Journaloctober 2004 · ManageMent Of trauMatic facial injurieS Tim Silegy, DDS, and Peter Scheer,...

d e p a r t m e n t s The Editor/Looking Back on the Journey — Some Highlights

Dr. Bob/Putting the Strain on S. Mutans

features Oral and MaxillOfacial Su r ge ry: Sav i ng face S — cha ngi ng l i v e S

An introduction to the issue.

Tim Silegy, DDS

Oral and MaxillOfacial Su r ge ry r e Si de ncy e du cati On

Alan L. Felsenfeld, MA, DDS, and Angelle Casagrande, DDS, MD

new cOnSideratiOnS in the tr e atMe nt Of cOM pr OM i Se d thi r d MOl a r S

Ronald M. Kaminishi, DDS, and Kurtis S. Kaminishi, BA

fifty yearS Of general ane Sthe Si a i n ca l i f Or ni a Or a l a nd M a xi l lOfaci a l Su r ge ry

John J. Lytle, DDS

OrthOgnathic Surgery: hiStOry, di agnOSi S a nd tr e atM e nt

Robert Relle, DDS, and Tim Silegy, DDS

ManageMent Of trauMatic faci a l i nju r i e S

Tim Silegy, DDS, and Peter Scheer, DDS, MS

teMpOrOMandibular jOint di Se aSe : a n u pdate Of Su r gi ca l tr e atMe nt

A. Thomas Indresano DMD; and Angelle Casagrande DDS MD

Overview Of facial cOSMeti c Su r ge ry

Simona C. Arcan DMD, MD

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CDA JournalVolume 32, Number 10o c to b e r 2 0 0 4 Journal

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 801

CDA’s subsequentefforts in the legislative arenato support a capon damages were important to bringing stability to theprofessional liability marketplace.

lengthy position of servicewith the pre-eminent statedental association inAmerica brings with it theprivilege of sharing somepersonal perspectives on

some of highlights in dentistry in Californiaduring the past 35 years of our service.

As former Journal Managing EditorSusan Lovelace noted in her marvelous his-tory of the California Dental Associationthat was published in July 1995, the firstmeeting of the California DentalAssociation occurred on June 29, 1870, inSan Francisco, just 21 years after Californiawas admitted to statehood. That makesCalifornia dentistry 134 years old this year.

My journey of service to the professioncommenced in 1969 in Los Angeles, justfour years prior to the unification in 1973 ofthe northern California Dental Associationand the Southern California DentalAssociation, forming the California DentalAssociation as we know it today. It startledus when we calculated that our 35 years ofvolunteer service represented 26 percent ofthe lifespan of organized dentistry here inCalifornia! We believe that statistic onlyserves to illustrate that dentistry is still a rel-atively young profession. I believe that thepeople we will mention and the events wewill review, while only a small sampling ofhighlights, will illustrate what a memorablejourney that California dentistry has trav-eled in that time.

In 1978, five years after unification, DaleRedig was hired as the third CDA executivedirector. The association offices had beenhoused in a relatively small leased office space(compared to today’s standards) in theTishman building complex in the LosAngeles Airport area. His hiring would mark

the beginning of an 18-year periodof significant and unprecedentedgrowth.

When we first became membersin the 1960s, liability insurance wasconsidered by many to be the mostimportant membership benefit. Inthe mid-1970s, premium levels hadstarted to soar to levels that were ofgreat concern to leadership, not tomention the members. J. DavidGaynor, who had the originalvision, along with other associationleaders, was instrumental in theuntiring efforts that ultimatelyresulted in the formation of TheDentists Insurance Company in1980, the first dentist-owned liability carrierin the country! The early years of TDIC’s exis-tence were not easy. Some of us can stillremember the Certificates of Contributionthat policy/shareholders purchased to sup-port the company during the trying forma-tive years. Despite the difficult times, includ-ing several challenging administrativechanges, TDIC has become a major successand a contributor to the financial health ofthis association. Policyholder dividends havebeen another highlight in recent years. Asidefrom the financial benefits derived fromTDIC by the association and its members, the“management” of the liability environmentby the profession via TDIC and its very exis-tence in the marketplace, helped to slowdown and to control the escalating premiumcosts both short term and to this day. In addi-tion, CDA’s subsequent efforts in the legisla-tive arena to support a cap on damages wereimportant to bringing stability to the profes-sional liability marketplace.

In April 1983, the CDA board, meetingin Newport Beach, Calif., voted to move the

The Editor

Looking Back on the Journey —Some Highlights

Jack F. Conley, DDS

A

802 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004

Marie Tokunaga who served us with dis-tinction for the next eight years. PattyReyes has now been managing the day-to-day development of the Journal formore than a year while Jeanne Marie hasoverall responsibility for publications.The quality of the five individuals whohave served us in this capacity has beena source of great personal satisfaction.Our successor, Alan Felsenfeld, will findthe contributions of Jeanne Marie andPatty to be a source of strength.

By the late ’80s, Dale Redig’s vision,coupled with his practical realizationthat CDA in a very few years was alreadystarting to outgrow the 818 K St. offices,pointed to the need to study the poten-tial of a move to one of two buildingsunder construction in downtownSacramento. While this decision, likethe previous Board of Trustees decisionto move the offices to Sacramento, wascontroversial with some trustees, webelieve this move has been the mostimportant event in the 30-year historyof the unified association.

Beyond the necessity of additionalspace, the 1201 K St. address thatbecame the CDA home in 1990, helpedto establish CDA as a major player inSacramento. Even when leadership wasfaced with some more difficult timesafter 1996, we believe that the presenceof the association at the 1201 K St. loca-tion has been extremely beneficial toCDA in undertaking its various initia-tives on behalf of the membership andthe public.

As many individuals who read thisknow, the next 61⁄2 years presented somedifficult leadership challenges fromtime to time. A positive perspective toshare is that volunteer leadership, andthe officer positions in particular,became out of necessity, more engagedin the process of governance. This in noway suggests that we have any lessadmiration for the performance or rep-resentation provided by the many out-standing leaders we served with from

she proofread copy for Journal issueswhile waiting to catch flights at the air-port while traveling on Sessions business.

We have been amazed time and againat the skills of our professional publica-tions staff, traits that have been therefrom the very beginning of our tenure. Inless than one month after his hiring,Doug Curley launched the first monthlyissue of Update while overseeing themonthly publication of the Journal. Webelieve that the monthly publication oftwo first-rate publications by a small, ded-

icated staff has been a remarkableachievement. Update to us has been animportant vehicle for CDA publications.It has enabled us to separate the news,information, opinion, and feedback thatwould be less appropriate to a profession-al journal. While we don’t have a surveyto back up our opinion, the belief here isthat the reader target audience for thetwo publications is quite different, under-lining the need for the two different pub-lications that validates the judgment ofthe leadership at that first-ever strategicplanning retreat.

In 1996, Susan Lovelace, who provid-ed outstanding skills in the productionof the Journal following Doug Curley’stenure as managing editor, left to serveSan Diego County Dental Society asexecutive director. The Journal experi-enced a smooth transition to Jeanne

CDA office to Sacramento and appoint-ed yours truly to serve as editor of thispublication. In August, 16 of 47 employ-ees employed in Los Angeles movedwith Dale Redig to open the CDA officein Sacramento. Dale’s vision that CDAneeded to be in Sacramento at the seatof state government would be validatedover and over during the next 20-plusyears. Among those who helped withthat move is current Chief GovernanceOfficer Janice Johnson, whose loyalty tothis organization has been unsurpassed.

In mid-August 1983, at about thetime of the move, a new managing edi-tor, Rich Martin, was hired in Sacramentobecause the Los Angeles Journal staff didnot follow the association to Sacramento.Rich had a background in newspaperjournalism. Speed of publication andshort deadlines were his forte. We were inawe of his ability to put together a quali-ty first issue of the Journal in Sacramento,in little more than two weeks. That firstissue, with a photo of the 818 K St. head-quarters building on the cover was await-ing the Board of Trustees on their deskson the first weekend after Labor Day atthe first trustee meeting in Sacramento.To this day, we appreciate the skills welearned from Rich.

In 1988, two things happened of sig-nificance to this writer. Rich Martinbecame ill with cancer and had to leavehis position after five years of marvelousservice. Earlier that year, feedback fromleadership at a strategic planning retreatidentified the need for a monthly“newsletter” type of publication. As shehad during the transition periodbetween Los Angeles and the newSacramento Journal staff, Cissie Cooper,who served various directorship posi-tions with the association includingScientific Sessions and Communications,again stepped in. She bridged the pro-duction gap between Rich Martin’sdeparture and the hiring of DouglasCurley as managing editor, months laterin January 1989. She confided to us that

The Editor

We believe that the presence of theassociation at the1201 K St. location has been extremelybeneficial to CDA in undertaking itsvarious initiatives


1983 until 1996. But it has been evidentthat additional demands on an officer’stime, opinions, and decisions started tooccur out of necessity in the post-1996period. We believe in retrospect, thatthe role modification we have witnessedhas been an important step in thegrowth of this organization.

CDA is now in the second year ofwhat we consider the profession’s futuredirection. Peter DuBois, during the past20 months, has demonstrated that hehas a vision, which is at the forefront ofhis efforts to restructure the association’soperation and to direct strategic initia-tives. He has demonstrated thus far howimportant the vision of an administratorcan be. He has also incorporated changesin organization structural efficiency thatare paramount in the business climate oftoday. We believe that time will show hisadministrative style, skills, and contribu-tions, while vastly different than those ofRedig and Gaynor, to also be of lastingimportance to the future strength of thisorganization.

The dedicated contributions of “Dr.Bob” Horseman have been critical tothe success of the Journal. He has beencontributing editor “par excellence” forthe past 22 years, providing a monthlyfeature unique to a professional journal.Many colleagues anxiously await Bob’shumorous creations every month, andtheir inclusion provides Journal a mar-velous balance of features for the reader.

Not to be forgotten are the ScientificSessions that have continued to grow insize and quality in the period since uni-fication. Staff and volunteers continueto attract the top experts to the north-ern and southern Sessions every year. Inaddition to quality educational offer-ings, exhibitors value the opportunityto participate in these meetings andcontribute to their financial successwhile introducing the latest in materialsand technology to the membership.

Next month, “I Believe it IS Time toGo ...” CDA

ral and maxillofacial surgerybegan as, and remains, a spe-cialty of dentistry. As the nameimplies, oral and maxillofacialsurgeons are dentists trained tosurgically address diseases anddeformities of the mouth, jaws,

and face. However, in spite of thedescriptive name, many general dentistsstill see the oral and maxillofacial sur-geon as the friendly person down thehall who takes out teeth.

As we enter the new millennium,confusion as to the scope of oral andmaxillofacial surgical practice remains.Recognizing this, the AmericanAssociation of Oral and MaxillofacialSurgeons has begun a nationwide edu-cational campaign designed to educatehealth care professionals, politiciansand the public. More information ontheir program can be found on their


Oral andMaxillofacialSurgery: Saving Faces –Changing LivesTim Silegy, DDS

Contributing Editor / Tim Silegy,DDS, is an oral and maxillofacialsurgeon in private practice inLong Beach, Calif., and a diplo-mate, American Board of Oral andMaxillofacial Surgery.

owebsite, www.aaoms.org.

It is the intention of this issue of theJournal of the California DentalAssociation to provide California den-tists with an overview of current oraland maxillofacial surgery training andpractice.

Drs. Alan Felsenfeld and AngelleCasagrande open this issue with a his-torical review of the specialty’s devel-opment. They then summarize currenttraining and accreditation guidelines,and finish with an overview of the oraland maxillofacial surgery residencytraining programs in California.

Dr. Jack Lytle follows with a papertracing the development of ambulatoryoutpatient anesthesia for oral and max-illofacial surgery. Interestingly, manyof these anesthesia pioneers practicedin California.

Third molar removal is a mainstay of

most oral and maxillofacial surgery prac-tices. Controversy still surrounds theindications for removal of asympto-matic compromised third molars. Dr.Ron Kaminishi and Kurtis Kaminishiillustrate how removal of retained thirdmolars in an ever-expanding aged popu-lation is associated with significant risks.

Traumatic maxillofacial injuries canhave a profound physical and emotion-al impact on the individual. For years,oral and maxillofacial surgeons havebeen instrumental in developing tech-niques to repair of these injuries. Dr.Peter Scheer and I illustrate the oral and

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maxillofacial surgeon’s role in traumamanagement.

Internal derangement of the tem-poromandibular joint results in pain,spasm, and hypomobility. While non-surgical management can be effective inmanaging symptoms, definitive surgicaltreatment may be indicated. Drs. A.Thomas Indresano and Casagrandereview the indications for, and surgicaloptions available to, patients who fail torespond to conservative therapy.

A strong relationship exists betweenfacial growth and dental occlusion. Dr.Robert Relle and I discuss the diagnosisand surgical correction of dentofacialdeformities. New technology and tech-niques have transformed what was oncean arduous surgery requiring days ofhospitalization into what today is com-monly an outpatient procedure.

Dr. Simona Arcan provides anoverview of facial cosmetic surgery.Patients seeking cosmetic dental pro-cedures often desire enhancement ofother facial structures. Appropriatelytrained oral and maxillofacial sur-geons can draw upon their expertise infacial anatomy to help patients reachtheir esthetic goals.

Conspicuously missing from thisissue is a discussion of dental implantol-ogy and bone grafting. While oral andmaxillofacial surgeons have been instru-mental in developing this technology, itis not exclusive to oral and maxillofacialsurgeons, and would require an entireissue to adequately review.

Finally, I would like to dedicate thisissue to the many fine men and womenin academic oral and maxillofacial sur-gical practice. Without their sacrificeand dedication, many of the advance-ments discussed in the pages that followwould not have been possible. CDA

Introduction

Oral and maxillofacial surgery is the

recognized specialty of dentistry that

is responsible for the diagnosis and

surgical and adjunctive treatment of

diseases, injuries and defects involving

both the functional and esthetic

aspects of the bone and soft tissues of

the oral and maxillofacial region.1 This

article will present a review of the edu-

cational process for residents in oral

and maxillofacial surgery as it has

evolved and current training standards.

o understand the need for thecomprehensive and detailededucation of residents, a briefreview of the patient care areasprovided by oral and maxillo-facial surgeons is indicated.Since the earliest days of thespecialty, the scope of practice

has evolved to include surgery of theentire maxillofacial complex. Theknowledge and skills of oral and max-illofacial surgeons make them proficientin the management of bony and soft tis-sue management of the entire maxillo-facial skeleton.2

OMS Procedures

Dentoalveolar SurgeryThe basis of most clinical practices

includes the extraction of diseased orimpacted teeth, as well as the surgicalexposure of impacted teeth to enabletheir orthodontic-assisted eruption intoa functional and esthetic position.Other traditional office proceduresinclude preparation of the mouth fordentures, including alveoloplasty, softand hard tissue grafts, and vestibulo-plasty procedures. Oral infections andbiopsy of suspicious lesions of the hardand soft tissues are also treated.

