far as a DDS performing facial surgery, Oral & Maxillofacial Surgery is a dental specialty and a dental degree is required. There really isn't anyone else who spends as much time and training on the face, except ENT is about the same. You can get more info at www.aaoms.org

 

[Doggie]

Hello all,
Anyways, my issue is a "Class III Malocclusion." Seeing as I'm not even an M1 yet, this means very little to me.

Not trying to be a troll or anything..............BUT even if you were a long time practicing physician, you would probably never come across the term "Class III Malocclusion" either.

 

[EuroOMFS]

There is no question this fracture requires treatment. I would treat w/i a week to allow edema to subside since there is no evidence of entrapment. I would approach the frature with a subtarsal incision, place a titanium mesh implant, fixate it with a couple of 1.0 screws on the intraorbital aspect of the rim, and do a forced duction. I would get a post op CT to ensure I've managed to place my implant over the posterior ledge given that it's not an uncommon pitfall to miss it in such a posterior fracture. There is no point to wait and see because this will progress to enophthalmos.

I agree, athough I'd probably use a transconj. approach. Titanium would also be my material of choice. One of our attendings argued that because of the persistent diplopia, he'd want to do surgery within 24 hrs. I'm somewhat inclined to agree with him. That same attending would use calvarium instead of titanium. The patient was form another country and went home to have surgery there, so I have no post-op CTs.

 

[IcedOMFS]

Hello all,

I'm a regular in the pre-med/med. forums, but I have a dental question for you all that I was hoping you could help me with: I'm scheduled to have orthognathic surgery this summer. First of all (please don't be offended, this is just my ignorance in the dental field), I had no clue that DDS could do residencies and then perform facial surgeries. But, the doctor handling my case is indeed a DDS. Anyways, my issue is a "Class III Malocclusion." Seeing as I'm not even an M1 yet, this means very little to me. I was just curious what standard protocol is on these procedures. I have orthdontics in place now, but how long is the surgery? Am I intubated for it? Is my jaw wired shut afterwards? For how long usually? How long are orthodontics kept on afterwards usually? My teeth are straight, it's just my jaw that is crooked. Any help you guys would provide would be very much appreciated, I yield to your wisdom. Feel free to PM me for anymore details. Thanks.

This question probably does not belong on the SDN boards...

However, it does form the basis of an interesting point for a case discussion...

How many people would do a mandibular setback for a, "Class 3 malocclusion"?

'Round here, we rarely set mandibles back, unless there is a very large A-P discrepancy and one could not solve it with a maxillary advancement alone...

 

[IcedOMFS]

I agree, athough I'd probably use a transconj. approach. Titanium would also be my material of choice. One of our attendings argued that because of the persistent diplopia, he'd want to do surgery within 24 hrs. I'm somewhat inclined to agree with him. That same attending would use calvarium instead of titanium. The patient was form another country and went home to have surgery there, so I have no post-op CTs.

I disagree with th 24 hour thingy - The persistent diplopia is probably because his globes are at completely different levels, and maybe some edema within the rectus muscle... Doesn't look like true muscle entrapment to me on the CT... I'd wait another 4 -5 days (it's been 3 already) and go in once the edema had subsided.

That's a pretty big defect - I agree with the subtarsal approach, particularly as the guy is old - He probably has pretty large eyelid creases to hide incisions in...

I'd probably go with a resorbable plate fixated to the rim with resorbable screws, just 'cause they're sexy... Calvarium would probably be my second choice, though for an isolated orbital floor fracture on an 83 year old man, it might be a bit much... Plus it turns a 30 minute case into a 2 hour case, diddling around with closing coronal flaps, shaping grafts, etc...

 

[IcedOMFS]

The surgery can be from 2 to maybe 6-7 hours depending on if they operate only one jaw or both, and if they have to cut the upper jaw into pieces, and if they're doing your chin, if they're doing your nose, and other factors. www.aaoms.org

6-7 hours! Christ! What the hell are you guys doing?

 

[toofache32]

6-7 hours! Christ! What the hell are you guys doing?

That would be when they get The Works.....3-piece maxilla, BSSO, and chin. Some of our faculty also do rhinoplasty at the same time while others wait.

 

[IcedOMFS]

That would be when they get The Works.....3-piece maxilla, BSSO, and chin. Some of our faculty also do rhinoplasty at the same time while others wait.

6-7 hours for a 3-piece maxilla, BSSO, and genio? I say again... Christ! What the hell are you guys doing?

