Spring - Western Society of Oral and Maxillofacial Surgeons

Transcription

PRESIDENT’S MESSAGE
from the desk of the president ….
Dr. Jay Malmquist
M
any of us are confronted with
pies. Everyone wants to hear how to
the hurdles that now occur in
address or avoid the misadventure
the operating room prior to
in surgery or subsequent treatment.
the start of a procedure. There is the
Author Atul Gawande has written two
“timeout,” the “red rules” and the “red
very successful books addressing
towel” that impede our progress toward
some of the issues related to mishaps
beginning a case in the name of safety
in medicine: Complications and The
and avoiding a complication. In our
Checklist Manifesto. In these books
own offices we spend time complying
he talks about “how messy, uncertain
with rules and issues to make
and surprising medicine turns
There
should
be
fewer
our practices safe, efficient and
out to be.” These books are
issues
with
patient
care
productive, all while meeting
a must-read for all who are
and
outcomes
the state and federal requireinterested in the complex is— and yet ....
ments. In addition, we continue
sues of untoward, unexpected
our own education regarding
outcomes.
techniques, trends and updates on the latest drug
therapy, surgical techniques and aids in diagnoSo the question one must ask is, “why?” Why are
sis. These are all designed to avoid complications
so many clinicians seeking solutions and guidance
and make our care for patients safer. We should
to problems when there seems to be so many apbe getting better. There should be fewer issues
proaches to successful treatment and treatment planwith patient care and outcomes. Yet, as we look
ning? Are the screening procedures really working?
at the continuing education topics, the single most
How can so many well-trained individuals have so
popular clinical issue still is the one centered on
many untoward results? Bone and soft issue graftcomplications or bad outcomes. It is a big draw! ing are topics at virtually all symposia, and threeAt this year’s March meeting of the Academy of
dimensional treatment planning is featured at every
Osseointegration in Seattle, at least 15 major preimplant related symposium. The advent of in-office
sentations covered complications of various theracone beam computed tomography scanners and
cont. on page 8
Why does Kurt Friedman, D.D.S., M.S. say
Windent OMS is the safest & best choice
in practice management systems?
“It’s complete, proven and tested.
1. It’s so simple — and I get quick, expert
responses when I need help.
2. It’s Internet friendly and I’m making good
use of that. We do online registrations of
patients before they come to the office.
3. I can customize it for my office.
Best of all, I can handle so many more
patients a day with less paperwork —
with just the stroke of a pen.”
“Just imagine: by pressing a couple of buttons on a tablet
PC chairside you can see patient X-rays, pre-authorizations,
treatment history and plans, front desk forms — and more.
Patients can sign off on treatments as they sit in the chair,
and you can print a walk out statement instantly.
When you’re making the decision to bring in a new practice
management system, Windent OMS is, by far, the safest bet.”
Kurt E. Friedman, d.d.s., m.s.
Oral Facial Reconstruction & Implant Center of South Florida
To find out how you, too, can benefit
from Windent OMS, call us...
© Healthsoft, Inc. www.windent.com
Page 2 - The Westerner - Spring 2014
Practice Management Software Specifically Designed
for Oral & Maxillofacial Surgeons
Invite a Resident to
the Annual Meeting
We are again inviting residents from the
programs in District VI to join the Western
Society and to attend our annual meeting
at the Benson Hotel in Portland, Ore.,
July 17th–21st, 2015. Residents may come to
the meeting as our guests for the scientific
sessions and social events. In addition, we can offer some financial
assistance (up to $500) to offset other expenses they may incur such as
travel, meals and lodging.
If you are friends with one of the program directors, ask them to consider
having one or more of their residents attend next year’s meeting. Program
directors or residents can receive more information on this by contacting
the central office at (775) 626-4478.
The Westerner -Spring 2014- Page 3
WSOMS Officers 2014–2015
President:
Dr. Jay Malmquist
5415 SW Westgate Drive # L-7
Portland, OR 97221
e-mail: [email protected]
President-Elect:
Dr. Steve Leighty
1240 High Street # 105
Auburn, CA 95603
Vice President:
Dr. Gabriel Kennedy
2266 Mission Street SE
Salem, OR 97302
Secretary-Treasurer:
Dr. Murray Jacobs
Loma Linda University
Loma Linda, CA 92350
Past President:
Dr. Daniel Klemmedson
3150 N. Swan Road
Tucson, AZ 85712
WSOMS Board of Directors 2014–2015
Dr. Anthony Bouneff
395 SW 153rd Drive # 100
Beaverton, OR 97006
e-mail:
tbouneff@beavertonoral surgery.com
(2013–2016)
Dr. Randall Blazic
1646 N. Litchfield Road # 130
Goodyear, AZ 85395
(2014–2017)
Dr. Paul Lambert
5398 N. Meadowbrook Way
Boise, ID 83702
(2012–2015)
Dr. Tracy Johnson
2040 Mitchell Road SE
Port Orchard, WA 98366
(2012–2015)
Dr. Keith Krueger
1475 SW Chandler Street # 101
Bend, OR 97702
(2012–2015)
Dr. Elizabeth Kutcipal
Seattle Children’s Hospital
Seattle, WA 98105
(2014–2017)
EX-OFFICIO BOARD
Dr. A. Thomas Indresano (District VI Trustee)
UOP School of Dentistry
2155 Webster Street # 522F
San Francisco, CA 94115
Dr. Charles Walter (Caucus Chairman)
3400 Squalicum Parkway
Bellingham, WA 98225
Dr. Gerald MacDonald (Resident Fund Chairman)
3109 Budding Oaks Court
Sparks, NV 89436
Dr. Daniel Orr II (Westerner Editor)
2040 W. Charleston Boulevard # 201
Las Vegas, NV 89102
Dr. John Bond (Nominating Committee Chairman)
5967 Post Oak Drive
San Jose, CA 95120
WHAT ARE OUR MEMBERS DOING?