Anesthesia The oral and maxillofacial surgeon

is an expert in all aspects of pain andanxiety control, including general anes-thesia or deep sedation, and conscious

sedation. A substantial portion of theirtraining focuses on ambulatory anesthe-sia and patient management, preparingthem to administer safe and effectiveanesthesia services in their offices forthe performance of surgical procedures.

Dental ImplantsA second significant area of modern

oral and maxillofacial surgery practice isthe planning and placement of dentalimplants. Patients can be diagnosed andtreated for the full range of implantdentistry. Evaluation, prophylacticextraction, site development includingbone and soft tissue reconstruction ofthe oral tissues as well as maintenanceare part of the training received and ser-vices offered to patients and restorativedentists.

Dentofacial Deformities andCongenital Defects

Surgeons can reconstruct andrealign the upper and lower jaws to pro-vide improved function and facial


Oral and Maxillofacial SurgeryResidency EducationAlan L. Felsenfeld, MA, DDS, and Angelle Casagrande, DDS, MD

Authors / Alan L. Felsenfeld, MA,DDS, is professor of clinical den-tistry and assistant residency pro-gram director at University ofCalifornia, Los Angeles, School ofDentistry. He is a member of thecommittee on residency, educa-tion and training for American

Association of Oral and Maxillofacial Surgeons.Angelle Casagrande, DDS, MD, is formerly

assistant professor, Oral and Maxillofacial Surgery,University of the Pacific, School of Dentistry, andassistant program director at Highlands GeneralHospital. She currently is in private practice inTucson, Ariz.

a b s t r a c t

educationResidency

T


John Gunther began a one-year basicscience program for oral surgeons at theUniversity of Pennsylvania in 1949 toprovide a consistency in the conceptualaspects of surgical training. The qualityof educational experiences was begin-ning to be considered. Evaluation ofadvanced education programs wassuperficially conducted by the Councilon Hospital Dental Service of the ADAfor its Council on Dental Education,with the main concern being space andfacilities for oral surgery clinics.

In 1956, the American Society ofOral Surgeons Committee on GraduateTraining provided the first descriptionof minimal requirements in the cate-gories of didactic education and clinicaltraining during a three-year period.Standards of education were offered forhospitals that conducted oral surgeryinternships and residencies. Also in1956, the ADA House of Delegatespassed a resolution transferring respon-sibility for the accreditation of intern-ships and residencies in hospitals to theCouncil on Dental Education.

From 1958 to 1964, six conferenceswere conducted by the ASOSCommittee on Graduate Training. Thefirst planning conference on graduatetraining took place in 1958 and resultedin the publication of The Essentials on anAdequate Training Program in OralSurgery. In 1964, the Council on DentalEducation approved the establishmentof the Review Commission onAdvanced Education in Oral Surgery.The newly constructed review commis-sion held its first official meeting inJanuary 1965. One of the purposes ofthe commission was to conduct site vis-its to evaluate training programs.

In May 1965, a second meeting ofthe review commission was held, andthe backlog of site visit evaluationswas considered. One of the first effortsof the review commission was torequire that all one-year programs

pain. Surgeons are educated in multi-ple treatment options including non-surgical treatment of TMJ disorders.The surgical management of TMJabnormalities includes arthrocentesis,arthroplasty and open joint proceduresas well as total joint replacement orreconstruction.

Evolution of EducationGiven the complexity and extensive

range of surgery, the education programfor residents needs to be comprehensiveand by definition is quite rigorous. Tocomplement the intensive growth inthe depth and range of surgical proce-dures performed by modern surgeons,the educational process has evolvedaccordingly. A brief history of howteaching has changed will bring betterunderstanding to the education that isreceived by residents today.3

The earliest recorded notes relativeto specialty scientific education forsurgery was in 1918 when the AmericanSociety of Exodontists, limited to thepractice of oral and maxillofacialsurgery, and initiated scientific meet-ings and publications. During the nextdecade, oral surgery became the firstofficial specialty the American DentalAssociation recognized, and the nameof the organization was changed to theAmerican Society of Oral Surgeons andExodontists. By 1946, with the estab-lishment of American Board of OralSurgery, major problems and wide dif-ferences in the training and educationof the specialty were brought to light.Some programs were university affiliat-ed and were three years in duration.Many however, were one-year programsisolated in hospitals where they lackedfull-time directors. All programs wereclinically oriented in a “preceptor” typeof educational process.

Carl Waldron and Henry Clark atthe University of Minnesota designed acorrespondence course in oral surgery.

appearance as they work as a team withorthodontists to align the maxillofacialstructures. Many are trained to correctcongenital and acquired defects of themaxillofacial region including cleft lipand palate.

Maxillofacial TraumaOral and maxillofacial surgeons

have extensive experience in repairingsimple and complex facial lacerations,setting fractured jaw and facial bones,reconnecting severed nerves and ducts,and treating other hard and soft tissueinjuries of the face and neck region.They are active participants in the emer-gency department management of themaxillofacial trauma patient.

Pathologic ConditionsThe diagnosis and management of

patients with diseases of the oral andmaxillofacial region, including cysts,benign and malignant tumors, soft tis-sue, and severe infections of the oralcavity and salivary glands is a serviceoffered to patients by the oral and max-illofacial surgeon.

Reconstructive and Cosmetic SurgerySurgeons are well trained to correct

jaw, facial bone and facial soft tissueproblems that occur because of traumaor pathology. This surgery to restoreform and function often includestransferring skin, bone, nerves, andother tissues from other parts of thebody to reconstruct the jaws and face.These same skills are also used whenoral and maxillofacial surgeons per-form cosmetic procedures for improve-ment of problems due to unwantedfacial features or aging.

Temporomandibular Joint DisordersTraining includes the diagnosis and

management of temporomandibularjoint disorders as well as differentialdiagnosis of head, neck, and facial

educationResidency

under continuous review and revision bythe American Association of Oral andMaxillofacial Surgeons to reflect changesin the education required for modern oraland maxillofacial surgery residents.

Education of SurgeonsThere are 102 accredited surgery res-

idency programs in the United Stateswith approximately 170 open positionsavailable annually. About 850 individu-als are in residency programs with halfbeing in MD-integrated training. As inall areas of dentistry and medicine, oraland maxillofacial surgery education hasbeen significantly enhanced during thepast 20 years. Training time has beenlengthened and a wider range of proce-

grams was increased from three to fouryears. This was done to accommodatethe increasing amount of educationalrequirements for surgeons. A blueprintfor the curriculum for the four-yeartraining programs was designed by theAmerican Association of Oral andMaxillofacial Surgeons Committee onResidency Education and Training andrepresentatives of the Section onEducation.

The Standards for Advanced SpecialtyEducation Programs in Oral andMaxillofacial Surgery, which serve as thebasic structure of all training programs,were approved for implementation bythe Commission on Dental Accreditationon July 1, 1988. These standards are

affiliate for a continuous, graduatedthree-year sequence rather than offeran isolated clinical-only exposure fortrainees.

The Essentials of an Adequate TrainingProgram in Oral Surgery, used as the blue-print for oral and maxillofacial surgeryresidency training since 1958, wasrevised from time to time before a majorrevision was made in 1982 and 1983.The reworked document was adoptedby the Commission on DentalAccreditation in May 1985 and becameeffective in 1986 as the yardstick forevaluation of oral and maxillofacialsurgery training.

In the early 1980s, the length of oraland maxillofacial surgery residency pro-



comprehensive management of the dis-eases, injuries and defects involvingboth the functional and esthetic aspectsof the hard and soft tissues of the oraland maxillofacial regions.

The Medical DegreeSome residency programs provide

education to earn a medical degree as anintegrated component of oral and max-illofacial surgery training. Regardless ofwhether a resident decides to completeresidency with or without a medicaldegree, the oral surgical training is sim-ilar. In accordance with accreditationstandards, all residents must completethe same rotations through the medical,surgical and anesthesia services with thesame level of responsibility. While themedical degree does not impact the oraland maxillofacial surgical education, itprovides an excellent opportunity forexpanded learning in the medical careof patients at all levels.

Because of their specialized educationin general, oral and maxillofacial sur-geons are trained to perform many proce-dures that are also performed by physi-cians, including reconstruction of thenose and orbits, maxillofacial surgery,cleft lip and palate and facial estheticsurgery. Regardless of degree, the oral andmaxillofacial surgeon who is trainedtoday is a competent individual who iscapable of many surgical procedures tohelp patients in need.5

California Training OpportunitiesWithin California, there are seven

fully accredited residency educationprograms for oral and maxillofacialsurgery.

University of California, Los Angeles

Earl G. Freymiller, DMD, MD,program director

The University of California, LosAngeles, has a six-year combined oral

tions in plastic surgery, otolaryngology,neurosurgery, infectious disease, andpediatric surgery. During this time, resi-dents learn management of both adultand pediatric patients.

The resident’s outpatient experi-ence is very broad, as a substantialamount of surgical activity is providedin this setting. Each oral and maxillofa-cial surgery resident sees more than3,000 patients per year on an ambula-tory basis. This would include at least100 general anesthetics or deep seda-tions for adults and children per seniorresident position for outpatient, ambu-latory surgical procedures.

The oral and maxillofacial surgeonadmits and manages a large number ofpatients to the hospital for major med-ical procedures. These patients fall intoa variety of categories, including trau-ma, reconstruction, orthognathicsurgery, pathology, and estheticsurgery. In support of the hospital-based procedures and general anesthe-sia training, the residents all becomecertified in advanced cardiac life sup-port and are trained in advanced trau-ma life support.

Residents also complete a struc-tured, didactic course in physical diag-nosis similar to that provided to med-ical students. This course is taught earlyin residency, enabling applicationthroughout training. It is reinforcedduring rotations to the medical, surgi-cal, and anesthesia services where oraland maxillofacial surgery residents mustfunction at the level of the other resi-dents in the respective services. Becauseof this specialized education, oral andmaxillofacial surgeons are capable ofperforming significant surgical proce-dures within a diverse scope of practice.

In summary, upon completion of anaccredited oral and maxillofacialsurgery program, the surgeon is compe-tent to perform a wide variety of diag-nostic and surgical procedures for the

dures have been incorporated into thecurriculum

The advent of accreditation hasassured minimal yet high standards thatprograms must fulfill to adequately edu-cate surgeons in the profession.4 TheCommission on Dental Accreditation, anationally recognized accrediting body, isresponsible for approving and adminis-tering the standards for accreditation. It isan independent group of individuals whoare appointed by the ADA as well as thenine recognized specialties, and otherdental agencies. Recognition as the ulti-mate accrediting body is given by thecontinued inspection and approval bythe U.S. Department of Education. Inconjunction with the AmericanAssociation of Oral and MaxillofacialSurgeons, it will set criteria for andapprove residency training programs. Thestandards cover a wide range of institu-tional, faculty, curriculum, programresources and patient care areas to assurea high level of education in all accreditedprograms. Each program is subject toreinspection every five years in distinc-tion to the general dental school and allother specialty cycle of seven years.

Residency CurriculumFollowing graduation from dental

school, resident surgeons complete a sur-gical residency of at least four years. Aminimum of 30 months is spent on theoral and maxillofacial surgery service pro-viding a broad scope of specific surgicalexperience for the resident. At least 18months are spent on off-service rotationson a variety of medical/surgical services,which are applicable to the oral and max-illofacial surgeon. There are severalrequired off-service rotations, including aminimum of four months of hospitalanesthesia, two months on the clinicalmedicine service, and four months onthe general surgery service. In addition, atleast eight months is spent on a variety ofother services, which may include rota-

educationResidency


University of the Pacific affiliated withthe long-standing Highland residency.At that time, the residency also made anaffiliation with Kaiser Permanente inOakland.

The residency currently accepts tworesidents per year for a four-year certifi-cation in oral and maxillofacial surgery.Next year, the residency will increase tothree positions per year. The educationof the residents includes didactic cours-es and hands-on dissection labs.

At Highland Hospital, the residentsgain experience in trauma, implants,pathology, dentoalveolar and TMJsurgery. The senior resident rotates atKaiser for six months during whichtime they receive extensive training inorthognathic surgery. At University ofPacific, the residents participate in ajoint orthognathic conference with theorthodontic residents and get experi-ence with complicated dentoalveolarcases. At both institutions, the resi-dents perform conscious and deepsedation.

In November, a team from the resi-dency goes to Mexico with theThousand Smiles program to performsurgery on cleft lip and palate patients.

Travis Air Force Base/David M. GrantMedical Center

Lt. Col. David Smith, DDS, MD,program director

To be a resident in this program, onemust be a member of the military.Travis has a four-year program leadingto an oral and maxillofacial surgery cer-tificate. They accept two residents peryear most of whom have the rank ofcaptain or major.

The residents rotate to Fresno at theUniversity Medical Center for eightmonths to get their trauma training.The main surgical procedures per-formed at Travis are orthognathic, cos-metic and dentoalveolar surgery.

length, allowing for three years ofresearch leading to the PhD.

The residents rotate throughUniversity of California, San FranciscoMedical Center, San Francisco GeneralHospital and San Francisco Veteran’sAdministration Medical Center. The res-idents get experience in pathology,reconstruction, orthognathic surgery,TMJ surgery, implants, dentoalveolarsurgery and anesthesia.

The residents receive intense trainingin didactic courses and lectures. They par-ticipate in the tumor board, journal cluband the orthognathic conference.

In their senior year, residents mayhave the opportunity to exchangepositions with a resident program inGreat Britain to afford a broad base ofeducation.

King/Drew Medical Center

Richard Leathers, DDS, programdirector

The King/Drew Medical Center takestwo residents a year for a four-year cer-tificate program in oral and maxillofa-cial surgery. The facility is a Level 1trauma hospital where the residentsspend the majority of their program.They also rotate to Harbor-UCLAMedical Center for their anesthesia andgeneral surgery training. At Kaiser hos-pital in Los Angeles, they get experiencein orthognathic surgery.

They are currently working on sev-eral projects including trauma andwound healing research.

University of the Pacific/HighlandHospital

A. Thomas Indresano, DMD,program director

The Alameda County HighlandHospital oral and maxillofacial surgeryresidency program was started in 1926as an independent program. By 2001,

and maxillofacial surgery and MDdegree program. Two residents areselected each year and their educationconsists of the required oral and max-illofacial surgery rotations as well as twoyears of medical school and one year ofgeneral surgery internship.