 

[esclavo]

I would treat the above patient within 17 days from initial injury. If the orbital floor fracture extends very posterior, you will need all the swelling gone in order to have retraction sufficient to get to the posterior edge. While I agree that the fracture needs treated 100%, you have plenty of time. I would expect that without treatment his diplopia, restricted ocular movements and enophthalmia would only get worse as the swelling decreases. I would treat him quicker if he was a working individual who needed excellent visual performance to do his job. I'd do a transconj and use mesh or a titanium mesh/implant (angel or space invader) and make sure that the forceduction test was liquid smooth! I'd only get a post op CT if I wasn't confident of my posterior ledge placement or if sigmntoms proceeded for an extended period of time after surgery. A bunch of those pictures in the ZMC orbital floor section of Petersons are mine including my very first retrobulbar hematomato when I was a dumb 'tern.... I love ZMC's, floors, and arches. Along with nasal fractures with septums, I'd have to say that they are my favorite trauma proceedures..... Outpatient surgeries about an hour to an hour and a half.... very fun!

 

[IcedOMFS]

I'd only get a post op CT if I wasn't confident of my posterior ledge placement or if sigmntoms proceeded for an extended period of time after surgery. A bunch of those pictures in the ZMC orbital floor section of Petersons are mine including my very first retrobulbar hematomato when I was a dumb 'tern.... I love ZMC's, floors, and arches. Along with nasal fractures with septums, I'd have to say that they are my favorite trauma proceedures..... Outpatient surgeries about an hour to an hour and a half.... very fun!

Do you close your transconj incisions, or leave them open? (assuming you haven't done a lateral canthotomy)

How about those who use subtarsal or subciliary approaches... What do you do to resuspend the soft tissue of the lower lid, and close?

 

[esclavo]

Do you close your transconj incisions, or leave them open? (assuming you haven't done a lateral canthotomy)

How about those who use subtarsal or subciliary approaches... What do you do to resuspend the soft tissue of the lower lid, and close?

I've done it both ways and I haven't noticed a huge difference if I close or don't close the conj (the first couple of closures I did broke anyways and at one week I'd look in and it looked pretty good inspite of the lack of closure). I almost always close the periosteum and if I want to watch the intern struggle or monitor their progress I'll have them bury 6.0 plain gut on the conj for giggles. It is a mucosal surface and heals very quickly like the mouth anyways. Since you only violate the posterior lamella, and I think it is the weakest of the support for the lower lid, I don't think you need to close it like a subcilliary or a mid tarsal... I think that the specific floor shown above would more than likely need a lateral canthotomy but I've surprised myself a few times and have done a fairly large floor without a canthotomy.... it can be a stretch for that poor access sometimes to squeeze the implant through....I think the most important closure for all external lower lids is the periostium and then the skin. I've gotten away from tacking the muscle.... just my experience

 

[esclavo]

Do you close your transconj incisions, or leave them open? (assuming you haven't done a lateral canthotomy)

How about those who use subtarsal or subciliary approaches... What do you do to resuspend the soft tissue of the lower lid, and close?

How do you close your canthotomies?

 

[IcedOMFS]

How do you close your canthotomies?

Do you always answer a question with a question?

 

[esclavo]

Do you always answer a question with a question?

I just forgot to put that question in the prior post after I gave you a verbose answer to your question.... soo.... I'm waiting....how do you close your canthotomies?

 

[EuroOMFS]

I think that the specific floor shown above would more than likely need a lateral canthotomy but I've surprised myself a few times and have done a fairly large floor without a canthotomy

A german colleague once told me, he never does a canthopexy, he just places his transconj. insicion far enough posterorly to allow for good exposure. I´ve seen him do this, and have myself tried it a couple of times with good results.

As for closure, I use Vicryl 6-0 og 7-0. Haven´t tried not to close.

 

[esclavo]

A german colleague once told me, he never does a canthopexy, he just places his transconj. insicion far enough posterorly to allow for good exposure. I´ve seen him do this, and have myself tried it a couple of times with good results.

As for closure, I use Vicryl 6-0 og 7-0. Haven´t tried not to close.

Canthopexy? The transconj approach isn't the constricting entity, it is the orbital aperature of the lids. I don't know how to stretch the orbital aperature to get in a big implant or access a ZMC fracture that has a comminuted rim without doing a lateral canthotomy with the transconj. That orbital aperature is pretty tight with the tarsal plates and tendons that just don't stretch like vestibules or soft tissue incisions only......I've only done canthopexies for enophthalmous or senile lower lids....

