OMFS case discussions

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Teefies said:
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.
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If you are spending 6-7 hours or more on a run-of-the-mill orthognathic surgery case, you should not be doing orthognathic surgery.
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IcedOMFS said:
If you are spending 6-7 hours or more on a run-of-the-mill orthognathic surgery case, you should not be doing orthognathic surgery.
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I don't know. A 4-piece Lefort, BSSO, genio, hip graft, turbinates, and skeletal fixation can take us 6 hours, and it seems we're moving pretty quick. I guess it depends on the combination of procedures.
 
toofache32 said:
I don't know. A 4-piece Lefort, BSSO, genio, hip graft, turbinates, and skeletal fixation can take us 6 hours, and it seems we're moving pretty quick. I guess it depends on the combination of procedures.
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i think 6 hours for that is very reasonable. i'd be happy. we don't do many 4 piece leforts (mostly 3 piece).
 
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scalpel2008 said:
i think 6 hours for that is very reasonable. i'd be happy. we don't do many 4 piece leforts (mostly 3 piece).
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We have one attending that likes doing "unusual" things like 4-piece leforts (he did a 5-piece once but I didn't see it), and mandibular subapical osteotomies. He trained back in the days when they did 3-5 orthognathic cases per week, so he's not scared of hardly anything.
 
toofache32 said:
We have one attending that likes doing "unusual" things like 4-piece leforts (he did a 5-piece once but I didn't see it), and mandibular subapical osteotomies. He trained back in the days when they did 3-5 orthognathic cases per week, so he's not scared of hardly anything.
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We do 3-5 orthognathic cases per week. Probably why I think it shouldn't take 6 hours.
 
IcedOMFS said:
We do 3-5 orthognathic cases per week. Probably why I think it shouldn't take 6 hours.
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Let me add my 2 cents since I graduated about 2 years ago and have done several jaw cases since then. I would highly recommend not worrying about how long these cases are taking right now while you are in residency. Just try and learn as much as you can during the surgery and especially the little nuances that make or break the case.

Learning where the little interferences are lurking when impacting a maxilla (like how to retract the descending palatine and different ways of removing the little lip of bone behind it) or how to quickly identify a bleeding artery that is behind the maxillary wall can save you a lot of headache in the future.

The other thing is that the time it takes to do these cases is really of little significance in the grand scheme of things. The surgery itself is the fun part. The insurance, the parents, the post-op complications are the things to worry about. These are the headaches. The surgery is the fun part so just relax and do a good job and don't worry about the time.

Of course, if you are getting to the 6+ hour mark routinely then perhaps there is something that should be examined in terms of technique but for the most part everyone is going to take the same amount of time on these cases give or take a couple of hours. It's really not a big deal.
 
IcedOMFS said:
We do 3-5 orthognathic cases per week. Probably why I think it shouldn't take 6 hours.
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Wow. Who pays for the surgery? Are these private paying patients or insurance? We've taken a big hit over the past couple of decades since insurance no longer pays (or pays much) for orthognathics to make it worthwhile.
 
Bifid "wondering where Gary Ruska is hiding" Uvula here....

Where is this cat hiding? I haven't seen a post from him in a while. Rumor has it he's in a Turkish Prison...
 
Bifid Uvula said:
Bifid "wondering where Gary Ruska is hiding" Uvula here....

Where is this cat hiding? I haven't seen a post from him in a while. Rumor has it he's in a Turkish Prison...
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What program is the Ruski at anyhow?
 
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Bifid Uvula said:
No no no... that's definitely not him. That's my former chief resident from Carle OMFS... GARY "Implant 24/7" RASKA, NOT GARY "SDN Extraoirdinaire" RUSKA. Ruska is a dual degree resident.
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Or Gary "hollow leg" Raska or Gary "slugging the colon" Raska or Gary "tight scrubs" Raska..... definitely not Gary "middle name schizophrenia" Ruska
 
Bifid Uvula said:
No no no... that's definitely not him. That's my former chief resident from Carle OMFS... GARY "Implant 24/7" RASKA, NOT GARY "SDN Extraoirdinaire" RUSKA. Ruska is a dual degree resident.
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Yeah, I've always assumed Parkland. If you look at his early posts, he refers to just about every resident listed on the Parkland site. In one thread, he randomly posts one time and states that his first name is Fayette. So, I thought I had figured it out a while ago...unlv oms gunnabe and I were talking about it and told me I was wrong and that Fayette is another famous SDNer. So, I have no clue either.:confused:
 
oms fan said:
Yeah, I've always assumed Parkland. If you look at his early posts, he refers to just about every resident listed on the Parkland site. In one thread, he randomly posts one time and states that his first name is Fayette. So, I thought I had figured it out a while ago...unlv oms gunnabe and I were talking about it and told me I was wrong and that Fayette is another famous SDNer. So, I have no clue either.:confused:
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I think he meant to say infamous.
 