The residents spend their time on theoral and maxillofacial surgery service byrotating at UCLA Medical Center,Harbor-UCLA, and Kaiser Permanente.They receive training in dentoalveolarsurgery, orthognathic surgery, traumaand pathology. Extensive implant andreconstructive surgery education is partof the curriculum as are trips to Mexicofor cleft surgery education. Being basedin the school of dentistry offers a multi-tude of opportunities for didactic educa-tion as well as significant interactionwith all the specialties of dentistry inpatient care.

The program allows for a one-yearinternship in oral and maxillofacialsurgery for individuals who would liketo experience additional education inthat area.

University of California, San Francisco

M. Anthony Pogrel, DDS, MD,program director

The residency program in oral andmaxillofacial surgery at UCSF leads toeither an MD degree from theUniversity of California, San Francisco,School of Medicine, or the University ofCalifornia, Davis, School of Medicine.Both MD programs require a one-yeargeneral surgery internship. The lengthof the residency program depends onthe placement of the resident into med-ical school with advanced training andcan last either six or seven years.

The residents may also combine aPhD in oral biology with their certifi-cate in oral and maxillofacial surgeryand their MD degree. This program isapproximately nine to 10 years in


Foundation grant for research onosteodistraction.

There is a one- year internshipavailable.

References / 1. ADA Definition of Oral andMaxillofacial Surgery, 1977.

2. Recruitment of Oral and MaxillofacialSurgery Residents, AAOMS, 2003.

3. The Building of a Specialty: Oral andMaxillofacial Surgery 1918-1998 EducationalStandards, AAOMS, 2000.

4. AAOMS Statement on Oral and MaxillofacialSurgeons, 2000.

5. Competencies of the Oral and MaxillofacialSurgeon at the Completion of Training, AAOMS,2002.

To request a printed copy of this article, pleasecontact / Alan L. Felsenfeld, DDS, professor ofClinical Dentistry, Oral and Maxillofacial Surgery,UCLA School of Dentistry, 10833 Le Conte Ave.,#53076, Los Angeles, Calif., 90095-3075.

surgery, craniofacial and dentoalveo-lar surgery.

USC/LAC Medical Center

Dennis Duke Yamashita, DDS,program director

The University of the SouthernCalifornia/Los Angeles County oraland maxillofacial surgery residencyprogram is celebrating its 50thanniversary this year. Yamashita, theresidency program director, has seensome changes in the curriculum overthe past several years. Ten years ago,the program took the first MD inte-grated resident. At present, the pro-gram takes two residents per year intothe six-year MD integrated, and one inthe four-year certificate program.

The MD program residents enterresidency by doing their four monthsof anesthesia and integrating with themedical school during their first year.In total, they complete 30 months ofmedical school. During that time, theyintegrate some of the clinical rotationson the oral and maxillofacial surgeryservice. After completing medicalschool, a mandatory one-year intern-ship is done on the general surgery ser-vice at Huntington Memorial Hospital.The residents complete their fifth andsixth year of training on the oral andmaxillofacial surgery service at LACounty Hospital.

LAC is a Level 1 trauma centerwhere residents spend the majority oftheir time. They also spend time atChildren’s Hospital where they gettheir orthognathic surgery trainingand are part of a craniofacial team. Atthe University of Southern California,School of Dentistry, they performother surgical procedures includingimplants.

Current research by the faculty andresidents include a grant for traumaresearch and an Oral and Maxillofacial

University Medical Center, Fresno

Robert Julian, DDS, MD, programdirector

One resident is accepted per year tothe four-year oral and maxillofacialsurgery certification program in Fresno.They do offer a one-year oral and max-illofacial surgery internship and haveone of the Travis Air Force Base resi-dents for eight months of the year.

The resident at UMC gets volumi-nous experience covering the VA,Children’s Hospital, Kaiser, St. Agnesand the Community Medical Centers ofFresno. The major areas of focus aretrauma, pathology and surgical oncolo-gy, orthognathic surgery and some cos-metic surgery.

Current research projects includeplating mandible fractures without theuse of maxillomandibular fixation,osteomyelitis and endoscopically treat-ed mandible fractures.

Loma Linda University

Alan Hereford, DDS, MD, programdirector

The oral and maxillofacial surgeryresidency at Loma Linda Universityoffers two tracks: a four-year certificate,and a six-year MD program. Residentsin the six-year MD program attend theLoma Linda University School ofMedicine. At the end of their medicaltraining, residents complete a one-yeargeneral surgery internship.

The program has affiliations withthe Loma Linda University, School ofDentistry, Loma Linda UniversityMedical Center, Riverside RegionalCounty Medical Center, and ArrowheadRegional Medical Center.

The training the residents receiveis full scope oral and maxillofacialsurgery including trauma, reconstruc-tion, pathology, orthognathic surgery,esthetic surgery, temporomandibular

CDA

educationResidency

Management of asymptomatic malposed third molars is a controversial topic.

As a result, many malposed or mildly pathologic third molars are not removed.

Historical pro and con arguments regarding removal centered around cost and

the aspects of the surgical removal itself. Current epidemiology and medical

advances address issues not considered before.

There is a large growth of the aging population (over 40 years). More and

more of these elderly patients are requiring third molar removal. Over a five-

year period, 1997-2002, the incidence almost doubled to 17.9 percent. This

age category is known to be high risk for third molar surgery.

An equally or higher risk is the rapidly growing number of patients seeking

third molar surgery who are moderately severely medically compromised.

This paper reviews how this lack of consensus results in delayed removal of

malposed third molars in this population. Preventive dental concepts, removing

compromised third molars earlier, would eliminate the high risk to this

aging population.

n 2004, there is no clearly definedconsensus on how to managecompromised third molars. Thereis also considerable disagreementon what constitutes a compro-mised third molar. Third molarsmay be erupted and carious, or ina variety of partially or complete-

ly unerupted states ranging from softtissue impactions to full bonyimpactions. While abnormal, in theabsence of symptoms, many cliniciansfollow the edict, “if it’s not botheringyou, leave it alone.”

This substantial variance of profes-sional opinion regarding removal ofthird molars illustrates a lack of unifor-mity in care currently provided. Theconflicting literature on the necessityfor and timing of third molar removal,shows a historical lack of consensus aswell. Unfortunately, this lack of consen-sus creates a credibility gap for the den-tal profession and confusion in the gen-eral public.

As “baby boomers” (the largest massof the population) approach middle andadvanced age, the need to resolve pro-phylactic third molar treatment issuesbecomes more pressing. With time, age


New Considerations in theTreatment of CompromisedThird MolarsRonald M. Kaminishi, DDS, and Kurtis S. Kaminishi, BA

Authors / Ronald M. Kaminishi,DDS, is in private practice inBellflower and Huntington Beach,Calif. He is a clinical professor atthe University of SouthernCalifornia School of Dentistry andan assistant clinical professor atLoma Linda University at the

University of California, Irvine, School of Medicine.Kurtis S. Kaminishi, BA, is a research associate.

MolarsThird

a b s t r a c t

I


to treat the patient’s infected teeth fortwo months without success. Theurgency was caused by a failing heartvalve. Cardiac valve replacementabsolutely cannot be done in the pres-ence of dental infections, due to bac-teremia or septicemia. Consultation withthe cardiac surgeon indicated the valvecould “blow” at anytime. Because theseteeth were not prophylactically removedwhen the patient was healthy, intra-oper-ative mortality becomes a very real risk.

Many dentists do not consider a 2-millimeter pericoronal radiolucency aconcern. Adelsperger, Glosser (1999)14

and Knights (1991)15 demonstrate thatthe absence of radiographic disease inimpacted third molars is not evidenceof absence of pathology. Biopsy speci-mens of pericoronal tissue of impactedthird molars with no radiographicpathology in patients over 21 years ofage show a 75 percent incidence ofsquamous metaplasia similar to thatfound in odontogenic cysts.14

Odontogenic cysts comprise themajority of major pathologies in com-promised third molars. The incidence ofsquamous cell carcinoma of dentalpathologic tissue is commonly consid-ered as being statistically rare.

Very few dentists are aware thatmalignancies arising from odontogeniccysts have a very high mortality rate.16-20

Although the incidence of such malig-nancies is low, Eversol21 andSchwimmer21 report a 47 percent and37 percent mortality two years aftertreatment.

Preventive dentistry has unequivo-cally demonstrated that early prophy-lactic treatment is more cost effectivethan waiting until potential pathologybecomes more severe or symptomatic.Under the “watchful waiting” protocol,the cost of biannual radiographs andclinical exams added to the increasedcost of a surgery with infection — con-sidered over a 40 to 50 year time span —easily exceeds the cost of prophylacticor early treatment of compromisedthird molars.

been generated over the years regardingthe timing of third molar removal. Inparticular, there is a large body of litera-ture documenting the increased inci-dence of dental complications whenthird molar surgery is performed on anaging population.4-12 Consequently, thispaper will not address the specific surgicalrisks and complications but will focusinstead on how the aging population isaffected by retained third molars.

Third Molars in the AgingPopulation

With human life expectancy on therise, the issue of the aging populationmass becomes a major factor in thirdmolar treatment planning. In a studydone by the authors, it was found thatbetween 1992 and 1997, 10.5 percent ofthe patients requiring removal of thirdmolars were middle or advanced age(older than 40). Fifty percent of thepatients over the age of 60 had com-plete bony impactions. From 1997 to2002, 17.9 percent of patients wereolder than 40. Of that population, 19.5percent were older than 60 (60- to 91-years old). One in five patients requir-ing third molar removal by a dentist isin the high to very high-risk category.

One reason for the increase in themiddle to advanced aged populationcan be attributed to medical advancesin treating disease. Current mortalitypatterns suggest that the mortality rateover age 85 is decreasing to equal therate under age 85, creating an expand-ing pool of patients who are at high tocritically high risk of having medicalcomplications associated with evenminor surgical procedures.13

Dentists are not accustomed to treat-ing critically high-risk patients. For exam-ple, a 40-year-old patient presents forurgent removal of bilateral periodontallyinfected third molars. The patient hadthe lower third molars extracted as ayoung adult. The upper impacted thirdmolars were not authorized by the insur-ance company because they were“asymptomatic.” The periodontist tried

and health status become increasinglysignificant risk factors. The dental pro-fession must maintain the confidence ofthe public. A step toward that aim is toensure that recommended care is consis-tent amongst dentists and that it is sup-ported by sound evidence-based studies.

It is significant that the largest pro-portion of the population is enteringmiddle or advanced age. At older ages,the risks and complications of dentalsurgery become significantly higher aspatients are more likely to have severechronic diseases such as cardiac prob-lems and strokes, or may not heal asrapidly as younger patients may. Thisincreased risk exposes dentists toincreased complications in surgery andpossibly increased episodes of litigation.For example, fragile cardiac or strokepatients kept alive by medications maynot survive a dental extraction.

Important arguments againstremoval of asymptomatic compromisedthird molars exist. Economic restric-tions involve HMOs, insurance compa-nies, third parties, and some membersof the dental profession. Because ofthese financial restraints, patients mayrefuse, and third-party payers fail toauthorize, removal of teeth regardless ofthe degree of pathology present.

Tulloch et al1 states that “this prac-tice (removal of “asymptomatic” com-promised third molars) appears neitherto be associated with the least expectedmorbidity to patients nor with theimperative of cost containment.” At the1977 National Institute of HealthConsensus Development Conference:Removal of Third Molars, it was con-cluded that the removal of asympto-matic non-pathologic teeth is non-essential surgery that exposes patientsto unnecessary risk.2 Oral and maxillo-facial surgeon, E. Preston Hicks statedthat, “routine removal of impacted orunerupted disease free third molars can-not be justified.”3

What are the indications for removalof asymptomatic compromised thirdmolars? A great deal of information has

MolarsThird


14. Glosser JW, Campbell JH, Pathologicchanges in soft tissues associated with radiographi-cally “normal” third molar impactions. Brit J OralMaxillofac Surg 37:259-60, 1999.

15. Knights EM, Brekaw WC, Kessler HP, Theincidence of dentigenous cysts associated with arandom sampling of unerupted third molars. GenDent 39:96-8, 1991.

16. Adelsperger J, Campbell J, Coates DB et al.Early soft tissue pathosis associated with impactedthird molar without pericoronal radiolucency. OralSurg Oral Med, Oral Path 89(4):402-260, April 2000.

17. Eversol LF, Sabes WR, Rovin S, Aggressivegrowth and neoplastic potential of odontogeniccysts. Cancer 35:270, 1975.

18. Fanibunda K, Soames JV, Malignant andpremalignant change in odontogenic cysts J OralMaxillofac Surg 53:1469-72, 1995.

19. Gardener AF, The odontogenic cyst as apotential carcinoma, a clinicopathologicalappraisal. J Am Dent Assoc 78:746, 1969.

20. Schwimmer AM, Aydin F, Morrison SN,Squamous cell carcinoma arising in residual odon-togenic cysts. Oral Surg Oral Med Oral Path, 72:218,1981.

21. Eversol LF, Sabes WR, Rovin S, Aggressivegrowth and neoplastic potential of odontogeniccysts. Cancer 35:270, 1975.

To request a printed copy of this article, pleasecontact / Ronald M. Kaminishi, DDS, 14343Bellflower Blvd., Bellflower, Calif., 90706-3135.

References / 1. Tulloch JF, Antczatk AA, Ung N,Evaluation of the cost and relative effectiveness ofalternative strategies for the removal of mandibularthird molars. Int J Tech Assess Health Care 6:505-15,1990.

2. NIH consensus development conference forremoval of third molars. J Oral Surg 38(3):235-36,March 1980.

3. Preston Hicks E, Third Molar Management:A case against routine removal in adolescent andyoung adult orthodontic patients. J Oral MaxillofacSurg 57:831-36, 1999.

4. Al-Khateeb TK, El-Marsafi AI, Butler NP, Therelationship between the indications for the surgi-cal removal of mandibular third molar and the inci-dence of alveolar osteitis. J Oral Maxillofac Surg49:141-45, 1991.

5. Bruce RA, Federickson GC, Small GS, Age ofpatients and morbidity associated with mandibularthird molar surgery. J Am Dent Assoc 101(2):240-45,August 1980.

6. Chiapasco M, Crescential M, Romanoni G,Germinectomy or delayed removal of mandibularcompacted third molars: The relationship betweenage and incidence of complications. J OralMaxillofac Surg 53:418-22, 1995.

7. deBoer MPJ, Raghoebar GM, Stegenga B etal. Complications after third molar surgery.Quintessence Int 26:779-84, 1995.