 

[IcedOMFS]

Canthopexy? The transconj approach isn't the constricting entity, it is the orbital aperature of the lids. I don't know how to stretch the orbital aperature to get in a big implant or access a ZMC fracture that has a comminuted rim without doing a lateral canthotomy with the transconj. That orbital aperature is pretty tight with the tarsal plates and tendons that just don't stretch like vestibules or soft tissue incisions only......I've only done canthopexies for enophthalmous or senile lower lids....

I agree about the stretch to the lids being a limiting factor when dealing with really big floor implants...

As for closure, I usually call the Periodontists... They do it pretty much ala Ellis and Zide, with a 5-0 vicryl to put the tarsal plate back to the remnant of the lateral canthal web, and try to tack it to the periosteum posterosuperiorly...

Then a 6-0 plain ophthalmologic gut in a continuous suture through the conjunctiva - Rather than burying the knot, it gets tied outside on the skin.

If it's just a transconj, the Periodontists tell me they have started to leave them without sutures...

(Kidding on the Periodontist thing...)

 

[EuroOMFS]

The transconj approach isn't the constricting entity, it is the orbital aperature of the lids.

I'm well aware of this. Take a look at:

Schön R, Metzger MC, Zizelmann C, Weyer N, Schmelzeisen R. Individually preformed titanum mesh implants for a true-to-original repair of orbital fractures. Int J Oral Maxillofac Surg, 2006; 35: 990-995.

19 patients with large orbital floor defects, >15mm (0,6 inches), all exposed with a tranconj without a lateral canthotomy (obviousily not a canthopexy ). The CT scans show they're not repairing with small implants.

It's possible.

 

[buck-E]

Just wondering if any of you out there have used an intra-op CT to check your plate placement in orbits. Of course it requires a special table, so you have to plan ahead a little. Often your hospital has them as ortho often uses them for complex pelvis repairs. We just realized that there has been one at our hospital for 3-4 years! Pretty handy to know where things are before you close when you are way back there at the apex.

 

[esclavo]

I'm well aware of this. Take a look at:

Schön R, Metzger MC, Zizelmann C, Weyer N, Schmelzeisen R. Individually preformed titanum mesh implants for a true-to-original repair of orbital fractures. Int J Oral Maxillofac Surg, 2006; 35: 990-995.

19 patients with large orbital floor defects, >15mm (0,6 inches), all exposed with a tranconj without a lateral canthotomy (obviousily not a canthopexy ). The CT scans show they're not repairing with small implants.

It's possible.

Thanks for the article, I'll look at it. In which dimension is the >15mm, A-P or Medio-lateral? It is usually the medio-lateral that is the tough squeeze. Ice's closure sounds interesting. My attendings are so dogmatic about closure of the lateral canthotomy that I haven't got to experiement much with the tarsus. I am using 6.0 PDS on the tarsal plate, 6.0 plain on the conj (suturing until it comes out the skin sounds ingenious-I am going to give it a try) and 6.0 prolene on the skin. Has anyone seen post ops with the lateral canthus a little too tight or lose? I tend to over constrict sometimes and they look a little pinched for a month, but then it seems to settle in...I don't try to attach the the canthal repair to the superior/lateral periosteum. I haven't had any downward slanting of the lateral canthus.....Our hospital doesn't have an OR CT must be nice

 

[esclavo]

I did a partially transected ear this weekend and decided to play with the leeches. My question for those out there is are you using antibiotics (prophylaxis) for leech therapy. There is somewhat of a debate in the leech community about this and I was wondering what others were doing. It was a fun little case....

 

[3rdmolarslayer]

pictures?

 

[buck-E]

I've always used cipro for prophylaxis. This guy was fleeing from police and rolled his car into a ditch. Of course he was unrestrained and ended up under the car. Once all the mud was removed we discovered what was left. As you can see in the first picture there was some bleeding at the distal aspect so we decided to suture it back and use leeches. First picture was immediately post op and second was 24 hours later. Suprisingly most of it survived- only a small area of the inner bowl necrosed.

