Oral and Maxillofacial Surgery: Saving Faces — Changing Lives an Introduction to the Issue

CDA Journal Volume 32, Number 10 Journal october 2004

departments 801 The Editor/Looking Back on the Journey — Some Highlights 870 Dr. Bob/Putting the Strain on S. Mutans features 815 Oral and Maxillofacial Surgery: Saving Faces — Changing Lives An introduction to the issue. Tim Silegy, DDS

817 Oral and Maxillofacial Surgery Residency Education Alan L. Felsenfeld, MA, DDS, and Angelle Casagrande, DDS, MD

823 New Considerations in the Treatment of Compromised Third Molars Ronald M. Kaminishi, DDS, and Kurtis S. Kaminishi, BA

827 Fifty Years of General Anesthesia in California Oral and Maxillofacial Surgery John J. Lytle, DDS

831 Orthognathic Surgery: History, Diagnosis and Treatment Robert Relle, DDS, and Tim Silegy, DDS

839 Management of Traumatic Facial Injuries Tim Silegy, DDS, and Peter Scheer, DDS, MS

845 Temporomandibular Joint Disease: An Update of Surgical Treatment A. Thomas Indresano DMD; and Angelle Casagrande DDS MD

849 Overview of Facial Cosmetic Surgery Simona C. Arcan DMD, MD The Editor Jack F. Conley, DDS

Looking Back on the Journey — Some Highlights

lengthy position of service the beginning of an 18-year period with the pre-eminent state of significant and unprecedented dental association in growth. America brings with it the When we first became members privilege of sharing some in the 1960s, liability insurance was personal perspectives on considered by many to be the most someA of highlights in dentistry in California important membership benefit. In during the past 35 years of our service. the mid-1970s, premium levels had As former Journal Managing Editor started to soar to levels that were of Susan Lovelace noted in her marvelous his- great concern to leadership, not to tory of the California Dental Association mention the members. J. David that was published in July 1995, the first Gaynor, who had the original meeting of the California Dental vision, along with other association Association occurred on June 29, 1870, in leaders, was instrumental in the San Francisco, just 21 years after California untiring efforts that ultimately was admitted to statehood. That makes resulted in the formation of The California dentistry 134 years old this year. Dentists Insurance Company in My journey of service to the profession 1980, the first dentist-owned liability carrier commenced in 1969 in Los Angeles, just in the country! The early years of TDIC’s exis- four years prior to the unification in 1973 of tence were not easy. Some of us can still the northern California Dental Association remember the Certificates of Contribution and the Southern California Dental that policy/shareholders purchased to sup- CDA’s subsequent Association, forming the California Dental port the company during the trying forma- Association as we know it today. It startled tive years. Despite the difficult times, includ- efforts in the us when we calculated that our 35 years of ing several challenging administrative volunteer service represented 26 percent of changes, TDIC has become a major success legislative arena the lifespan of organized dentistry here in and a contributor to the financial health of to support a cap California! We believe that statistic only this association. Policyholder dividends have serves to illustrate that dentistry is still a rel- been another highlight in recent years. Aside on damages atively young profession. I believe that the from the financial benefits derived from people we will mention and the events we TDIC by the association and its members, the were important will review, while only a small sampling of “management” of the liability environment to bringing highlights, will illustrate what a memorable by the profession via TDIC and its very exis- journey that California dentistry has trav- tence in the marketplace, helped to slow stability to the eled in that time. down and to control the escalating premium In 1978, five years after unification, Dale costs both short term and to this day. In addi- professional Redig was hired as the third CDA executive tion, CDA’s subsequent efforts in the legisla- liability director. The association offices had been tive arena to support a cap on damages were housed in a relatively small leased office space important to bringing stability to the profes- marketplace. (compared to today’s standards) in the sional liability marketplace. Tishman building complex in the Los In April 1983, the CDA board, meeting Angeles Airport area. His hiring would mark in Newport Beach, Calif., voted to move the

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

CDA office to Sacramento and appoint- she proofread copy for Journal issues Marie Tokunaga who served us with dis- ed yours truly to serve as editor of this while waiting to catch flights at the air- tinction for the next eight years. Patty publication. In August, 16 of 47 employ- port while traveling on Sessions business. Reyes has now been managing the day- ees employed in Los Angeles moved We have been amazed time and again to-day development of the Journal for with Dale Redig to open the CDA office at the skills of our professional publica- more than a year while Jeanne Marie has in Sacramento. Dale’s vision that CDA tions staff, traits that have been there overall responsibility for publications. needed to be in Sacramento at the seat from the very beginning of our tenure. In The quality of the five individuals who of state government would be validated less than one month after his hiring, have served us in this capacity has been over and over during the next 20-plus Doug Curley launched the first monthly a source of great personal satisfaction. years. Among those who helped with issue of Update while overseeing the Our successor, Alan Felsenfeld, will find that move is current Chief Governance monthly publication of the Journal. We the contributions of Jeanne Marie and Officer Janice Johnson, whose loyalty to believe that the monthly publication of Patty to be a source of strength. this organization has been unsurpassed. two first-rate publications by a small, ded- By the late ’80s, Dale Redig’s vision, In mid-August 1983, at about the coupled with his practical realization time of the move, a new managing edi- that CDA in a very few years was already tor, Rich Martin, was hired in Sacramento We believe that starting to outgrow the 818 K St. offices, because the Los Angeles Journal staff did the presence of the pointed to the need to study the poten- not follow the association to Sacramento. tial of a move to one of two buildings Rich had a background in newspaper association at the under construction in downtown journalism. Speed of publication and Sacramento. While this decision, like short deadlines were his forte. We were in 1201 K St. location the previous Board of Trustees decision awe of his ability to put together a quali- has been extremely to move the offices to Sacramento, was ty first issue of the Journal in Sacramento, controversial with some trustees, we in little more than two weeks. That first beneficial to CDA believe this move has been the most issue, with a photo of the 818 K St. head- important event in the 30-year history quarters building on the cover was await- in undertaking its of the unified association. ing the Board of Trustees on their desks various initiatives Beyond the necessity of additional on the first weekend after Labor Day at space, the 1201 K St. address that the first trustee meeting in Sacramento. became the CDA home in 1990, helped To this day, we appreciate the skills we icated staff has been a remarkable to establish CDA as a major player in learned from Rich. achievement. Update to us has been an Sacramento. Even when leadership was In 1988, two things happened of sig- important vehicle for CDA publications. faced with some more difficult times nificance to this writer. Rich Martin It has enabled us to separate the news, after 1996, we believe that the presence became ill with cancer and had to leave information, opinion, and feedback that of the association at the 1201 K St. loca- his position after five years of marvelous would be less appropriate to a profession- tion has been extremely beneficial to service. Earlier that year, feedback from al journal. While we don’t have a survey CDA in undertaking its various initia- leadership at a strategic planning retreat to back up our opinion, the belief here is tives on behalf of the membership and identified the need for a monthly that the reader target audience for the the public. “newsletter” type of publication. As she two publications is quite different, under- As many individuals who read this 1 had during the transition period lining the need for the two different pub- know, the next 6 ⁄2 years presented some between Los Angeles and the new lications that validates the judgment of difficult leadership challenges from Sacramento Journal staff, Cissie Cooper, the leadership at that first-ever strategic time to time. A positive perspective to who served various directorship posi- planning retreat. share is that volunteer leadership, and tions with the association including In 1996, Susan Lovelace, who provid- the officer positions in particular, Scientific Sessions and Communications, ed outstanding skills in the production became out of necessity, more engaged again stepped in. She bridged the pro- of the Journal following Doug Curley’s in the process of governance. This in no duction gap between Rich Martin’s tenure as managing editor, left to serve way suggests that we have any less departure and the hiring of Douglas San Diego County Dental Society as admiration for the performance or rep- Curley as managing editor, months later executive director. The Journal experi- resentation provided by the many out- in January 1989. She confided to us that enced a smooth transition to Jeanne standing leaders we served with from

802 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 1983 until 1996. But it has been evident that additional demands on an officer’s time, opinions, and decisions started to occur out of necessity in the post-1996 period. We believe in retrospect, that the role modification we have witnessed has been an important step in the growth of this organization. CDA is now in the second year of what we consider the profession’s future direction. Peter DuBois, during the past 20 months, has demonstrated that he has a vision, which is at the forefront of his efforts to restructure the association’s operation and to direct strategic initiatives. He has demonstrated thus far how important the vision of an administrator can be. He has also incorporated changes in organization structural efficiency that are paramount in the business climate of today. We believe that time will show his administrative style, skills, and contributions, while vastly different than those of Redig and Gaynor, to also be of lasting importance to the future strength of this organization. The dedicated contributions of “Dr. Bob” Horseman have been critical to the success of the Journal. He has been contributing editor “par excellence” for the past 22 years, providing a monthly feature unique to a professional journal. Many colleagues anxiously await Bob’s humorous creations every month, and their inclusion provides Journal a marvelous balance of features for the reader. Not to be forgotten are the Scientific Sessions that have continued to grow in size and quality in the period since unification. Staff and volunteers continue to attract the top experts to the northern and southern Sessions every year. In addition to quality educational offer- ings, exhibitors value the opportunity to participate in these meetings and contribute to their financial success while introducing the latest in materials and technology to the membership. Next month, “I Believe it IS Time to Go ...” CDA

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 803 tists Rights Society (ARS), New York

Introduction Oral and Maxillofacial Surgery: Saving Faces – Changing Lives

ral and maxillofacial surgery website, www.aaoms.org. most oral and maxillofacial surgery prac- began as, and remains, a spe- It is the intention of this issue of the tices. Controversy still surrounds the cialty of dentistry. As the name Journal of the California Dental indications for removal of asympto- implies, oral and maxillofacial Association to provide California den- matic compromised third molars. Dr. surgeons are dentists trained to tists with an overview of current oral Ron Kaminishi and Kurtis Kaminishi o surgically address diseases and and maxillofacial surgery training and illustrate how removal of retained third deformities of the mouth, jaws, practice. molars in an ever-expanding aged popu- and face. However, in spite of the Drs. Alan Felsenfeld and Angelle lation is associated with significant risks. descriptive name, many general dentists Casagrande open this issue with a his- Traumatic maxillofacial injuries can still see the oral and maxillofacial sur- torical review of the specialty’s devel- have a profound physical and emotion- geon as the friendly person down the opment. They then summarize current al impact on the individual. For years, hall who takes out teeth. training and accreditation guidelines, oral and maxillofacial surgeons have As we enter the new millennium, and finish with an overview of the oral been instrumental in developing tech- confusion as to the scope of oral and and maxillofacial surgery residency niques to repair of these injuries. Dr. maxillofacial surgical practice remains. training programs in California. Peter Scheer and I illustrate the oral and Recognizing this, the American Dr. Jack Lytle follows with a paper

Association of Oral and Maxillofacial tracing the development of ambulatory Contributing Editor / Tim Silegy, Surgeons has begun a nationwide edu- outpatient anesthesia for oral and max- DDS, is an oral and maxillofacial surgeon in private practice in cational campaign designed to educate illofacial surgery. Interestingly, many Long Beach, Calif., and a diplo- health care professionals, politicians of these anesthesia pioneers practiced mate, American Board of Oral and Maxillofacial Surgery. and the public. More information on in California. their program can be found on their Third molar removal is a mainstay of

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 815 Introduction

maxillofacial surgeon’s role in trauma management. Internal derangement of the temporomandibular joint results in pain, spasm, and hypomobility. While nonsurgical management can be effective in managing symptoms, definitive surgical treatment may be indicated. Drs. A. Thomas Indresano and Casagrande review the indications for, and surgical options available to, patients who fail to respond to conservative therapy. A strong relationship exists between facial growth and dental occlusion. Dr. Robert Relle and I discuss the diagnosis and surgical correction of dentofacial deformities. New technology and techniques have transformed what was once an arduous surgery requiring days of hospitalization into what today is commonly an outpatient procedure. Dr. Simona Arcan provides an overview of facial cosmetic surgery. Patients seeking cosmetic dental procedures often desire enhancement of other facial structures. Appropriately trained oral and maxillofacial surgeons can draw upon their expertise in facial anatomy to help patients reach their esthetic goals. Conspicuously missing from this issue is a discussion of dental implantol- ogy and bone grafting. While oral and maxillofacial surgeons have been instrumental in developing this technology, it is not exclusive to oral and maxillofacial surgeons, and would require an entire issue to adequately review. Finally, I would like to dedicate this issue to the many fine men and women in academic oral and maxillofacial surgical practice. Without their sacrifice and dedication, many of the advance- ments discussed in the pages that follow would not have been possible. CDA