Can you OMS residents tell me about your experiences performing a distraction osteogenesis procedure at the mandibular symphysis? I'm referring to doing this procedure when a healthy patient is in comprehensive ortho treatment and has mandibular crowding + a constricted mandible, and using a tooth-borne hyrax device. I'm not talking about doing it for cranio-facial syndrome patients. In our orthodontic program (and I'm guess most programs), we won't hesitate to do a non-surgical maxillary rapid palatal expander to gain space in a constricted maxilla in a patient under age 17. However, when that same patient has a narrow and crowded mandible, the solution doesn't seem so obvious.

Our director told me that DO at the mandibular symphysis can be done with IV sedation in the OMS clinic and probably doesn't cost or involve much more than extracting 4 premolars under IV. From what I read, it seems like it would be a really useful procedure to gain arch width in the mandible when you don't want to extract teeth, but it's apparently not very widely accepted in the orthodontic community. Why? Is it because there are reasons that OMS out in private practice wouldn't want to do this procedure? Or is it just that the orthodontists are scared to recommend and manage it?
 
gryffindor said:
... but it's apparently not very widely accepted in the orthodontic community. Why? Is it because there are reasons that OMS out in private practice wouldn't want to do this procedure? Or is it just that the orthodontists are scared to recommend and manage it?
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Is this a stable move? My experience is that the biggest reason orthodontists balk at certain procedures/techniques is stability. But I have no idea how stable this treatment is.
 
toofache32 said:
Is this a stable move? My experience is that the biggest reason orthodontists balk at certain procedures/techniques is stability. But I have no idea how stable this treatment is.
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As I sit here leafing through my texts, I see sources pointing in both directions.

Nanda's "Biomechanics and Esthetic Strategies in Clinical Orthodontics" says that symphyseal DO results in both basal and alveolar bone being formed. It states that case selection is important and the ideal patient for symphyseal DO would have either a constricted maxilla and bilateral buccal crossbites in the dentition, or a constricted maxilla and mandible where you want to widen both to alleviate crowding. It concludes that this procedure is basically not performed as frequently right now, but as more people do it, more data will be produced.

Proffit's "Contemporary Orthodontics" says that orthodontic expansion only at the alveolar bone level to correct mandibular crowding has doubtful stability, especially if you expand the canines without retracting them. But then it gets wishy-washy about whether basal bone expansion with symphyseal DO would be a more stable choice. Instead the text seems to suggest that the orthodontist should just skip either attempt at widening the mandibular bone to alleviate crowding and just treatment plan the extraction of mandibular premolars instead. Then it implies that the lip and cheek pressure against the mandibular canines expanded with symphyseal DO might be an issue as well.

So there isn't much data out there to support basal bone expansion via symphyseal DO. Looks like Guerrero is the one who has done some studies on it since he is credited with doing it with a tooth-borne hyrax device. There seems to be a growing anti-extraction sentiment in ortho, so I'm just trying to explore all options out there to alleviate crowding. This is why I'm wondering how often you OMS residents encounter symphyseal DO in your residencies or know of it being done in private practice.
 
gryffindor said:
As I sit here leafing through my texts, I see sources pointing in both directions.

Nanda's "Biomechanics and Esthetic Strategies in Clinical Orthodontics" says that symphyseal DO results in both basal and alveolar bone being formed. It states that case selection is important and the ideal patient for symphyseal DO would have either a constricted maxilla and bilateral buccal crossbites in the dentition, or a constricted maxilla and mandible where you want to widen both to alleviate crowding. It concludes that this procedure is basically not performed as frequently right now, but as more people do it, more data will be produced.