 

[buck-E]

Speaking of animal therapy, has anyone used maggots to clean a wound? We had a very large nec fasc case a couple of weeks ago. Once we had debrided everything we had looked into using maggots to further clean the wound (nasty fibrin layer that forms). We were unsuccessful in finding a company in the US that supplies some sort of "maggots in a bag"(ie fine mesh bag that they can feed through). We didn't want to use "free-range maggots" due to trach, and deep extension into infratemporal region. Ended up using Accuzyme because we couldn't get the maggots- very disappointing. Just wondering if anyone has used them before in the head and neck and how you kept track of them....

 

[OMFSCardsFan]

Speaking of animal therapy, has anyone used maggots to clean a wound? We had a very large nec fasc case a couple of weeks ago. Once we had debrided everything we had looked into using maggots to further clean the wound (nasty fibrin layer that forms). We were unsuccessful in finding a company in the US that supplies some sort of "maggots in a bag"(ie fine mesh bag that they can feed through). We didn't want to use "free-range maggots" due to trach, and deep extension into infratemporal region. Ended up using Accuzyme because we couldn't get the maggots- very disappointing. Just wondering if anyone has used them before in the head and neck and how you kept track of them....

That looks amazingly similar to a case we did last year...I repacked that wound with Kerlix every other day for two months...ugghhh...

 

[esclavo]

pictures?

He is coming in this friday. I'll try to get some 5/6 day post op/leech pics.

 

[rrc]

That last one sort of reminds me of this:

http://www.astor-theatre.com/images/in-line/posters/postersS/slither-ver2.jpg

 

[esclavo]

I've always used cipro for prophylaxis. This guy was fleeing from police and rolled his car into a ditch. Of course he was unrestrained and ended up under the car. Once all the mud was removed we discovered what was left. As you can see in the first picture there was some bleeding at the distal aspect so we decided to suture it back and use leeches. First picture was immediately post op and second was 24 hours later. Suprisingly most of it survived- only a small area of the inner bowl necrosed.

Great pictures. Your transection (almost complete amputation) was a little more complete than mine. My ear had that anterior/superior skin holding it on. The cartilagenous bowl was in about 10 pieces and the antire posterior attachment was gone. I had a ton of debris (twigs, dirt, corn) in the wound. The other complicating factor is that I got him 8 hours after the accident. As I cleaned him in the OR, I just couldn't get alot of the edges to bleed. I wondered if I would have gotten him fresh if I'd even needed leeches because I could have reattached and he wouldn't have lost some precious time....

 

[IcedOMFS]

I did a partially transected ear this weekend and decided to play with the leeches. My question for those out there is are you using antibiotics (prophylaxis) for leech therapy. There is somewhat of a debate in the leech community about this and I was wondering what others were doing. It was a fun little case....

Funny you should ask this... There was a question on the OMSSAT this year about the bateria you needed to cover when using leeches...

 

[toofache32]

Funny you should ask this... There was a question on the OMSSAT this year about the bateria you needed to cover when using leeches...

The night before the OMSSAT, I was up all night replanting an ear and ordering leeches. I got that question right because I read a little about it while I was waiting on the leeches. Probably the only question I got right....

 

[MAXFAC]

Leeches are worms that feed on blood from a mammalian host. While the first uses of leeches for medicinal purposes date back 3500 years, their modern use in flap surgery dates from 1960 while their use in digital replantation dates from 1981. Incidentally, the term leech derives from the Old English word for physician.

The species most commonly used is Hirudo medicinalis. Leeches are indicated for venous congestion which threatens a flap or digit. Survival for threatened pedicle flaps or replanted digits with leech application are currently 60-70%. Leeches have a front sucker which makes a 2-mm incision and can extract about 5-15 cc of blood over 30 minutes. Their primary benefit results from the injection of an anticoagulant, hirudin, present in leech saliva which can last for several hours after detachment permitting up to 50 cc of venous oozing. Hirudin inhibits thrombin, blocking the conversion of fibrinogen to fibrin and platelet aggregation response to thrombin. Poor leech sucking is considered a bad prognostic sign for flap survival and may indicate the presence of arterial insufficiency.

The leech is applied to a clean area of the flap with the head (narrow end) directed toward the area needing treatment. The skin may need to be pricked to produce a drop of blood in order to induce feeding. The leech will usually detach after 30 minutes. If an area stops oozing after leech detachment, it can be wiped with a heparin-soaked gauze to promote rebleeding. Leeches cannot be reused. After use they are placed in alcohol and disposed of with the biohazardous waste. They are applied about every 4 hours but the frequency should be tailored to the circumstances. In situations where no oozing is seen after leech detachment, they can be applied every 30 minutes.

