The Oral and Maxillofacial Surgery Anesthesia Team Model.

Oral and maxillofacial surgeons have been providing safe anesthesia to their patients using the anesthesia team model; this has allowed access to care for patients that have significant anxiety. The AAOMS strives to maintain the excellent safety record of the anesthesia team model by creating simulation programs in anesthesia, regularly updating the office anesthesia evaluation program, convening anesthesia safety conferences and strengthening the standards in our training programs. Through these efforts, our delivery of anesthesia to our patients will remain safe and effective.

Stryker SMARTLock Hybrid Maxillomandibular Fixation System: Clinical Application, Complications, and Radiographic Findings.

BACKGROUND: The SMARTLock Hybrid MMF System from Stryker is a newer approach for maxillomandibular fixation. This study was performed to determine the clinical application, complications, radiographic findings, and cost effectiveness of the SMARTLock system. METHODS: A retrospective cohort study was performed with the SMARTLock system over 6 months. Demographics, history, fracture location, placement/removal time, and complications were obtained, along with cost analysis. RESULTS: The authors identified 35 patients with the SMARTLock system. Twenty-four patients remained after exclusion criteria. There were 19 male patients (79 percent) and five female patients (21 percent), with a mean age of 30.7 years. The mean application time of the SMARTLock system was 14.4 minutes, and the mean removal time was 10.5 minutes. Three hundred nineteen total screws were placed. The number and percentage of patients with complications associated with the SMARTLock system were as follows: mucosal overgrowth [n = 9 (38 percent)], screw loosening [n = 4 (17 percent)], lip irritation [n = 4 (17 percent)], malocclusion [n = 3 (13 percent)], nonunion [n = 1 (4 percent)], wound dehiscence [n = 1 (4 percent)], screw loss [n = 1 (4 percent)], tooth devitalization [n = 1 (4 percent)], loose plate [n = 1 (4 percent)], and plate fracture [n = 1 (4 percent)]. There were no instances of sharps exposure, tooth loss, or infection. One tooth required endodontic therapy. The number of screws that damaged teeth on cone-beam computed tomographic imaging was 24 (7.5 percent). The cost analysis showed similar cost between Erich arch bars and the SMARTLock system. CONCLUSIONS: This study suggests that the SMARTLock Hybrid MMF System is safe and easy to use, and with a cost similar to that of Erich arch bars. Appropriate treatment planning and previous surgical experience should be used to determine appropriate case selection, as this system is not ideal in all situations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Radiographic findings in bisphosphonate-treated patients with stage 0 disease in the absence of bone exposure.

PURPOSE: Radiographic features in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ) are well described, but less is known in bisphosphonate-exposed individuals with stage 0 disease (clinical symptoms without exposed necrotic bone) considered at risk for BRONJ. We sought to characterize radiographic findings in a subgroup of patients with concerning clinical symptoms and bisphosphonate exposure to identify imaging features that may presage development of BRONJ. MATERIALS AND METHODS: A dental symptom survey was returned by 8,572 Kaiser Permanente Health Plan members receiving chronic oral bisphosphonate therapy, and 1,005 patients reporting pertinent dental symptoms or complications after dental procedures were examined. Those without BRONJ but with concerning symptoms were referred for clinical evaluation, including imaging. Among the subset who received maxillofacial imaging, we identified those with stage 0 disease and abnormal radiographic features. RESULTS: There were a total of 30 patients without exposed bone but with concerning symptoms who received maxillofacial imaging (panoramic radiography or computed tomography) in the context of clinical care. Among these 30 patients, 10 had stage 0 disease with similar radiographic features of regional or diffuse osteosclerosis in clinically symptomatic areas, most with extension beyond the involved site. Other findings in these 10 patients included density confluence of cortical and cancellous bone, prominence of the inferior alveolar nerve canal, markedly thickened and sclerotic lamina dura, uniform periradicular radiolucencies, cortical disruption, lack of bone fill after extraction, and a persisting alveolar socket. None had exposed bone develop during 1-year follow-up. The remaining 20 patients had normal or localized radiographic findings consistent with odontogenic pathology. CONCLUSION: In 10 of 30 symptomatic patients referred for clinical evaluation and imaging, a consistent finding was conspicuous osteosclerosis in clinically symptomatic areas characteristic of stage 0 disease. These data support the need to better understand radiographic features associated with bisphosphonate exposure and to determine whether osteosclerosis is a specific finding indicative of the risk for progression to BRONJ.

Characteristics of implant failures in patients with a history of oral bisphosphonate therapy.

