This afternoon I observed an orthognathic surgery consult in a high end practice. I was familiar with orthognathic surgery from Columbia’s emphasis on medicine and high reputation in oral and maxillofacial surgery. However this was the first time I had really witnessed a consultation for orthognathic surgery in a very practical setting.

A 28 year old female patient presented to the clinic because she was unhappy with her facial proportions. She had orthodontic treatment for 2 years prior, but was unhappy with her prominent upper lip, retruded lower lip, and also mentioned that she was unhappy with her nose being too wide (despite having a previous rhinoplasty).

Seeing this patient reinforced how important it is to take a good history of the patient. This patient in particular had a history of plastic surgery, included the rhinoplasty, so right away one has to be aware that she is going to be very particular about the results. Often patients like these change their minds, so even if the surgery gives her what she wants, she may be unhappy with it at a later point in time. It is important for the surgeon not to make guarantees, and to thoroughly advise the patient on their options.

The consulting surgeon was simply brilliant in the manner he conducted his consult. This oral surgeon is an attending at Columbia and I have met him before. However this was the first time I got to see the wealth of his knowledge in full action. He is a very powerful presence but he listened to the patient and all her needs and concerns. He then advised her on the possible options, however the patient was still adamant that she wanted to have her maxilla retruded. The oral surgeon was very honest with her and explained that women pay thousands of dollars to have her full look. He pointed out that if you retract the maxilla, the soft tissues will fall back as well, and she would lose that youthful look that she naturally has.

One of the most impressive parts of his consultation was that he was still very knowledgeable about general dentistry. He took two sets of impressions and was very proficient at taking them for an oral surgeon!

He found two issues from his exam and consult:

1. Deficient mandible/class II skeletal discrepancy

2. Wide alar base

His best treatment plan at this point was mandibular advancement via BSSO (bilateral saggital split osteotomy) along with an alar cinch to address the patient’s issue with the width of her nose. The alar cinch procedure was an intriguing option and gave the patient an alternative to getting another rhinoplasty. He  explained to the patient that an oral surgeon can go intra-orally with the alar cinch procedure which is more effective and does not produce the scarring that is possible from a rhinoplasty performed by a plastic surgeon. He explained that plastic surgeons are limited in what they can do because they cannot work intra-orally.

The patient finally became convinced that it was not a good idea to touch the maxilla, and mandibular advancement was the best solution. The oral surgeon didn’t shoot her down right away, and he advised her to choose between the given choices. However he took it step by step, until the patient saw the benefits of a less invasive approach.

The patient would also have a consult with the orthodontist because she would probably need brief orthodontic treatment after the surgery to adjust the bite so it is properly aligned.

R.A., Columbia University School of Dental Medicine

This afternoon I viewed a patient who was in for an implant placement on #9. The 25 year old female had the tooth extracted over 10 years ago because the tooth would not erupt and was not able to be orthodontically erupted. Prior to the implant surgery a bacterial culture was taken because of a few severe localized pockets on select molars and premolars, which may be indicative of post-juvenile periodontitis. (See Image #1) The bacterial culture was taken by placing paper points into the facial and lingual sites of each deep pocket location for a few seconds, and then placed into the culture solution. The culture will be sent to an oral microbiology lab for testing and further treatment will be decided on then.

The patient received profound anesthesia prior to the implant placement. The size and location of the edentulous area indicated the use of a 3.5mm x 12mm implant in the area of #9. (See Image #2 and #3) Radiographs were taken to verify the placement and seating of the implant and healing abutment and sutures were placed to reapproximate the tissues for successful healing. The patient has been wearing a flipper for approximately 8 years and therefore the seating of the flipper post-surgery was confirmed and no adjustments were necessary.

N.S., New York University College of Dentistry

42 year old female presented for an implant placement in the space of tooth #18. Previously it was noted that the patient was having periodontal problems, had undergone several rounds of scaling and root planning and had been placed on amoxicillin with metronidozole to resolve the condition. A periodontal culture was taken to determine the type of pathogens and if any resistant strains were present. The lab results showed gram negative rods resistant to both of the antibiotics. The patient was placed on 500 mg Cipro BID 7 days. A follow up visit revealed the gums were in a better condition. The patient was also referred to Dr. Keith Berkowitz (www.centerforbalancedhealth.com) to test for fasting blood sugar levels due to the suspicion of a systemic cause of the periodontal condition, prior to implant placement. The blood test revealed a fasting blood sugar level of 139 and the patient was diagnosed with diabetes.  Dr. Berkowitz recommended controlling the diabetes with diet modification for this health-oriented, compliant patient.

Today, the patient was anesthetized and given proper surgical dressing. A flap was made from teeth 20 to18. A 6 x 9 mm implant was placed, as well as a 5.7 x 3mm healing abutment was placed out of occlusion. Slight enamelplasty was done on tooth 18 to allow room for the healing abutment, due to the severe mesial angulation of tooth 18. A panoramic film was taken to verify proper placement of the implant as well as proper seating of the healing implant. The tooth was left without a temporary for the time being to allow integration of the implant and bone.