8. Hinds, E.C., Rey, KF, Hazards of retainedthird molars in older persons: report of 15 cases. JAm Dent Assoc 101:246-50, August 1980.

9. Osborn TP, Federickson G, Small IA et al. Aprospective study of complications related tomandibular third molar surgery. J Oral MaxillofacSurg 43:767-69, 1985.

10. Tate, TE, Impactions: observe or treat? JCalif Dent Assoc 22(6):59-64, June 1994.

11. Beeman, CS Third molar management: Acase for routine removal in adolescent and youngadult orthodontic patients. J Oral Maxillofac Surg57:824-30, 1999.

12. Carr SJ, Preventive oral surgery. South CalifDent Assoc 34(11):501-8, November 1966.

13. Rothenberg R, Lentzner HR, Parker RA,Population aging patterns: the expansion of mor-tality. J Gerontol 46(2):566-70 March 1991.

ConclusionThe present day lack of consensus

regarding compromised yet asympto-matic third molars, creates confusion indiagnosis of patients. Ultimately, eachcase must be based on individual fac-tors. The pros and cons of early or pro-phylactic treatment of compromisedthird molars should be considered.

The aging mass of our populationand the surging number of functionalbut medically compromised patientsplaces a stronger emphasis on timelytreatment. Preventive dentistrybecomes a more critical issue. In twodecades, the population mass of babyboomers will be in their 60s and 70swith even more serious medical handi-caps. “Simple” surgical and dental pro-cedures might require the advised con-sent of “risk of death.” It is thus imper-ative that dentistry develop a consensusregarding treatment of compromisedthird molars with a sound scientificbasis. Third parties and self-serving enti-ties usually assume no liability butstrongly try to influence our decisions.Early or prophylactic treatment resultsof compromised third molars appearconsistent with the tried and true expe-rience of preventive dentistry. CDA

review of the general anes-thesia techniques used in oraland maxillofacial surgeryduring the last 50 years of the20th century cannot be fullyappreciated without referenc-ing at least briefly, what tookplace in the previous 106

years that encompassed the discoveryand development of general anesthesia tothe mid-20th century. Dentalstudents learn with pride thatW.T.G. Morton and HoraceWells were two dentists credit-ed with the discovery of gener-al anesthesia in the middle1840s.1 Nitrous oxide was theprimary agent that foundacceptance and widespread use in den-tistry, largely through the actions ofGardner Colton, who established a groupof dental practices that specialized intooth extractions. Ether, ethylene, andchloroform were widely used in medi-cine, but nitrous oxide use was refined byElmer I. McKesson and Jay A. Heidbrink,who developed anesthesia machines thatcould deliver precise proportions of oxy-gen and nitrous oxide.2

Oral surgeons in the early 20th cen-tury through the 1930s used nitrousoxide as their primary agent to inducegeneral anesthesia. Alfred Einhorn ofGermany discovered procaine in 1905and local anesthesia became common inthe United States three decades later forroutine dental procedures. But it was theexodontists (later called oral surgeons)

who continued to use nitrous oxide toeliminate the pain associated withremoval of teeth until intravenous anes-thesia became available and popular.

In Southern California, Lock Hales,DDS, started an exodontia practice inGlendale in 1929. He first worked withFrank Chandler, DDS, in Hollywoodand learned the nitrous oxide, oxygendesaturation method that was intro-

duced and popularized by McKesson 30years earlier.3 He learned that orallyadministered pentobarbital (Nembutal)improved his working time and did notrequire hypoxic levels of nitrous oxide.Orlan K. Bullard, DDS, in San Diegoand Dr. Barkley Wykoff in SantaBarbara began using a new intravenousagent, hexobarbital (Evipal) in 1936,but both oral surgeons subsequentlychanged to thiopental (Pentothal)because of its greater versatility.4

Adrian Hubbell, DDS, learned aboutthe studies being done at the MayoClinic with thiopental, and he spentthree years in a surgical fellowship thereto learn as much as possible about thistechnique. He returned to Los Angeles in1940 and worked in Hollywood withFrank Chandler’s successor in practice,


Fifty Years of GeneralAnesthesia in California Oraland Maxillofacial SurgeryJohn J. Lytle, DDS

Author / John J. Lytle, DDS, MD, isan oral and maxillofacial surgeonin private practice in SouthernCalifornia. He is the Wilbur N. andRuth VanZile professor of Oral andMaxillofacial Surgery at theUniversity of Southern CaliforniaSchool of Dentistry.

Berto Olson, DDS. In one year, he con-verted that nitrous oxide practice to athiopental practice. He then moved toLong Beach where he opened his ownpractice, which eventually became adominant force in Southern Californiaand throughout the nation in populariz-ing the technique of intravenousthiopental and later methohexital(Brevital) for general anesthesia in oral

surgery.5

Six of Hubbell’s students,Frank M. McCarthy DDS, MD;Bill Bogart, DDS; HowardDavis, DDS; Bill Wagner, DDS;Ralph O’Brien, DDS; andRobert Steiner, DMD, staffedthe first hospital-based outpa-

tient thiopental dental general anesthe-sia training program at the Los AngelesCounty General Hospital in 1956.Marsh Robinson, DDS, MD, hadbecome chief of oral surgery in 1954and was able to enlist the support ofSam Denson, MD, head of medicalanesthesia at the hospital at that time.That program continues today at theLos Angeles County/USC MedicalCenter, where future oral and maxillo-facial surgeons are learning the latesttechniques in office general anesthesia.

Orally administered pentobarbital (Nembutal) improved his working time and didnot require hypoxic levels of nitrous oxide.

commentary

A


relaxants, but this is not practical inoffice oral surgery. When given inamounts up to 100 micrograms,Fentanyl has rarely been associated withthis complication, and smaller doseswere established for use in office generalanesthesia. Fentanyl continues to beused in many practices. Fentanyl clearlyraises the pain threshold, works quickly,and is short acting. Other synthetic nar-cotic agents such as pentazocine (Talwin)and oxymorphone (Numorphan) were

introduced, but for the majori-ty of surgeons they were not asuseful as fentanyl.

Meanwhile, new monitor-ing devices were being intro-duced, and older progressivesurgeons and young surgeonsfinishing training were more

comfortable using these electronicdevices to assess patients under anes-thesia. Simple monitors to indicatepulse rate were first introduced. Theelectrocardiograph (ECG) was beingused commonly in hospitals but wasthought by oral surgeons to scarepatients. Consequently, many surgeonswere reluctant to use this device. Itwould be another decade before oralsurgeons added the ECG to their moni-toring armamentarium and then onlyafter state regulations made possessionand use of the device mandatory.

During that decade, the publicbecame more aware of the ECG andchest leads through the entertainmentmedia and television shows. The auto-matic sphygmomanometer was intro-duced and became well accepted. It iseasy to use, gives the pulse rate in addi-tion to the blood pressure, and alertssurgeons to sudden changes in bloodpressure preoperatively, intraoperative-ly, and postoperatively.

In the 1980s even better things werein store for oral surgeons monitoringtheir patients. The pulse oximeter wasintroduced, displaying blood oxygena-tion as a percent of oxygen-saturatedhemoglobin. Moment-to-moment

the “purists” or single agent proponent— most prominently the Hubbell groupand his disciples — and the “balancedtechnique” group, who used atropine, anarcotic such as meperidine, methohex-ital, and local anesthesia. Each groupclaimed superiority for their preferredtechnique, and gave convincing argu-ments for their favorite method.

The 1960s saw the introduction ofbenzodiazepines, principally diazepam(Valium), which was first administered

orally and then intravenously. Some sur-geons used diazepam as their only intra-venous agent along with local anesthe-sia, nitrous oxide/ oxygen, and foundthis technique successful. Many surgeonsbegan using methohexital as their princi-pal barbiturate. The onset of methohexi-tal anesthesia was similar to thiopentalbut the duration of action was shorterand the occurrence of laryngospasm lessfrequent. Methohexital was given in a 1percent solution, and thrombophlebitisseemed less frequent than with the moreconcentrated 2.5 percent solution ofthiopental. This unpleasant complica-tion again became more frequent whendiazepam was injected in small veins,with or without other drugs.

In the 1970s, fast-acting, short-dura-tion synthetic narcotics were introduced.Fentanyl (Sublimaze) was being used inhospital general anesthesia cases often asthe sole intravenous agent along withnitrous oxide/oxygen, and was found tobe very safe for debilitated patientsundergoing major procedures. One com-plication, “rigid chest syndrome,”occurred infrequently and only whenhigher doses of fentanyl were used. Inthe hospital environment, this complica-tion can be easily treated with muscle

Hubbell introduced the use of suc-cinylcholine into oral surgery practice inorder to treat laryngospasm. Hedescribed administering increasing dosesto himself and colleagues. They discov-ered that 5 mg was sufficient to “break”most spasms and that a full depolarizingdose was not necessary. He developed anadministration device that allowed himto administer a small dose of thiopentalrapidly, which he called the “surge tech-nique.” The “Hubbell Bubble” is stillused by a few oral surgeons. Itwas possible for an oral sur-geon to begin practice as Halesdid using nitrous oxide and toprogress through the use oforal barbiturates in combina-tion with nitrous oxide, andthen to go on to use intra-venous thiopental and finally metho-hexital in a 30-year span of practice. Ourpredecessors in practice from 1930 to1960 lived through a period when revo-lutionary changes took place.

The 1950s encompassed a periodwhen refinement of techniques for intra-venous general anesthesia occurred. Theuse of thiopental alone came under criti-cism from proponents of balanced anes-thesia techniques in which meperidine(Demerol) was given as an adjunctiveagent to raise the pain threshold, reducethe amount of thiopental needed, andreduce unpleasant and painful emergencefrom general anesthesia. It became com-mon to administer local anesthesia afterthe patient was asleep to provide postop-erative pain relief and to reduce intra-operative bleeding. Atropine and scopo-lamine were sometimes added to the bal-anced techniques to reduce secretions,and block the vagus nerve thus prevent-ing bradycardia. Monitoring was still in itsinfancy, and no oral surgery office usedintra-operative electronic monitoring.Monitoring was common although rudi-mentary in hospital general anesthesia.

Two schools of thought developedin dentistry and oral surgery regardinganesthesia techniques, represented by

Each group claimed superiority for their preferred technique, and gave convincing

arguments for their favorite method.

commentary


ing to the airway, and does not increasepharyngeal secretions or stimulate laryn-gospasm. The onset of anesthesia is rapidand when used in children, there is usu-ally very little or no excitement phase.Most important, sevoflurane does notcause myocardial irritability commonwith Halothane. The major disadvantageto its use at this time is cost.

Presently, sevoflurane is used pri-marily in children to produce a smoothinduction of anesthesia before place-

ment of an intravenous lineand in some very short cases,as the sole anesthetic agent.In adults, sevoflurane has thepotency to permit theremoval of four third molarswhile providing for a rapidand smooth emergence.

Postoperative nausea has been veryinfrequent with sevoflurane. It has beenpredicted that this agent will becomeincreasingly popular with oral surgeonsduring the coming decade.

SummaryIn summary, the advances of the last

half of the 20th century in general anes-thesia delivery by oral and maxillofacialsurgeons are the following:

1. Oral and maxillofacial surgeons intraining are exposed to significantly morehospital general anesthesia training andin addition spent much of their residencytraining performing general anesthesiaon outpatient dental patients undergoingdentoalveolar surgery. Training programsincreased from one year to three years,then to four years and finally, many six-year programs were developed that awardthe MD degree during or following com-pletion of the residency program.

2. Self-evaluation programs were ini-tiated in the late 1960s and evolved intomandatory in-office evaluation by peerpractitioners and later into state-regu-lated evaluation. These programs beganin Southern California and spread toencompass the entire United States.

3. Intravenous ultra-fast acting bar-

muscular drug that had been availablesince the late 1960s but which displayedhallucinogenic side effects that many feltwere unacceptable. Emergence hallucina-tions, which were not prominent in chil-dren, were very distressing to adults. Veryoften, ketamine acted much like an LSDexperience that persisted in some indi-viduals for a prolonged period.

In very much reduced dosage, keta-mine has been used in children andadults to produce a dissociative state,

where the patient appears awake but iscooperative and retains protectivereflexes. The drug is commonly used inmedical emergency rooms in the man-agement of the very young. Still, one-third of dentists using this drug reportthat they have seen emergence halluci-nations in their patients.5

During the 50 years that oral andmaxillofacial surgeons were depending onintravenous agents, the search for an idealinhalation anesthetic continued. In thelate 1950s halothane (Fluothane) wasintroduced. This potent agent displayedrapid onset, a relatively pleasant odor, andthe ability to produce a surgical plane ofanesthesia quickly. It became very popu-lar in hospital-based anesthesia and wasthe standard until newer gases in thesame class displayed better characteristics.The reason halothane did not becomemore popular in the office environmentwas that it had the potential to cause car-diac arrhythmias and death if not careful-ly monitored and precisely given.

In 1996, a new inhalation anestheticwas introduced and again was initiallyused in hospital-based operating rooms.This agent, sevoflurane, has most of theproperties of an ideal inhalation anes-thetic.7 It is pleasant to smell, nonirritat-

changes were revealed and at last, amonitor was available that couldanswer the most critical question, “Isthe patient getting sufficient oxygen?”This device soon became the singlemost important monitor and is requiredto be present in every office utilizingpediatric oral sedation, intravenoussedation, or general anesthesia.

Today, the pulse oximeter, the ECG,and continuous blood pressure devicesform the basis for monitoring patientsundergoing office generalanesthesia in oral surgerypractices in California andthroughout the United States.

A new benzodiazepineagent midazolam (Versed)appeared in this decade. Thisagent was found to have arapid onset of action, much fastermetabolism than diazepam, and aboveall was not a cause of thrombophlebitis.Midazolam has become the standardintravenous benzodiazepine for the vastmajority of surgeons who utilize thesedrugs.5

By the 1990s, research in anesthesiahad seen the development of anotherclass of intravenous anesthetic agents.The new drug propofol (Diprivan) is awhite liquid that looks much like milkwhen seen in the syringe. Propofol hasa smooth, rapid onset of action andduration of action similar to methohex-ital. However, many patients exhibit amarkedly rapid emergence when thedrug is used alone. Since methohexitalwas being used primarily by oral andmaxillofacial surgeons (a relativelysmall market segment) and not by med-ical anesthesiologists, the manufacturersold the rights to produce the drug andduring the early 2000s, methohexitalwas intermittently unavailable. Somesurgeons returned to using thiopental,but many took the lead of medical anes-thesiologists and began using propofolas their main intravenous agent.6

A few surgeons began to rely on keta-mine (Ketalar), an intravenous or intra-

Very often, ketamine acted much like an LSD experience that persisted in some

individuals for a prolonged period.