PURPOSE: This study examines the pattern of implant failures reported in a large cohort of patients who received oral bisphosphonate therapy. MATERIALS AND METHODS: A total of 8,572 individuals who received oral bisphosphonate drugs returned a dental survey that obtained information pertaining to implant placement and related complications. Among the 589 individuals reporting dental implants, 16 reported implant failures that were verified by dental records. Implant placement, timing of failure, and bisphosphonate duration were ascertained to determine the characteristics of implant loss in the setting of oral bisphosphonate exposure. RESULTS: Among the 16 patients (all women, aged 70.2 +/- 7.6 yrs) there were 26 implant failures; 8 had failure of 12 implants in the maxilla and 9 had failure of 14 implants in the mandible. Early failure (1 yr after placement) occurred in 10 patients (18 implants); 2 patients had both early and late failures. CONCLUSIONS: Overall, few patients reported implant failures. However, among these, there were more late than early failures and a slightly higher proportion of failures in the mandible versus the maxilla. Further studies should investigate the role of chronic bisphosphonate therapy in implant survival and long-term implant osseointegration.

History of temporomandibular joint surgery.

This article reviews past surgical treatments for TMJ and their rationale. Because of poor outcomes with alloplastic materials in the 1980s, many experts believed TMJ surgery had failed. Those who advocated nonsurgical treatment condemned the entire discipline without recognizing the benefits of many surgical approaches. Only after 20 years of "good science" has TMJ surgery reemerged with many procedures proven highly effective.

Prospective multicenter comparison of 4 temporomandibular joint operations.

PURPOSE: This study was designed to compare the outcomes of 4 operations used for the treatment of painful temporomandibular joints with an internal derangement. PATIENTS AND METHODS: A prospective, controlled study of arthroscopy, condylotomy, discectomy, and disc repositioning was conducted at 3 sites. All sites used the same inclusion and exclusion criteria. Trained, independent examiners assessed pain, diet, and range of motion before operation and 1 month and 1 year after operation. RESULTS: There were statistically significant reductions in the amount of pain ( P < .001) and daily time in pain ( P < .001) that were similar for all 4 operations 1 month and 1 year after the procedures. The degrees of change after each of the 4 procedures were not statistically different from each other (amount: P = .453 and time: P = .416). Ability to chew, as measured by diet visual analog scale, was substantially improved 1 year after operation ( P < .001). The degrees of change for diet at 1 year also were not different from each other ( P = .314). There were, however, statistically significant differences ( P < .05) in range of motion that varied with procedure. CONCLUSIONS: All 4 operations were followed by marked improvements in pain and diet. The amounts of improvement varied slightly by operation, but these differences were not statistically significant. There were small but statistically significant differences between procedures for range of motion. If these findings are confirmed, they have an important implication for procedure selection.

Dental status and quality of life in long-term head and neck cancer survivors.

OBJECTIVES: To analyze how the dental status of long-term head and neck cancer survivors affects their subjective quality of life. STUDY DESIGN: Observational case series. METHODS: A convenience sample of 5-year head and neck cancer survivors underwent the following battery of tests: 1) targeted head and neck examination, 2) updated medical history, 3) dental evaluation, 4) standardized quality of life questionnaires. RESULTS: Eighty-six survivors were included in the study. The following associations were identified: 1) those who became edentulous secondary to cancer treatment and those without occlusion at time of the study demonstrated worse Pain, Activity, Recreation/Entertainment, Chewing, Swallowing, Speech, Eating in Public, Normalcy of Diet, Physical Well-Being, Social/Family Well-Being, Functional Well-Being, and Additional Concerns scores; 2) higher Decayed/Missing/Filled scores were associated with worse Pain, Disfigurement, Activity, Recreation/Entertainment, Employment, Chewing, Swallowing, Speech, Eating in Public, Understandability of Speech, Normalcy of Diet, Physical Well-Being, Additional Concerns scores, and weight loss; 3) decreased oral opening measurements were associated with worse Chewing, Swallowing, Eating in Public, Normalcy of Diet, Additional Concerns scores, and weight loss; 4) edentulous survivors who did not use dentures had worse Pain, Activity, Recreation/Entertainment, Understandability of Speech, and Eating in Public scores. CONCLUSIONS: Although previous studies have shown that many of the effects of cancer treatment disappear between 1 and 3 years, this study shows that the dental status has a persistent impact on subjective quality of life.

Temporomandibular joint disease: an update of surgical treatment.

The temporomandibular joint is one of the most complicated joints in the human body. Because signs and symptoms of TMJ problems often disrupt mastication, the general dentist may be the first health care provider the patient sees. Cases that are refractory to nonsurgical treatment are frequently referred to an oral and maxillofacial surgeon. This paper provides an overview of the surgical procedures used to manage internal derangement of the TMJ.

The morbidity and mortality conference: a case assessment tool, quality control measure, and teaching method.

The morbidity and mortality conference and other traditions in hospital-based training inculcate the habits of understanding evidence and its clinical application and being able to articulate these to one's peers and to learn from unanticipated outcomes. By contrast, predoctoral dental training and the environment of general dental practice do not encourage collegial reflection on the outcomes of practice. Benefits and cautions in applying the habits learned through M&M conferences are discussed for both the oral and maxillofacial and the general practice settings.