Dr. Steve Leighty
Dr. Leighty recently traveled to the Island of Cattle (Ile a Vache) off the southern coast of Haiti. The Flying Doctors (Los Médicos Voladores) is the banner
under which this project flies, and several of them are Rotarians (Auburn,
Granite Bay and 49er Breakfast Rotary of Nevada City). The same group of
dentists traveled to Chyangba, Nepal, in 2008, and Papua
New Guinea in 2011. Dr. Leighty says, “We trust each other
and have proven that we can work together.”
T
hanks for all of the comments and support
I’ve received from you. The Haiti Dental team
indeed survived our trip to Ile a Vache, through the
project and the return back home, and are mostly
back in the saddle again.
Like expected, the first week back from a project is
accompanied with piles of notes, paperwork, mail
and questions to be dealt with. I am stressed with
feeling like I’m behind schedule, and yet there is
an unmistakable sense of reward and calm with
another project completed.
Dr. Ken Marti from Granite Bay
was our lead dentist for the trip.
Drs. Barry Turner (Grass Valley),
Ed Weiss (Auburn), and Terry
Prechter (Yuba City) rounded
out our dental team. I am an oral
surgeon practicing in Auburn
and Roseville, and as you might
expect, a majority of my practice
involves tooth extractions. The
other dentists not only extracted
teeth while in Haiti, but provided
restorative services (fillings).
Dental hygienists Vicki Bayne
and Anna Skacel cleaned teeth,
applied sealants and provided
education for our patients.
Our three RNs (Robin Prechter, Karen Leighty
and Sharyn Turner) acted as dental assistants,
provided instrument maintenance and sterilization,
education, and supported the medical interests of
the volunteers and the patients. Ruth Terao served
as dental assistant and Spanish translator. Bernice
Owczarzak also served as dental assistant and had
a birthday during our mission.
Jill Marti (Physical Therapy)
investigated Sister Flora’s orphanage and school facilities,
patients and staff with regard to
physical therapy issues. Brian
Kuhl was a general volunteer.
Monte Short (Flying Doctors)
served as trip coordinator not
only for our dental clinic, but
for the medical clinic the week
following our dental clinic.
Mandy Thody, manager of
WHAT ARE OUR MEMBERS DOING?
Good Samaritan of Haiti, served as host coordinator and worked with Monte on the hundreds of
details needed to sponsor a dental clinic (such as
providing patients for the doctors and keeping the
volunteers fed and sheltered).
After arriving in Port-au-Prince, a 4½-hour bus trip
and 1-hour boat trip were required to reach Ile a
Vache (Island of Cattle) and the village of Castra.
A resort at Port Morgan (45 minutes) and the orphanage operated by Sister Flora were the closest
things to a business that I saw on the island. A few
motorcycles and some fishing boats were seen,
but walking was the way to travel. (I did see a few
people riding donkeys.) Other livestock commonly
seen included chickens, pigs, goats, sheep, horses
and some cattle.
Two generators, two shop vacs, an air compressor
and lots of electrical cords all needed assembling
for the energy to operate our clinic. We treated
about 250 patients with approximately $150,000
worth of dentistry. I took one biopsy for a benign
lesion which was processed by UCSF Dermatology
Pathology Department. At least one patient was
referred to a dentist on the “mainland” of Haiti for
extensive dental work.
N
ew friendships were developed and others
strengthened during our week in Haiti. Living
conditions were simple as expected, especially
with regard to our hygiene, food and bathroom
expectations. Electric fans seem like one of the
best inventions ever. Although the conditions required adjustments on our part, we all agreed they
probably had a positive effect on the inhabitants.
Obesity is virtually unknown here, as a testament
to the diet and walking. A few exceptions to this
were the ease of obtaining Coca-Cola, Sprite and
Prestige beer, and the candy bars available at
roadway (walkway) stands.
Essential hypertension and malaria (and other
mosquito-borne diseases) were the illnesses of
which we saw evidence or history. Most of us on
the team were taking doxycycline or malarone for
prophylaxis. We were provided mosquito nets for
sleeping. Five or six of us shared some sort of URI
or bronchitis about halfway through our clinic week,
depleting the medical clinic’s supply of Zithromycin
in the process. Glad that’s over with.
A few of our patients admitted to having been treated by a dentist. Interestingly, most of our patients
had a few carious teeth, but many had multiple
hopeless teeth. Most of the patients with the more
cont. on page 9
PRESIDENT’S MESSAGE (CONTINUED FROM PAGE 1)
the three-dimension software provides an additional
method for evaluating complex cases. There is very
little information that we cannot obtain about patients
before they go into surgery. So why with these advances in technology and techniques do we continue
to see an increase in complications, problems and
less-than-ideal results?
