How do patients perceive resident participation in facial cosmetic treatment?

PURPOSE: The main objective of this study was to determine patient attitudes toward resident participation in their facial cosmetic treatment. MATERIALS AND METHODS: The study design was a cross-sectional study which consisted of an anonymous questionnaire regarding the patient's opinion of resident involvement in their care. Patients who presented to a single academic center seeking facial cosmetic care were surveyed over a period of 10 months. The primary outcome variables were degree of training, analysis of resident involvement impacting quality of care, and resident gender. RESULTS: Fifty patients were surveyed. All participants agreed that they would be comfortable if a resident observed their consultation or treatment and 94% agreed they would be comfortable if a resident interviewed and examined before meeting with the surgeon (n = 47). When asked if they would prefer a resident to be far along in their training if they were involved in the surgical care, the majority, 68% (n = 34), agreed. Only 18% (n = 9) of the patients reported feeling a resident's involvement in their surgery may lower the quality of their care. CONCLUSION: Patient perception of resident participation in their cosmetic treatment is favorable, but it appears patients do prefer that residents be well into their training years.

Patients' Preference for Receiving Informed Consent Information Regarding Third Molar Surgery.

PURPOSE: It is important that patients have adequate information about a surgical procedure and its risks and benefits before giving consent to proceed. The purpose of this study was to determine patients' satisfaction with various methods of presenting such information and their preferred method. MATERIALS AND METHODS: Patients presenting for removal of impacted third molars were shown an informational video discussing the diagnosis of impacted teeth, the potential risks of not having them removed, their treatment, the surgical complications, and the anesthetic options and risks. They subsequently met with the treating doctor, who again reviewed the material shown in the video and answered any questions before patients signed the informed consent document. Patients then completed a brief questionnaire asking them to rate their satisfaction with the 2 presentation methods and to indicate their preferred method. RESULTS: A total of 50 patients (18 male and 32 female patients; average age, 26 years) completed the questionnaire. Of these patients, 58% had a high school education whereas 42% had some college or a college degree. Sixty-six percent of patients found the video very helpful, and 78% found the oral presentation very helpful. However, when asked which format provided the best information, 62% indicated the video whereas 38% indicated the oral presentation. CONCLUSIONS: Because there was no clear consensus among patients regarding the best format, providing both a video and an oral presentation is the ideal situation.

The Opinion of Different Observer Groups About the Esthetic Impact and Need for Surgical Correction of Varying Submental Lengths.

PURPOSE: This study evaluated the opinion of different observer groups about the influence of the submental length on perceived attractiveness and when surgical correction was deemed necessary. MATERIALS AND METHODS: The submental length of an idealized silhouette of a white male profile was altered incrementally between 5 and 95 mm. Images were rated for attractiveness on a Likert scale by pretreatment orthognathic surgery patients (n = 75), laypersons (n = 75), and clinicians (maxillofacial surgeons and orthodontists) (n = 35). RESULTS: For perceived attractiveness, the ideal submental length was approximately 50 mm (range, 40 to 75 mm). A submental length shorter than or equal to 30 mm was deemed unattractive by all 3 groups. Overall, a submental length less than 40 mm generally was judged less attractive than a comparable increase in length. Clinicians were generally least likely to suggest surgery for varying submental lengths. For this group, the cutoff at which the majority suggested surgery was a submental length of 25 mm or less. For the patient and layperson groups, the corresponding cutoff values were a length shorter than or equal to 30 mm or equal to 95 mm. CONCLUSIONS: A submental length of approximately 50 mm (range, 40 to 75 mm) was viewed by most observers as attractive. At 30 mm or less, it was generally deemed progressively less attractive. Clinicians were less likely to suggest corrective surgery than were the patient and layperson groups. For comparative proportional relationships, the submental length should be between the lower lip-chin height and lower facial height, assuming an otherwise proportional facial profile.

Recognition of the Asymmetrical Smile: A Comparison of Orthodontists, Oral and Maxillofacial Surgeons, and Laypersons.