Infection and low blood volume are the main complications of leech use. Within the leech gut is a gram-negative rod, Aeromonas hydrophilia, which can cause infections within 10 days after leech use. Infection rates of 0-20% have been reported. Empiric antibiotic therapy using an aminoglycoside or third-generation cephalosporin is advocated by some clinicians.

 

[goosestuff]

Leeches cannot be reused. After use they are placed in alcohol and disposed of with the biohazardous waste.

Animal Cruelty!
Suckas. Do they sizzle when they hit the alcohol?
Where is PETA when you need them?!

 

[PulpShredder]

There have been no reported studies but in my opinion, I'd doubt if HBO will do jack for BRORNJ. The problem is hyperdense bone with no osteoclastic function. I don't know how HBO would help reactivate osteoclasts. HBO supposedly helps macrophages in hypoxic environments to secret angiogenic factors. But according to the "experts" there is no "space" for angiogenesis to occur....once the osteoclasts return to function and create the necessary bone resorption areas (space) then maybe HBO would work, but the key according to the "experts" is return of osteoclast function.....

I just took a bone biology course and studied the effect of osteoblast induction of osteoclastic activity... have any of you heard anything about this in your programs or literature?

 

[armorshell]

Animal Cruelty!
Suckas. Do they sizzle when they hit the alcohol?
Where is PETA when you need them?!

PETA only cares about cute animals.

 

[Bifid Uvula]

There have been no reported studies but in my opinion, I'd doubt if HBO will do jack for BRORNJ. The problem is hyperdense bone with no osteoclastic function. I don't know how HBO would help reactivate osteoclasts. HBO supposedly helps macrophages in hypoxic environments to secret angiogenic factors. But according to the "experts" there is no "space" for angiogenesis to occur....once the osteoclasts return to function and create the necessary bone resorption areas (space) then maybe HBO would work, but the key according to the "experts" is return of osteoclast function.....

I just took a bone biology course and studied the effect of osteoblast induction of osteoclastic activity... have any of you heard anything about this in your programs or literature?

I'm ordering C-Telopeptide labs on most of my bisphosphonate patients with impeding extractions... Anybody else checking this?

 

[esclavo]

Leeches are worms that feed on blood from a mammalian host. While the first uses of leeches for medicinal purposes date back 3500 years, their modern use in flap surgery dates from 1960 while their use in digital replantation dates from 1981. Incidentally, the term leech derives from the Old English word for physician.

The species most commonly used is Hirudo medicinalis. Leeches are indicated for venous congestion which threatens a flap or digit. Survival for threatened pedicle flaps or replanted digits with leech application are currently 60-70%. Leeches have a front sucker which makes a 2-mm incision and can extract about 5-15 cc of blood over 30 minutes. Their primary benefit results from the injection of an anticoagulant, hirudin, present in leech saliva which can last for several hours after detachment permitting up to 50 cc of venous oozing. Hirudin inhibits thrombin, blocking the conversion of fibrinogen to fibrin and platelet aggregation response to thrombin. Poor leech sucking is considered a bad prognostic sign for flap survival and may indicate the presence of arterial insufficiency.

The leech is applied to a clean area of the flap with the head (narrow end) directed toward the area needing treatment. The skin may need to be pricked to produce a drop of blood in order to induce feeding. The leech will usually detach after 30 minutes. If an area stops oozing after leech detachment, it can be wiped with a heparin-soaked gauze to promote rebleeding. Leeches cannot be reused. After use they are placed in alcohol and disposed of with the biohazardous waste. They are applied about every 4 hours but the frequency should be tailored to the circumstances. In situations where no oozing is seen after leech detachment, they can be applied every 30 minutes.

Infection and low blood volume are the main complications of leech use. Within the leech gut is a gram-negative rod, Aeromonas hydrophilia, which can cause infections within 10 days after leech use. Infection rates of 0-20% have been reported. Empiric antibiotic therapy using an aminoglycoside or third-generation cephalosporin is advocated by some clinicians.

So I go back to my original question.... is anyone using empiric abs when using leaches? I guess the next question is, has anyone seen a legitimate infectioned which cultured a. hydrophilia from having used leaches? The only reports I've read of morbidity and mortality from a. hydrophilia have been enteric infections which I assume had nothing to due with leach therapy (but then again maybe someone just got hungry while they were out fishing and started eating the bait!)