References / 1. Hubbell AO, The early days of gen-eral anesthesia in oral surgery, proceedings ofAnesthesia Symposium VI, 2-8, September 1993.

2. Clement FW, Nitrous oxide-oxygen anesthe-sia, Lea and Febiger, Chapter 7, 107-17, 1951.

3. McKesson EI, Anesthesia papers, privatelyprinted K.C. McCarthy, Md., 9-25, 1953.

4. Lytle JJ, Office anesthesia in the sixties andseventies, proceedings of Anesthesia SymposiumVI, 15-28, September 1993.

5. Lytle JJ, Report of the 2003 anesthesia sur-vey of the California association of oral and max-illofacial surgeons, December 2003.

6. Valtonen M, et al, Propofol infusion forsedation in outpatient oral surgery, a comparisonwith diazepam, Anaesthesia, 44(9):730-4, September1989.

7. Eger EI, New inhaled anesthetics,Anesthesiology, 80(4):906-22, April 1994.

To request a printed copy of this article, pleasecontact / John J. Lytle, DDS, 1370 Foothill Blvd.,Suite 200, LaCanada Flintridge, Calif., 91011-2117.

monitors are required by the Californiageneral anesthesia regulations.

7. Propofol, an entirely new type ofintravenous agent, was introduced andis used by more than half of oral sur-geons reporting in a survey of drugsused in 2003.5 Propofol may be used byincremental injection or by continuousinfusion incorporating an automaticinfusion pump.

8. Sevoflurane, a potent inhalationanesthetic that has many properties ofan ideal agent — rapid onset, potent,easily delivered by calibrated vaporiz-ers, rapid emergence, infrequent post-operative nausea, and favorable accep-tance by almost all patients about toundergo general anesthesia — is gain-ing acceptance and use by oral andmaxillofacial surgeons.

biturate office anesthesia became veryrefined and several combination drug“balanced” techniques developed.

4. Benzodiazepines, first diazepamthen midazolam were introduced andgained wide acceptance by the dentalprofession.

5. New synthetic narcotic agentswere introduced, which give the oralsurgeon another pain control and anes-thesia supplement. The new agentswere short acting but very effective forthe period necessary to complete mostoffice surgical procedures. Fentanyl isthe prototype for these agents.

6. Monitoring devices were incorpo-rated into practice, and currently alloral surgeons use the pulse oximeter,the electrocardiograph, and blood pres-sure monitoring devices. All of these CDA

commentary

Corrective jaw (orthognathic) surgery

is indicated for patients with a maloc-

clusion caused by a skeletal deformity.

This paper will discuss current con-

cepts in patient evaluation and review

contemporary surgical treatment.

he concept that “form followsfunction” is a notion universal toall aspects of dentistry.1 Formany it is something learnedearly in didactic dental educa-tion. Nowhere is this conceptmore plainly demonstrated thanin the science of facial growth

and development. Maturation of the facial skeleton

and dentition through childhood andadolescence most often results in bal-anced facial features in harmony with afunctional dental occlusion. Whetherthe product of an inherited condition ora developmental disorder, disturbancesin growth of the facial skeleton maylead to a discrepancy that manifests as adental malocclusion (Figure 1).

Problems associated with imbal-ances of the facial skeleton and the den-tal occlusion are so inseparable, thatthey are commonly described as dento-facial deformities. Orthodontic therapyis effective in managing most problems

by camouflaging the skeletal deformity.However, individuals with the mostsevere facial skeletal discrepancies willbenefit from orthognathic surgery torestore facial balance and establish afunctional dental occlusion (Figure 2).

Untreated, dentofacial deformitiescan create problems with manyaspects of oral function, including dif-ficulties with speech, swallowing, andmastication (Figure 3). They may alsocause occlusal trauma from dentalocclusion that is not mutually protect-ed (Figure 4).


Orthognathic Surgery:Diagnosis and Treatment ofDentofacial DeformitiesRobert Relle, DDS, and Tim Silegy, DDS

Authors / RobertRelle, DDS, adiplomate of theAmerican Boardof Oral and Max-illofacial Surgery,maintains a pri-vate practice in

Encino, Calif., and is affiliated with KaiserPermanente in Los Angeles.Tim Silegy, DDS, is an oral and maxillofacial sur-geon in private practice in Long Beach, Calif., anda diplomate, American Board of Oral andMaxillofacial Surgery.

Figure 1a. Profile radiograph of a patient witha significant facial skeletal growth disturbance.Courtesy of Dr. Donald Montano, Bakersfield, Calif.

Figure 1b. The resulting dental malocclusion.Courtesy of Dr. Montano.

SurgeryOrthognathic

a b s t r a c t

T


multiple spatial planes. A systematic,compartmentalized evaluation of thedentofacial deformity will bring theproblem to the forefront.

Many clinical evaluation schemesattempt to evaluate anterior-posteriordiscrepancies and vertical discrepanciesindependently. Some of the more com-mon deformities are described in thispaper.

erly diagnosing dental malocclusionand applying the correct classifica-tion, i.e. Angle’s Class I, II, and III,open bite, and deep bite.2 However,the skeletal imbalances that producethe more pronounced dental maloc-clusions are sometimes difficult toappreciate. This is because thesedentofacial deformities often repre-sent a combination of problems in

The dentist is uniquely trained toidentify a disturbance in growth of thefacial skeleton and to understand how itmay be the foundation of a dental mal-occlusion. With this awareness, he orshe can educate patients and discuss theappropriate available treatment.

DiagnosisMost clinicians are adept at prop-

Figure2a. Profileof patient inFigure 1 priorto combinedorthodonticand surgicaltreatment.

Figure2b. Profile ofpatient aftersurgery toadvance themaxilla and setback themandible.

Figure 2c. Finished dental occlusion.

Figure 3. Patient with a dentofacial deformi-ty. Note the anterior cross bite. This malocclusionis often associated with difficulty tearing andchewing food. Courtesy of Dr. Merilynn Yamada,Burbank, Calif.

Figure 4a. This traumatic occlusion hascaused attrition at the occlusal edge of the lowerright premolar. Courtesy of Dr. Yamada.

Figure 4b. Finished dental occlusion aftercombined orthodontic and surgical treatment forcorrection of mandibular hyperplasia withmandibular set back. Courtesy of Dr. Yamada.

Figure 5. Radiographic profile of a patientwith mandibular hypoplasia. The upper incisorsare resting on the lower lip.

Figure 6a.Patient withmandibularhypoplasia dis-playing increasedfacial convexityand a retrudedchin. Note thechin position rel-ative to a verticalline passingthrough the baseof the nose.Courtesy of Dr.Montano.

Figure6b. Profilechanges aftersurgery toadvance themandible.Courtesy ofDr. Montano.

SurgeryOrthognathic


associated with Class III dental malocclu-sion. With isolated maxillary hypoplasia,the upper lip will appear deficient andfrom the profile, the angle between theupper lip and the nasal base will be acute.There is often deficient projection of theface to the side of the nose and in the areaof the cheekbones. Independent evalua-tion of mandibular projection will revealthat the chin is actually in an acceptableposition relative to the vertical referenceline (Figure 11).

Quite commonly, both mandibularhyperplasia and maxillary hypoplasia

and a prominent chin. Using the samevertical line passing through the base ofthe nose, one will find the lower lip andchin positioned in front of this reference(Figure 9). The natural dental compensa-tions include retrusion and crowding ofthe lower incisors and flaring of theupper incisors. This may occur withdiastemas, if the maxilla is sufficientlywide, or there may be dental crowding ifthe maxilla is narrow (Figure 10).

Care must be taken to differentiatemandibular hyperplasia from maxillaryhypoplasia because both conditions are

Horizontal Discrepancies

Mandibular Hypoplasia

Anterior-posterior mandibular hypo-plasia (mandibular retrusion) is usuallyassociated with Class II dental malocclu-sion. Individuals with this condition usu-ally have increased facial convexity and aretruded chin. They tend to display aneverted lower lip and a deep labiomentalfold, especially if the dental malocclusionis large enough to cause the upperincisors to rest on the lower lip (Figure 5).

To evaluate the facial profile, thepatient is instructed to assume a relaxedhead posture tilting neither up nordown. This may be facilitated by havinghim or her gaze into a mirror placed ateye level across the examination room.The clinician is positioned to examinethe patients profile and an imaginaryvertical line passing through the base ofthe nose is constructed.3,4 Withmandibular hypoplasia, the point of thechin will be positioned well behind thisreference line (Figure 6).

When mandibular hypoplasia is sig-nificant it causes the nose to appear rel-atively prominent. In fact, manypatients seeking cosmetic surgery con-sultation for what they perceive as anexcessively prominent nose have in real-ity, a hypoplastic mandible (Figure 7).

Natural dental compensations areusually observed in individuals withmandibular retrusion. The lower anteri-or teeth are often tipped forward andextruded. The upper incisors are crowd-ed and positioned relatively upright.(Figure 8.)

Mandibular Hyperplasia andMaxillary Hypoplasia

Mandibular hyperplasia is generallyassociated with Class III dental malocclu-sion. The characteristics common to thiscondition include a concave facial profile

Figure7a. Patientwithmandibularhypoplasiawho has arelativelyprominentnose.

Figure7b. Samepatient aftersurgery toadvance themandible.Straighteningof the profilereduces therelativeprominenceof the nose.

Figure 8a. Class II malocclusion of apatient with mandibular hypoplasia. Note theupper incisor crowding.

Figure 8b. Same patient after combinedorthodontic and surgical treatment that involved amandibular advancement.

Figure 9.Patient withmandibularhyperplasia.Note the posi-tion of thechin relativeto the refer-ence line.

Figure 9b.Surgery to setback the mandiblelessens the facialconcavity.

occur simultaneously. In this instance,features common to both deformitieswill be evident.

Vertical Discrepancies The face is typically divided into

thirds when performing a verticalanalysis. The upper facial third is mea-sured from the hairline to the mid-brow. The middle third is measuredfrom the midbrow to the base of thenose. The lower facial third is mea-sured from the base of the nose to thebottom of the chin. Most verticaldentofacial discrepancies are manifestin the lower facial third.

Vertical discrepancies have a pro-found effect on facial projection. Oneexample of this condition is thepatient with an anterior open bite(Figure 12). This condition will accen-tuate facial convexity and cause themandible to appear more retrusive andthe chin to appear vertically elongat-ed. These individuals will have a longslender face, as downward and back-ward rotation of the mandible causesjaw line definition to be weak. Thisappearance is further accentuated asthe patient draws the lips together toproduce a seal. This causes flatteningof the labiomental fold and the char-acteristic “orange peel” effect of men-talis muscle strain.

Figure 10. Note the natural dental compen-sation for this patient with mandibular hyperpla-sia. The upper incisors are flared forward and thelower incisors are retruded and slightly crowded.

Figure11a.Vertical refer-ence linereveals thispatient’s chinto be in cor-rect positionand maxillato be retrud-ed. Courtesyof Dr. MarioPaz, Marinadel Rey, Calif.

Figure 12b. Preorthodontic occlusionshowing open bite. Courtesy of Dr. Montano.

Figure12a. Theprofile of thispatient showsa retrudedchin and lipincompe-tence.Courtesy ofDr. Montano.

Figure 12d. Post-treatment occlusion.Courtesy of Dr. Montano.

Figure12c.Profile after amaxillaryimpaction.Note promi-nence ofchin. Courtesyof Dr.Montano.

Figure11b. Thesame patientafter maxil-lary advance-ment.Courtesy ofDr. Paz.

Figure 13a. Preorthodontic occlusion show-ing with minimal room for skeletal movement.

Figure 13b. Occlusion after orthodontictreatment. Eliminating dental compensation creat-ed the space for optimal movement of jaws.


SurgeryOrthognathic

ery and comfort immediately aftersurgery. Rapidly metabolized anestheticagents, effective non-narcotic anal-gesics, and powerful antiemetic drugshave been instrumental in shorteningrecovery time, frequently permittingthe orthognathic surgery patient toreturn home only two or three hoursafter the procedure has been completed.

With intimate knowledge of thefacial anatomy, the oral and maxillofa-cial surgeon is able to move componentsof the facial skeleton into the desiredrelationships using precise bone cuts(osteotomies) and controlled fractures.Most dentofacial deformities are correct-ed with one or a combination of the fol-lowing osteotomies: Le Fort I (maxillary)osteotomy, sagittal osteotomy of themandibular rami, and osseous genio-plasty7,8,9 (Figure 14). Additional cos-metic procedures may be employed toenhance the result. A power saw with afine blade is the primary surgical instru-ment for these procedures (Figure 15).

Once the osteotomies have beencompleted, the skeletal part can berepositioned as desired and then rigidlyfixated using small titanium plates andscrews (Figure 16).

ConclusionThis article demonstrates basic prin-

ciples in the diagnosis and correction ofdentofacial deformities. Early recogni-

harmony with a Class I dental occlusion(Figure 13).

SurgeryModern orthognathic surgery is safe

and predictable. In many cases the sur-gical procedures can be done in an out-patient setting, eliminating the incon-venience and expense of a hospital stay.Patients are far less inconvenienced bymodern surgery owing to technologicaladvances such as rigid internal fixation,a method of stabilizing the bony cuts(osteotomies) such that immobilizationof the jaws with wire is avoided.6 Thispermits speech and a soft diet soon aftersurgery. Patients often return to lightactivities in as little as one or two weeks.

Modern general anesthesia, arequirement for orthognathic surgery,has also greatly facilitated patient recov-

Treatment

OrthodonticWith few exceptions, the correc-

tion of a pronounced dentofacialdeformity requires combined ortho-dontic and surgical treatment. As men-tioned earlier, patients with dentofa-cial deformities usually present withsome degree of dental compensation.An important goal of orthodontic ther-apy is to eliminate these compensa-tions so that the magnitude of the den-tal discrepancy is equivalent to themagnitude of the skeletal discrepancy.When presurgical orthodontic treat-ment has been completed, the occlusaldiscrepancy will be more pronounced.5

This critical part of the treatment isthe key that allows orthognathicsurgery to provide a balanced face in

Figure 14a. Le Fort I osteotomy. Figure 14b. Sagittal osteotomy ofmandibular ramus.

Figure 14c. Horizontal osteotomy of ante-rior mandible below mental foramina.

Figure 15. Small power saw used to perform osteotomy.

Figure 16. Titanium plate and screws used to rigidly fixate osteotomy.



tion by the general practitioner andreferral to an oral and maxillofacial sur-geon can provide patients with a stable,functional occlusion and enhancedfacial esthetics.

References / 1. Enlow DH, Hans MG, Essentials ofFacial Growth, Philadelphia, PA, WB Saunders Co.,1996.