Proffit's "Contemporary Orthodontics" says that orthodontic expansion only at the alveolar bone level to correct mandibular crowding has doubtful stability, especially if you expand the canines without retracting them. But then it gets wishy-washy about whether basal bone expansion with symphyseal DO would be a more stable choice. Instead the text seems to suggest that the orthodontist should just skip either attempt at widening the mandibular bone to alleviate crowding and just treatment plan the extraction of mandibular premolars instead. Then it implies that the lip and cheek pressure against the mandibular canines expanded with symphyseal DO might be an issue as well.

So there isn't much data out there to support basal bone expansion via symphyseal DO. Looks like Guerrero is the one who has done some studies on it since he is credited with doing it with a tooth-borne hyrax device. There seems to be a growing anti-extraction sentiment in ortho, so I'm just trying to explore all options out there to alleviate crowding. This is why I'm wondering how often you OMS residents encounter symphyseal DO in your residencies or know of it being done in private practice.
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Except that if you have transverse maxillary deficiency, you wouldn't correct it with DO to widen the mandible, as you would only make the discrepancy worse (SARPE or segmental lefort would be a better way to fix transverse maxillary deficiency) ... Conversely, a midline split of the mandible to narrow the mandible IS a way to address transverse maxillary deficiency. Typically one would do this if you wanted to avoid doing a maxillary osteotomy in a patient already receiving a mandibular osteotomy. The only problem with it is the midline split makes the whole thing considerably less stable.

A midline osteotomy with or without DO creates a situation identical a symphyseal fracture (actually, even less stable than a symphyseal fracture, because there is no micromechanical locking to the segments). It is hard to control, and you have forces in many directions potentially pulling you off course, torsion being the worst. Don't forget the effects widening the symphysis would have on the position of the condyles within the temperomandibular joint, or on flaring of the gonial angles, either. Everything you do has a price. In a feminine looking girl, you risk making her look more masculine with gonial flaring.

Serial extractions are more predictable with fewer and less serious complications than osteotomies or distraction.

Now, I've met Guerrero, and he's a cool guy and all, but Venezuela is a little different than North America and Europe. You can get away with experimenting on people down there. Here, not so much.
 
Thanks IcedOMFS. So far, all I've read about this procedure is in the textbooks. I came across a teenage patient with blocked out canines and crowding in only the anterior segments of both jaws and nice class I occlusion in the posterior segments. One suggested treatment plan was RPE in the maxilla and DO in the mandible instead of premolar extractions based on the facial esthetics being helped with broader arches. So that got me thinking more about it. I'll see if I can post some pics tomorrow. Also our OMS department showed some surgical sleep apnea cases where symphyseal DO was part of the complete orthodontic and surgical treatment plans (SARPE & symphyseal DO, followed by two jaw advancement I think) and it seemed intuitive and neat.

I am aware that to correct a transverse maxillary deficiency, the maxilla has to be widened either with an RPE in a growing patient or surgically in the adult. As far as effects on the TMJ, the Nanda text quotes "There appears to be translation at the condyle with no clinically significant effects or development of any joint symptoms" with a reference to a 2002 article in the AJODO. I didn't realize Guerrero was in Venezuela.
 
Shouldn't we try to keep up the case discussions?

This is a case that was treated some years ago at our department.

A 38 yr old woman came to our department with multiple facial fractures after a beating by her boyfriend. Her MH was significant for alchol abuse and Tourett's, her SH for multiple ED visits in the last many years because of spousal violence.

A CT revealed multiple facial fractures, most of which were only mildly displaced. There was a maxillary (LeFort I), nasal and orbital fracture. There were also two fractures of the right mandibular condyle, with the condylar head displaced medially and anteriorly, and the condylar neck displaced laterally.

How would you treat the condylar fractures? Elastic IMF only or ORIF? I don't know if any of you guys use an endoscope for candylar fracture repair, but would you consider that as an option.
 

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EuroOMFS said:
Shouldn't we try to keep up the case discussions?

This is a case that was treated some years ago at our department.

A 38 yr old woman came to our department with multiple facial fractures after a beating by her boyfriend. Her MH was significant for alchol abuse and Tourett's, her SH for multiple ED visits in the last many years because of spousal violence.

A CT revealed multiple facial fractures, most of which were only mildly displaced. There was a maxillary (LeFort I), nasal and orbital fracture. There were also two fractures of the right mandibular condyle, with the condylar head displaced medially and anteriorly, and the condylar neck displaced laterally.