A
s I consider this complex problem, several
thoughts come to mind regarding the institution of new techniques and the renewal of old
procedures. First, many clinicians seem to divorce
themselves from the basics of biology and wound
healing. The understanding of the vascular supply to a given area and the basic principle of why
something heals is often lost in the mecca of some
new technique or technology. Flap design, suturing
techniques, and patient health and habits all play
an important role in short- and long-term treatment
results. The idea that technology can somehow
replace sound surgical principles is something that
is pervasive in today’s throwaway literature. Gimmicks have replaced treatment planning principles.
It seems that an instrument can somehow endow a
clinician with the ability to accomplish a procedure
that is inherently at odds with the basic biology of
the region. Perhaps a microscope will allow us to
see better, but it will not change the underlying
tissue bed nor will it allow us to augment bone
with little or no blood supply. Three-dimensional
imaging is great, but it will not allow us to change
the implant receptor site, only identify the potential
implant position. Our goal should be to harmonize
the biology of an area with new materials, drugs
or instruments — not to sacrifice one for the other.
Yet we all fall prey to these temptations, sometimes
resulting in a poor outcome.
Of equal concern is the continuous litany of CE
course materials that espouse the merits of certain
treatments, products and the ability to achieve
perfection, when in fact perfection is not attainable.
A question we all must ask is how many images
of patients were culled to find the ideal case for
the presenter, and if a given case is only one in
10, then can we realistically expect to be able to
incorporate the technique into our daily practice?
Continuing education is important but it should not
be tainted with the arrogance of a company logo
or the backdrop of a certain material or product.
Product claims are just that and often not substantiated with sound data. Determining what is practical and what is real is often difficult. We all want
the best for our patients. However, as we look at
case studies, we must realize that many times a
certain technique or treatment is just not feasible
for a particular patient. Sometimes it is better to
simply say that it cannot be done than to push
the envelope for an unattainable goal. In part, our
reliance on questionable continuing education and
questionable products creates an atmosphere for
failure. Evidenced-based treatment must be the
paramount benchmark for patient care.
Technology is wonderful; it has taken all of us to
the next level of therapy. However, it is my plea
that we do not abandon the basic biologic lessons
that we all learned years ago. The bone cell, the
soft tissue matrix, and the influence of drugs and
systemic health are factors that we should not
forget. Some of our best results are achieved using basic procedures rather than high technology
developed in the labs of large corporations. Many
of us still follow the impeccable basic principles
introduced by Professor P-I Branemark more
cont. on page 9
PRESIDENT’S MESSAGE (CONTINUED FROM PAGE 8)
than 30 years ago and resist the more current
treatment options. Nothing has changed in the
human species during that time that makes the
bone or soft tissue cell different. It has only
been the advent of technology that has tried to
move us forward, perhaps too quickly and for
the wrong reasons. We must maintain the basic
principles and resist the urge to sprint ahead.
We must continue to practice evidence-based
therapy. We must encourage our colleagues in
the non-specialties to join with us, get proper
training and avoid the urge to propagate the
“Lone Wolf” philosophy. Perhaps then we will
see fewer complications and a reduced impact of negative results on all of our patients.
We should all remember that if we lose the
confidence of the patient we will have lost our
identity as a profession. In closing, our degrees
are based on years of sound science and not
on short-term techniques or gimmicks. It is
something to think about. Complications may
then take less of the treatment limelight.
WHAT ARE OUR MEMBERS DOING? (CONTINUED FROM PAGE 7)
serious dental problems showed a combination of caries (cavities) or
periodontal (gum) disease.
Jill Marti commented that some of the equipment at the orphanage was
comparable to some PT clinics in the United States. The biggest problem
she saw was the lack of trained staff to work with their patients, which is
mirrored in the spectrum of health care needs in Haiti in general.
Upon our return, we were bused into the hotel compound with 12-foot tall
gates and armed guards. There was a restaurant
on-site and most importantly, a swimming pool,
which was where half of us made a beeline for.
I’m not going to repeat the boring details of getting
through customs/immigration in Port-au-Prince
nor JFK. The most interesting thing for sure about
the flight home was the four-hour long sunset.
We’ll have a debriefing someday with most of the
team, but for now we are still getting settled into
our routines again.
For more information on Los Médicos Voladores,
visit www.flyingdocs.org.
EDITOR’S PAGE
Dr. Daniel Orr II, Westerner Editor
Maintenance of
Certification
R
ecently I was informally asked if I
would be interested in becoming
an ABOMS examiner. I expressed two
concerns to the query:
1. One has to be very committed to
be an examiner, and
2. The ABOMS might frown about my posture
regarding maintenance of certification (MOC).
In a nutshell, I am opposed to redundant,
wasteful, expensive and unproven MOC
paradigms that force doctors to take time
away from patient care.