2. Proffit WR, Contemporary Orthodontics, St.Louis, MO, CV Mosby Co., 1986.

3. Lundstrom F, Lundstrom A, Natural headposition as a basis for cephalometric analysis, Am JOrthod Dentofacial Orthop 101(3):244-7, 1992.

4. Houston WJ, Basis for the analysis ofcephalometric radiographs: Intracranial referencestructure or natural head position, Proc Finn DentSoc 87:43, 1991.

5. Shanker S, Vig KWL, OrthodonticPreparation for Orthognathic Surgery In: Oral andMaxillofacial Surgery By, Fonseca RJ, W.B. SaundersCo., Philadelphia, PA, 2000.

6. Jeter TS, Van Sickels JE, Dolwick FM,Modern Techniques for Internal Fixation of SagittalRamus Osteotomies, J Oral Maxillofac Surg42(4):270, 1984.

7. Bell WH, Le Fort I Osteotomy for Correctionof Maxillary Deformities, J Oral Surg 33(6):412-26,1975.

8. Trauner R, Obwegeser H, Operative OralSurgery: The correction of mandibular prognathismand retrognathia with consideration of genioplasty,J Oral Surg (Chic) 10(7):677, 1957.

9. Converse JM, Wood-Suth D, HorizontalOsteotomy of the Mandible, Plast Reconstr Surg34:464-71, 1964.

To request a printed copy of this article, pleasecontact / Robert Relle, DDS, 4900 W. Sunset Blvd.,Los Angeles, Calif., 90027-5814.

CDA

Whether minor or major, traumatic

injuries to the maxillofacial area have

far-reaching physical and emotional

effects. Because the dentition dictates

facial form and function, the oral and

maxillofacial surgeon, a dental special-

ist with a minimum of four years of

hospital-based surgical training, is

uniquely qualified to manage these

injuries. At times, the expertise of the

general dentist and other dental spe-

cialists may be needed to provide

definitive care. Several cases are pro-

vided to illustrate management of facial

trauma.

rauma remains a major healthand social issue throughout theworld. In the United Statesalone, every year thousands ofpeople of all ages sustain facialinjuries from automobile andother various vehicular acci-dents, firearms, athletic activi-

ties and altercations.1,2,3 Regardless ofthe mechanism, traumatic maxillofacialinjuries can significantly affect the phys-ical and psychological health of theindividual. Because oral and maxillofa-cial surgeons have a broad educationalbase in dentistry and medicine, they areuniquely qualified to mange traumaticinjuries to this area. This paper reviewsthe role of the oral and maxillofacial sur-geon in providing care to these patients.

There are many ways to categorizefacial injuries. For the purposes of thispaper however, traumatic facial injurieswill be divided into minor trauma andmajor trauma.

Minor trauma refers to localizedinjuries that typically lack the potentialto be life threatening. These include iso-lated lacerations, fractured and sub-luxed teeth, and non-complex facialfractures such as isolated fractures of thezygomatic arch, maxilla and mandibleand alveolar processes. Surgery to cor-rect these problems can frequently becarried out in the office or surgical cen-ter environment.

Major trauma usually involves morethan one body system. Because of theseverity of the injury, multiple health

professionals generally manage thepatient in the hospital environment.

Trauma in general has many mech-anisms. Blunt trauma is the result of anunstoppable force meeting an immov-able object. Falls, physical assaults andmotor vehicle accidents are examples.Resultant soft tissue injuries can rangefrom contusion to avulsion. Hard tis-sue injuries may be relatively minorand include subluxed and fracturedteeth and non-displaced facial frac-tures. More severe injuries range fromisolated mandible fractures to pan-facial fractures.

When sharp or fast moving objectspierce the soft tissue of the maxillofacialarea, significant injuries can result.Gunshot wounds, knives, and foreignbodies are common mechanisms ofpenetrating injury. Penetrating injuriescan quickly become life threatening dueto vascular and respiratory compromise.

Patient AssessmentForces sufficient to cause even

minor damage to the maxillofacial com-plex can also harm the central nervoussystem.4 The brain and spinal chord aremost susceptible to injury and a com-


Management of TraumaticFacial InjuriesTim Silegy, DDS, and Peter Scheer, DDS, MS

Authors / Tim Silegy, DDS, is anoral and maxillofacial surgeon inprivate practice in Long Beach,Calif., and a diplomate, AmericanBoard of Oral and MaxillofacialSurgery.

Peter Scheer, DDS, MS, is inprivate practice in Rancho Mirage,

Calif. He is a diplomate of the American Board ofOral and Maxillofacial Surgery.

TraumaFacial

a b s t r a c t

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severe maxillofacial injuries frequentlyare victims of other body trauma and assuch, are generally brought to hospitalemergency departments by way of para-medic ambulance. On presentation,their airway, breathing, and circulationare evaluated and managed. Life-threat-ening injuries are identified and emer-gency surgery performed. Once stabi-lized, their maxillofacial injuries can beaddressed.

In the last 20 years, two medicaladvances have revolutionized the waytraumatic facial injuries are managed.Most commonly, the extent of theinjuries are determined by computer-ized tomography (CT) scanning.5,6

Images obtained allow the surgeon tovisualize a complete 3-dimensionalreconstruction of the facial skeleton.This enhances his or her ability todetect the full extent of injuries and for-mulate a precise surgical plan.7

The development and use of rigid

Figures 2a-2c show a 5-year-oldfemale who presented to the emer-gency room after having been bittenby a dog. Due to the age of the child,this complex laceration was managedin the operating room under generalanesthesia.

After thoroughly irrigating thewound with a triple antibiotic solution,the vermillion border was re-approxi-mated. The oral mucosa was closedusing 4-0 gut suture. The orbicularis orismuscle was closed with resorbablesuture and the skin closed with 5-0nylon suture. Because of the potentialfor infection, the patient receivedantibiotics.

Management of Major TraumaticInjuries

At some point during their profes-sional careers, most oral and maxillofa-cial surgeons are part of a trauma man-agement team. Patients who sustain

plete neurological exam is indicated inthese patients. Patients with alteredmental status and/or neck pain shouldhave head and cervical spine injuriesruled out by CT scan.

Management of Minor TraumaticInjuries

The oral and maxillofacial surgeonwill frequently be called upon to man-age minor traumatic injuries. Many ofthese cases can be handled expeditious-ly in the office environment. Figures1a-d show a 9-year-old female who sus-tained blunt trauma as a result of fallingoff a pogo stick.

The patient was referred to her gen-eral dentist by her pediatrician formanagement of an upper lip lacerationand damaged central incisors. The gen-eral dentist subsequently referred herto one of the authors for definitivecare. There were no associated neuro-logical findings and her head and neckexam was normal.

After reassuring the patient andreducing anxiety with nitrousoxide/oxygen, local anesthesia wasadministered. A more thorough intrao-ral examination revealed Ellis Class IIIfractures of teeth Nos. 8 and 9. Thesame teeth were also subluxed palatally.The anterior labial gingival was slightlydegloved and the maxillary labialmucosa macerated. An occlusal radi-ograph showed widening of the peri-odontal ligament space at the apex.There was no evidence of root fracture.

A straight forceps was used to repo-sition the central incisors labially. Theteeth were then splinted to the adjacentlateral incisors using 24-gauge roundwire. Calcium hydroxide was placed onthe exposed pulp and topped with athin layer of composite. The gingivallacerations were closed using 3-0 gutsuture. The splint was removed twoweeks later and the patient was referredto an endodontist for management ofpulpal necrosis.

1a.Abrasion onchin and liplaceration.

1b. Lip laceration and subluxed teeth Nos. 8 and 9.

1c. Occlusal radiograph showing root displacement.

1d. Teeth reduced and splinted with thin wire.

TraumaFacial


into his trachea. Arch bars were thenplaced on the maxillary and mandibu-lar teeth to provide for maxillo-mandibular fixation. With the patient’spre-morbid occlusion reproduced, thefractures were accessed via skin inci-sions in natural neck creases. Once thefracture segments were aligned, rigidtitanium plates and screws were used tohold the segments in the correct posi-tion. The inter-dental fixation wasremoved just two weeks after surgery,which allowed the patient to consumea soft diet.

result in mandible fractures. Figures 3a-3f show a 41-year-old man who wasassaulted during an argument. Hereceived a single blow to the left chin,the force of which fractured the leftmandibular body and the rightmandibular angle. Muscle pull furtherdisplaced the fracture. The patient hadno other injuries.

The patient was taken to the operat-ing room where his surgery was per-formed under general anesthesia. Hisairway was protected by passing abreathing tube through his nose and

internal fixation to stabilize facial frac-tures is the second advancement.8-13

Well-tolerated titanium plates andscrews have replaced stainless steel wireand provide absolute immobilization offractures decreasing the incidence ofpostoperative complications and elimi-nating the need for long-term inter-dental wiring. Consequently, thepatient can return to normal functionearlier without compromising healing.The cases that follow illustrate the prac-tical application of these technologies.

Physical altercations frequently

2a.Throughandthrough liplacerationextendingto leftnares.

2b.Postoper-ative view.

2c. Three-month follow up.

3a. Panoramic showing severely displaced fractures.

3b. Displaced mandibular body fracture. 3c. Patient placed in maxillo-mandibular fixation.

3d. Titanium plate rigidly fixating body fracture.

3e. Postoperative panoramic radiograph.

3f. Post-operativePA radi-ograph.


orbito-ethmoid (NOE) complex and leftand right zygomatic buttress. The frontalsinus was also fractured. He then under-went extensive surgery to repair his frac-tures and complex facial lacerations.

The patient’s dentition was utilizedas a guide for the initial facial fracturereduction, using maxillo-mandibularfixation. Titanium plates and screwswere then used to rigidly fixate his frac-tures and were placed through his exist-ing facial lacerations, as well as a modi-fied coronal flap.

The frontal sinus was then debrided.The sinus membrane was removed in itsentirety, and the defect was obliteratedwith autologous fat obtained from theabdominal wall superior to the umbili-cus. Once the hard tissues were repaired,attention was turned to the soft tissuedefects. The transected right facial nerveand parotid duct were repaired. Lastly,his facial lacerations were closed and hisnearly avulsed ear repaired. The patientremained in the hospital for several

occlusion would be consistent with thepreoperative occlusion. The large boneydefect was then bridged by a locking tita-nium reconstruction plate. After copi-ously irrigating the wound, a drain wasplaced and the oral mucosa and extra-oral sites were closed primarily.

The patient is presently undergoingorthodontic treatment. Once complete,the boney defect of the left mandibularbody will be reconstructed with boneharvested from the iliac crest. After aperiod of healing, her missing teeth willbe replaced with dental implants.

The final case illustrates the effect ofsevere blunt facial trauma. (Figures 5a-g.) This 21-year-old male, was the victimof a single car rollover accident in theearly morning hours. He sustained mul-tiple severe craniofacial, maxillofacial,and orthopedic injuries. He was airliftedto a regional trauma center where hiscondition was stabilized. A CT scan wasperformed which revealed a classic LeFort III fracture involving the naso-

Figures 4a-g represent a 20-year-oldfemale who was the victim of a largecaliber gunshot wound at close range.The patient was stabilized by the trau-ma team and admitted to the surgicalintensive care unit.

The wound was debrided in the oper-ating room while the patient was undergeneral anesthesia. Nonviable bone,tooth, and bullet fragments were careful-ly removed. Intact teeth were used toplace the patient into maxillo-mandibu-lar fixation assuring the postoperative

4a. PA radi-ograph showingbullet and bonefragments.

4b. CT scan (axial view). 4c. Entrance wound left cheek.

4d. Intra-oral view. 4e. Locking titanium reconstruction plate. 4f. Primary closure of entrance wound.

4g. Fifteen-month follow up showing minimalscarring.

TraumaFacial


tures. J Oral Maxillofac Surg 61:861, 2003. 9. Cunningham LL, Haug RH, Ford J, Firearm

injuries to the maxillofacial region: An overview ofcurrent thoughts regarding demographics, patho-physiology, and management. J Oral Maxillofac Surg61:932, 2003.

10. Scolozzi P, Richter M, Treatment of severemandibular fractures using AO reconstructionplates, J Oral Maxillofac Surg 61:458-61, 2003.

11. Ellis E, Koury M, Rigid internal fixation forthe treatment of infected mandibular fractures, JOral Maxillofac Surg 50(5):434-43, 1992.

12. Dodson TB, Perrott DH, et al., Fixation ofmandibular fractures: A comparative analysis ofrigid internal fixation and standard fixation tech-niques, J Oral Maxillofac Surg 48(4):362-6, 1990.

13. Ellis E, Potter J, Treatment of mandibularangle fractures with a malleable noncompressionminiplate, J Oral Maxillofac Surg 57(3): 288-92,1999.

To request a printed copy of this article, pleasecontact / Tim Silegy, DDS, 6226 E. Spring St., Suite315, Long Beach, Calif., 90815-1449.

maxillofacial injuries the oral and max-illofacial surgeon may be called upon tomanage. A comprehensive education indentistry, medicine, and surgery pro-vides these dental specialists with theskills necessary to give trauma victimsexcellent care.

References / 1. Advanced Trauma Life SupportStudent Manual, 6th Ed., American College ofSurgeons, Chicago, IL, 1997.

2. Assael LA, Managing the trauma pandemic:Learning from the past, J Oral Maxillofac Surg 61(8):859-60, 2003.

3. Laskin D, Best AM, Current trends in thetreatment of maxillofacial injuries in the unitedstates, J Oral Maxillofac Surg 58(2):207-15, 2000.

4. Lalani Z, Bonanthaya KM, Cervical spineinjury in maxillofacial trauma, Br J Oral MaxillofacSurg 35(4):243-5, 1997.

5. Furst IM, Austin P, et al., The use of com-puted tomography to define zygomatic complexposition, J Oral Maxillofac Surg 59(6): 647-54, 2001.

6. Ploder O, Clemens K, et al., Evaluation ofcomputer-based area and volume measurementfrom coronal computed tomography scans in iso-lated blowout fractures of the orbital floor, J OralMaxillofac Surg 60(11):1267-72, 2002.

7. Broumand SR, Lales JD, et al., The role ofthree dimensional computed tomography in theevaluation of acute craniofacial trauma, Ann PlastSurg 31(6):488, 1993.

8. Ellis E III, Muniz O, Anand K. Treatmentconsiderations for comminuted mandibular frac-

days postoperatively.Since the initial surgery, he has

undergone multiple scar revisions utiliz-ing CO2 and YAG lasers, as well as pri-mary excision of residual scar tissue.This fall, the final refinements will becompleted by performing a correctivesepto-rhinoplasty to finalize his post-traumatic rehabilitation.