How would you treat the condylar fractures? Elastic IMF only or ORIF? I don't know if any of you guys use an endoscope for candylar fracture repair, but would you consider that as an option.
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You are dealing with a subcondylar fracture and a medial pole fracture. The subcondylar segment is laterally displaced. It appears to be low enough to plate. Such laterally displaced subcondylar fractures (even though the medial pole is displaced medially) are better off with ORIF I think, especially if you are dealing with a concomitant lefort fracture, as you alluded. We don't do endoscopic repair of subcondylar fractures but if you are good and quick at it, I guess that would be an option. We typically use a retromandibular transparotid approach and retract CN 7 out of the way if we see it.
 
ORIF is probably the best bet, but I do agree... If you are quick and comfortable with the endoscope its definitely another option.
 
Bifid Uvula said:
ORIF is probably the best bet, but I do agree... If you are quick and comfortable with the endoscope its definitely another option.
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I've done a few endoscope-assisted condylar fr. repairs and it's not easy. Someone well trained in using it would probably be able to do this fracture that way, but I don't think I could at this point. The subcondylar fracture is simply too high. I´d use a retromandibular approach.

She was treated with max/mand fixation. Her occlusion turned out OK, but with reduced MIO. She returned a year later with pain and crepitation in the right joint that was intially treated with an occlusal appliance without much success. There was talk of open TMJ surgery but she was then lost to followup. I my opinion ORIF would have been the way to go in this case.
 
EuroOMFS said:
Do you use a nerve locator to find the facial nerve?
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we usually have a nerve stimulator available. however, my feeling is that the facial nerve in the retromandibular region is within the parotid and once i cut through the capsule I only use blunt dissection until I reach the masseter and periosteum. However if I do come across a "band" that needs to be cut and my suspicion is relatively high I will check it with the nerve stimulator before cutting it.
 
Just make sure when you infiltrate the local, stay superficial, and not deep into the muscle / parotid gland, as it can blunt the effect of the nerve stimulator on the various branches of the facial nerve.
 
Question to OMS res.: When closing a through and through ear laceration that is totally confined within the auricle but has some minor avulsion of cartilage do you : 1. Suture just the perichondrium and skin knowing there will be some dead space in the wound or 2. Try to reapproximate some of the cartilage, eliminating some of the dead space thus trying to prevent hematoma but knowing there is now an increased risk of chondritis? Just curious as to thoughts on this matter. And do most people cover this type of laceration with systemic antibiotics?
 
OMSPlayer05 said:
Question to OMS res.: When closing a through and through ear laceration that is totally confined within the auricle but has some minor avulsion of cartilage do you : 1. Suture just the perichondrium and skin knowing there will be some dead space in the wound or 2. Try to reapproximate some of the cartilage, eliminating some of the dead space thus trying to prevent hematoma but knowing there is now an increased risk of chondritis? Just curious as to thoughts on this matter. And do most people cover this type of laceration with systemic antibiotics?
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i usually tack the cartilage back with some 5-0 clear prolene and then close skin. If my suspicion for a hematoma is high then I apply a bolster dressing. I also usually prescribe abx for lacs.
 
This was a fun one... not really. Did this one near the end of my first year under local anesthetic in the ER. Young female patient thrown from her horse and stepped on by the horse. 95% avulsed. Its literally hanging on by a thread of skin on the posterior.

I put a doppler on it and I was pretty sure we were gonna lose the lower third. Microvascular anastamosis is hit or miss in the literature. We didn't use sterile leaches on this one either.

I placed her on antibiotics, but typically for routine ear lacs I don't routinely place the patients on antibiotics.
 

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toofache32 said:
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.
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I had that last year (lower jaw forward, upper jaw back, chin adjusted), and it took I think 3 or 4 hours.
 
Bifid Uvula said:
This was a fun one... not really. Did this one near the end of my first year under local anesthetic in the ER. Young female patient thrown from her horse and stepped on by the horse. 95% avulsed. Its literally hanging on by a thread of skin on the posterior.

I put a doppler on it and I was pretty sure we were gonna lose the lower third. Microvascular anastamosis is hit or miss in the literature. We didn't use sterile leaches on this one either.

I placed her on antibiotics, but typically for routine ear lacs I don't routinely place the patients on antibiotics.
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Did the ear survive? Do these type of injuries benefit greatly from HBO?
 