816 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Residencyeducation

Oral and Maxillofacial Surgery Residency Education

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

Oral and maxillofacial surgery is the o understand the need for the sedation. A substantial portion of their comprehensive and detailed training focuses on ambulatory anesthe- recognized specialty of dentistry that education of residents, a brief sia and patient management, preparing review of the patient care areas them to administer safe and effective is responsible for the diagnosis and provided by oral and maxillo- anesthesia services in their offices for facial surgeons is indicated. the performance of surgical procedures. surgical and adjunctive treatment of T Since the earliest days of the specialty, the scope of practice Dental Implants diseases, injuries and defects involving has evolved to include surgery of the A second significant area of modern both the functional and esthetic entire maxillofacial complex. The oral and maxillofacial surgery practice is knowledge and skills of oral and max- the planning and placement of dental aspects of the bone and soft tissues of illofacial surgeons make them proficient implants. Patients can be diagnosed and in the management of bony and soft tis- treated for the full range of implant the oral and maxillofacial region.1 This sue management of the entire maxillo- dentistry. Evaluation, prophylactic facial skeleton.2 extraction, site development including article will present a review of the edu- bone and soft tissue reconstruction of OMS Procedures the oral tissues as well as maintenance cational process for residents in oral are part of the training received and ser- Dentoalveolar Surgery vices offered to patients and restorative and maxillofacial surgery as it has The basis of most clinical practices dentists. evolved and current training standards. includes the extraction of diseased or impacted teeth, as well as the surgical Dentofacial Deformities and exposure of impacted teeth to enable Congenital Defects their orthodontic-assisted eruption into Surgeons can reconstruct and a functional and esthetic position. realign the upper and lower jaws to pro- Other traditional office procedures vide improved function and facial include preparation of the mouth for dentures, including alveoloplasty, soft and hard tissue grafts, and vestibulo- Authors / Alan L. Felsenfeld, MA, DDS, is professor of clinical den- plasty procedures. Oral infections and tistry and assistant residency pro- biopsy of suspicious lesions of the hard gram director at University of California, Los Angeles, School of and soft tissues are also treated. Dentistry. He is a member of the committee on residency, education and training for American Anesthesia Association of Oral and Maxillofacial Surgeons. The oral and maxillofacial surgeon Angelle Casagrande, DDS, MD, is formerly assistant professor, Oral and Maxillofacial Surgery, is an expert in all aspects of pain and University of the Pacific, School of Dentistry, and anxiety control, including general anes- assistant program director at Highlands General Hospital. She currently is in private practice in thesia or deep sedation, and conscious Tucson, Ariz.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 817 Residencyeducation

appearance as they work as a team with pain. Surgeons are educated in multi- John Gunther began a one-year basic orthodontists to align the maxillofacial ple treatment options including non- science program for oral surgeons at the structures. Many are trained to correct surgical treatment of TMJ disorders. University of Pennsylvania in 1949 to congenital and acquired defects of the The surgical management of TMJ provide a consistency in the conceptual maxillofacial region including cleft lip abnormalities includes arthrocentesis, aspects of surgical training. The quality and palate. arthroplasty and open joint procedures of educational experiences was begin- as well as total joint replacement or ning to be considered. Evaluation of Maxillofacial Trauma reconstruction. advanced education programs was Oral and maxillofacial surgeons superficially conducted by the Council have extensive experience in repairing Evolution of Education on Hospital Dental Service of the ADA simple and complex facial lacerations, Given the complexity and extensive for its Council on Dental Education, setting fractured jaw and facial bones, range of surgery, the education program with the main concern being space and reconnecting severed nerves and ducts, for residents needs to be comprehensive facilities for oral surgery clinics. and treating other hard and soft tissue and by definition is quite rigorous. To In 1956, the American Society of injuries of the face and neck region. complement the intensive growth in Oral Surgeons Committee on Graduate They are active participants in the emer- the depth and range of surgical proce- Training provided the first description gency department management of the dures performed by modern surgeons, of minimal requirements in the cate- maxillofacial trauma patient. the educational process has evolved gories of didactic education and clinical accordingly. A brief history of how training during a three-year period. Pathologic Conditions teaching has changed will bring better Standards of education were offered for The diagnosis and management of understanding to the education that is hospitals that conducted oral surgery patients with diseases of the oral and received by residents today.3 internships and residencies. Also in maxillofacial region, including cysts, The earliest recorded notes relative 1956, the ADA House of Delegates benign and malignant tumors, soft tis- to specialty scientific education for passed a resolution transferring respon- sue, and severe infections of the oral surgery was in 1918 when the American sibility for the accreditation of intern- cavity and salivary glands is a service Society of Exodontists, limited to the ships and residencies in hospitals to the offered to patients by the oral and max- practice of oral and maxillofacial Council on Dental Education. illofacial surgeon. surgery, and initiated scientific meet- From 1958 to 1964, six conferences ings and publications. During the next were conducted by the ASOS Reconstructive and Cosmetic Surgery decade, oral surgery became the first Committee on Graduate Training. The Surgeons are well trained to correct official specialty the American Dental first planning conference on graduate jaw, facial bone and facial soft tissue Association recognized, and the name training took place in 1958 and resulted problems that occur because of trauma of the organization was changed to the in the publication of The Essentials on an or pathology. This surgery to restore American Society of Oral Surgeons and Adequate Training Program in Oral form and function often includes Exodontists. By 1946, with the estab- Surgery. In 1964, the Council on Dental transferring skin, bone, nerves, and lishment of American Board of Oral Education approved the establishment other tissues from other parts of the Surgery, major problems and wide dif- of the Review Commission on body to reconstruct the jaws and face. ferences in the training and education Advanced Education in Oral Surgery. These same skills are also used when of the specialty were brought to light. The newly constructed review commis- oral and maxillofacial surgeons per- Some programs were university affiliat- sion held its first official meeting in form cosmetic procedures for improve- ed and were three years in duration. January 1965. One of the purposes of ment of problems due to unwanted Many however, were one-year programs the commission was to conduct site vis- facial features or aging. isolated in hospitals where they lacked its to evaluate training programs. full-time directors. All programs were In May 1965, a second meeting of Temporomandibular Joint Disorders clinically oriented in a “preceptor” type the review commission was held, and Training includes the diagnosis and of educational process. the backlog of site visit evaluations management of temporomandibular Carl Waldron and Henry Clark at was considered. One of the first efforts joint disorders as well as differential the University of Minnesota designed a of the review commission was to diagnosis of head, neck, and facial correspondence course in oral surgery. require that all one-year programs

818 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 affiliate for a continuous, graduated grams was increased from three to four under continuous review and revision by three-year sequence rather than offer years. This was done to accommodate the American Association of Oral and an isolated clinical-only exposure for the increasing amount of educational Maxillofacial Surgeons to reflect changes trainees. requirements for surgeons. A blueprint in the education required for modern oral The Essentials of an Adequate Training for the curriculum for the four-year and maxillofacial surgery residents. Program in Oral Surgery, used as the blue- training programs was designed by the print for oral and maxillofacial surgery American Association of Oral and Education of Surgeons residency training since 1958, was Maxillofacial Surgeons Committee on There are 102 accredited surgery res- revised from time to time before a major Residency Education and Training and idency programs in the United States revision was made in 1982 and 1983. representatives of the Section on with approximately 170 open positions The reworked document was adopted Education. available annually. About 850 individu- by the Commission on Dental The Standards for Advanced Specialty als are in residency programs with half Accreditation in May 1985 and became Education Programs in Oral and being in MD-integrated training. As in effective in 1986 as the yardstick for Maxillofacial Surgery, which serve as the all areas of dentistry and medicine, oral evaluation of oral and maxillofacial basic structure of all training programs, and maxillofacial surgery education has surgery training. were approved for implementation by been significantly enhanced during the In the early 1980s, the length of oral the Commission on Dental Accreditation past 20 years. Training time has been and maxillofacial surgery residency pro- on July 1, 1988. These standards are lengthened and a wider range of proce-

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 819 Residencyeducation

dures have been incorporated into the tions in plastic surgery, otolaryngology, comprehensive management of the dis- curriculum neurosurgery, infectious disease, and eases, injuries and defects involving The advent of accreditation has pediatric surgery. During this time, resi- both the functional and esthetic aspects assured minimal yet high standards that dents learn management of both adult of the hard and soft tissues of the oral programs must fulfill to adequately edu- and pediatric patients. and maxillofacial regions. cate surgeons in the profession.4 The The resident’s outpatient experi- Commission on Dental Accreditation, a ence is very broad, as a substantial The Medical Degree nationally recognized accrediting body, is amount of surgical activity is provided Some residency programs provide responsible for approving and adminis- in this setting. Each oral and maxillofa- education to earn a medical degree as an tering the standards for accreditation. It is cial surgery resident sees more than integrated component of oral and max- an independent group of individuals who 3,000 patients per year on an ambula- illofacial surgery training. Regardless of are appointed by the ADA as well as the tory basis. This would include at least whether a resident decides to complete nine recognized specialties, and other 100 general anesthetics or deep seda- residency with or without a medical dental agencies. Recognition as the ulti- tions for adults and children per senior degree, the oral surgical training is sim- mate accrediting body is given by the resident position for outpatient, ambu- ilar. In accordance with accreditation continued inspection and approval by latory surgical procedures. standards, all residents must complete the U.S. Department of Education. In The oral and maxillofacial surgeon the same rotations through the medical, conjunction with the American admits and manages a large number of surgical and anesthesia services with the Association of Oral and Maxillofacial patients to the hospital for major med- same level of responsibility. While the Surgeons, it will set criteria for and ical procedures. These patients fall into medical degree does not impact the oral approve residency training programs. The a variety of categories, including trau- and maxillofacial surgical education, it standards cover a wide range of institu- ma, reconstruction, orthognathic provides an excellent opportunity for tional, faculty, curriculum, program surgery, pathology, and esthetic expanded learning in the medical care resources and patient care areas to assure surgery. In support of the hospital- of patients at all levels. a high level of education in all accredited based procedures and general anesthe- Because of their specialized education programs. Each program is subject to sia training, the residents all become in general, oral and maxillofacial sur- reinspection every five years in distinc- certified in advanced cardiac life sup- geons are trained to perform many proce- tion to the general dental school and all port and are trained in advanced trau- dures that are also performed by physi- other specialty cycle of seven years. ma life support. cians, including reconstruction of the Residents also complete a struc- nose and orbits, maxillofacial surgery, Residency Curriculum tured, didactic course in physical diag- cleft lip and palate and facial esthetic Following graduation from dental nosis similar to that provided to med- surgery. Regardless of degree, the oral and school, resident surgeons complete a sur- ical students. This course is taught early maxillofacial surgeon who is trained gical residency of at least four years. A in residency, enabling application today is a competent individual who is minimum of 30 months is spent on the throughout training. It is reinforced capable of many surgical procedures to oral and maxillofacial surgery service pro- during rotations to the medical, surgi- help patients in need.5 viding a broad scope of specific surgical cal, and anesthesia services where oral experience for the resident. At least 18 and maxillofacial surgery residents must California Training Opportunities months are spent on off-service rotations function at the level of the other resi- Within California, there are seven on a variety of medical/surgical services, dents in the respective services. Because fully accredited residency education which are applicable to the oral and max- of this specialized education, oral and programs for oral and maxillofacial illofacial surgeon. There are several maxillofacial surgeons are capable of surgery. required off-service rotations, including a performing significant surgical proce- minimum of four months of hospital dures within a diverse scope of practice. University of California, Los Angeles anesthesia, two months on the clinical In summary, upon completion of an medicine service, and four months on accredited oral and maxillofacial Earl G. Freymiller, DMD, MD, the general surgery service. In addition, at surgery program, the surgeon is compe- program director least eight months is spent on a variety of tent to perform a wide variety of diag- The University of California, Los other services, which may include rota- nostic and surgical procedures for the Angeles, has a six-year combined oral

820 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 and maxillofacial surgery and MD length, allowing for three years of University of the Pacific affiliated with degree program. Two residents are research leading to the PhD. the long-standing Highland residency. selected each year and their education The residents rotate through At that time, the residency also made an consists of the required oral and max- University of California, San Francisco affiliation with Kaiser Permanente in illofacial surgery rotations as well as two Medical Center, San Francisco General Oakland. years of medical school and one year of Hospital and San Francisco Veteran’s The residency currently accepts two general surgery internship. Administration Medical Center. The res- residents per year for a four-year certifi- The residents spend their time on the idents get experience in pathology, cation in oral and maxillofacial surgery. oral and maxillofacial surgery service by reconstruction, orthognathic surgery, Next year, the residency will increase to rotating at UCLA Medical Center, TMJ surgery, implants, dentoalveolar three positions per year. The education Harbor-UCLA, and Kaiser Permanente. surgery and anesthesia. of the residents includes didactic cours- They receive training in dentoalveolar The residents receive intense training es and hands-on dissection labs. surgery, orthognathic surgery, trauma in didactic courses and lectures. They par- At Highland Hospital, the residents and pathology. Extensive implant and ticipate in the tumor board, journal club gain experience in trauma, implants, reconstructive surgery education is part and the orthognathic conference. pathology, dentoalveolar and TMJ of the curriculum as are trips to Mexico In their senior year, residents may surgery. The senior resident rotates at for cleft surgery education. Being based have the opportunity to exchange Kaiser for six months during which in the school of dentistry offers a multi- positions with a resident program in time they receive extensive training in tude of opportunities for didactic educa- Great Britain to afford a broad base of orthognathic surgery. At University of tion as well as significant interaction education. Pacific, the residents participate in a with all the specialties of dentistry in joint orthognathic conference with the patient care. King/Drew Medical Center orthodontic residents and get experi- The program allows for a one-year ence with complicated dentoalveolar internship in oral and maxillofacial Richard Leathers, DDS, program cases. At both institutions, the resi- surgery for individuals who would like director dents perform conscious and deep to experience additional education in The King/Drew Medical Center takes sedation. that area. two residents a year for a four-year cer- In November, a team from the resi- tificate program in oral and maxillofa- dency goes to Mexico with the University of California, San Francisco cial surgery. The facility is a Level 1 Thousand Smiles program to perform trauma hospital where the residents surgery on cleft lip and palate patients. M. Anthony Pogrel, DDS, MD, spend the majority of their program. program director They also rotate to Harbor-UCLA Travis Air Force Base/David M. Grant The residency program in oral and Medical Center for their anesthesia and Medical Center maxillofacial surgery at UCSF leads to general surgery training. At Kaiser hos- either an MD degree from the pital in Los Angeles, they get experience Lt. Col. David Smith, DDS, MD, University of California, San Francisco, in orthognathic surgery. program director School of Medicine, or the University of They are currently working on sev- To be a resident in this program, one California, Davis, School of Medicine. eral projects including trauma and must be a member of the military. Both MD programs require a one-year wound healing research. Travis has a four-year program leading general surgery internship. The length to an oral and maxillofacial surgery cer- of the residency program depends on University of the Pacific/Highland tificate. They accept two residents per the placement of the resident into med- Hospital year most of whom have the rank of ical school with advanced training and captain or major. can last either six or seven years. A. Thomas Indresano, DMD, The residents rotate to Fresno at the The residents may also combine a program director University Medical Center for eight PhD in oral biology with their certifi- The Alameda County Highland months to get their trauma training. cate in oral and maxillofacial surgery Hospital oral and maxillofacial surgery The main surgical procedures per- and their MD degree. This program is residency program was started in 1926 formed at Travis are orthognathic, cos- approximately nine to 10 years in as an independent program. By 2001, metic and dentoalveolar surgery.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 821 Residencyeducation