I am of the generation of doctors for which board
certification was very optional. The question coming out of residency was, “Are you going to take
the exam?” vs. today’s “When are you going to
take the exam?” I was trained and mentored early
in my career by many fine professionals and am
not sure if even half of them were boarded. Before
finishing my residency, I was leaning toward not
taking the board for the simple fact that certification did not really bestow any tangible benefit. But
then, after graduation, when I didn’t “have” to do
anything educationally, I found that I desired to
legitimize my training, just for myself. Taking the
board would be the logical way to see where one
stands after years and years of education. Surprisingly, in studying for the board, I found that for the
first time since kindergarten I was not being forced
to study by a third party … and I actually enjoyed
the process. Over the years I have found a lot of
joy in studying all kinds of things …
like the academic aspects of sports.1
Baseball is my first love, but for quite
a few years I have found as much
fulfillment in studying its science and
strategy2,3 as a coach as when I did
hitting a grand slam at Tempe Diablo
Stadium.
However, with MOC once again the
professions have third parties eviscerating personal agency and decision-making and
forcing professionals to “be good,” usually via an
onerous and expensive examination process. The
“voluntary” process is only voluntary if one doesn’t
care about being credentialed for insurance carriers,
hospital privileges or state licensure … in other words,
working as a doctor.
Besides another loss of individual freedom in health
care, no one has ever shown that MOC does a thing
to improve care. Some have documented that MOC
is likely harmful to patients.4 MOC is reminiscent
of the worse-than-useless decades of American
Heart Association (AHA) mandated prophylactic
antibiotic administration for patients with hearts,
and maybe a murmur. Ultimately, heroic dentist
Tom Pallasch5 did as much as anyone to convince
the AHA that their paradigm was actually not doing
what it was intended to do, and was in fact doing
quite a bit to create super infections secondary to
the evolution strains of microbes resistant to every
overused antibiotic known.
Some board entities now mandate MOC on fiveyear cycles. What has driven the growth of the
EDITOR’S PAGE
time-consuming, expensive, arguably worthless
institution? It is not hard to find the genesis of the
phenomenon. In 2011, 24 specialty boards of the
American Board of Medical Specialties had combined revenues of $320,000,000, much of this from
MOC fees. The boards’ administrators, often paid
compensation packages worth over $1,000,000,
are doing very well since the non-profit corporate
entities have to distribute all their earnings in order
to show no profit at year end. This information and
more is available at www.guidestar.org, a public
charity 501(c)(3) website.
Many of our medical specialty colleagues are reacting to the overly burdensome requirements of
MOC. A national organization of physicians committed to reforming the MOC process to better
serve patients states:
“MOC is, for lack of a better term, a farce that
does not improve upon the existing continuing
medical education system. The cost and
inconvenience is unjustified, and the secure
exam format is demeaning and does not reflect
the collaborative approach promoted by the
health reformers, nor does it take advantage
of technological developments. It could easily
be replaced by specialty specific modules that
are completed online in a rotating fashion so
that every ten years, physicians cycle through
their specialty’s entire curriculum. Such an
option would be inexpensive and effective.
The main purpose of MOC appears to be the
generation of fee revenue. To that end, it is
undeniably effective!”6
There are many options other than recreating the
original board certification examination process
every 5 to10 years to help doctors keep abreast of
their fields, as eloquently iterated by the American
Association of Physicians and Surgeons (AAPS)7
and others. AAPS has filed suit against the ABMS
for imposing “enormous “recertification” burdens on
physicians, which are not justified by any significant
improvements in patient care.”8
As mentioned above, board certification historically
was a voluntary, personal decision. It still should be.
*Dr. Orr chose to become certified by the ABOMS
(and does not have to participate in ABOMS MOC
examinations because his generation of diplomates
voted to exempt themselves and only require examination for future ABOMS diplomates). He is also
certified by the American Dental Board of Anesthesiology (which requires 120 hours of ADBA approved
CE every six years, BLS and ACLS9), the National
Dental Board of Anesthesiology (which requires
ADSA membership, six hours of anesthesiology
related CE per year, and ACLS10), and the American
Board of Legal Medicine (lifetime certification).
(Endnotes)
1 Brancazio PJ, Sport Science: Physical Laws and Optimal
Performance, Touchstone, 1985.
2 Williams T, Underwood J, The Science of Hitting, Simon &
Schuster, 1986.
3 McCarver T, Baseball for Brain Surgeons, Villard, 1999.
4 Christman KD, Why Patients Should Avoid Physicians Who
Submit to Specialty Board Recertification, J Am Phys and
Surg, 19:1, 5-9, Spring 2014.
5 Orr D, Focal Tales, NV Dent Assn J, 9:1, 4-6, Spring 2008.
6 Change Board Recertification, http://www.
changeboardrecert.com/index.php, accessed 15 June
2014.
7 http://www.aapsonline.org, accessed 15 June 2014.
8 Schlafly, AL, U.S. District Court Complaint, 23 April 2013,
http://www.aapsonline.org/AAPSvABMScomplaint.pdf,
accessed 15 May 2014.
9 ADBA recertification requirements, http://www.adba.org/
recertification.html, accessed 26 June 2014.
10 NDBA Bylaws, http://www.ndbahome.org/images/
NDBABylaws.pdf, accessed 26 June 2014.