ConclusionThe cases presented in this paper

represent in part, the wide variety of

5a. Three-dimensional CTscan showingfractures.

5b. Partially avulsed left ear. 5c. Scalp laceration extending to right eyelid.

5d. Titanium mini-plates used to repair fractured orbit.

5e. Coronal flap used to access orbits andfrontal sinus.

5f. Left ear reattached.

5g. Frontalview 11 monthsafter injury.

CDA

The temporomandibular joint is one of

the most complicated joints in the

human body. Because signs and symp-

toms of TMJ problems often disrupt

mastication, the general dentist may be

the first health care provider the

patient sees. Cases that are refractory

to nonsurgical treatment are frequently

referred to an oral and maxillofacial

surgeon. This paper provides an

overview of the surgical procedures

used to manage internal derangement

of the TMJ.

emporomandibular disordersis a set of symptoms (that mayor may not have pathology)that can be treated surgically.Surgical treatment is typicallyemployed only when theestablished diagnoses areamenable to surgical treat-

ment. Unfortunately, many times “fail-ure of conservative treatment” hasbecome a reason for surgery. This exclu-sionary diagnosis is fraught with failure.Pain is not a diagnosis that can be treat-ed with surgery. The goal of surgicalintervention is to correct demonstrablepathology.

Many pathologic conditions havesurgical solutions. These include inter-nal derangement, degenerative arthritis,inflammatory arthritis, and iatrogenicjoint destruction. Other conditions thatmay contribute to TMD can be treatedwith techniques performed by oral andmaxillofacial surgeons. These includedentofacial deformities, myalgia, andmyositis.

Botox InjectionsWhile not a surgical procedure,

Botox can be very helpful for refractorypain due to muscle problems in surgicaland nonsurgical cases. Patients withmuscle pain from primary myositisrespond to injection of Botox into the

masseter, and temporalis muscles.Injection of the drug decreases the mus-cle activity in discreet areas. The agentmust be injected using an electromyo-graphically directed needle. A tuber-culin syringe attached to the EMG nee-dle is used to inject 10 to 70 units ofBotox per side, usually 40 to 50 units infive divided doses in the masseter and20 to 30 units in the temporalis.

This treatment causes a decrease inthe contractility in certain areas of themuscle, which decreases the hyperactiv-ity and allows for rest and repair.Patients do not notice a decrease inchewing strength. One would expectthe results to last about six weeks (theduration of Botox), but the effects seemto last much longer, possibly becausethe cycle of muscle parafunction is bro-ken. The patient may remain asympto-matic if no inciting event resumes.Botox has been used on very refractorypatients with very good success, lasting


Temporomandibular JointDisease: An Update ofSurgical TreatmentA. Thomas Indresano, DMD, and Angelle Casagrande, DDS, MD

Authors / A. Thomas IndresanoDMD, is professor and chair, Oraland Maxillofacial Surgery, Univer-sity of the Pacific, and programdirector at Highland GeneralHospital.

Angelle Casagrande DDS, MD,is formerly assistant professor Oral

and Maxillofacial Surgery, University of the Pacific,and assistant program director at Highland GeneralHospital. She currently is in private practice inTucson, Ariz.

DiseaseTMJ

a b s t r a c t

T


ature.11 An arthroscope is passed intothe inferior joint space allowing thesurgeon to visualize the joint.Arthroscopy can be diagnostic or thera-peutic. It was first used to treat closedlock and is presently used for all stagesof ID and DJD. Those who developedthe technique refined it so that fullarthroscopic arthroplasty could be per-formed. Unfortunately, triangulationand complicated maneuvers like laser

products like kinins which have beenshown to cause pain.5,6 The techniquecan be used as a means of placing med-ications in the joint which may prove tobe the best reason for performing it inthe future. Various forms of steroidshave been used to reduce inflammation.Hyaluronic acid has been used toincrease joint lubrication. NSAIDS havebeen tried to give long-acting pain reliefas well as reduced inflammation.Narcotics have been used to break thepain cycle, and sclerosing agents havebeen used to stabilize loose joint liga-ments (Figure 1).

ArthroscopyArthroscopy is a very useful tech-

nique with a wealth of supportive liter-

as long as one year, with repeated suc-cess on subsequent injections.1,2

Arthrocentesis The introduction of a needle into

the superior joint space is an outgrowthof arthroscopy. Experience with arthro-scopic lysis and lavage showed the ben-efits of irrigation. Therefore, since thereseemed to be no reason to actually lookinside the joint in many situations,arthrocentesis was derived.3,4 The tech-nique has become the first line treat-ment for newly diagnosed patients withinternal derangement and has beenused for all stages of ID and DJD.However, the literature best supports itsuse for locking joints. Irrigation isdeemed useful to remove “breakdown”

Wilkes Staging of Internal Derangement7

STAGE CLINICAL IMAGING SURGICALI. EARLY Painless clicking Slightly forward Normal disc form

No restricted motion disc, reducing Slight anterior displacementNormal osseous contours Passive incoordination

(clicking)

II EARLY/ INTERMEDIATE Occasional painful Slightly forward disc, Anterior disc displacementclicking reducing Thickened discIntermittent locking Early disc deformityHeadaches Normal osseous contours

III. INTERMEDIATE Frequent pain Anterior disc displacement, Disc deformed and displacedJoint tenderness, reducing early progressing Variable adhesionsheadaches to non-reducing late No bone changesLocking Moderate to markedRestricted motion disc thickeningPainful chewing Normal osseous contours

IV. INTERMEDIATE/LATE Chronic pain, headache Anterior disc displacement, Degenerative remodelingRestricted motion non-reducing marked of bony surfaces

disc thickening abnormal Osteophytes Adhesions,bone contours deformed disc without

perforation

V. LATE Variable pain Anterior disc displacement, Gross degenerative changesJoint crepitus non-reducing with perforation of disc and hard tissues; Painful function and gross disc deformity Perforation

Degenerative osseous Multiple adhesionchanges

Table 1

Figure 1.Arthrocentesisof right TMJ.

DiseaseTMJ


itself under the displaced disc. Outcomesare similar to other surgical treatments,but acceptance has been limited.

Total Joint ReplacementReplacement of bone substance for

severely degenerated joints has been avail-able for many years. Autogenous graftingwith hip or rib has been used along witha number of more unusual donor sites.Most autogenous grafting has the prob-lem of previous scarring and limitedblood supply. Rib grafting is often used forgrowing children since growth can becontinued at the costochondral interface.

Replacement using allogeneic sys-tems has increased since Mercuri pub-lished outcome studies over 20 yearsshowing excellent retention and correc-tion of severe DJD12 (Figure 5).

Distraction OsteogenesisDeveloped for orthognathic proce-

dures, it recently has been used for thereplacement of condyles that have beenseverely degenerated as well as forfailed allogeneic total joints. The theo-ry is appealing since slow distractioncauses bone deposition and soft tissuegrowth, including new vascularity.While a small number of surgeons havereported success, long-term results haveyet to be reported.

ConclusionA wide variety of surgical procedures

are available to correct pathologic tem-poromandibular joints. Over the years,the authors have performed all of the

DiscectomyThe most written about and most suc-

cessful surgical technique related to TMJsurgery since the early part of the 20thcentury, discectomy (surgical removal ofthe articular disk) has been used in theUnited States and in Europe to deal withadvanced degenerative joint disease.8

Silver has a follow up greater than 50years on these patients.9 Removing thedisk in its entirety, the surgery getspatients out of pain and improves func-tion. Eventually the patient exhibits radi-ographic changes in the bone and jointcrepitance. These signs were accepted inEurope and explained as accelerating the“natural history of the disease” or takinga Wilkes Stage 2 or 3 and advancing it toa Stage 4. This was deemed acceptable asthe patient returned to a state of pain freemobility.

In this country, these changes werenot deemed acceptable and consequent-ly, spurred a number of attempts at discreplacement, which included using der-mis, ear cartilage, femoral head carti-lage, temporalis muscle and a variety ofalloplastic materials as substitutes forthe missing disk (Figure 4).

CondylotomyThis technique stemmed from the

reports that patients who underwent ver-tical ramus osteotomies for orthognathiccorrection improved their TMJ symptoms.First used in Britain by Ward-Booth, it hasbeen championed by Hall.10 The theory isthat instead of placing the disc over thecondyle, one allows the condyle to find

usage are technically difficult, causingarthrocentesis to be used more fre-quently. The value of arthroscopy isthat an arthroplasty can be performedwithout surgically opening the joint,thereby reducing the potential for scar-ring and limitation of motion. Thosewho can perform arthroscopic arthro-plasty do so quickly with minimal trau-ma, but this takes extraordinary skilland must be performed frequently tokeep up the skills of the surgeon(Figure 2).

Open ArthroplastyOpen arthroplasty is a technique

widely used in the 1970s to repair vari-ous stages of internal derangement. Theintention of this operation is to repairand reposition a damaged and displacedarticular disk. However, studies usingpostoperative MRIs have shown thatthis repaired position does not holdover time (Figure 3).

Figure 2. Arthroscopic anterior release per-formed with YAG laser.

Figure 5. CAD Cam construction model ofcustom TMJ replacement.

Figure 3. Openarthroplasty showingthe superior joint spacewith hypervascular discprior to wedge resection.

Figure 4.Discectomy withoutreplacement.


listed procedures. Generally speaking,the authors’ experiences have paral-leled the literature.

Following conservative treatment,arthrocentesis is an effective first inter-vention for internal derangement. If anarthroplasty is needed, arthroscopy withHo:YAG laser, is preferential because itcauses less scarring than open proce-dures. In cases where the disk cannot berepaired/repositioned, discectomy with-out placement of interpositional materi-al has withstood the test of time.

For adults with severe DJD or multi-ply operated degenerated joint allogene-ic total joint replacement is indicated. Ingrowing children, costochondral graftingis preferential due to increased bloodsupply and potential for growth.

References / 1. Freund B, Schwartz M, SymingtonJM, The use of botulinum toxin for the treatmentof temporomandibular disorders: preliminary find-ings. J Oral Maxillofac Surg 57(8): 916-20; discussion920-1, August 1999.

2. Freund B, Schwartz M, Symington JM,Botulinum toxin: new treatment for temporo-mandibular disorders. Br J Oral Maxillofac Surg38(5): 466-71, October 2000.

3. Nitzan D.W., Samson B, Better G: Long-term outcome of Arthrocentesis in severe closedlock. J Oral Maxillofac Surg 55:151-7, 1997.

4. Nitzan DW, Price A, The use of arthrocente-sis fro the treatment of osteoarthritic temporo-mandibular joint. J Oral Maxillofac Surg 59(10):154-9, 2001.

5. Milam SB, Pathophysiology of articular diskdisplacements of the TMJ in Oral and MaxillofacialSurgery. Ed. Fonseca RJ WB Saunders Co,Philadelphia, 46-72, 2000.

6. Zardeneta G, Milam SB, Schmitz JP, Elutionof soluble proteins by continuous TMJArthrocentesis J Oral Maxillofac Surg 55:709-15,1997.

7. Wilkes CH, Surgical treatment of internalderangements of temporomandibular joint. ArchOtolarngol Head Neck Surg 117:64, 1991.

8. Boman K, Temporomandibular joint

arthrosis and its treatment by extirpation of thedisc. Acta Chir Scand 95(suppl 118), 1947.

9. Silver CM, Long-term results of meniscecto-my of the temporomandibular joint. J CraniomandPract 3:46, 1985.

10. Hall HD., Navarro EZ, Gibbs SJ, One- andthree-year prospective outcome study of modifiedcondylotomy for treatment of reducing disk dis-placement. J Oral Maxillofac Surg 58:7, 2000.

11. McCain JP, Sanders B, Koslin MG, QuinnJD, Peters PB, Indresano, AT, TemporomandibularJoint-Arthroscopy: A Six-Year Multi-CenterRetrospective Study of 4,831 Joints. J OralMaxillofacial Surg 50:926-30, 1992.

12. Mercuri LG et al, Long-term follow up ofthe CAD/CAM patient-fitted total temporo-mandibular joint reconstruction system. J OralMaxillofacial Surg 60:1440-8, 2002.

To request a printed copy of this article, pleasecontact / A. Thomas Indresano, DMD, 2155Webster St., Room 522J, San Francisco, Calif.,94115-2333.

CDA

DiseaseTMJ

Dentists routinely refer patients to

oral and maxillofacial surgeons for

dentoalveolar surgery, however few

of these dentists are fully informed as

to the full scope of surgical practice.

Appropriately trained oral and maxillofa-

cial surgeons may also offer cosmetic

facial surgery to their patients under

certain circumstances. This paper will

provide an overview of cosmetic facial

surgery.

he specialties of oral and max-illofacial surgery and plasticsurgery share common origins.The first plastic surgery organi-zation in the world was formedat the Chicago Athletic Club in1921, and was called theAmerican Association of Oral

and Maxillofacial Surgeons. Of the 20founding members, 18 had both MD andDDS degrees.1

In 1926, the name changed to theAmerican Association of Oral and PlasticSurgeons, and the requirement for a den-tal degree was dropped. They subsequent-ly became the American Association ofPlastic Surgeons in 1941. A subgroup ofthese members created a new organiza-tion in 1947 called the American Societyof Maxillofacial Surgeons, includingmembers with both MD and DDS degreesonce more, and focusing their interest onmaxillofacial surgery.1

Oral and maxillofacial surgery asdefined by the American DentalAssociation includes the diagnosis, sur-gical and adjunctive treatment of dis-eases, injuries and defects involvingboth the functional and esthetic aspectsof the hard and soft tissues of the oraland maxillofacial regions.1

Oral and maxillofacial surgeonshave long been involved in changing orimproving people’s skeletal featuresthrough orthognathic surgery, recon-structive surgery, and repair of facialfractures.2 While many of these surg-eries are carried out through small intra-

oral incisions, others require incisionsto be made in visible areas of the face.

Additionally, because changes of thefacial skeleton have corresponding softtissue changes, oral and maxillofacialsurgeons are keenly aware that anesthetic result can only be achieved ifattention is paid to both of these fac-tors. It is, therefore, a natural progres-sion to extend this expertise into cos-metic surgery procedures.

Most oral and maxillofacial surgeryresidencies now teach esthetic surgeryof the face as part of their curriculum.3

Today, candidates for certification bythe American Board of Oral andMaxillofacial Surgery are examined onthe evaluation, diagnosis, and treat-ment of the patient with cosmetic con-cerns. Additional, concentrated train-ing, is also available at several post-resi-dency fellowship programs.