University Medical Center, Fresno surgery, craniofacial and dentoalveo- Foundation grant for research on lar surgery. osteodistraction. Robert Julian, DDS, MD, program There is a one- year internship director USC/LAC Medical Center available. CDA One resident is accepted per year to the four-year oral and maxillofacial Dennis Duke Yamashita, DDS, References / 1. ADA Definition of Oral and Maxillofacial Surgery, 1977. surgery certification program in Fresno. program director 2. Recruitment of Oral and Maxillofacial They do offer a one-year oral and max- The University of the Southern Surgery Residents, AAOMS, 2003. 3. The Building of a Specialty: Oral and illofacial surgery internship and have California/Los Angeles County oral Maxillofacial Surgery 1918-1998 Educational one of the Travis Air Force Base resi- and maxillofacial surgery residency Standards, AAOMS, 2000. 4. AAOMS Statement on Oral and Maxillofacial dents for eight months of the year. program is celebrating its 50th Surgeons, 2000. The resident at UMC gets volumi- anniversary this year. Yamashita, the 5. Competencies of the Oral and Maxillofacial Surgeon at the Completion of Training, AAOMS, nous experience covering the VA, residency program director, has seen 2002. Children’s Hospital, Kaiser, St. Agnes some changes in the curriculum over To request a printed copy of this article, please and the Community Medical Centers of the past several years. Ten years ago, contact / Alan L. Felsenfeld, DDS, professor of Fresno. The major areas of focus are the program took the first MD inte- Clinical Dentistry, Oral and Maxillofacial Surgery, UCLA School of Dentistry, 10833 Le Conte Ave., trauma, pathology and surgical oncolo- grated resident. At present, the pro- #53076, Los Angeles, Calif., 90095-3075. gy, orthognathic surgery and some cos- gram takes two residents per year into metic surgery. the six-year MD integrated, and one in Current research projects include the four-year certificate program. plating mandible fractures without the The MD program residents enter use of maxillomandibular fixation, residency by doing their four months osteomyelitis and endoscopically treat- of anesthesia and integrating with the ed mandible fractures. medical school during their first year. In total, they complete 30 months of Loma Linda University medical school. During that time, they integrate some of the clinical rotations Alan Hereford, DDS, MD, program on the oral and maxillofacial surgery director service. After completing medical The oral and maxillofacial surgery school, a mandatory one-year intern- residency at Loma Linda University ship is done on the general surgery ser- offers two tracks: a four-year certificate, vice at Huntington Memorial Hospital. and a six-year MD program. Residents The residents complete their fifth and in the six-year MD program attend the sixth year of training on the oral and Loma Linda University School of maxillofacial surgery service at LA Medicine. At the end of their medical County Hospital. training, residents complete a one-year LAC is a Level 1 trauma center general surgery internship. where residents spend the majority of The program has affiliations with their time. They also spend time at the Loma Linda University, School of Children’s Hospital where they get Dentistry, Loma Linda University their orthognathic surgery training Medical Center, Riverside Regional and are part of a craniofacial team. At County Medical Center, and Arrowhead the University of Southern California, Regional Medical Center. School of Dentistry, they perform The training the residents receive other surgical procedures including is full scope oral and maxillofacial implants. surgery including trauma, reconstruc- Current research by the faculty and tion, pathology, orthognathic surgery, residents include a grant for trauma esthetic surgery, temporomandibular research and an Oral and Maxillofacial

822 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Third Molars

New Considerations in the Treatment of Compromised Third Molars Ronald M. Kaminishi, DDS, and Kurtis S. Kaminishi, BA abstract Management of asymptomatic malposed third molars is a controversial topic. n 2004, there is no clearly defined consensus on how to manage As a result, many malposed or mildly pathologic third molars are not removed. compromised third molars. There is also considerable disagreement Historical pro and con arguments regarding removal centered around cost and on what constitutes a compromised third molar. Third molars the aspects of the surgical removal itself. Current epidemiology and medical I may be erupted and carious, or in advances address issues not considered before. a variety of partially or complete- ly unerupted states ranging from soft tissue impactions to full bony There is a large growth of the aging population (over 40 years). More and impactions. While abnormal, in the absence of symptoms, many clinicians more of these elderly patients are requiring third molar removal. Over a five- follow the edict, “if it’s not bothering you, leave it alone.” year period, 1997-2002, the incidence almost doubled to 17.9 percent. This This substantial variance of profes- age category is known to be high risk for third molar surgery. sional opinion regarding removal of third molars illustrates a lack of unifor- mity in care currently provided. The An equally or higher risk is the rapidly growing number of patients seeking conflicting literature on the necessity for and timing of third molar removal, third molar surgery who are moderately severely medically compromised. shows a historical lack of consensus as well. Unfortunately, this lack of consen- This paper reviews how this lack of consensus results in delayed removal of sus creates a credibility gap for the dental profession and confusion in the gen- malposed third molars in this population. Preventive dental concepts, removing eral public. compromised third molars earlier, would eliminate the high risk to this As “baby boomers” (the largest mass of the population) approach middle and aging population. advanced age, the need to resolve prophylactic third molar treatment issues becomes more pressing. With time, age

Authors / Ronald M. Kaminishi, DDS, is in private practice in Bellflower and Huntington Beach, Calif. He is a clinical professor at the University of Southern California School of Dentistry and an assistant clinical professor at Loma Linda University at the University of California, Irvine, School of Medicine. Kurtis S. Kaminishi, BA, is a research associate.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 823 Third Molars

and health status become increasingly been generated over the years regarding to treat the patient’s infected teeth for significant risk factors. The dental pro- the timing of third molar removal. In two months without success. The fession must maintain the confidence of particular, there is a large body of litera- urgency was caused by a failing heart the public. A step toward that aim is to ture documenting the increased inci- valve. Cardiac valve replacement ensure that recommended care is consis- dence of dental complications when absolutely cannot be done in the pres- tent amongst dentists and that it is sup- third molar surgery is performed on an ence of dental infections, due to bac- ported by sound evidence-based studies. aging population.4-12 Consequently, this teremia or septicemia. Consultation with It is significant that the largest pro- paper will not address the specific surgical the cardiac surgeon indicated the valve portion of the population is entering risks and complications but will focus could “blow” at anytime. Because these middle or advanced age. At older ages, instead on how the aging population is teeth were not prophylactically removed the risks and complications of dental affected by retained third molars. when the patient was healthy, intra-oper- surgery become significantly higher as ative mortality becomes a very real risk. patients are more likely to have severe Third Molars in the Aging Many dentists do not consider a 2- chronic diseases such as cardiac prob- Population millimeter pericoronal radiolucency a lems and strokes, or may not heal as With human life expectancy on the concern. Adelsperger, Glosser (1999)14 rapidly as younger patients may. This rise, the issue of the aging population and Knights (1991)15 demonstrate that increased risk exposes dentists to mass becomes a major factor in third the absence of radiographic disease in increased complications in surgery and molar treatment planning. In a study impacted third molars is not evidence possibly increased episodes of litigation. done by the authors, it was found that of absence of pathology. Biopsy speci- For example, fragile cardiac or stroke between 1992 and 1997, 10.5 percent of mens of pericoronal tissue of impacted patients kept alive by medications may the patients requiring removal of third third molars with no radiographic not survive a dental extraction. molars were middle or advanced age pathology in patients over 21 years of Important arguments against (older than 40). Fifty percent of the age show a 75 percent incidence of removal of asymptomatic compromised patients over the age of 60 had com- squamous metaplasia similar to that third molars exist. Economic restric- plete bony impactions. From 1997 to found in odontogenic cysts.14 tions involve HMOs, insurance compa- 2002, 17.9 percent of patients were Odontogenic cysts comprise the nies, third parties, and some members older than 40. Of that population, 19.5 majority of major pathologies in com- of the dental profession. Because of percent were older than 60 (60- to 91- promised third molars. The incidence of these financial restraints, patients may years old). One in five patients requir- squamous cell carcinoma of dental refuse, and third-party payers fail to ing third molar removal by a dentist is pathologic tissue is commonly consid- authorize, removal of teeth regardless of in the high to very high-risk category. ered as being statistically rare. the degree of pathology present. One reason for the increase in the Very few dentists are aware that Tulloch et al1 states that “this prac- middle to advanced aged population malignancies arising from odontogenic tice (removal of “asymptomatic” com- can be attributed to medical advances cysts have a very high mortality rate.16-20 promised third molars) appears neither in treating disease. Current mortality Although the incidence of such malig- to be associated with the least expected patterns suggest that the mortality rate nancies is low, Eversol21 and morbidity to patients nor with the over age 85 is decreasing to equal the Schwimmer21 report a 47 percent and imperative of cost containment.” At the rate under age 85, creating an expand- 37 percent mortality two years after 1977 National Institute of Health ing pool of patients who are at high to treatment. Consensus Development Conference: critically high risk of having medical Preventive dentistry has unequivo- Removal of Third Molars, it was con- complications associated with even cally demonstrated that early prophy- cluded that the removal of asympto- minor surgical procedures.13 lactic treatment is more cost effective matic non-pathologic teeth is non- Dentists are not accustomed to treat- than waiting until potential pathology essential surgery that exposes patients ing critically high-risk patients. For exam- becomes more severe or symptomatic. to unnecessary risk.2 Oral and maxillo- ple, a 40-year-old patient presents for Under the “watchful waiting” protocol, facial surgeon, E. Preston Hicks stated urgent removal of bilateral periodontally the cost of biannual radiographs and that, “routine removal of impacted or infected third molars. The patient had clinical exams added to the increased unerupted disease free third molars can- the lower third molars extracted as a cost of a surgery with infection — con- not be justified.”3 young adult. The upper impacted third sidered over a 40 to 50 year time span — What are the indications for removal molars were not authorized by the insur- easily exceeds the cost of prophylactic of asymptomatic compromised third ance company because they were or early treatment of compromised molars? A great deal of information has “asymptomatic.” The periodontist tried third molars.

824 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Conclusion References / 1. Tulloch JF, Antczatk AA, Ung N, 14. Glosser JW, Campbell JH, Pathologic Evaluation of the cost and relative effectiveness of changes in soft tissues associated with radiographi- The present day lack of consensus alternative strategies for the removal of mandibular cally “normal” third molar impactions. Brit J Oral regarding compromised yet asympto- third molars. Int J Tech Assess Health Care 6:505-15, Maxillofac Surg 37:259-60, 1999. 1990. 15. Knights EM, Brekaw WC, Kessler HP, The matic third molars, creates confusion in 2. NIH consensus development conference for incidence of dentigenous cysts associated with a diagnosis of patients. Ultimately, each removal of third molars. J Oral Surg 38(3):235-36, random sampling of unerupted third molars. Gen March 1980. Dent 39:96-8, 1991. case must be based on individual fac- 3. Preston Hicks E, Third Molar Management: 16. Adelsperger J, Campbell J, Coates DB et al. tors. The pros and cons of early or pro- A case against routine removal in adolescent and Early soft tissue pathosis associated with impacted young adult orthodontic patients. J Oral Maxillofac third molar without pericoronal radiolucency. Oral phylactic treatment of compromised Surg 57:831-36, 1999. Surg Oral Med, Oral Path 89(4):402-260, April 2000. third molars should be considered. 4. Al-Khateeb TK, El-Marsafi AI, Butler NP, The 17. Eversol LF, Sabes WR, Rovin S, Aggressive relationship between the indications for the surgi- growth and neoplastic potential of odontogenic The aging mass of our population cal removal of mandibular third molar and the inci- cysts. Cancer 35:270, 1975. and the surging number of functional dence of alveolar osteitis. J Oral Maxillofac Surg 18. Fanibunda K, Soames JV, Malignant and 49:141-45, 1991. premalignant change in odontogenic cysts J Oral but medically compromised patients 5. Bruce RA, Federickson GC, Small GS, Age of Maxillofac Surg 53:1469-72, 1995. places a stronger emphasis on timely patients and morbidity associated with mandibular 19. Gardener AF, The odontogenic cyst as a third molar surgery. J Am Dent Assoc 101(2):240-45, potential carcinoma, a clinicopathological treatment. Preventive dentistry August 1980. appraisal. J Am Dent Assoc 78:746, 1969. becomes a more critical issue. In two 6. Chiapasco M, Crescential M, Romanoni G, 20. Schwimmer AM, Aydin F, Morrison SN, Germinectomy or delayed removal of mandibular Squamous cell carcinoma arising in residual odon- decades, the population mass of baby compacted third molars: The relationship between togenic cysts. Oral Surg Oral Med Oral Path, 72:218, boomers will be in their 60s and 70s age and incidence of complications. J Oral 1981. Maxillofac Surg 53:418-22, 1995. 21. Eversol LF, Sabes WR, Rovin S, Aggressive with even more serious medical handi- 7. deBoer MPJ, Raghoebar GM, Stegenga B et growth and neoplastic potential of odontogenic caps. “Simple” surgical and dental pro- al. Complications after third molar surgery. cysts. Cancer 35:270, 1975. Quintessence Int 26:779-84, 1995. cedures might require the advised con- 8. Hinds, E.C., Rey, KF, Hazards of retained sent of “risk of death.” It is thus imper- third molars in older persons: report of 15 cases. J To request a printed copy of this article, please Am Dent Assoc 101:246-50, August 1980. contact / Ronald M. Kaminishi, DDS, 14343 ative that dentistry develop a consensus 9. Osborn TP, Federickson G, Small IA et al. A Bellflower Blvd., Bellflower, Calif., 90706-3135. regarding treatment of compromised prospective study of complications related to mandibular third molar surgery. J Oral Maxillofac third molars with a sound scientific Surg 43:767-69, 1985. basis. Third parties and self-serving enti- 10. Tate, TE, Impactions: observe or treat? J Calif Dent Assoc 22(6):59-64, June 1994. ties usually assume no liability but 11. Beeman, CS Third molar management: A strongly try to influence our decisions. case for routine removal in adolescent and young adult orthodontic patients. J Oral Maxillofac Surg Early or prophylactic treatment results 57:824-30, 1999. of compromised third molars appear 12. Carr SJ, Preventive oral surgery. South Calif Dent Assoc 34(11):501-8, November 1966. consistent with the tried and true expe- 13. Rothenberg R, Lentzner HR, Parker RA, rience of preventive dentistry. CDA Population aging patterns: the expansion of mortality. J Gerontol 46(2):566-70 March 1991.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 825 commentary