DISTRICT VI TRUSTEE REPORT
Dr. A. Thomas Indresano, District VI Trustee
The Future
M
any pundits are attempting to
predict the future of oral and maxillofacial surgery. While I’m no oracle, I
do know that the type of practice that
attracted us to a dental specialty is fast
waning. Most of us wanted a career that
allowed us to be the captain of our ship.
More than even medicine, we were the
independent entrepreneurs. We could
practice in our offices, charge a reasonable fee, get
paid immediately and determine our own destiny.
Even the small group of us who went into full-time
academics could feel in charge of our own destiny.
That is a myth today.
We must work in an environment that now demands
review of our cases, privileges based on participation
volume, quality measures and numbers of cases.
We must accept payment from state and federal
entities, or file paperwork to stay out of it. Hospital
participation mandates you enter the public payer
system. Your board certification depends on continuous certification maintenance that ties your credentials to several measures you must keep track of. In
order to attract patients from your competition, you
must market your skills. Years ago advertising was
unethical. Now you need a social media site and
favorable reviews by people who rate you, presumably patients.
All of this sounds like I am advocating closing up shop
and going fishing. Well, if you can afford it, it may be
the right move for those who can’t or
won’t adapt
For the rest of us, however, it is a new
day. The old ways are gone. It may be
a different practice but it still can be
rewarding on many levels … but you
need to be prepared.
Your association is leading and you
need to be available to be led.
MARKETING: AAOMS has started a nationwide
informational campaign to attract new patients and
establish name recognition in the areas we serve; to
use media to disseminate our message about who we
are and what we do; to ensure that the public thinks
of us first in all the areas in which we provide care.
COMPETITION: AAOMS has clinical practice-based
research initiatives begun in common procedures
to establish efficacy, volume and competency. First
they will be initiated in the “bread and butter” areas of
implants, anesthesia and third molars. Later all areas
will be included. We are starting registries of what we
do to aid in defending our ”turf.”
COMPENSATION: AAOMS is establishing patient
registries to collect data about everything we do so
we can use this powerful tool to facilitate ease of billing and establish the highest compensation levels.
Registries will also allow us to defend our areas of
practice in the hospitals, with the regulatory agencies
and in the minds of our competition.
cont. on page 13
MEET YOUR NEW BOARD MEMBERS
Dr. Randall Blazic
obtained
his dental degree at the University of Southern California. Commissioned in the U.S. Air Force,
he served three years active
duty while completing a one-year
advanced dental residency. Dr.
Blazic furthered his education at
Wayne State University Medical
School, completing one year of
General Surgery at the Detroit
Medical Center. His six-year residency specialty in Oral
& Maxillofacial Surgery was also completed at Wayne
State/Detroit Medical Center.
Dr. Blazic is board certified through the American Board
of Oral & Maxillofacial Surgeons and has a medical
license in the state of Arizona. He maintains memberships in the American Association of Oral & Maxillofacial Surgeons, the American Medical Association,
the American Dental Society of Anesthesiology, the
American Dental Association, the Maricopa Medical
Society and the Phoenix Society of Oral & Maxillofacial
Surgery. Dr. Blazic is the treasurer of the Arizona Board
of Oral & Maxillofacial Surgeons.
Locally, Dr. Blazic presides over the Goodyear Study
Club. He also sponsors continuing education seminars
in the field of dentistry, thereby collaborating with his
colleagues on further training in current, advanced
techniques in oral surgery and dentistry. He is active in
his community and is strongly committed to supporting
the Boys & Girls Club of America and the West Valley
Sojourners Women’s Center.
Dr. Elizabeth (Libby) Kutcipal is an oral and maxillofacial surgeon in Seattle. She grew up in Northern
Michigan, then attended Smith College in Northampton,
Maine. Libby earned her dental degree from the University of Michigan. She moved
to Seattle for a General Practice
Residency at the University of
Washington. Her training continued in Seattle at the UW for
OMFS residency. Following this
training, she left for Pittsburgh,
under the tutelage of BJ Costello
at Pittsburgh Children’s Hospital.
Once this fellowship concluded,
she moved back to Seattle and
has been there ever since. She
works at Seattle Children’s Hospital with Mark Egbert
and in private practice one day per week.
Libby lives on a little houseboat in the middle of Seattle
with her dog, Delilah. She enjoys everything that Seattle
has to offer. She enjoys many activities — most recently
the flying trapeze!
DISTRICT VI TRUSTEE REPORT (CONTINUED FROM PAGE 12)
SAFETY: AAOMS is working to move into anesthesia simulation as a way to prove the safety and
efficacy of our office anesthesia team model. One day we can boast of our office preparation due to
in-office training by simulation.
These efforts require your participation. The membership must get involved to establish the numbers
of cases, procedures and models that we all have been practicing for our whole careers. We need to
give the data collectors the ammunition. Once we set this foundation of data we can finally prove who
we are: the experts in faces, jaws and mouths. Then there will be no disputing our leadership in third
molars, implants, office anesthesia or in any other area in which we perform.
MEMBER’S CORNER
Dr. Don Devlin
Dr. Donald Devlin has contributed the following
article on the history of the Western Society of
Oral & Maxillofacial Surgeons, and includes
some of his favorite
memories. He has
been one of the Society’s greatest supporters, serving as the
Westerner editor for
14 years, and having
the 2001 meeting in
Scottsdale dedicated
to him.