Here's a pt with BRONJ I saw last week. Was on Fosamax for 10 years. No known history of trauma, just a big palatal torus. Started her on PCN and peridex.
 

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Just thought you might enjoy these. This is a zygoma fracture our ENT friends at another hospital "reduced" 10 days ago, through a small incision in the upper eyebrow! This is a CT scan we obtained yesterday.
 

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Wow... never ceases to amaze me. I'm sure we could all dig around and pull out files of piss-poor reductions.

My favorites are the plates that look like they were bent by a drunken gorilla and placed anywhere they managed to have bony contact. Just for good measure they drive the screws through the IAN and right into the teeth and out the other cortex well beyond what would be considered "bicortical".
 
EuroOMFS said:
Just thought you might enjoy these. This is a zygoma fracture our ENT friends at another hospital "reduced" 10 days ago, through a small incision in the upper eyebrow! This is a CT scan we obtained yesterday.
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Why did they come see you for a new CT scan? What was the indication? Why not follow up with ENT?

For a closed reduction it actually looks very good IMO.
 
rrc said:
Why did they come see you for a new CT scan? What was the indication? Why not follow up with ENT?
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When the swelling went down, she (this is a 18 year old girl) noted that her cheek appeared flattened on the injured side. Also her mouth opening was 15 mm, had been so since her accident, and was unaffected by the surgery performed by the ENT guys. Her primary physician referred her to us because of this. She was initially treated by ENT at a hospital in another city, where she goes to school. She then went home to her parents to recover and they happen to live in the city where my hospital is, which is why she was referred to us.

rrc said:
For a closed reduction it actually looks very good IMO.
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This is a case that should never have been treated with closed reduction. This is a "quadroped" fracture, that should in my opinion be done by an open approach and with osteosynthesis. You can see on the horizontal CT that her zygoma on the right side is pushed posteriorly 5-8 mm, and this is post-reduction. It's a shame I don't have photographs of the girl to show you how flat her right cheek looked.

This 3D CT shows zygomas position a little better.
 

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It's hard to really say how good the reduction is without seeing pre-op images.
 
Yikes, the axial view (the recon one) tells a different story. Thanks for sharing the rest of the history. And I agree that this should have been treated more aggressively.
 
toofache32 said:
It's hard to really say how good the reduction is without seeing pre-op images.
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True, no way to know how it was to begin with, since we don't have the pre-op CT. Maybe it was much worse. But I think you'd agree that in the modern world, this is not an acceptable result. Especially for an 18 yr old.
 
You guys may just be able to give me some concrete info on this:


My hygenist just attended a lecture on anasthesia, during which they were told that absolutely no perio should be done in patients who had a heart attack in the last 6mo. My husbund who is an intensive care unit doc and does a lot of cardiology, says it should be no problem, other than being careful w/ bleeding if pt is no blood thinners. Though one should still do perio and definitly not stop the thinners.

Which one is it? I don't see any logic to why increasing bacteria load by doing perio, would affect a pt who had a heart attack caused by athrosclerosis, with a stent placed to prevent further blockage.
What is waiting 6mo going to achieve??



 
I think the guidelines have more to do with functional reserve/Stress from procedure; as opposed to bacterial load. The idea is to wait until pt. can tolerate the a potential elevation in heart-rate from percieved stress.
 
Huggies said:
You guys may just be able to give me some concrete info on this:


My hygenist just attended a lecture on anasthesia, during which they were told that absolutely no perio should be done in patients who had a heart attack in the last 6mo. My husbund who is an intensive care unit doc and does a lot of cardiology, says it should be no problem, other than being careful w/ bleeding if pt is no blood thinners. Though one should still do perio and definitly not stop the thinners.

Which one is it? I don't see any logic to why increasing bacteria load by doing perio, would affect a pt who had a heart attack caused by athrosclerosis, with a stent placed to prevent further blockage.
What is waiting 6mo going to achieve??
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I agree with your husband and the dental student posting immediately before me. I would consider beta blocker premedication and/or IV sedation for any dental treatment if patient anxiety is a concern. FYI, in residency I performed full-mouth extraction (25 teeth or so) on a patient who had experienced an MI three days prior. I expect the lecturer would have fainted on the spot to hear that.
 
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