Fifty Years of General Anesthesia in California Oral and Maxillofacial Surgery John J. Lytle, DDS

review of the general anes- who continued to use nitrous oxide to Berto Olson, DDS. In one year, he con- thesia techniques used in oral eliminate the pain associated with verted that nitrous oxide practice to a and maxillofacial surgery removal of teeth until intravenous anes- thiopental practice. He then moved to during the last 50 years of the thesia became available and popular. Long Beach where he opened his own 20th century cannot be fully In Southern California, Lock Hales, practice, which eventually became a appreciated without referenc- DDS, started an exodontia practice in dominant force in Southern California ing at least briefly, what took Glendale in 1929. He first worked with and throughout the nation in populariz- A place in the previous 106 Frank Chandler, DDS, in Hollywood ing the technique of intravenous years that encompassed the discovery and learned the nitrous oxide, oxygen thiopental and later methohexital and development of general anesthesia to desaturation method that was intro- (Brevital) for general anesthesia in oral the mid-20th century. Dental surgery.5 students learn with pride that Orally administered pentobarbital Six of Hubbell’s students, W.T.G. Morton and Horace Frank M. McCarthy DDS, MD; Wells were two dentists credit- (Nembutal) improved his working time and did Bill Bogart, DDS; Howard ed with the discovery of gener- Davis, DDS; Bill Wagner, DDS; al anesthesia in the middle not require hypoxic levels of nitrous oxide. Ralph O’Brien, DDS; and 1840s.1 Nitrous oxide was the Robert Steiner, DMD, staffed primary agent that found the first hospital-based outpa- acceptance and widespread use in den- duced and popularized by McKesson 30 tient thiopental dental general anesthe- tistry, largely through the actions of years earlier.3 He learned that orally sia training program at the Los Angeles Gardner Colton, who established a group administered pentobarbital (Nembutal) County General Hospital in 1956. of dental practices that specialized in improved his working time and did not Marsh Robinson, DDS, MD, had tooth extractions. Ether, ethylene, and require hypoxic levels of nitrous oxide. become chief of oral surgery in 1954 chloroform were widely used in medi- Orlan K. Bullard, DDS, in San Diego and was able to enlist the support of cine, but nitrous oxide use was refined by and Dr. Barkley Wykoff in Santa Sam Denson, MD, head of medical Elmer I. McKesson and Jay A. Heidbrink, Barbara began using a new intravenous anesthesia at the hospital at that time. who developed anesthesia machines that agent, hexobarbital (Evipal) in 1936, That program continues today at the could deliver precise proportions of oxy- but both oral surgeons subsequently Los Angeles County/USC Medical gen and nitrous oxide.2 changed to thiopental (Pentothal) Center, where future oral and maxillo- Oral surgeons in the early 20th cen- because of its greater versatility.4 facial surgeons are learning the latest tury through the 1930s used nitrous Adrian Hubbell, DDS, learned about techniques in office general anesthesia. oxide as their primary agent to induce the studies being done at the Mayo general anesthesia. Alfred Einhorn of Clinic with thiopental, and he spent Author / John J. Lytle, DDS, MD, is Germany discovered procaine in 1905 three years in a surgical fellowship there an oral and maxillofacial surgeon and local anesthesia became common in to learn as much as possible about this in private practice in Southern California. He is the Wilbur N. and the United States three decades later for technique. He returned to Los Angeles in Ruth VanZile professor of Oral and routine dental procedures. But it was the 1940 and worked in Hollywood with Maxillofacial Surgery at the University of Southern California exodontists (later called oral surgeons) Frank Chandler’s successor in practice, School of Dentistry.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 827 commentary

Hubbell introduced the use of suc- the “purists” or single agent proponent relaxants, but this is not practical in cinylcholine into oral surgery practice in — most prominently the Hubbell group office oral surgery. When given in order to treat laryngospasm. He and his disciples — and the “balanced amounts up to 100 micrograms, described administering increasing doses technique” group, who used atropine, a Fentanyl has rarely been associated with to himself and colleagues. They discov- narcotic such as meperidine, methohex- this complication, and smaller doses ered that 5 mg was sufficient to “break” ital, and local anesthesia. Each group were established for use in office general most spasms and that a full depolarizing claimed superiority for their preferred anesthesia. Fentanyl continues to be dose was not necessary. He developed an technique, and gave convincing argu- used in many practices. Fentanyl clearly administration device that allowed him ments for their favorite method. raises the pain threshold, works quickly, to administer a small dose of thiopental The 1960s saw the introduction of and is short acting. Other synthetic nar- rapidly, which he called the “surge tech- benzodiazepines, principally diazepam cotic agents such as pentazocine (Talwin) nique.” The “Hubbell Bubble” is still (Valium), which was first administered and oxymorphone (Numorphan) were used by a few oral surgeons. It introduced, but for the majori- was possible for an oral sur- ty of surgeons they were not as geon to begin practice as Hales Each group claimed superiority for their useful as fentanyl. did using nitrous oxide and to preferred technique, and gave convincing Meanwhile, new monitor- progress through the use of ing devices were being intro- oral barbiturates in combina- arguments for their favorite method. duced, and older progressive tion with nitrous oxide, and surgeons and young surgeons then to go on to use intra- finishing training were more venous thiopental and finally metho- orally and then intravenously. Some sur- comfortable using these electronic hexital in a 30-year span of practice. Our geons used diazepam as their only intra- devices to assess patients under anes- predecessors in practice from 1930 to venous agent along with local anesthe- thesia. Simple monitors to indicate 1960 lived through a period when revo- sia, nitrous oxide/ oxygen, and found pulse rate were first introduced. The lutionary changes took place. this technique successful. Many surgeons electrocardiograph (ECG) was being The 1950s encompassed a period began using methohexital as their princi- used commonly in hospitals but was when refinement of techniques for intra- pal barbiturate. The onset of methohexi- thought by oral surgeons to scare venous general anesthesia occurred. The tal anesthesia was similar to thiopental patients. Consequently, many surgeons use of thiopental alone came under criti- but the duration of action was shorter were reluctant to use this device. It cism from proponents of balanced anes- and the occurrence of laryngospasm less would be another decade before oral thesia techniques in which meperidine frequent. Methohexital was given in a 1 surgeons added the ECG to their moni- (Demerol) was given as an adjunctive percent solution, and thrombophlebitis toring armamentarium and then only agent to raise the pain threshold, reduce seemed less frequent than with the more after state regulations made possession the amount of thiopental needed, and concentrated 2.5 percent solution of and use of the device mandatory. reduce unpleasant and painful emergence thiopental. This unpleasant complica- During that decade, the public from general anesthesia. It became com- tion again became more frequent when became more aware of the ECG and mon to administer local anesthesia after diazepam was injected in small veins, chest leads through the entertainment the patient was asleep to provide postop- with or without other drugs. media and television shows. The auto- erative pain relief and to reduce intra- In the 1970s, fast-acting, short-dura- matic sphygmomanometer was intro- operative bleeding. Atropine and scopo- tion synthetic narcotics were introduced. duced and became well accepted. It is lamine were sometimes added to the bal- Fentanyl (Sublimaze) was being used in easy to use, gives the pulse rate in addi- anced techniques to reduce secretions, hospital general anesthesia cases often as tion to the blood pressure, and alerts and block the vagus nerve thus prevent- the sole intravenous agent along with surgeons to sudden changes in blood ing bradycardia. Monitoring was still in its nitrous oxide/oxygen, and was found to pressure preoperatively, intraoperative- infancy, and no oral surgery office used be very safe for debilitated patients ly, and postoperatively. intra-operative electronic monitoring. undergoing major procedures. One com- In the 1980s even better things were Monitoring was common although rudi- plication, “rigid chest syndrome,” in store for oral surgeons monitoring mentary in hospital general anesthesia. occurred infrequently and only when their patients. The pulse oximeter was Two schools of thought developed higher doses of fentanyl were used. In introduced, displaying blood oxygena- in dentistry and oral surgery regarding the hospital environment, this complication as a percent of oxygen-saturated anesthesia techniques, represented by tion can be easily treated with muscle hemoglobin. Moment-to-moment

828 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 changes were revealed and at last, a muscular drug that had been available ing to the airway, and does not increase monitor was available that could since the late 1960s but which displayed pharyngeal secretions or stimulate laryn- answer the most critical question, “Is hallucinogenic side effects that many felt gospasm. The onset of anesthesia is rapid the patient getting sufficient oxygen?” were unacceptable. Emergence hallucina- and when used in children, there is usu- This device soon became the single tions, which were not prominent in chil- ally very little or no excitement phase. most important monitor and is required dren, were very distressing to adults. Very Most important, sevoflurane does not to be present in every office utilizing often, ketamine acted much like an LSD cause myocardial irritability common pediatric oral sedation, intravenous experience that persisted in some indi- with Halothane. The major disadvantage sedation, or general anesthesia. viduals for a prolonged period. to its use at this time is cost. Today, the pulse oximeter, the ECG, In very much reduced dosage, keta- Presently, sevoflurane is used pri- and continuous blood pressure devices mine has been used in children and marily in children to produce a smooth form the basis for monitoring patients adults to produce a dissociative state, induction of anesthesia before place- undergoing office general ment of an intravenous line anesthesia in oral surgery and in some very short cases, practices in California and Very often, ketamine acted much like an as the sole anesthetic agent. throughout the United States. LSD experience that persisted in some In adults, sevoflurane has the A new benzodiazepine potency to permit the agent midazolam (Versed) individuals for a prolonged period. removal of four third molars appeared in this decade. This while providing for a rapid agent was found to have a and smooth emergence. rapid onset of action, much faster where the patient appears awake but is Postoperative nausea has been very metabolism than diazepam, and above cooperative and retains protective infrequent with sevoflurane. It has been all was not a cause of thrombophlebitis. reflexes. The drug is commonly used in predicted that this agent will become Midazolam has become the standard medical emergency rooms in the man- increasingly popular with oral surgeons intravenous benzodiazepine for the vast agement of the very young. Still, one- during the coming decade. majority of surgeons who utilize these third of dentists using this drug report drugs.5 that they have seen emergence halluci- Summary By the 1990s, research in anesthesia nations in their patients.5 In summary, the advances of the last had seen the development of another During the 50 years that oral and half of the 20th century in general anes- class of intravenous anesthetic agents. maxillofacial surgeons were depending on thesia delivery by oral and maxillofacial The new drug propofol (Diprivan) is a intravenous agents, the search for an ideal surgeons are the following: white liquid that looks much like milk inhalation anesthetic continued. In the 1. Oral and maxillofacial surgeons in when seen in the syringe. Propofol has late 1950s halothane (Fluothane) was training are exposed to significantly more a smooth, rapid onset of action and introduced. This potent agent displayed hospital general anesthesia training and duration of action similar to methohex- rapid onset, a relatively pleasant odor, and in addition spent much of their residency ital. However, many patients exhibit a the ability to produce a surgical plane of training performing general anesthesia markedly rapid emergence when the anesthesia quickly. It became very popu- on outpatient dental patients undergoing drug is used alone. Since methohexital lar in hospital-based anesthesia and was dentoalveolar surgery. Training programs was being used primarily by oral and the standard until newer gases in the increased from one year to three years, maxillofacial surgeons (a relatively same class displayed better characteristics. then to four years and finally, many six- small market segment) and not by med- The reason halothane did not become year programs were developed that award ical anesthesiologists, the manufacturer more popular in the office environment the MD degree during or following com- sold the rights to produce the drug and was that it had the potential to cause car- pletion of the residency program. during the early 2000s, methohexital diac arrhythmias and death if not careful- 2. Self-evaluation programs were ini- was intermittently unavailable. Some ly monitored and precisely given. tiated in the late 1960s and evolved into surgeons returned to using thiopental, In 1996, a new inhalation anesthetic mandatory in-office evaluation by peer but many took the lead of medical anes- was introduced and again was initially practitioners and later into state-regu- thesiologists and began using propofol used in hospital-based operating rooms. lated evaluation. These programs began as their main intravenous agent.6 This agent, sevoflurane, has most of the in Southern California and spread to A few surgeons began to rely on keta- properties of an ideal inhalation anes- encompass the entire United States. mine (Ketalar), an intravenous or intra- thetic.7 It is pleasant to smell, nonirritat- 3. Intravenous ultra-fast acting bar-