Dr. Devlin is a native San Franciscan who received his D.D.S. from the University of San
Francisco and his oral surgery training at the
University of Oklahoma, Northwestern University and Cook County Hospital in Chicago.
Dr. Devlin’s dedication to our specialty spans
more than 60 years and includes many practice
milestones, some of which include serving as
Past President of NCOMS (1964), ABOMS
Advisory Committee member and examiner,
academic appointments to the University of
California and the Directorship at Alameda
County’s Highland Hospital’s OMFS Program.
He also served during the Korean conflict and
was stationed at Fort Ord Army Hospital as a
staff oral surgeon. His many contributions to
the specialty of Oral and Maxillofacial Surgery
are greatly appreciated by our membership.
Some Thoughts from the Past
A brief history of the WSOMS
It was back in 1973 at a meeting in the Carmel
area, perhaps at the Del Monte Lodge, that the
organizational meeting of the Western Society
took place. Our first president, DeWayne Briscoe,
spoke of the importance or organizing to speak
in one voice at our yearly national meetings. Our
national organization at that time was known as
the American Society of Oral Surgeons (ASOS). At
the annual meeting of the House of Delegates of
ASOS, the House would depend on various regions
to send a “trustee” to the quarterly ASOS Board
meetings. Other regions of the country were highly
organized and well represented at those quarterly
board meetings. In the west, the “trustee” would
be on a rotational basis between the Northern
and Southern California Oral Surgeons’ Societies.
There was no cohesive agreement or working relationship among the western states at that time. The
anesthesia techniques used on those early years
by those in the west and the rest of the country
were at each end of the spectrum. We were looked
down upon, in spite of the fact that many of our
members were pioneers in intravenous anesthetic
administration, while the majority of other regions
(especially in the east) were using nitrous oxide in
conjunction with other inhalants. Our offices were
frequently referred to as “pentothal factories” or
“parlors.” The insurance for our procedures frequently offered less coverage in our region than
in other parts of the country.
The need for a unified Western States Society finally arrived when in the early 1970s we were not
cont. on page 16
MEMBER’S CORNER (CONTINUED FROM PAGE 15)
able to place our “trustee” as a board member at
the annual quarterly meeting of ASOS. In effect,
our region was denied representation. Thanks to
DeWayne Briscoe and Terry Slaughter along with
several others, the Western Society of Oral & Maxillofacial Surgeons was formed.
T
he second meeting of the WSOMS was held
in 1974 at Sun Valley, Idaho, under the leadership of President Howard Boller. I recall attending
a conference, perhaps on anesthesia, sponsored
by the American Society in the first part of July. I
boarded a plane in Chicago to Salt Lake City, and
then took a small eight-passenger plane from there
to Sun Valley. Passengers on that flight were all
oral surgeons heading to the second annual meeting. Terry Slaughter was seated alongside the pilot
and served as the “co-pilot” and helped with the
navigation. Vic Frank, the president of ASOS at that
time, was also on board. Lou Hansen from UCSF
spoke on oral pathology, and it was apparent that
the Society was off to a strong start.
Meetings were held for the most part around the
Fourth of July, and an effort was made to direct
these meetings to family participation. The Independence Day holiday was ideal.
A meeting in 1981 stands out in my mind — perhaps because of the story our speaker, Bill Evans,
related to me regarding his trip to Avia Beach near
San Luis Obispo. Bill flew in from Ohio to Los Angeles the evening prior to the meeting. He arrived
in the early evening, and unfortunately he was
informed that all the rental cars were unavailable
even though he had reserved one. Fortunately,
since Bill had a pilot’s license, he was able to rent
a plane. He flew without difficulty and finally spot-
MEMBER’S CORNER
ted the airport he thought to be San Luis Obispo.
When he landed the plane, cars raced out from
various directions! Men jumped out with machine
guns and wanted to know what he thought he was
doing there. Bill had just landed at President Ronald Reagan’s private airport. The Secret Service
treated Bill very nicely, however, and drove him to
the meeting at Avia Beach. That was quite an experience, and Bill Evans will never forget his arrival.
would be, and he certainly was correct.
Another meeting that stands out in my mind was
our first meeting at the Lodge in Sunriver, Ore. The
year was 1989, and Fred Mantz was our Society
president at that time. This was the largest meeting that I can recall our Society having, with more
than 200 attendees. That was largely because of
the personal effort given by President Mantz. For
many months prior to this meeting, Fred took every
opportunity to announce what a great meeting this
Those dedicated officers and directors of the Western Society have attempted to present the highest
quality of educational programs while balancing
these events with enjoyable, relaxing family time
at some of the finest resorts in the western states.
At the same time, the Western Society has been
a forceful influence in the direction the American
Association of Oral & Maxillofacial Surgeons has
taken over these past 40 years.
The Western Society has always attempted to bring
the finest clinicians to these annual meetings. For
instance, in 1978 in Portland, Ore., our president
Frank Pavel was able to have Hugo Obwegeser as
our clinician. In 1990, Professor Obwegeser was
once again our clinician, and at that meeting was
awarded Honorary Membership in our Society.