PURPOSE: Studies have shown that an asymmetrical smile is a relatively common problem. Yet, many patients are unaware of having this condition. Because having an asymmetrical smile can affect the final esthetic result of orthodontic therapy or orthognathic surgery, such patients need to be aware of the problem. The purpose of this study was to determine what amount of smile asymmetry is clinically evident to orthodontists, oral and maxillofacial surgeons (OMSs), and the lay public. MATERIALS AND METHODS: A total of 56 OMSs, 117 orthodontists, and 123 laypersons participated in the study. They were asked to view a randomly arranged series of computer-generated male and female facial photographs with the smile symmetrical or altered in 0.5-mm increments from 1 to 4 mm and to indicate whether the person had an asymmetrical smile. RESULTS: The OMSs and orthodontists were able to recognize relatively smaller amounts of asymmetry than the laypersons (2 mm vs 3 to 3.5 mm). CONCLUSIONS: Although the clinicians performed better than the laypersons, both groups were able to recognize relatively small amounts of asymmetry. Because such a condition is generally not correctable and can affect the esthetic result, patients undergoing orthodontic therapy or orthognathic surgery need to be made aware of the situation before treatment.

What do patients fear most about having oral surgery?

OBJECTIVE: Considerable emphasis has been placed on the fear that patients undergoing oral surgery have of the local anesthetic injection. However, other potential factors such as fear of pain during the operation, fear of the operation itself, and fear of postoperative pain are often not considered. The purpose of this study was to determine how patients rank their fear of these four factors. Such information can be helpful in improving patient management. METHOD AND MATERIALS: Patients 18 years of age and older presenting to the Oral Surgery Clinic of the Virginia Commonwealth University School of Dentistry for tooth extraction were asked to complete a brief questionnaire ranking their fear of the four previously noted factors, as well as to include their age, gender, and level of education. RESULTS: One hundred patients (52 females and 48 males), ranging in age from 18 to 93 years, completed the survey. Sixty-one had a high school education, 22 had some college education, and 17 had a college degree or higher. Twenty-five ranked pain from the local anesthetic as their greatest fear, 26 ranked pain during the operation as their greatest fear, 18 ranked the operation as their greatest fear, and 31 ranked fear of postoperative pain the highest. There were some significant differences in the rankings between females and males. CONCLUSIONS: The results of this study show that patients have fear of pain during and after the procedure as well as of the local anesthetic injection. To maximize patient comfort, how all these factors will be properly managed needs to be discussed preoperatively.

How Important Are Letters of Recommendation? A Survey of Oral and Maxillofacial Surgery Residency Program Directors.

PURPOSE: Letters of recommendation are currently part of the application process for residencies in oral and maxillofacial surgery. However, the value placed on the information contained in such letters by program directors is unclear. The purpose of this study was to determine what role letters of recommendation play in the decision-making process. MATERIALS AND METHODS: In this cross-sectional study, a questionnaire was sent to 122 current and former program directors asking them to rate the importance they gave to letters of recommendation compared with other application attributes through a visual analog scale that ranged from 0 ("not important") to 100 ("very important"). Respondents also specified the format in which they would prefer recommendations be sent and, if they preferred letters, to state why. Responses were summarized with descriptive statistics (counts and percentages). The average perceived importance of applicant attributes and components of recommendations was compared using random-effects models to adjust for multiple responses from the same respondent. Post hoc pairwise comparisons were performed using Tukey adjustment. RESULTS: Of the 122 questionnaires sent, 14 were not deliverable. Forty-one of the 108 remaining program directors answered, for a response rate of 38%. Only 10% of respondents indicated that they do not consider letters of recommendation. However, they rated class rank, comprehensive basic science score, and leadership qualities more important than letters of recommendation. They preferred letters of recommendation from a faculty member rather than from a dean or non-oral surgeon and favored letters over a standard recommendation form, which they believed provided information not found in supporting documents. CONCLUSIONS: Despite some deficiencies found with letters of recommendation, and the varying importance given to the information they contain, program directors still find that they provide some useful information.

Does Viewing a Third Molar Informed Consent Video Decrease Patients' Anxiety?

PURPOSE: Before having impacted third molars removed, patients are frequently asked to view a brief video describing the operation and its benefits and risks. The purpose of this study was to determine whether such information reduces or increases patients' anxiety level. PATIENTS AND METHODS: In this prospective cohort study, 100 patients presenting for consultation regarding removal of their impacted third molars completed a form asking them to grade their anxiety level before and after viewing the informational video as calm, slightly anxious, moderately anxious, or very anxious. RESULTS: Thirty-one percent reported increased anxiety after viewing the video. Only 12% showed a decrease, and in 57%, there was no change (28% were still slightly, moderately, or very anxious). Scoring of the pre- and post-viewing anxiety levels showed a statistically significant increase in anxiety after viewing. CONCLUSIONS: Viewing the video increased or did not reduce the anxiety level in a significant number of patients. Therefore, it is important to complement this video with positive verbal and written reinforcement of such aspects as patient comfort, procedural safety, and adequate pain control.