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 829 commentary

biturate office anesthesia became very monitors are required by the California References / 1. Hubbell AO, The early days of general anesthesia in oral surgery, proceedings of refined and several combination drug general anesthesia regulations. Anesthesia Symposium VI, 2-8, September 1993. “balanced” techniques developed. 7. Propofol, an entirely new type of 2. Clement FW, Nitrous oxide-oxygen anesthesia, Lea and Febiger, Chapter 7, 107-17, 1951. 4. Benzodiazepines, first diazepam intravenous agent, was introduced and 3. McKesson EI, Anesthesia papers, privately then midazolam were introduced and is used by more than half of oral sur- printed K.C. McCarthy, Md., 9-25, 1953. 4. Lytle JJ, Office anesthesia in the sixties and gained wide acceptance by the dental geons reporting in a survey of drugs seventies, proceedings of Anesthesia Symposium profession. used in 2003.5 Propofol may be used by VI, 15-28, September 1993. 5. Lytle JJ, Report of the 2003 anesthesia sur- 5. New synthetic narcotic agents incremental injection or by continuous vey of the California association of oral and max- were introduced, which give the oral infusion incorporating an automatic illofacial surgeons, December 2003. 6. Valtonen M, et al, Propofol infusion for surgeon another pain control and anes- infusion pump. sedation in outpatient oral surgery, a comparison thesia supplement. The new agents 8. Sevoflurane, a potent inhalation with diazepam, Anaesthesia, 44(9):730-4, September 1989. were short acting but very effective for anesthetic that has many properties of 7. Eger EI, New inhaled anesthetics, the period necessary to complete most an ideal agent — rapid onset, potent, Anesthesiology, 80(4):906-22, April 1994. office surgical procedures. Fentanyl is easily delivered by calibrated vaporiz- the prototype for these agents. ers, rapid emergence, infrequent post- To request a printed copy of this article, please contact / John J. Lytle, DDS, 1370 Foothill Blvd., 6. Monitoring devices were incorpo- operative nausea, and favorable accep- Suite 200, LaCanada Flintridge, Calif., 91011-2117. rated into practice, and currently all tance by almost all patients about to oral surgeons use the pulse oximeter, undergo general anesthesia — is gain- the electrocardiograph, and blood pres- ing acceptance and use by oral and sure monitoring devices. All of these maxillofacial surgeons. CDA

830 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Orthognathic Surgery

Orthognathic Surgery: Diagnosis and Treatment of Dentofacial Deformities Robert Relle, DDS, and Tim Silegy, DDS abstract

Corrective jaw (orthognathic) surgery is indicated for patients with a malocclusion caused by a skeletal deformity.

This paper will discuss current concepts in patient evaluation and review Figure 1b. The resulting dental malocclusion. Courtesy of Dr. Montano. contemporary surgical treatment. Figure 1a. Profile radiograph of a patient with a significant facial skeletal growth disturbance. Courtesy of Dr. Donald Montano, Bakersfield, Calif.

he concept that “form follows by camouflaging the skeletal deformity. function” is a notion universal to However, individuals with the most all aspects of dentistry.1 For severe facial skeletal discrepancies will many it is something learned benefit from orthognathic surgery to early in didactic dental educa- restore facial balance and establish a tion. Nowhere is this concept functional dental occlusion (Figure 2). T more plainly demonstrated than Untreated, dentofacial deformities in the science of facial growth can create problems with many and development. aspects of oral function, including dif- Maturation of the facial skeleton ficulties with speech, swallowing, and and dentition through childhood and mastication (Figure 3). They may also adolescence most often results in bal- cause occlusal trauma from dental anced facial features in harmony with a occlusion that is not mutually protect- functional dental occlusion. Whether ed (Figure 4). the product of an inherited condition or

a developmental disorder, disturbances Authors / Robert in growth of the facial skeleton may Relle, DDS, a diplomate of the lead to a discrepancy that manifests as a American Board dental malocclusion (Figure 1). of Oral and Max- illofacial Surgery, Problems associated with imbal- maintains a pri- ances of the facial skeleton and the den- vate practice in Encino, Calif., and is affiliated with Kaiser tal occlusion are so inseparable, that Permanente in Los Angeles. they are commonly described as dento- Tim Silegy, DDS, is an oral and maxillofacial surgeon in private practice in Long Beach, Calif., and facial deformities. Orthodontic therapy a diplomate, American Board of Oral and is effective in managing most problems Maxillofacial Surgery.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 831 Orthognathic Surgery

Figure Figure 2a. Profile 2b. Profile of of patient in patient after Figure 1 prior surgery to to combined advance the orthodontic maxilla and set and surgical back the treatment. mandible.

Figure 2c. Finished dental occlusion.

Figure 3. Patient with a dentofacial deformi- Figure 4a. This traumatic occlusion has Figure 4b. Finished dental occlusion after ty. Note the anterior cross bite. This malocclusion caused attrition at the occlusal edge of the lower combined orthodontic and surgical treatment for is often associated with difficulty tearing and right premolar. Courtesy of Dr. Yamada. correction of mandibular hyperplasia with chewing food. Courtesy of Dr. Merilynn Yamada, mandibular set back. Courtesy of Dr. Yamada. Burbank, Calif.

Figure 6a. Figure Patient with 6b. Profile mandibular changes after hypoplasia dis- surgery to playing increased advance the facial convexity mandible. and a retruded Courtesy of chin. Note the Dr. Montano. chin position relative to a vertical line passing through the base of the nose. Courtesy of Dr. Montano. Figure 5. Radiographic profile of a patient with mandibular hypoplasia. The upper incisors are resting on the lower lip.

The dentist is uniquely trained to erly diagnosing dental malocclusion multiple spatial planes. A systematic, identify a disturbance in growth of the and applying the correct classifica- compartmentalized evaluation of the facial skeleton and to understand how it tion, i.e. Angle’s Class I, II, and III, dentofacial deformity will bring the may be the foundation of a dental mal- open bite, and deep bite.2 However, problem to the forefront. occlusion. With this awareness, he or the skeletal imbalances that produce Many clinical evaluation schemes she can educate patients and discuss the the more pronounced dental maloc- attempt to evaluate anterior-posterior appropriate available treatment. clusions are sometimes difficult to discrepancies and vertical discrepancies appreciate. This is because these independently. Some of the more com- Diagnosis dentofacial deformities often repre- mon deformities are described in this Most clinicians are adept at prop- sent a combination of problems in paper.

832 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Horizontal Discrepancies Figure Figure 7a. Patient 7b. Same with patient after Mandibular Hypoplasia mandibular surgery to hypoplasia advance the Anterior-posterior mandibular hypo- who has a mandible. relatively Straightening plasia (mandibular retrusion) is usually prominent of the profile associated with Class II dental malocclu- nose. reduces the relative sion. Individuals with this condition usu- prominence ally have increased facial convexity and a of the nose. retruded chin. They tend to display an everted lower lip and a deep labiomental fold, especially if the dental malocclusion is large enough to cause the upper incisors to rest on the lower lip (Figure 5). To evaluate the facial profile, the patient is instructed to assume a relaxed head posture tilting neither up nor down. This may be facilitated by having him or her gaze into a mirror placed at Figure 8a. Class II malocclusion of a Figure 8b. Same patient after combined eye level across the examination room. patient with mandibular hypoplasia. Note the orthodontic and surgical treatment that involved a upper incisor crowding. mandibular advancement. The clinician is positioned to examine the patients profile and an imaginary vertical line passing through the base of Figure 9. Figure 9b. 3,4 Patient with Surgery to set the nose is constructed. With mandibular back the mandible mandibular hypoplasia, the point of the hyperplasia. lessens the facial Note the posi- concavity. chin will be positioned well behind this tion of the reference line (Figure 6). chin relative to the refer- When mandibular hypoplasia is sig- ence line. nificant it causes the nose to appear relatively prominent. In fact, many patients seeking cosmetic surgery consultation for what they perceive as an excessively prominent nose have in real- ity, a hypoplastic mandible (Figure 7). Natural dental compensations are and a prominent chin. Using the same associated with Class III dental malocclu- usually observed in individuals with vertical line passing through the base of sion. With isolated maxillary hypoplasia, mandibular retrusion. The lower anteri- the nose, one will find the lower lip and the upper lip will appear deficient and or teeth are often tipped forward and chin positioned in front of this reference from the profile, the angle between the extruded. The upper incisors are crowd- (Figure 9). The natural dental compensa- upper lip and the nasal base will be acute. ed and positioned relatively upright. tions include retrusion and crowding of There is often deficient projection of the (Figure 8.) the lower incisors and flaring of the face to the side of the nose and in the area upper incisors. This may occur with of the cheekbones. Independent evalua- Mandibular Hyperplasia and diastemas, if the maxilla is sufficiently tion of mandibular projection will reveal Maxillary Hypoplasia wide, or there may be dental crowding if that the chin is actually in an acceptable Mandibular hyperplasia is generally the maxilla is narrow (Figure 10). position relative to the vertical reference associated with Class III dental malocclu- Care must be taken to differentiate line (Figure 11). sion. The characteristics common to this mandibular hyperplasia from maxillary Quite commonly, both mandibular condition include a concave facial profile hypoplasia because both conditions are hyperplasia and maxillary hypoplasia

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 833 Orthognathic Surgery

Figure Figure 11a. 11b. The Vertical refer- same patient ence line after maxil- reveals this lary advance- patient’s chin ment. to be in cor- Courtesy of rect position Dr. Paz. and maxilla to be retruded. Courtesy of Dr. Mario Paz, Marina Figure 10. Note the natural dental compen- del Rey, Calif. sation for this patient with mandibular hyperplasia. The upper incisors are flared forward and the lower incisors are retruded and slightly crowded.

Figure occur simultaneously. In this instance, 12a. The profile of this features common to both deformities patient shows will be evident. a retruded chin and lip incompe- Vertical Discrepancies tence. Courtesy of The face is typically divided into Dr. Montano. thirds when performing a vertical analysis. The upper facial third is mea- Figure 12b. Preorthodontic occlusion sured from the hairline to the mid- showing open bite. Courtesy of Dr. Montano. brow. The middle third is measured from the midbrow to the base of the nose. The lower facial third is measured from the base of the nose to the Figure bottom of the chin. Most vertical 12c. dentofacial discrepancies are manifest Profile after a maxillary in the lower facial third. impaction. Vertical discrepancies have a pro- Note prominence of found effect on facial projection. One chin. Courtesy example of this condition is the of Dr. Montano. patient with an anterior open bite (Figure 12). This condition will accen-

Figure 12d. Post-treatment occlusion. tuate facial convexity and cause the Courtesy of Dr. Montano. mandible to appear more retrusive and the chin to appear vertically elongat- ed. These individuals will have a long slender face, as downward and back- ward rotation of the mandible causes jaw line definition to be weak. This appearance is further accentuated as the patient draws the lips together to produce a seal. This causes flattening of the labiomental fold and the char- Figure 13a. Preorthodontic occlusion show- Figure 13b. Occlusion after orthodontic acteristic “orange peel” effect of men- ing with minimal room for skeletal movement. treatment. Eliminating dental compensation created the space for optimal movement of jaws. talis muscle strain.

834 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Figure 14a. Le Fort I osteotomy. Figure 14b. Sagittal osteotomy of Figure 14c. Horizontal osteotomy of ante- mandibular ramus. rior mandible below mental foramina.

ery and comfort immediately after surgery. Rapidly metabolized anesthetic agents, effective non-narcotic anal- gesics, and powerful antiemetic drugs have been instrumental in shortening recovery time, frequently permitting the orthognathic surgery patient to return home only two or three hours after the procedure has been completed. With intimate knowledge of the facial anatomy, the oral and maxillofa- Figure 15. Small power saw used to Figure 16. Titanium plate and screws perform osteotomy. used to rigidly fixate osteotomy. cial surgeon is able to move components of the facial skeleton into the desired relationships using precise bone cuts Treatment harmony with a Class I dental occlusion (osteotomies) and controlled fractures. (Figure 13). Most dentofacial deformities are correct- Orthodontic ed with one or a combination of the fol- With few exceptions, the correc- Surgery lowing osteotomies: Le Fort I (maxillary) tion of a pronounced dentofacial Modern orthognathic surgery is safe osteotomy, sagittal osteotomy of the deformity requires combined ortho- and predictable. In many cases the sur- mandibular rami, and osseous genio- dontic and surgical treatment. As men- gical procedures can be done in an out- plasty7,8,9 (Figure 14). Additional cos- tioned earlier, patients with dentofa- patient setting, eliminating the incon- metic procedures may be employed to cial deformities usually present with venience and expense of a hospital stay. enhance the result. A power saw with a some degree of dental compensation. Patients are far less inconvenienced by fine blade is the primary surgical instru- An important goal of orthodontic ther- modern surgery owing to technological ment for these procedures (Figure 15). apy is to eliminate these compensa- advances such as rigid internal fixation, Once the osteotomies have been tions so that the magnitude of the den- a method of stabilizing the bony cuts completed, the skeletal part can be tal discrepancy is equivalent to the (osteotomies) such that immobilization repositioned as desired and then rigidly magnitude of the skeletal discrepancy. of the jaws with wire is avoided.6 This fixated using small titanium plates and When presurgical orthodontic treat- permits speech and a soft diet soon after screws (Figure 16). ment has been completed, the occlusal surgery. Patients often return to light discrepancy will be more pronounced.5 activities in as little as one or two weeks. Conclusion This critical part of the treatment is Modern general anesthesia, a This article demonstrates basic prin- the key that allows orthognathic requirement for orthognathic surgery, ciples in the diagnosis and correction of surgery to provide a balanced face in has also greatly facilitated patient recov- dentofacial deformities. Early recogni-

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 835 tion by the general practitioner and referral to an oral and maxillofacial surgeon can provide patients with a stable, functional occlusion and enhanced facial esthetics. CDA References / 1. Enlow DH, Hans MG, Essentials of Facial 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 head position as a basis for cephalometric analysis, Am J Orthod Dentofacial Orthop 101(3):244-7, 1992. 4. Houston WJ, Basis for the analysis of cephalometric radiographs: Intracranial reference structure or natural head position, Proc Finn Dent Soc 87:43, 1991. 5. Shanker S, Vig KWL, Orthodontic Preparation for Orthognathic Surgery In: Oral and Maxillofacial Surgery By, Fonseca RJ, W.B. Saunders Co., Philadelphia, PA, 2000. 6. Jeter TS, Van Sickels JE, Dolwick FM, Modern Techniques for Internal Fixation of Sagittal Ramus Osteotomies, J Oral Maxillofac Surg 42(4):270, 1984. 7. Bell WH, Le Fort I Osteotomy for Correction of Maxillary Deformities, J Oral Surg 33(6):412-26, 1975. 8. Trauner R, Obwegeser H, Operative Oral Surgery: The correction of mandibular prognathism and retrognathia with consideration of genioplasty, J Oral Surg (Chic) 10(7):677, 1957. 9. Converse JM, Wood-Suth D, Horizontal Osteotomy of the Mandible, Plast Reconstr Surg 34:464-71, 1964.