RESIDENT’S CORNER
Immediate Reconstruction of Critical Size Continuity Defect of the Mandible with a
Combination of rhBMP-2 and Autogenous Bone Graft: A Case Report
Chan Park, DDS, MD, David L. McAninch IV, DDS, A. Thomas Indresano, DMD
Reconstruction of continuity defects of the mandible has posed a challenge to oral and maxillofacial
surgeons for decades. The requirements of any method of reconstruction are restoration of continuity
and replication of the original form to allow normal mandibular motion, with maintenance of preexisting jaw and soft tissue spatial relationships and the ability for implant rehabilitation6. The major
forms of reconstruction for such defects include vascularized bone flaps and autogenous bone grafts.
Among other factors, autogenous bone grafts have been shown to be advantageous over vascularized
bone flaps in reduced intraoperative surgical time, diminished hospital stay and financial burden, as well
as decreased donor site morbidity. However, vascularized bone grafts have been endorsed as the
primary method when immediate reconstruction is desired2 while autogenous bone grafts have been
endorsed for smaller defects only and as a two step procedure5. This case report aims to present
immediate reconstruction of a critical size mandibular continuity defect at the time of tumor ablative
surgery with rhBMP-2 and autogenous bone graft.
Case Report
Our patient is an 18 year old male who presented to the Highland General Hospital Oral and
Maxillofacial Surgery Clinic in Oakland, CA. The patient’s chief complaint was “my jaw has been
hurting.” Upon further questioning, the patient provided a history of 1.5 months of noticeable swelling
in the right perimandibular region. He had been having pain for a week and initially presented to his
general dentist who subsequently referred him to our clinic. Of note, the patient denied any paresthesia
of his right cranial nerve V3 distribution. He denied any significant medical or surgical history (including
removal of his third molars) and did not endorse any habits (Figure 1).
A
B
C
Figure 1: A-C: Preoperative photographs of the patient on initial presentation. Mild fullness can be appreciated in the right perimandibular
region extraorally. Minimal fullness of the right posterior mandibular vestibule can be seen intraorally.
RESIDENT’S CORNER
A panoramic radiograph and medical grade CT scan were obtained which revealed a multiloculated
radiolucent lesion of the right posterior mandible extending from the parasymphisis to the condyle
(Figure 2). An incisional biopsy was performed which had a final diagnosis of ameloblastoma.
A
C
B
D
E
Figure 2: Panoramic radiograph and medical grade CT scan demonstrating the radiolucent lesion. A: Displacement of #32 and erosion of
the apices of teeth # #29-31. B-E: Axial, Saggital, Frontal and 3D views of the lesion demonstrating expansion and erosion of the lateral and
medial buccal cortices.
Surgery was planned for hemimandibulectomy and for immediate reconstruction utilizing anterior iliac
crest bone graft combined with rhBMP-2. A custom 2.7mm KLS reconstruction plate with condylar head
was prefabricated to reconstruct the defect immediately. The patient underwent right hemimandibulectomy and placement of a reconstruction plate with a temporary condyle. Anterior iliac crest
bone graft was harvested from the left hip. The graft was divided, with cortical portions placed on the
plates and secured with locking screws. Remainder of the bone was morselized and mixed with medium
size rhBMP-2 (1.5mg/ml) and placed into the defect. The periosteum was closed around the graft and
watertight closure of intraoral and extraoral wounds were obtained (Figure 4).
His postoperative course was complicated by a small right
submandibular infection 8 weeks after the initial surgery. An incision
and drainage of the small loculation was completed in the clinic and the
infection resolved without further issue. He also began to suffer from
myofacial pain of the right masseter and temporalis, which were treated
with physiotherapy, warm compresses, ibuprofen and flexeril. Seven
months after his immediate reconstruction in June of 2013, four 4 x
Figure 3: Prefabricated 2.4mm KLS reconstruction plate with condylar head mounted on a computer replicated surgical model.
cont. on page 20
RESIDENT’S CORNER (CONTINUED FROM PAGE 19)
13mm Nobel implants were placed into the reconstructed area without complication (Figure 5).
A
B
C
D
Figure 4: A: Intraoperative photograph with lesion presented. B: Resected surgical specimen. C: Reconstruction plate with harvested cortical anterior
iliac crest secured to reconstruction plate. D: Moreselized autogenous bone and rhBMP-2 mixed together prior to placement.
A
B
RESIDENT’S CORNER
C
E
D
F
Figure 5: A: Preoperative implant panoramic radiograph. B: Intraoral photograph of planned implant site. C: Implant surgical guide in place.
D: Intraoperative image of grafted site showing adequate bone stock. E: Implants after placement. F: Postoperative panoramic radiograph.
Discussion
Continuity defects of the mandible may result from trauma, infection or neoplastic process.
Consequently, reconstruction of the region becomes a necessity to return the patient to proper form
and function. The two major types of reconstruction in common practice today are vascularized bone
grafts and autogenous bone grafts.
Common donor sites for vascularized bone grafts include scapula, fibula, iliac crest and radius. The
advantages of vascularized grafts are that the graft can be placed immediately after resection, soft
tissue can be supplied simultaneously, the graft can be placed in irradiated tissue, and implants can be
placed primarily2. However there are significant drawbacks to vascularized bone grafts. These include
involvement of two teams and a prolonged OR time resulting in increased costs. Also higher donor site
morbidity, prolonged hospital stay and the potential need for physical therapy cannot be discounted.