 

[scalpel2008]

So I go back to my original question.... is anyone using empiric abs when using leaches? I guess the next question is, has anyone seen a legitimate infectioned which cultured a. hydrophilia from having used leaches? The only reports I've read of morbidity and mortality from a. hydrophilia have been enteric infections which I assume had nothing to due with leach therapy (but then again maybe someone just got hungry while they were out fishing and started eating the bait!)

if i'm using some nasty "medical grade" parasite that punctures a flap on my patient and uses its skanky saliva as an anticoagulant to decongest, you better believe that i'm going to give some prophylactic abx. This is a case that i'm willing to overlook evidence; afterall, i've got bugs sucking away at my surgical site.

 

[IcedOMFS]

if i'm using some nasty "medical grade" parasite that punctures a flap on my patient and uses its skanky saliva as an anticoagulant to decongest, you better believe that i'm going to give some prophylactic abx. This is a case that i'm willing to overlook evidence; afterall, i've got bugs sucking away at my surgical site.

Skanky saliva, prophylactics, and sucking away... Leave it to you to turn leeches into sexual innuendo...

 

[scalpel2008]

Skanky saliva, prophylactics, and sucking away... Leave it to you to turn leeches into sexual innuendo...

wanted to see if there were other pervs who could decipher my subliminal encrypted message.

 

[esclavo]

if i'm using some nasty "medical grade" parasite that punctures a flap on my patient and uses its skanky saliva as an anticoagulant to decongest, you better believe that i'm going to give some prophylactic abx. This is a case that i'm willing to overlook evidence; afterall, i've got bugs sucking away at my surgical site.

playing devil's advocate....(bare with me I'm not used to playing this role ) but leach saliva has proven antimicrobial properties in and of itself.... many have been using it for years without ever culturing an infection of a. hydrophilia.... are you giving all of your third molar patients post op antibiotics because of that skanky hall drill with its dripping lubricant into those deep bony sockets? Those leaches are just about as gnotobiotic (sp?) as a cute little creature can get....

 

[scalpel2008]

playing devil's advocate....(bare with me I'm not used to playing this role ) but leach saliva has proven antimicrobial properties in and of itself.... many have been using it for years without ever culturing an infection of a. hydrophilia.... are you giving all of your third molar patients post op antibiotics because of that skanky hall drill with its dripping lubricant into those deep bony sockets? Those leaches are just about as gnotobiotic (sp?) as a cute little creature can get....

I would like to respond before icedOMFS gets any more ideas after reading about "skanky saliva and dripping lubricant " in the same sentence. First off, no I don't give post op antibiotics to my post op third molar cases. I think there's sufficient evidence in the literature that shows it to be of no benefit. Secondly, I have to assume my hall handpiece is sterile i.e. free of pathogens (including the lubricant because the handpiece, bur, and the cord are sterlized). Also, I'm working in a clean contaminated environment with saliva.
This situation is entirely different than the leech issue. First off A hydrophila is a proven pathogen capable of causing infection. Also, there is no question it is present in leech saliva. The arguement one can make is whether the innoculum is of clinical significance. A quick lit search clearly shows that there have been several cases of wound infection that have been linked to leech therapy. If prophylactic antibiotics have been shown to be beneficial for making a skin incision with a sterile scalpel in a perfectly healthy individual in healthy tissue that has been prepped with betadine, does it not make sense to do so when exposing a congested flap (which can be viewed as a local area that is immunocomprimised given that cutting into such flaps obviously demonstrates that it lacks oxygenated blood) to a known pathogen? I know the lierature on the matter is scant, but like I said, although I'm all for evidence based practice, I will go with my gut and logic on this one. Now if there's sufficient literature that shows it to be of no benefit, i'm open to that.