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

836 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Facial Trauma

Management of Traumatic Facial Injuries Tim Silegy, DDS, and Peter Scheer, DDS, MS abstract

Whether minor or major, traumatic rauma remains a major health professionals generally manage the and social issue throughout the patient in the hospital environment. injuries to the maxillofacial area have world. In the United States Trauma in general has many mech- alone, every year thousands of anisms. Blunt trauma is the result of an far-reaching physical and emotional people of all ages sustain facial unstoppable force meeting an immov- injuries from automobile and able object. Falls, physical assaults and effects. Because the dentition dictates T other various vehicular acci- motor vehicle accidents are examples. dents, firearms, athletic activi- Resultant soft tissue injuries can range facial form and function, the oral and ties and altercations.1,2,3 Regardless of from contusion to avulsion. Hard tis- maxillofacial surgeon, a dental special- the mechanism, traumatic maxillofacial sue injuries may be relatively minor injuries can significantly affect the phys- and include subluxed and fractured ist with a minimum of four years of ical and psychological health of the teeth and non-displaced facial frac- individual. Because oral and maxillofa- tures. More severe injuries range from hospital-based surgical training, is cial surgeons have a broad educational isolated mandible fractures to pan- base in dentistry and medicine, they are facial fractures. uniquely qualified to manage these uniquely qualified to mange traumatic When sharp or fast moving objects injuries to this area. This paper reviews pierce the soft tissue of the maxillofacial injuries. At times, the expertise of the the role of the oral and maxillofacial sur- area, significant injuries can result. geon in providing care to these patients. Gunshot wounds, knives, and foreign general dentist and other dental spe- There are many ways to categorize bodies are common mechanisms of cialists may be needed to provide facial injuries. For the purposes of this penetrating injury. Penetrating injuries paper however, traumatic facial injuries can quickly become life threatening due definitive care. Several cases are pro- will be divided into minor trauma and to vascular and respiratory compromise. major trauma. vided to illustrate management of facial Minor trauma refers to localized Patient Assessment injuries that typically lack the potential Forces sufficient to cause even trauma. to be life threatening. These include iso- minor damage to the maxillofacial com- lated lacerations, fractured and sub- plex can also harm the central nervous luxed teeth, and non-complex facial system.4 The brain and spinal chord are fractures such as isolated fractures of the most susceptible to injury and a com- zygomatic arch, maxilla and mandible and alveolar processes. Surgery to cor- Authors / Tim Silegy, DDS, is an oral and maxillofacial surgeon in rect these problems can frequently be private practice in Long Beach, carried out in the office or surgical cen- Calif., and a diplomate, American Board of Oral and Maxillofacial ter environment. Surgery. Major trauma usually involves more Peter Scheer, DDS, MS, is in private practice in Rancho Mirage, than one body system. Because of the Calif. He is a diplomate of the American Board of severity of the injury, multiple health Oral and Maxillofacial Surgery.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 839 Facial Trauma

plete neurological exam is indicated in these patients. Patients with altered 1a. Abrasion on mental status and/or neck pain should chin and lip have head and cervical spine injuries laceration. ruled out by CT scan.

Management of Minor Traumatic Injuries The oral and maxillofacial surgeon will frequently be called upon to manage minor traumatic injuries. Many of these cases can be handled expeditious- 1b. Lip laceration and subluxed teeth Nos. 8 and 9. ly in the office environment. Figures 1a-d show a 9-year-old female who sustained blunt trauma as a result of falling off a pogo stick. The patient was referred to her general dentist by her pediatrician for management of an upper lip laceration and damaged central incisors. The general dentist subsequently referred her to one of the authors for definitive care. There were no associated neurological findings and her head and neck 1c. Occlusal radiograph showing root 1d. Teeth reduced and splinted with thin wire. exam was normal. displacement. After reassuring the patient and reducing anxiety with nitrous Figures 2a-2c show a 5-year-old severe maxillofacial injuries frequently oxide/oxygen, local anesthesia was female who presented to the emer- are victims of other body trauma and as administered. A more thorough intrao- gency room after having been bitten such, are generally brought to hospital ral examination revealed Ellis Class III by a dog. Due to the age of the child, emergency departments by way of para- fractures of teeth Nos. 8 and 9. The this complex laceration was managed medic ambulance. On presentation, same teeth were also subluxed palatally. in the operating room under general their airway, breathing, and circulation The anterior labial gingival was slightly anesthesia. are evaluated and managed. Life-threat- degloved and the maxillary labial After thoroughly irrigating the ening injuries are identified and emer- mucosa macerated. An occlusal radi- wound with a triple antibiotic solution, gency surgery performed. Once stabi- ograph showed widening of the peri- the vermillion border was re-approxi- lized, their maxillofacial injuries can be odontal ligament space at the apex. mated. The oral mucosa was closed addressed. There was no evidence of root fracture. using 4-0 gut suture. The orbicularis oris In the last 20 years, two medical A straight forceps was used to repo- muscle was closed with resorbable advances have revolutionized the way sition the central incisors labially. The suture and the skin closed with 5-0 traumatic facial injuries are managed. teeth were then splinted to the adjacent nylon suture. Because of the potential Most commonly, the extent of the lateral incisors using 24-gauge round for infection, the patient received injuries are determined by computer- wire. Calcium hydroxide was placed on antibiotics. ized tomography (CT) scanning.5,6 the exposed pulp and topped with a Images obtained allow the surgeon to thin layer of composite. The gingival Management of Major Traumatic visualize a complete 3-dimensional lacerations were closed using 3-0 gut Injuries reconstruction of the facial skeleton. suture. The splint was removed two At some point during their profes- This enhances his or her ability to weeks later and the patient was referred sional careers, most oral and maxillofa- detect the full extent of injuries and for- to an endodontist for management of cial surgeons are part of a trauma man- mulate a precise surgical plan.7 pulpal necrosis. agement team. Patients who sustain The development and use of rigid

840 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 2a. 2b. 2c. Through Postoper- Three- and ative view. month through lip follow up. laceration extending to left nares.

3a. Panoramic showing severely displaced fractures.

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

3f. Post- operative PA radiograph.

3e. Postoperative panoramic radiograph.

3d. Titanium plate rigidly fixating body fracture. internal fixation to stabilize facial frac- result in mandible fractures. Figures 3a- into his trachea. Arch bars were then tures is the second advancement.8-13 3f show a 41-year-old man who was placed on the maxillary and mandibu- Well-tolerated titanium plates and assaulted during an argument. He lar teeth to provide for maxillo- screws have replaced stainless steel wire received a single blow to the left chin, mandibular fixation. With the patient’s and provide absolute immobilization of the force of which fractured the left pre-morbid occlusion reproduced, the fractures decreasing the incidence of mandibular body and the right fractures were accessed via skin inci- postoperative complications and elimi- mandibular angle. Muscle pull further sions in natural neck creases. Once the nating the need for long-term inter- displaced the fracture. The patient had fracture segments were aligned, rigid dental wiring. Consequently, the no other injuries. titanium plates and screws were used to patient can return to normal function The patient was taken to the operat- hold the segments in the correct posi- earlier without compromising healing. ing room where his surgery was per- tion. The inter-dental fixation was The cases that follow illustrate the prac- formed under general anesthesia. His removed just two weeks after surgery, tical application of these technologies. airway was protected by passing a which allowed the patient to consume Physical altercations frequently breathing tube through his nose and a soft diet.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 841 Facial Trauma

4a. PA radiograph showing bullet and bone fragments.

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.

occlusion would be consistent with the orbito-ethmoid (NOE) complex and left preoperative occlusion. The large boney and right zygomatic buttress. The frontal defect was then bridged by a locking tita- sinus was also fractured. He then under- nium reconstruction plate. After copi- went extensive surgery to repair his frac- ously irrigating the wound, a drain was tures and complex facial lacerations. placed and the oral mucosa and extra- The patient’s dentition was utilized oral sites were closed primarily. as a guide for the initial facial fracture The patient is presently undergoing reduction, using maxillo-mandibular orthodontic treatment. Once complete, fixation. Titanium plates and screws the boney defect of the left mandibular were then used to rigidly fixate his frac- 4g. Fifteen-month follow up showing minimal scarring. body will be reconstructed with bone tures and were placed through his exist- harvested from the iliac crest. After a ing facial lacerations, as well as a modi- Figures 4a-g represent a 20-year-old period of healing, her missing teeth will fied coronal flap. female who was the victim of a large be replaced with dental implants. The frontal sinus was then debrided. caliber gunshot wound at close range. The final case illustrates the effect of The sinus membrane was removed in its The patient was stabilized by the trau- severe blunt facial trauma. (Figures 5a- entirety, and the defect was obliterated ma team and admitted to the surgical g.) This 21-year-old male, was the victim with autologous fat obtained from the intensive care unit. of a single car rollover accident in the abdominal wall superior to the umbili- The wound was debrided in the oper- early morning hours. He sustained mul- cus. Once the hard tissues were repaired, ating room while the patient was under tiple severe craniofacial, maxillofacial, attention was turned to the soft tissue general anesthesia. Nonviable bone, and orthopedic injuries. He was airlifted defects. The transected right facial nerve tooth, and bullet fragments were careful- to a regional trauma center where his and parotid duct were repaired. Lastly, ly removed. Intact teeth were used to condition was stabilized. A CT scan was his facial lacerations were closed and his place the patient into maxillo-mandibu- performed which revealed a classic Le nearly avulsed ear repaired. The patient lar fixation assuring the postoperative Fort III fracture involving the naso- remained in the hospital for several

842 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 5a. Three- dimensional CT scan showing fractures.

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

5d. Titanium mini-plates used to repair 5e. Coronal flap used to access orbits and 5f. Left ear reattached. fractured orbit. frontal sinus. maxillofacial injuries the oral and max- tures. J Oral Maxillofac Surg 61:861, 2003. 9. Cunningham LL, Haug RH, Ford J, Firearm 5g. Frontal illofacial surgeon may be called upon to injuries to the maxillofacial region: An overview of view 11 months manage. A comprehensive education in current thoughts regarding demographics, patho- after injury. physiology, and management. J Oral Maxillofac Surg dentistry, medicine, and surgery pro- 61:932, 2003. vides these dental specialists with the 10. Scolozzi P, Richter M, Treatment of severe mandibular fractures using AO reconstruction skills necessary to give trauma victims plates, J Oral Maxillofac Surg 61:458-61, 2003. excellent care. CDA 11. Ellis E, Koury M, Rigid internal fixation for the treatment of infected mandibular fractures, J Oral Maxillofac Surg 50(5):434-43, 1992. 12. Dodson TB, Perrott DH, et al., Fixation of References / 1. Advanced Trauma Life Support mandibular fractures: A comparative analysis of Student Manual, 6th Ed., American College of rigid internal fixation and standard fixation tech- Surgeons, Chicago, IL, 1997. niques, J Oral Maxillofac Surg 48(4):362-6, 1990. 2. Assael LA, Managing the trauma pandemic: 13. Ellis E, Potter J, Treatment of mandibular Learning from the past, J Oral Maxillofac Surg 61(8): angle fractures with a malleable noncompression 859-60, 2003. miniplate, J Oral Maxillofac Surg 57(3): 288-92, 1999. days postoperatively. 3. Laskin D, Best AM, Current trends in the treatment of maxillofacial injuries in the united Since the initial surgery, he has states, J Oral Maxillofac Surg 58(2):207-15, 2000. undergone multiple scar revisions utiliz- 4. Lalani Z, Bonanthaya KM, Cervical spine injury in maxillofacial trauma, Br J Oral Maxillofac To request a printed copy of this article, please ing CO and YAG lasers, as well as pri- Surg 35(4):243-5, 1997. 2 contact / Tim Silegy, DDS, 6226 E. Spring St., Suite 5. Furst IM, Austin P, et al., The use of com- mary excision of residual scar tissue. 315, Long Beach, Calif., 90815-1449. puted tomography to define zygomatic complex This fall, the final refinements will be position, J Oral Maxillofac Surg 59(6): 647-54, 2001. completed by performing a corrective 6. Ploder O, Clemens K, et al., Evaluation of computer-based area and volume measurement septo-rhinoplasty to finalize his post- from coronal computed tomography scans in iso- traumatic rehabilitation. lated blowout fractures of the orbital floor, J Oral Maxillofac Surg 60(11):1267-72, 2002. 7. Broumand SR, Lales JD, et al., The role of Conclusion three dimensional computed tomography in the evaluation of acute craniofacial trauma, Ann Plast The cases presented in this paper Surg 31(6):488, 1993. represent in part, the wide variety of 8. Ellis E III, Muniz O, Anand K. Treatment considerations for comminuted mandibular frac-