Cosmetic facial surgery can begrouped into three categories: soft tis-sue, osteocartilagenous, and minimallyinvasive procedures. Soft tissue proce-dures include blepharoplasty (eyelidsurgery), rhytidectomy (facelift),browlift, submental lipectomy (liposuc-tion) and deep chemical peels or laserskin resurfacing.4


Overview of Facial CosmeticSurgerySimona C. Arcan DMD, MD

Author / Simona C. Arcan, DMD,MD, is a board-certified oral andmaxillofacial surgeon in Bellflowerand Huntington Beach, Calif.

ProceduresCosmetic

a b s t r a c t

T


Osteocartilagenous procedures in-clude rhinoplasty, otoplasty, cheekimplants, and chin implants or slidinggenioplasty. These surgeries may be per-formed independently or in conjunc-tion with orthognathic surgery.5

Minimally invasive proceduresinclude botulinum toxin injection ofthe muscles of facial expression, lip aug-mentation, treatment of deep smilelines or prominent nasolabial folds withvarious tissue fillers or autologous fatinjections, light to medium facial peelsand photofacials.

Soft Tissue ProceduresIn the aging face, the eyelid skin

becomes less elastic and tends to formexcessive folds on the upper lid. Theorbicularis oculi muscle also becomeweakened, allowing the orbital fat toherniate through it. This gives theappearance of “bags” under the eye.

Blepharoplasty is the surgical rejuve-nation of the upper and lower eyelids.This procedure entails the removal ofexcess skin and orbicularis oculi muscle,and either repositioning or removing aportion of the fat pads (Figure 1). Inorder to avoid a gaunt, skeletinizedlook, less fat removal and more superiorrepositioning may be indicated.

Endoscopic browlift is the procedurewhereby the forehead skin and browsare elevated through three to five smallscalp incisions, using a camera to visu-alize the underlying structures. This is aprocedure most often recommendedwith an upper blepharoplasty, therebyminimizing the amount of skin removalnecessary to obtain a refreshed look ofthe eyes. An open coronal approach canalso be used to elevate the brow andresect the corrugators and procerusmuscles.

Rhytidectomy or facelifting proce-dures are more extensive rejuvenationsurgeries, involving the use of a surgicalincision extending from the temporalregion anterior to the ear, to the post-

Figure 1. Preop upper and lower lids. Figure 1b. Postop upper and lower lid blepharoplasty.

Figures 2a and b. Premandibular/chin advancement and submental liposuction.

Figures 2c and d. Postmandibular/chin advancement and submental liposuction

ProceduresCosmetic


of the nose (Figure 3). Septoplasty,along with rhinoplasty is sometimesindicated in straightening of the severe-ly deviated nose. Surgery on the nosecan be performed separately or concur-rent to an orthognathic procedure.5

Otoplasty entails the correction ofthe floppy ear by removing part of theconchal bowl and reconstruction of theantihelix. This surgery can be done onpatients as young as 5- to 6-years old,prior to entering first grade, to helpavoid developing a stigma from con-stant teasing from other children.

Cheek implants can be used to aug-ment mid-face deficiencies in patientswho are unwilling to undergo ortho-

degree of penetration into the skin lay-ers. They are divided into light, mediumand deep skin peels, with the deep peelsbeing equivalent to the laser resurfac-ing. Dermabrasion is still very effectivein smoothing out severe acne scars.

Osteocartilagenous ProceduresRhinoplasty is one of the most pop-

ular procedures performed on the facialskeleton. It can be as simple as reducinga prominent dorsal hump or as compli-cated as reconstructing a cleft nose. Themost common procedures performed toreshape the nose are dorsal humpreduction, refining and/or rotating ofthe nasal tip and narrowing of the base

auricular area curving around the ear-lobe. There are multiple schools ofthought as to which flaps are more suc-cessful, and this usually correlates withthe invasiveness of the procedure. Thesesurgeries can be quite extensive and haveknown complications including bloodloss, facial nerve injury and scarring.

Submental lipectomy involves thereshaping of the mentocervical angle. Itcan be used in conjunction withorthognathic surgery in more severeClass II or Class III skeletal deformitypatients.5 In severe Class II skeletalpatients, this procedure can be used tofurther achieve a more esthetic mento-cervical angle (see Figure 2). In a severeClass III mandibular hyperplasticpatient, when doing a mandibular set-back, the mentocervical angle canbecome less defined and a lipectomymay be necessary to avoid compromis-ing this esthetic unit. A small submentalincision and two additional postauricu-lar incisions are used to insert a liposuc-tion microcanula. Removal of lobules offat is achieved through a suctioning andvacuuming technique. This procedurecan also be performed as an isolatedsurgery in an office setting.

Laser skin resurfacing is achievedwith either the CO2 laser, Erbium-YAGlaser or a combination of both. Skinresurfacing removes the top layer of theskin and allows a new layer of skin todevelop. This improves appearance ofsun-damaged skin, smoothes outrhytids (wrinkles), improves mild scar-ring, destroys epidermal lesions (e.g.actinic keratosis and lentigines), amelio-rates underlying skin diseases (e.g. acneand rosacea) and blends the effects ofother resurfacing procedures.

Chemical peels and dermabrasionshave been used in the past to achievethe same results that laser resurfacingdoes today. There may still be someindications for these procedures in cer-tain patients. There are different typesof peels available, depending on the

Figures 3a and b. Premandibular setback, chin reduction and rhinoplasty.

Figures 3c and d. Postsetback of mandible, chin reduction and rhinoplasty.


advancement genioplasty and later achin implant.

Minimally Invasive ProceduresIn light of the FDA approval of new

products like Botox Cosmetic, Restylane

and vertical dimension. She was treatedwith a mandibular setback and a reduc-tion genioplasty. Occasionally, apatient with severe mandibular microg-nathia may require a mandibularosteotomy with forward movement,

dontics and/or a maxillary osteotomy tocorrect their skeletal discrepancy. Theycan also be used in conjunction withmaxillary osteotomy to achieve a fullermid-face in those patients with severemid-face deficiencies, as those encoun-tered in certain syndromes.

Chin implants vs. sliding genioplas-ty has always been a hot topic of con-troversy.6,7 With a sliding genioplasty,one can achieve a 3-dimensional move-ment of the chin, rather than just thesingle forward movement obtainedwith a chin implant.6,8,9 The patient inFigure 2 had a mandibular deficiencywhich was treated with a mandibularadvancement and advancement genio-plasty. The patient in Figure 3 had amandibular hyperplasia in a horizontal

Figures 4a. Pre-Botox injections forehead. Figure 4b. Post-Botox injections forehead.

ProceduresCosmetic


harmony than either surgery could alone, Am JCosmet Surg 21:77-87, June 2004.

6. Strauss R, Abubaker AO, Genioplasty: A casefor advancement osteotomy, J Oral Maxillofac Surg58(7):783-7, 2000.

7. Reed EH, Smith RG, Genioplasty: A case foralloplastic chin augmentation, J Oral Maxillofac Surg58(7):788-93, 2000.

8. Guyuron B, Raszeswki RL, A critical compar-ison of osteoplastic and alloplastic augmentationgenioplasty, Aesthetic Plast Surg 14(3):199-206,1990.

9. Chang EW, Lam SM, Karen M, Donlevy JL,Sliding Genioplasty for Correction of ChinAbnormalities, Arch Facial Plast Surg 3(1):8-15,2001.

10. Sposito MM, New indications for botu-linum toxin type A in cosmetics: mouth and neck,Aesthetic Plast Surg 110(2):601-11, August 2002.

11. Sadick N, Weiss R, Intense pulsed-lightphotorejuvenation, Semin Cutan Med Surg21(4):280-7, 2002.

To request a printed copy of this article, pleasecontact / Simona C. Arcan, DMD, MD, 14343Bellflower Blvd., Bellflower, Calif., 90706-3135.

sion with appearance. Patients alwayswanted to look like the movie stars theysee on TV or on the big screen, but untilrecently, the “average Joe” most likelystayed the “average Joe.” With the adventof television programs such as “ExtremeMakeover” and “The Swan,” the public isnow aware of what it takes to make thembeautiful and youthful looking and mayseek the advice of their dentist.Consequently, it is important for dentiststo inform their patients of the dental andsurgical procedures available to addresstheir esthetic concerns.

References: / 1. Hiranaka DK Hiranaka JG,Aesthetic maxillofacial surgery Part I, Hawaii Dent J30(3):6-9 May/June 1999.

2. Poswillo DE, The relationship between oraland plastic surgery, Brit J Plast Surg 30(1):74-80,1977.

3. Edwards R, Foley WJ, Expanding the special-ty: a survey of oral and maxillofacial surgery resi-dencies in the United States, J Oral Maxillofac Surg51(5):559-62, 1993.

4. Harmon FW, Cosmetic oral and maxillofa-cial surgery, LDA J 53(1): 7-8, 1994.

5. Belinfante L, Combining cosmetic soft tissueand skeletal surgeries to achieve greater total facial

and other collagen fillers, there has beena change toward these less invasive typesof procedures being performed. This alsohas been attributed to patient unwilling-ness to take weeks off of work to heal.

More patients are interested indoing “preventative” cosmetic surgery,rather than large overhauls. The morecommon of these are used to temporar-ily freeze movement of the muscles offacial expression with botulinum toxin(Botox Cosmetic, Figure 4).10 Varioustissue fillers (i.e. Restylane and collagen)are used to restore lost volume in theface, and plump up deep nasolabialfolds, smile lines and marionette linesin the corner of the lips (Figure 5), aswell as augment thin lips (Figure 6).

Another emerging method to stimu-late collagen production, minimize finewrinkles, as well as improve the sun-damaged skin is the photofacial therapy.This non-invasive procedure involvesthe use of intense pulse light (IPL) andresults are more permanent than thoseobtained with just Botox and tissuefillers.11 The IPL treatment can also beused to treat telangiactasias (broken cap-illaries) of the face, rosacea (a commondermatological condition of the face)and rhinophyma (red, thick-skinnednose), as well as remove unwanted hair.

SummaryThere is a great amount of emphasis

on appearance these days. Hollywoodcontinues to be a major source of obses-

Figure 5a. Pre-implant surgery. Figure 5b. Post-implant surgery/pre-Restylane.

Figure 5c. Post-Restylane nasolabial foldand lip

Figure 6a. Pre-Restylane lip augmentation. Figure 6b. Post-Restylane lip augmentation.

CDA

revolution coming and whether you acceptit or start decamping for Canada, YOU arepart of it. There are 15 to 30 volunteersalready enlisted according to dentalresearcher Hillman at the University ofFlorida. These intrepid souls who possiblywere under the impression that they were tobe given some SPF 45 to test on their baredepidermis at South Beach while lavishlyensconced at the Miami Hilton for 30 daysare, instead, to be lavishly swabbed withStreptococcus mutans on their bare teeth!

Would you be foolish enough to volun-teer for this? Of course not! As a scientifictooth-oriented health professional, youknow the story of S. mutans. These mean-spirited bacteria grow on human teeth, con-verting sugar into lactic acid that rots thosevery same teeth. That S. mutans are largely

here is something going on at the Universityof Florida. This is FYEO (For Your Eyes Only)stuff, so unless you have TSC (Top SecretClearance), you are to SRRN (Stop ReadingRight Now).

Jeffrey Hillman, DMD, PhD, of Oragenicsknows about it; so does Kenneth Burrell,DDS, senior director of the American DentalAssociation, Council on Scientific Affairs.Because we are among a very select group ofscientific elitists, we have access to all thishush-hush material discreetly issued period-ically OAM (Once a Month) by a privatelyfunded publication called PS (PopularScience). One-year subscription (12 issues),pay $12.95 (save 73 percent).

If you pass the gimlet-eyed scrutiny ofsecurity, this is the

skinny: There is a

Dr. Bob

Putting the Strain on

tThere is

a revolutioncoming andwhether you

accept it or startdecamping forCanada, YOUare part of it.

Robert E. Horseman, DDS


Continued on Page 869


responsible for providing us with a liv-ing is beside the point. The point is thatHillman has engineered a new strain ofthese bacteria that doesn’t produce lacticacid. How Hillman was able to convinceeven one S. mutans, let alone an entiretest tube of them, to eschew the pro-duction of lactic acid is on a NTK (NeedTo Know) basis for which even PopularScience is not privy.

There’s more. Instead of lactic acid,this newly engineered S. mutans hasbeen outfitted with an antibiotic “thathelps it displace the indigenous cavity-inducing strain.” Here’s where youcome in. Armed with nothing morethan a Q-Tip and maybe a SIG-Sauer 9mm, you swab your volunteer’s teethwith Hillman’s mutant bacteria.Offering any explanation that seemseven remotely plausible, the swabee isgiven a sack full of Tootsie Rolls andGummi Bears, and dispatched home toeat even more sugar. If this advice sticksin your craw, maybe Hillman himselfwill have to put in a personal appear-ance to explain in simple terms that theingested sugar will help colonize thenew S. mutans strain. These new con-fused bacteria, instead of creating a cav-ity as they had been trained to do sinceearly childhood, are now unwittinglyforming a tooth security guard. Thiswill revolutionize the practice of den-tistry in terms of drilling and filling.Who knows what engineered bacteriacan be trained to do or not do next?How about eating fat?

What the revolutionized practicewill be like is not clear, but it underlinesthe necessity of not letting this infor-mation leak to the nation’s restorative

dentists who will immediately try toconfiscate and horde all Q-Tip supplies.Hillman is ecstatic. “If there was a mar-ket for preventing cavities in rats, I’d bea millionaire,” he exalted.

Hillman should be made aware thatthere wasn’t a market for bleachingteeth until a relatively short time ago,so anything is possible.

Burrell, ADA’s man, is equallyblown away, although he doesn’t seem

“If there was a market for

preventing cavities in rats, I’d be

a millionaire.”—Jeffrey Hillman, DMD, PhD

to hold any patents on these newmodel streptococci. Both these spokes-men are thinking outside the box,because they are not sure whether thenew strain can be transferred to otherswith, say, a kiss. Should this occur, theBureau of Osculatory Interdiction,under the aegis of the Food and DrugAdministration, will most certainlydelay the revolution by at least 20years. Hillman, however, is confidentthere will be no “horizontal transmis-sion” as he delicately put it. Just tomake sure, however, spouses of thevolunteers will be monitored. Shouldthe volunteer not have a spouse, onewill be provided. If the strain has thedecency to stay put, not wanderingwilly-nilly from mouth to mouth, the

Dr. Bob

Continued from Page 870

dental revolution could get airbornecommercial-wise within five to sixyears. If it doesn’t, there could be a lotof kissing going on and the Q-Tipmarket would bottom out.

If you are interested in some inten-sive osculatory experimentation in thename of science, contact the Universityof Florida at their research facility inKissimmee, Fla. CDA

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