Upper Lip Asymmetry During Smiling: An Analysis Using Three-Dimensional Images.

OBJECTIVE: The aim of this study was to use three-dimensional images to determine the presence of upper lip asymmetry at rest and during smiling in a group of individuals with no history of orthodontics or facial cosmetic surgery. METHODS: Standardized three-dimensional frontal resting and smiling images of 54 volunteers were analyzed using the 3dMDvultus software (3dMD, Atlanta, GA). Measurements were made from the soft tissue nasion, ipsilateral ala, subnasale, and menton to the right and left commissures of the lip. A 2.5 mm or greater difference between the right and left sides was defined as an asymmetry. The agreement on the presence or absence of asymmetry between the subjects' states of rest and smiling was determined by the McNemar's chi-squared test. Statistical significance was defined as p<0.05. RESULTS: Menton was the most stable facial landmark to evaluate the upper lip symmetry at rest and during smiling (p=0.002). Using menton as a landmark, only one of the 54 subjects showed asymmetry while resting, but 12 (22%) showed asymmetry when smiling. CONCLUSION: As part of treatment planning for orthodontics or orthognathic surgery, patients should be evaluated for the upper lip symmetry during resting and smiling. The presence of asymmetry during smiling is a significant clinical problem that needs to be recognized so that patients can be informed about the effect it can have on the final esthetic result.

The Use of Botulinum Toxin for the Treatment of Myofascial Pain in the Masticatory Muscles.

Although the use of botulinum toxin has been recommended for the management of myofascial pain and dysfunction, the precise mechanism of its action remains undetermined and studies on its effectiveness are equivocal. Moreover, even if such treatment may temporarily relieve the symptoms, it does not address the cause of the problem. Also, its use is not free of potential complications. On this basis, botulinum toxin does not seem to be a logical treatment of myofascial pain and dysfunction.

Injectable Agents Versus Surgery for Recurrent Temporomandibular Joint Dislocation.

Recurrent temporomandibular joint dislocation (TMJD) is a distressing entity to the patient and a therapeutic challenge to the treating provider. Absence of high-level evidence in literature among currently available treatment options creates a lack of consistency in management. This article reviews the current literature on common injectable agents used and the open surgical techniques. Based on the findings, an injectable agent is the initial treatment of choice for recurrent TMJD, with capsulorraphy and eminectomy being used in nonresponding patients.

Arthroscopy Versus Arthrocentesis for Treating Internal Derangements of the Temporomandibular Joint.

The introduction of arthroscopy of the temporomandibular joint represented a major change in the management of internal derangements and to the realization that re-establishing joint mobility by arthroscopic lysis and lavage was as effective as surgically restoring disc position. It was subsequently shown that such treatment could be done without joint visualization. This raised the question of whether the inability to visualize the joint and perform other surgical manipulations limited its usefulness. A comparison of the literature shows that although their effectiveness is essentially the same, arthrocentesis is simpler, has less morbidity, and has fewer complications than arthroscopic surgery.

In Vivo Tooth-Supported Implant Surgical Guides Fabricated With Desktop Stereolithographic Printers: Fully Guided Surgery Is More Accurate Than Partially Guided Surgery.

PURPOSE: Desktop stereolithographic printers combined with intraoral scanning and implant planning software promise precise and cost-effective guided implant surgery. The purpose of the present study was to determine the overall range of accuracy of tooth-supported guided implant surgery using desktop printed stereolithographic guides. MATERIALS AND METHODS: A cross-sectional study comparing fully and partially guided implant surgery was conducted. Preoperative cone beam computed tomography (CBCT) and intraoral scans were used to plan the implant sites. Surgical guides were then fabricated using a desktop stereolithographic 3-dimensional printer. Postoperative CBCT was used to evaluate the accuracy of placement. Deviations from the planned positions were used as the primary outcome variables. The planning software used, implant systems, and anterior/posterior positions were the secondary outcome variables. The differences between the planned and actual implant positions in the mesial, distal, buccal, and lingual dimensions and buccolingual angulations were determined, and the accuracy was compared statistically using the 1-tail F-test (P = .01), box plots, and 95% confidence intervals for the mean. RESULTS: Sixteen partially edentulous patients requiring placement of 31 implants were included in the present study. The implant deviations from the planned positions for mesial, distal, buccal, and lingual dimensions and buccolingual angulations with the fully guided protocol (n = 20) were 0.17 ± 0.78 mm, 0.44 ± 0.78 mm, 0.23 ± 1.08 mm, -0.22 ± 1.44 mm, and -0.32° ± 2.36°, respectively. The corresponding implant deviations for the partially guided protocol (n = 11) were 0.33 ± 1.38 mm, -0.03 ± 1.59 mm, 0.62 ± 1.15 mm, -0.27 ± 1.61 mm, and 0.59° ± 6.83°. The difference between the variances for fully and partially guided surgery for the distal and angulation dimensions was statistically significant (P = .006 and P < .001, respectively). No statistically significant difference was found between the software programs. Anterior implants had less variation in deviation than posterior implants. CONCLUSIONS: Fully guided implant surgery is more accurate than partially guided implant surgery. Implant positional deviation is influenced by implant location but not implant systems or software. If possible, clinicians should use guided surgery protocols that allow placement of implants through a surgical guide.