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 843 TMJ Disease

Temporomandibular Joint Disease: An Update of Surgical Treatment A. Thomas Indresano, DMD, and Angelle Casagrande, DDS, MD

abstract

The temporomandibular joint is one of emporomandibular disorders masseter, and temporalis muscles. is a set of symptoms (that may Injection of the drug decreases the mus- the most complicated joints in the or may not have pathology) cle activity in discreet areas. The agent that can be treated surgically. must be injected using an electromyo- human body. Because signs and symp- Surgical treatment is typically graphically directed needle. A tuber- employed only when the culin syringe attached to the EMG nee- toms of TMJ problems often disrupt T established diagnoses are dle is used to inject 10 to 70 units of amenable to surgical treat- Botox per side, usually 40 to 50 units in mastication, the general dentist may be ment. Unfortunately, many times “fail- five divided doses in the masseter and the first health care provider the ure of conservative treatment” has 20 to 30 units in the temporalis. become a reason for surgery. This exclu- This treatment causes a decrease in patient sees. Cases that are refractory sionary diagnosis is fraught with failure. the contractility in certain areas of the Pain is not a diagnosis that can be treat- muscle, which decreases the hyperactiv- to nonsurgical treatment are frequently ed with surgery. The goal of surgical ity and allows for rest and repair. intervention is to correct demonstrable Patients do not notice a decrease in referred to an oral and maxillofacial pathology. chewing strength. One would expect Many pathologic conditions have the results to last about six weeks (the surgeon. This paper provides an surgical solutions. These include inter- duration of Botox), but the effects seem nal derangement, degenerative arthritis, to last much longer, possibly because overview of the surgical procedures inflammatory arthritis, and iatrogenic the cycle of muscle parafunction is bro- used to manage internal derangement joint destruction. Other conditions that ken. The patient may remain asympto- may contribute to TMD can be treated matic if no inciting event resumes. of the TMJ. with techniques performed by oral and Botox has been used on very refractory maxillofacial surgeons. These include patients with very good success, lasting dentofacial deformities, myalgia, and myositis. Authors / A. Thomas Indresano DMD, is professor and chair, Oral Botox Injections and Maxillofacial Surgery, Univer- While not a surgical procedure, sity of the Pacific, and program director at Highland General Botox can be very helpful for refractory Hospital. pain due to muscle problems in surgical Angelle Casagrande DDS, MD, is formerly assistant professor Oral and nonsurgical cases. Patients with and Maxillofacial Surgery, University of the Pacific, muscle pain from primary myositis and assistant program director at Highland General Hospital. She currently is in private practice in respond to injection of Botox into the Tucson, Ariz.

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 845 TMJ Disease

Table 1 Wilkes Staging of Internal Derangement7 STAGE CLINICAL IMAGING SURGICAL I. EARLY Painless clicking Slightly forward Normal disc form No restricted motion disc, reducing Slight anterior displacement Normal osseous contours Passive incoordination (clicking) II EARLY/ INTERMEDIATE Occasional painful Slightly forward disc, Anterior disc displacement clicking reducing Thickened disc Intermittent locking Early disc deformity Headaches Normal osseous contours III. INTERMEDIATE Frequent pain Anterior disc displacement, Disc deformed and displaced Joint tenderness, reducing early progressing Variable adhesions headaches to non-reducing late No bone changes Locking Moderate to marked Restricted motion disc thickening Painful chewing Normal osseous contours IV. INTERMEDIATE/LATE Chronic pain, headache Anterior disc displacement, Degenerative remodeling Restricted 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 changes Joint crepitus non-reducing with perforation of disc and hard tissues; Painful function and gross disc deformity Perforation Degenerative osseous Multiple adhesion changes

as long as one year, with repeated suc- products like kinins which have been Figure 1. 1,2 5,6 cess on subsequent injections. shown to cause pain. The technique Arthrocentesis can be used as a means of placing med- of right TMJ. Arthrocentesis ications in the joint which may prove to The introduction of a needle into be the best reason for performing it in the superior joint space is an outgrowth the future. Various forms of steroids of arthroscopy. Experience with arthro- have been used to reduce inflammation. scopic lysis and lavage showed the ben- Hyaluronic acid has been used to efits of irrigation. Therefore, since there increase joint lubrication. NSAIDS have ature.11 An arthroscope is passed into seemed to be no reason to actually look been tried to give long-acting pain relief the inferior joint space allowing the inside the joint in many situations, as well as reduced inflammation. surgeon to visualize the joint. arthrocentesis was derived.3,4 The tech- Narcotics have been used to break the Arthroscopy can be diagnostic or thera- nique has become the first line treat- pain cycle, and sclerosing agents have peutic. It was first used to treat closed ment for newly diagnosed patients with been used to stabilize loose joint liga- lock and is presently used for all stages internal derangement and has been ments (Figure 1). of ID and DJD. Those who developed used for all stages of ID and DJD. the technique refined it so that full However, the literature best supports its Arthroscopy arthroscopic arthroplasty could be per- use for locking joints. Irrigation is Arthroscopy is a very useful tech- formed. Unfortunately, triangulation deemed useful to remove “breakdown” nique with a wealth of supportive liter- and complicated maneuvers like laser

846 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Figure 3. Open Figure 4. arthroplasty showing Discectomy without the superior joint space replacement. with hypervascular disc prior to wedge resection.

Figure 2. Arthroscopic anterior release performed with YAG laser. Discectomy itself under the displaced disc. Outcomes The most written about and most suc- are similar to other surgical treatments, cessful surgical technique related to TMJ but acceptance has been limited. surgery since the early part of the 20th century, discectomy (surgical removal of Total Joint Replacement the articular disk) has been used in the Replacement of bone substance for United States and in Europe to deal with severely degenerated joints has been avail- advanced degenerative joint disease.8 able for many years. Autogenous grafting Silver has a follow up greater than 50 with hip or rib has been used along with years on these patients.9 Removing the a number of more unusual donor sites. disk in its entirety, the surgery gets Most autogenous grafting has the prob- patients out of pain and improves func- lem of previous scarring and limited

Figure 5. CAD Cam construction model of tion. Eventually the patient exhibits radi- blood supply. Rib grafting is often used for custom TMJ replacement. ographic changes in the bone and joint growing children since growth can be crepitance. These signs were accepted in continued at the costochondral interface. usage are technically difficult, causing Europe and explained as accelerating the Replacement using allogeneic sys- arthrocentesis to be used more fre- “natural history of the disease” or taking tems has increased since Mercuri pub- quently. The value of arthroscopy is a Wilkes Stage 2 or 3 and advancing it to lished outcome studies over 20 years that an arthroplasty can be performed a Stage 4. This was deemed acceptable as showing excellent retention and correc- without surgically opening the joint, the patient returned to a state of pain free tion of severe DJD12 (Figure 5). thereby reducing the potential for scar- mobility. ring and limitation of motion. Those In this country, these changes were Distraction Osteogenesis who can perform arthroscopic arthro- not deemed acceptable and consequent- Developed for orthognathic proce- plasty do so quickly with minimal trau- ly, spurred a number of attempts at disc dures, it recently has been used for the ma, but this takes extraordinary skill replacement, which included using der- replacement of condyles that have been and must be performed frequently to mis, ear cartilage, femoral head carti- severely degenerated as well as for keep up the skills of the surgeon lage, temporalis muscle and a variety of failed allogeneic total joints. The theo- (Figure 2). alloplastic materials as substitutes for ry is appealing since slow distraction the missing disk (Figure 4). causes bone deposition and soft tissue Open Arthroplasty growth, including new vascularity. Open arthroplasty is a technique Condylotomy While a small number of surgeons have widely used in the 1970s to repair vari- This technique stemmed from the reported success, long-term results have ous stages of internal derangement. The reports that patients who underwent ver- yet to be reported. intention of this operation is to repair tical ramus osteotomies for orthognathic and reposition a damaged and displaced correction improved their TMJ symptoms. Conclusion articular disk. However, studies using First used in Britain by Ward-Booth, it has A wide variety of surgical procedures postoperative MRIs have shown that been championed by Hall.10 The theory is are available to correct pathologic tem- this repaired position does not hold that instead of placing the disc over the poromandibular joints. Over the years, over time (Figure 3). condyle, one allows the condyle to find the authors have performed all of the

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 847 TMJ Disease

listed procedures. Generally speaking, References / 1. Freund B, Schwartz M, Symington arthrosis and its treatment by extirpation of the JM, The use of botulinum toxin for the treatment disc. Acta Chir Scand 95(suppl 118), 1947. the authors’ experiences have paral- of temporomandibular disorders: preliminary find- 9. Silver CM, Long-term results of meniscecto- leled the literature. ings. J Oral Maxillofac Surg 57(8): 916-20; discussion my of the temporomandibular joint. J Craniomand 920-1, August 1999. Pract 3:46, 1985. Following conservative treatment, 2. Freund B, Schwartz M, Symington JM, 10. Hall HD., Navarro EZ, Gibbs SJ, One- and arthrocentesis is an effective first inter- Botulinum toxin: new treatment for temporo- three-year prospective outcome study of modified mandibular disorders. Br J Oral Maxillofac Surg condylotomy for treatment of reducing disk dis- vention for internal derangement. If an 38(5): 466-71, October 2000. placement. J Oral Maxillofac Surg 58:7, 2000. arthroplasty is needed, arthroscopy with 3. Nitzan D.W., Samson B, Better G: Long- 11. McCain JP, Sanders B, Koslin MG, Quinn term outcome of Arthrocentesis in severe closed JD, Peters PB, Indresano, AT, Temporomandibular Ho:YAG laser, is preferential because it lock. J Oral Maxillofac Surg 55:151-7, 1997. Joint-Arthroscopy: A Six-Year Multi-Center causes less scarring than open proce- 4. Nitzan DW, Price A, The use of arthrocente- Retrospective Study of 4,831 Joints. J Oral sis fro the treatment of osteoarthritic temporo- Maxillofacial Surg 50:926-30, 1992. dures. In cases where the disk cannot be mandibular joint. J Oral Maxillofac Surg 59(10):154- 12. Mercuri LG et al, Long-term follow up of repaired/repositioned, discectomy with- 9, 2001. the CAD/CAM patient-fitted total temporo- 5. Milam SB, Pathophysiology of articular disk mandibular joint reconstruction system. J Oral out placement of interpositional materi- displacements of the TMJ in Oral and Maxillofacial Maxillofacial Surg 60:1440-8, 2002. al has withstood the test of time. Surgery. Ed. Fonseca RJ WB Saunders Co, Philadelphia, 46-72, 2000. For adults with severe DJD or multi- 6. Zardeneta G, Milam SB, Schmitz JP, Elution ply operated degenerated joint allogene- of soluble proteins by continuous TMJ To request a printed copy of this article, please Arthrocentesis J Oral Maxillofac Surg 55:709-15, contact / A. Thomas Indresano, DMD, 2155 ic total joint replacement is indicated. In 1997. Webster St., Room 522J, San Francisco, Calif., growing children, costochondral grafting 7. Wilkes CH, Surgical treatment of internal 94115-2333. derangements of temporomandibular joint. Arch is preferential due to increased blood Otolarngol Head Neck Surg 117:64, 1991. supply and potential for growth. CDA 8. Boman K, Temporomandibular joint

848 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Cosmetic Procedures

Overview of Facial Cosmetic Surgery Simona C. Arcan DMD, MD abstract

Dentists routinely refer patients to he specialties of oral and max- oral incisions, others require incisions illofacial surgery and plastic to be made in visible areas of the face. oral and maxillofacial surgeons for surgery share common origins. Additionally, because changes of the The first plastic surgery organi- facial skeleton have corresponding soft dentoalveolar surgery, however few zation in the world was formed tissue changes, oral and maxillofacial at the Chicago Athletic Club in surgeons are keenly aware that an of these dentists are fully informed as T 1921, and was called the esthetic result can only be achieved if to the full scope of surgical practice. American Association of Oral attention is paid to both of these fac- and Maxillofacial Surgeons. Of the 20 tors. It is, therefore, a natural progres- Appropriately trained oral and maxillofa- founding members, 18 had both MD and sion to extend this expertise into cos- DDS degrees.1 metic surgery procedures. cial surgeons may also offer cosmetic In 1926, the name changed to the Most oral and maxillofacial surgery American Association of Oral and Plastic residencies now teach esthetic surgery facial surgery to their patients under Surgeons, and the requirement for a den- of the face as part of their curriculum.3 tal degree was dropped. They subsequent- Today, candidates for certification by certain circumstances. This paper will ly became the American Association of the American Board of Oral and Plastic Surgeons in 1941. A subgroup of Maxillofacial Surgery are examined on provide an overview of cosmetic facial these members created a new organiza- the evaluation, diagnosis, and treat- surgery. tion in 1947 called the American Society ment of the patient with cosmetic con- of Maxillofacial Surgeons, including cerns. Additional, concentrated train- members with both MD and DDS degrees ing, is also available at several post-resi- once more, and focusing their interest on dency fellowship programs. maxillofacial surgery.1 Cosmetic facial surgery can be Oral and maxillofacial surgery as grouped into three categories: soft tis- defined by the American Dental sue, osteocartilagenous, and minimally Association includes the diagnosis, sur- invasive procedures. Soft tissue proce- gical and adjunctive treatment of dis- dures include blepharoplasty (eyelid eases, injuries and defects involving surgery), rhytidectomy (facelift), both the functional and esthetic aspects browlift, submental lipectomy (liposuc- of the hard and soft tissues of the oral tion) and deep chemical peels or laser and maxillofacial regions.1 skin resurfacing.4 Oral and maxillofacial surgeons have long been involved in changing or Author / Simona C. Arcan, DMD, improving people’s skeletal features MD, is a board-certified oral and through orthognathic surgery, recon- maxillofacial surgeon in Bellflower and Huntington Beach, Calif. structive surgery, and repair of facial fractures.2 While many of these surgeries are carried out through small intra-

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 849 Cosmetic Procedures

Osteocartilagenous procedures include rhinoplasty, otoplasty, cheek implants, and chin implants or sliding genioplasty. These surgeries may be performed independently or in conjunction with orthognathic surgery.5 Minimally invasive procedures include botulinum toxin injection of the muscles of facial expression, lip augmentation, treatment of deep smile Figure 1. Preop upper and lower lids. Figure 1b. Postop upper and lower lid lines or prominent nasolabial folds with blepharoplasty. various tissue fillers or autologous fat injections, light to medium facial peels and photofacials.