 

[esclavo]

I would like to respond before icedOMFS gets any more ideas after reading about "skanky saliva and dripping lubricant " in the same sentence. First off, no I don't give post op antibiotics to my post op third molar cases. I think there's sufficient evidence in the literature that shows it to be of no benefit. Secondly, I have to assume my hall handpiece is sterile i.e. free of pathogens (including the lubricant because the handpiece, bur, and the cord are sterlized). Also, I'm working in a clean contaminated environment with saliva.
This situation is entirely different than the leech issue. First off A hydrophila is a proven pathogen capable of causing infection. Also, there is no question it is present in leech saliva. The arguement one can make is whether the innoculum is of clinical significance. A quick lit search clearly shows that there have been several cases of wound infection that have been linked to leech therapy. If prophylactic antibiotics have been shown to be beneficial for making a skin incision with a sterile scalpel in a perfectly healthy individual in healthy tissue that has been prepped with betadine, does it not make sense to do so when exposing a congested flap (which can be viewed as a local area that is immunocomprimised given that cutting into such flaps obviously demonstrates that it lacks oxygenated blood) to a known pathogen? I know the lierature on the matter is scant, but like I said, although I'm all for evidence based practice, I will go with my gut and logic on this one. Now if there's sufficient literature that shows it to be of no benefit, i'm open to that.

I love playing devil's advocate or if you ask my first year resident, I am the devil himself! I like scalpels thought process...

 

[Bifid Uvula]

I love playing devil's advocate or if you ask my first year resident, I am the devil himself! I like scalpels thought process...

I agree... I like Scalpel's thought process. ABO coverage all the way when it comes to leaches.

As your former resident, I didn't think of you as the devil, but sometimes you got a little too carried away with your hot-sauce salsa--- eventually unleashing smells that could have only come from the depths of hell.

I can only pitty those poor young ladies serving under you now.

 

[Teefies]

6-7 hours for a 3-piece maxilla, BSSO, and genio? I say again... Christ! What the hell are you guys doing?

Watch the language tough guy and please spare us all the macho b.s. about how absurd it would be to spend that much time on such procedures.

 

[Bifid Uvula]

So once again, I'm asking... are you guys and gals getting CTX- C Telopeptide lab results on your bisphosphonate patients?

A lot more literature on this is around the corner...

 

[rrc]

So once again, I'm asking... are you guys and gals getting CTX- C Telopeptide lab results on your bisphosphonate patients?

A lot more literature on this is around the corner...

I am in private practice and am not obtaining this. If the patient has been on it more than 3 years then stop for 3 months and resume once healing has occurred. If it is an emergency then tell them the risks and deal with it. This is for oral.

If IV then you never should take the tooth out. If it is an absolute necessity to extract then maybe get the CTX and go from there. Although they say stopping IV bisphosphonates will not lower the CTX unless they are off it for a very long time.

 

[toofache32]

I am in private practice and am not obtaining this. If the patient has been on it more than 3 years then stop for 3 months and resume once healing has occurred. If it is an emergency then tell them the risks and deal with it. This is for oral.

If IV then you never should take the tooth out. If it is an absolute necessity to extract then maybe get the CTX and go from there. Although they say stopping IV bisphosphonates will not lower the CTX unless they are off it for a very long time.

I've been meaning to ask you this forever....what is that xray in your avatar? It looks like a shotgun wound, maybe a lateral ceph or oblique....and sometimes I think it's half a pelvis.

And if you're wondering...my avatar is a fat dude dancing proudly in a thong....

 

[rrc]

I've been meaning to ask you this forever....what is that xray in your avatar? It looks like a shotgun wound, maybe a lateral ceph or oblique....and sometimes I think it's half a pelvis.

And if you're wondering...my avatar is a fat dude dancing proudly in a thong....

Just some plain film of a dude who got his head blown off. I found it on the internet. I don't know if it's self inflicted or what.

Ya, the thong is sweet.

 

[Bifid Uvula]

I am in private practice and am not obtaining this. If the patient has been on it more than 3 years then stop for 3 months and resume once healing has occurred. If it is an emergency then tell them the risks and deal with it. This is for oral.

If IV then you never should take the tooth out. If it is an absolute necessity to extract then maybe get the CTX and go from there. Although they say stopping IV bisphosphonates will not lower the CTX unless they are off it for a very long time.

I've been getting the CTX labs for the last few months and 2 weeks ago I was fortunate enough to be at the American College of Oral & Maxillofacial Surgery meeting in Orlando, where I went to Marx's lecture.

I really think the CTX is our best tool/predictor for which patients are at greatest risk for an oral bisphosphonate induced osteonecrosis. The 3-6 month drug holiday has consistently shown an increase in the C-telopeptide value (usually above the 150 pcg level) that we want to see prior to an extraction.

Less than 3 years of BisPhossy's, low liklihood/low risk... take the tooth. If something happens, you deal with it and treat it accordingly.

Over 3 years of Bissphossy's... A definite CTX, drug-holiday, extract the tooth if non restorable and deal with complications if they arise.