Management of the Maxillary Diastema by Various Dental Specialties.

PURPOSE: There is considerable controversy in the literature concerning the indications for frenectomy for treating a maxillary diastema and for timing of the procedure. The purpose of this study was to survey pediatric dentists, orthodontists, and oral and maxillofacial surgeons on their opinion of this matter to develop a consensus. MATERIALS AND METHODS: An anonymous 7-item electronic questionnaire was sent to members of the American Academy of Pediatric Dentists, the American Association of Orthodontists, and the American Association of Oral and Maxillofacial Surgeons asking about the etiology of the maxillary diastema, its diagnosis, and treatment. RESULTS: Although there was no agreement among the oral and maxillofacial surgeons for the timing of frenectomy and when the diastema should be closed, the pediatric dentists and orthodontists generally agreed that frenectomy should not be performed before the permanent canines are erupted and that the operation should follow orthodontic closure of the space. CONCLUSION: Although there was no complete consensus among the 3 groups, a logical treatment approach for the maxillary diastema is proposed.

How Accurate Are Implant Surgical Guides Produced With Desktop Stereolithographic 3-Dimentional Printers?

PURPOSE: The use of tooth-supported static stereolithographic guides has greatly improved the ability to ideally place implants. This study was designed to determine the accuracy of in office-printed implant surgical guides. MATERIALS AND METHODS: Using 3shape Implant Studio, a treatment plan for implant placement for tooth 8 was developed using a digital intraoral scan from a Trios scanner and cone-beam computed tomography. Ten stereolithographic guides were printed using a Form2 3-dimensional printer. Pre- and post-implant insertion digital scans were used to determine distance and angulation differences in the mesiodistal and faciolingual positions of the implants compared with the planned position. RESULTS: The mean difference in mesiodistal direction at the alveolar crest between planned implants and placed implants was 0.28 mm (range, 0.05 to 0.62 mm) and the difference in the faciolingual direction was 0.49 mm (range, 0.08 to 0.72 mm). The mean mesiodistal angulation deviation was 0.84° (range, 0.08° to 4.48°) and the mean faciolingual angulation deviation was 3.37° (range, 1.12° to 6.43°). CONCLUSIONS: In-office fabricated stereolithographic implant surgical guides show similar accuracy to laboratory- or manufacturer-prepared guides. This technique provides a convenient and cost-effective means of assuring proper implant placement.

Patient Recall of Information on a Third Molar Informed Consent Video.

PURPOSE: Experience has shown that in malpractice cases patients often claim certain information was not provided during the informed consent process. The purposes of this study were to determine how much of an informed consent video patients initially remember and how much is recalled when there is a hiatus from viewing the video to the surgery. PATIENTS AND METHODS: In this prospective cohort study, patients presenting for impacted third molar removal in an academic setting (n = 50) or a private office (n = 50) viewed an informed consent video and then met with the treating doctor for further discussion and signing of an informed consent form. Then, they were given a 10-item test containing questions relating to the information provided on the video. At the subsequent time of surgery, they were again given the same test. The number of correct answers at the 2 points was compared. RESULTS: There was a significant difference in the number of correct responses between the 2 time points (P = .0212) and between patients from the 2 practice settings (P = .0076). However, these differences were less than 0.5 of a possible 10. The number of correct responses was not associated with age (P = .1203), gender (P = .6647), or number of days between testing (P = .7272). CONCLUSION: Patients have good recall of the information provided by the informed consent video. However, because some information was forgotten, a presurgical review of the information is advisable.