Soft Tissue Procedures In the aging face, the eyelid skin becomes less elastic and tends to form excessive folds on the upper lid. The orbicularis oculi muscle also become weakened, allowing the orbital fat to herniate through it. This gives the appearance of “bags” under the eye. Blepharoplasty is the surgical rejuvenation of the upper and lower eyelids. This procedure entails the removal of excess skin and orbicularis oculi muscle, Figures 2a and b. Premandibular/chin advancement and submental liposuction. and either repositioning or removing a portion of the fat pads (Figure 1). In order to avoid a gaunt, skeletinized look, less fat removal and more superior repositioning may be indicated. Endoscopic browlift is the procedure whereby the forehead skin and brows are elevated through three to five small scalp incisions, using a camera to visualize the underlying structures. This is a procedure most often recommended with an upper blepharoplasty, thereby minimizing the amount of skin removal necessary to obtain a refreshed look of the eyes. An open coronal approach can also be used to elevate the brow and resect the corrugators and procerus Figures 2c and d. Postmandibular/chin advancement and submental liposuction muscles. Rhytidectomy or facelifting procedures are more extensive rejuvenation surgeries, involving the use of a surgical incision extending from the temporal region anterior to the ear, to the post-

850 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 auricular area curving around the ear- lobe. There are multiple schools of thought as to which flaps are more successful, and this usually correlates with the invasiveness of the procedure. These surgeries can be quite extensive and have known complications including blood loss, facial nerve injury and scarring. Submental lipectomy involves the reshaping of the mentocervical angle. It can be used in conjunction with orthognathic surgery in more severe Class II or Class III skeletal deformity patients.5 In severe Class II skeletal patients, this procedure can be used to Figures 3a and b. Premandibular setback, chin reduction and rhinoplasty. further achieve a more esthetic mentocervical angle (see Figure 2). In a severe Class III mandibular hyperplastic patient, when doing a mandibular setback, the mentocervical angle can become less defined and a lipectomy may be necessary to avoid compromising this esthetic unit. A small submental incision and two additional postauricu- lar incisions are used to insert a liposuction microcanula. Removal of lobules of fat is achieved through a suctioning and vacuuming technique. This procedure can also be performed as an isolated surgery in an office setting. Laser skin resurfacing is achieved Figures 3c and d. Postsetback of mandible, chin reduction and rhinoplasty. with either the CO2 laser, Erbium-YAG laser or a combination of both. Skin resurfacing removes the top layer of the degree of penetration into the skin lay- of the nose (Figure 3). Septoplasty, skin and allows a new layer of skin to ers. They are divided into light, medium along with rhinoplasty is sometimes develop. This improves appearance of and deep skin peels, with the deep peels indicated in straightening of the severe- sun-damaged skin, smoothes out being equivalent to the laser resurfac- ly deviated nose. Surgery on the nose rhytids (wrinkles), improves mild scar- ing. Dermabrasion is still very effective can be performed separately or concur- ring, destroys epidermal lesions (e.g. in smoothing out severe acne scars. rent to an orthognathic procedure.5 actinic keratosis and lentigines), amelio- Otoplasty entails the correction of rates underlying skin diseases (e.g. acne Osteocartilagenous Procedures the floppy ear by removing part of the and rosacea) and blends the effects of Rhinoplasty is one of the most pop- conchal bowl and reconstruction of the other resurfacing procedures. ular procedures performed on the facial antihelix. This surgery can be done on Chemical peels and dermabrasions skeleton. It can be as simple as reducing patients as young as 5- to 6-years old, have been used in the past to achieve a prominent dorsal hump or as compli- prior to entering first grade, to help the same results that laser resurfacing cated as reconstructing a cleft nose. The avoid developing a stigma from con- does today. There may still be some most common procedures performed to stant teasing from other children. indications for these procedures in cer- reshape the nose are dorsal hump Cheek implants can be used to aug- tain patients. There are different types reduction, refining and/or rotating of ment mid-face deficiencies in patients of peels available, depending on the the nasal tip and narrowing of the base who are unwilling to undergo ortho-

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 851 Cosmetic Procedures

dontics and/or a maxillary osteotomy to correct their skeletal discrepancy. They can also be used in conjunction with maxillary osteotomy to achieve a fuller mid-face in those patients with severe mid-face deficiencies, as those encoun- tered in certain syndromes. Chin implants vs. sliding genioplasty has always been a hot topic of controversy.6,7 With a sliding genioplasty, one can achieve a 3-dimensional movement of the chin, rather than just the Figures 4a. Pre-Botox injections forehead. Figure 4b. Post-Botox injections forehead. single forward movement obtained with a chin implant.6,8,9 The patient in and vertical dimension. She was treated advancement genioplasty and later a Figure 2 had a mandibular deficiency with a mandibular setback and a reduc- chin implant. which was treated with a mandibular tion genioplasty. Occasionally, a advancement and advancement genio- patient with severe mandibular microg- Minimally Invasive Procedures plasty. The patient in Figure 3 had a nathia may require a mandibular In light of the FDA approval of new mandibular hyperplasia in a horizontal osteotomy with forward movement, products like Botox Cosmetic, Restylane

852 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Figure 5a. Pre-implant surgery. Figure 5b. Post-implant surgery/pre- Figure 5c. Post-Restylane nasolabial fold Restylane. and lip and other collagen fillers, there has been a change toward these less invasive types of procedures being performed. This also has been attributed to patient unwilling- ness to take weeks off of work to heal. More patients are interested in doing “preventative” cosmetic surgery, rather than large overhauls. The more common of these are used to temporar- ily freeze movement of the muscles of facial expression with botulinum toxin (Botox Cosmetic, Figure 4).10 Various Figure 6a. Pre-Restylane lip augmentation. Figure 6b. Post-Restylane lip augmentation. tissue fillers (i.e. Restylane and collagen) harmony than either surgery could alone, Am J are used to restore lost volume in the sion with appearance. Patients always Cosmet Surg 21:77-87, June 2004. face, and plump up deep nasolabial wanted to look like the movie stars they 6. Strauss R, Abubaker AO, Genioplasty: A case for advancement osteotomy, J Oral Maxillofac Surg folds, smile lines and marionette lines see on TV or on the big screen, but until 58(7):783-7, 2000. in the corner of the lips (Figure 5), as recently, the “average Joe” most likely 7. Reed EH, Smith RG, Genioplasty: A case for alloplastic chin augmentation, J Oral Maxillofac Surg well as augment thin lips (Figure 6). stayed the “average Joe.” With the advent 58(7):788-93, 2000. Another emerging method to stimu- of television programs such as “Extreme 8. Guyuron B, Raszeswki RL, A critical comparison of osteoplastic and alloplastic augmentation late collagen production, minimize fine Makeover” and “The Swan,” the public is genioplasty, Aesthetic Plast Surg 14(3):199-206, wrinkles, as well as improve the sun- now aware of what it takes to make them 1990. 9. Chang EW, Lam SM, Karen M, Donlevy JL, damaged skin is the photofacial therapy. beautiful and youthful looking and may Sliding Genioplasty for Correction of Chin This non-invasive procedure involves seek the advice of their dentist. Abnormalities, Arch Facial Plast Surg 3(1):8-15, 2001. the use of intense pulse light (IPL) and Consequently, it is important for dentists 10. Sposito MM, New indications for botu- results are more permanent than those to inform their patients of the dental and linum toxin type A in cosmetics: mouth and neck, Aesthetic Plast Surg 110(2):601-11, August 2002. obtained with just Botox and tissue surgical procedures available to address 11. Sadick N, Weiss R, Intense pulsed-light fillers.11 The IPL treatment can also be their esthetic concerns. CDA photorejuvenation, Semin Cutan Med Surg 21(4):280-7, 2002. used to treat telangiactasias (broken cap- illaries) of the face, rosacea (a common References: / 1. Hiranaka DK Hiranaka JG, Aesthetic maxillofacial surgery Part I, Hawaii Dent J To request a printed copy of this article, please dermatological condition of the face) 30(3):6-9 May/June 1999. contact / Simona C. Arcan, DMD, MD, 14343 2. Poswillo DE, The relationship between oral and rhinophyma (red, thick-skinned Bellflower Blvd., Bellflower, Calif., 90706-3135. and plastic surgery, Brit J Plast Surg 30(1):74-80, nose), as well as remove unwanted hair. 1977. 3. Edwards R, Foley WJ, Expanding the specialty: a survey of oral and maxillofacial surgery resi- Summary dencies in the United States, J Oral Maxillofac Surg There is a great amount of emphasis 51(5):559-62, 1993. 4. Harmon FW, Cosmetic oral and maxillofa- on appearance these days. Hollywood cial surgery, LDA J 53(1): 7-8, 1994. continues to be a major source of obses- 5. Belinfante L, Combining cosmetic soft tissue and skeletal surgeries to achieve greater total facial

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 853 Dr. Bob Robert E. Horseman, DDS

Putting the Strain on

here is something going on at the University revolution coming and whether you accept of Florida. This is FYEO (For Your Eyes Only) it or start decamping for Canada, YOU are stuff, so unless you have TSC (Top Secret part of it. There are 15 to 30 volunteers Clearance), you are to SRRN (Stop Reading already enlisted according to dental Right Now). researcher Hillman at the University of Jeffrey Hillman, DMD, PhD, of Oragenics Florida. These intrepid souls who possibly knows about it; so does Kenneth Burrell, were under the impression that they were to t DDS, senior director of the American Dental be given some SPF 45 to test on their bared Association, Council on Scientific Affairs. epidermis at South Beach while lavishly There is Because we are among a very select group of ensconced at the Miami Hilton for 30 days a revolution scientific elitists, we have access to all this are, instead, to be lavishly swabbed with hush-hush material discreetly issued period- Streptococcus mutans on their bare teeth! coming and ically OAM (Once a Month) by a privately Would you be foolish enough to volun- funded publication called PS (Popular teer for this? Of course not! As a scientific whether you Science). One-year subscription (12 issues), tooth-oriented health professional, you accept it or start pay $12.95 (save 73 percent). know the story of S. mutans. These mean- If you pass the gimlet-eyed scrutiny of spirited bacteria grow on human teeth, con- decamping for security, this is the verting sugar into lactic acid that rots those skinny: There is a very same teeth. That S. mutans are largely Canada, YOU Continued on Page 869 are part of it.

870 CDA.JOURNAL.VOL.32.NO.10.OCTOBER.2004 Dr. Bob

Continued from Page 870 responsible for providing us with a liv- dentists who will immediately try to dental revolution could get airborne ing is beside the point. The point is that confiscate and horde all Q-Tip supplies. commercial-wise within five to six Hillman has engineered a new strain of Hillman is ecstatic. “If there was a mar- years. If it doesn’t, there could be a lot these bacteria that doesn’t produce lactic ket for preventing cavities in rats, I’d be of kissing going on and the Q-Tip acid. How Hillman was able to convince a millionaire,” he exalted. market would bottom out. even one S. mutans, let alone an entire Hillman should be made aware that If you are interested in some inten- test tube of them, to eschew the pro- there wasn’t a market for bleaching sive osculatory experimentation in the duction of lactic acid is on a NTK (Need teeth until a relatively short time ago, name of science, contact the University To Know) basis for which even Popular so anything is possible. of Florida at their research facility in Science is not privy. Burrell, ADA’s man, is equally Kissimmee, Fla. CDA There’s more. Instead of lactic acid, blown away, although he doesn’t seem this newly engineered S. mutans has been outfitted with an antibiotic “that helps it displace the indigenous cavity- “If there was a inducing strain.” Here’s where you market for come in. Armed with nothing more than a Q-Tip and maybe a SIG-Sauer 9 preventing cavities mm, you swab your volunteer’s teeth with Hillman’s mutant bacteria. in rats, I’d be Offering any explanation that seems a millionaire.” even remotely plausible, the swabee is given a sack full of Tootsie Rolls and —Jeffrey Hillman, DMD, PhD Gummi Bears, and dispatched home to eat even more sugar. If this advice sticks to hold any patents on these new in your craw, maybe Hillman himself model streptococci. Both these spokes- will have to put in a personal appear- men are thinking outside the box, ance to explain in simple terms that the because they are not sure whether the ingested sugar will help colonize the new strain can be transferred to others new S. mutans strain. These new con- with, say, a kiss. Should this occur, the fused bacteria, instead of creating a cav- Bureau of Osculatory Interdiction, ity as they had been trained to do since under the aegis of the Food and Drug early childhood, are now unwittingly Administration, will most certainly forming a tooth security guard. This delay the revolution by at least 20 will revolutionize the practice of den- years. Hillman, however, is confident tistry in terms of drilling and filling. there will be no “horizontal transmis- Who knows what engineered bacteria sion” as he delicately put it. Just to can be trained to do or not do next? make sure, however, spouses of the How about eating fat? volunteers will be monitored. Should What the revolutionized practice the volunteer not have a spouse, one will be like is not clear, but it underlines will be provided. If the strain has the the necessity of not letting this infor- decency to stay put, not wandering mation leak to the nation’s restorative willy-nilly from mouth to mouth, the

OCTOBER.2004.VOL.32.NO.10.CDA.JOURNAL 869