With the exception of the iliac crest free-flap, most free- flaps lack sufficient bone height and width to
cont. on page 22
RESIDENT’S CORNER (CONTINUED FROM PAGE 21)
support dental implant placement in order to satisfy requirements for implant length–crown height ratio
without needing additional bone grafting or distraction osteogenesis procedures3.
In comparison with vascularized bone grafts, autogenous bone grafts can provide better bulk of bone for
placement of dental implants2. Traditionally, the use of autogenous bone grafts has been utilized as a
secondary procedure. The first stage is an ablative surgery with placement of a reconstruction plate,
followed by closure of the wound. This is to allow healing of the wound beds. A secondary procedure
for bone grafting is performed via an extraoral approach to minimize contamination from the oral
cavity2. Some advocate immediate reconstruction at the time of ablative surgery. Many techniques
have been described including but not limited to pedicled and free vascularized bone grafts,
nonvascularized bone grafts, reconstruction plates, growth factors and modular endoprosthesis3,7,8.
Bone Morphogenic Proteins are growth factors that are osteoinductive in nature4. Herford and Boyne
demonstrated that rhBMP-2 can be used alone to stimulate osteogenesis1. As previously described,
autogenous bone grafts have been used alone or in conjunction with reconstruction plates to
immediately reconstruct the mandible. However there have been limited studies discussing the use of
both autogenous graft and rhBMP-2 together to immediately reconstruct the mandible9,10.
Reconstruction of critical sized mandibular continuity defects remains a challenge to any surgeon
regardless of modality implemented. There are pros and cons to each treatment modality whether it is
vascularized free flaps, autogenous grafts alone, rhBMP-2 alone or in our case, autogenous graft and
rhBMP-2 used in conjunction. With our technique, we believe we are able to maximize the amount of
bone available for implant rehabilitation in the shortest time frame while also minimizing donor site
morbidity.
References
1. Herford, Alan S., DDS, MD, and Philip J. Boyne, DMD, MS, DSc. "Reconstruction of Mandibular
Continuity Defect With Bone Morphogenetic Protein-2 (rhBMP-2)." Journal of Oral and
Maxillofacial Surgery 66 (2008): 616-24. Web.
2. Pogrel, M.A., DDS, MD, FRCS, Scott Podlesh, DDS, James P. Anthony, MD, and John Alexander,
MD. "A Comparison of Vascularized and Nonvascularized Bone Grafts for Reconstruction of
Mandibular Continuity Defects." Journal of Oral and Maxillofacial Surgery 55 (1997): 1200-206.
Web.
3. R. C. W. Wong, H. Tideman, L. Kin, M. A. W. Merkx: Biomechanics of mandibular reconstruction:
a review. Int. J. Oral Maxillofac. Surg. 2010; 39: 313–319. #2009. International Association of
Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
4. Abu-Serriah, Muammar, Ashraf Ayoub, David Wray, Nicola Milne, Stuart Carmichael, and Jack
Boyd. "Contour and Volume Assessment of Repairing Mandibular Osteoperiosteal Continuity
Defects in Sheep Using Recombinant Human Osteogenic Protein 1." Journal of CranioMaxillofacial Surgery34.3 (2006): 162-67. Web.
RESIDENT’S CORNER
5. Gemert, Johannes T.m. Van, Robert J.j. Van Es, Ellen M. Van Cann, and Ron Koole.
"Nonvascularized Bone Grafts for Segmental Reconstruction of the Mandible—A
Reappraisal." Journal of Oral and Maxillofacial Surgery67.7 (2009): 1446-452. Web.
6. Baker, Andrew, Jeremy Mcmahon, and Sat Parmar. "Part I: Immediate Reconstruction of
Continuity Defects of the Mandible after Tumor Surgery."Journal of Oral and Maxillofacial
Surgery 59.11 (2001): 1333-339. Web.
7. Goh, Bee Tin, Shermin Lee, Henk Tideman, and Paul J.w. Stoelinga. "Mandibular Reconstruction
in Adults: A Review." International Journal of Oral and Maxillofacial Surgery 37.7 (2008): 597605. Web.
8. Li, Zubing, Yifang Zhao, Sheng Yao, Jihong Zhao, Shibin Yu, and Wenfeng Zhang. "Immediate
Reconstruction of Mandibular Defects: A Retrospective Report of 242 Cases." Journal of Oral
and Maxillofacial Surgery 65.5 (2007): 883-90. Web.
9. Seto, Ichiro, Izumi Asahina, Mitsuo Oda, and Shoji Enomoto. "Reconstruction of the Primate
Mandible with a Combination Graft of Recombinant Human Bone Morphogenetic Protein-2 and
Bone Marrow." Journal of Oral and Maxillofacial Surgery 59.1 (2001): 53-61. Web.
10. Carter, Todd G., Pardeep S. Brar, Andrew Tolas, and O. Ross Beirne. "Off-Label Use of
Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) for Reconstruction of
Mandibular Bone Defects in Humans." Journal of Oral and Maxillofacial Surgery 66.7 (2008):
1417-425. Web.
The Westerner
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