N.D., New York University College of Dentistry

Today I observed a cementation of a gold post and core of tooth #7, a shoulder preparation, fabrication of a temporary pre-fabricated crown, final impression technique of the prepped tooth, and then observed the temporary cementation of the #7 pre-fab crown.  

Patient presented with a past root canal treatment done on #7, but had recently fallen, hitting her front teeth, especially # 7 and #8.  She was seen by an Oral Surgeon to make sure that there was no bone or facial fracture and was given a splint to keep her anterior teeth intact. 

I learned that there are different treatment options for this patient.  She could have extracted #7 and placed an implant, or extracted #7 and make a 3 unit bridge from #6 to #8, or do ortho to recline #7 and then prep it to make a PFM crown or an all ceramic crown.  Since the patient fell and could have fractured her root or crown of #7, ortho tx to move tooth would cause more fractures, so the prognosis would be poor; therefore, ortho treatment before crown prep would not be a treatment option.  

The observation first began by opening up the access of #7 by removing the temp filling with a bur. Then the gold post and core of #7 was inserted. The post was refined with a bur, then it was checked with occlude spray to observe for pressure/tight areas. Once the post and core fit adequately, then it was permanently cemented which took 12 minutes to cement.  Then a shoulder prep was done with a bur, made the margins clear and checked to see if the prep was tapered and not labially reduced, in another words made the prep slightly more lingual on the facial side.  Then I observed the selection process of a pre-fab #7 crown.  Once the pre-fab crown was chosen, the margins were reduced to make it fit the prepped tooth.  A mixture of monomer and acrylic was made and poured into the pre-fab crown, and then the crown was placed into the prepared tooth to get the internal fit of the pre-fab crown.  Then, the excess was removed around the margins.   

After that, I observed the final impression of #7 prepped tooth.   Since the patient has existing porcelain veneers on her anterior teeth, it’s a good technique to put Vaseline on the veneers and to block out the embrasures with wax, so that when the impression is taken and then removed, there is no chance of her other porcelain veneers coming out.  I learned how to analyze an impression to see if the margins came out or not.  I observed the selection of the final shade of the porcelain crown which was B1. A Polaroid film was taken, so that the lab could match the correct shade. Then, the pre-fab temp crown was refined with a mixture of monomer and acrylic and the excess was removed with a bur.  Finally, once the fit was adequate, then the pre-fab temp crown was cemented with temporary cement.  I also observed the bite registration technique; the registration of the anterior incisors where taken so that the lab has the patient’s occlusion which helps with the fabrication of the porcelain crown.  Then the lower anterior incisal impression was taken with alginate, so that the lab could pour up a lower anterior cast as a guide to make the porcelain crown and check the occlusion. 

In conclusion, today’s observation was a great learning experience.  I learned that we should never put Vaseline on the prepped tooth to get the internal fit of the pre-fab crown because it could contaminate the cements.  Also, I learned that it’s more efficient to fabricate the temp crown before taking the final impression of the prepped tooth. 

G.Y., New York University College of Dentistry, Observation 1

Last Monday was a very educational and rewarding experience. I observed many procedures done by different specialists.

The first one that I participated in was Phase I Therapy of single implant placement on a middle-aged male patient. The surgery was done by an oral surgeon. He used an approach of first creating a flap to help visualize the path of implant insertion. I asked him afterwards whether there was a specific reason that he created a flap first instead of directly “drilling into bone”, and he said there wasn’t, except for the fact as I mentioned to enhance visibility (good reason for me if it means implant will be placed correctly). I was able to see on the x-ray the alignment of the placed implant, and according to my still limited knowledge, it was excellently positioned.

The treatment of the same patient was continued by the general dentist who cemented a temporary bridge in area where implant was placed.

In another treatment, the endodontist performed a root canal therapy on the mandibular molar of another patient. She demonstrated the lateral condensation technique when obturating all 3 canals. This time I saw her using an apex locator, a great device which as she explained showed her the apex both radiographically and clinically. She told me that it is the best to stay within 0.5 mm around the apex when placing master cone with the cement, because that will prevent excessive widening of the apex and perforation of the canal. Upon completion of the RCT I saw the final radiograph, which again showed a very successful end result.

After RCT, the patient was transferred to a different room, where the treatment continued with the core buildup and crown prep done by the general dentist. The patient did not need post and core placements because there was enough tooth structure to ensure longevity of the fixed restoration with the composite core. The finish line of the crown prep was a combination of shoulder with bevel and chamfer, done as such to avoid unnecessary compromise of the tooth structure. After the final impression and shade selection, a temporary crown (constructed at the chair-side via “block technique”) was cemented and patient was dismissed.

Throughout the entire time, what was most apparent in the office was the nature of the comprehensive and personalized treatment, excellent pain control and sensitivity to patient’s comfort. Interaction between Doctor and Patient was constant and conducted in comfortable yet respectful manner. The pain control was done not only during the procedure but also after the visit; because at the end of the treatment Dr Dorfman made sure the patient received post-op instructions and pain medication.

E.T., New York University College of Dentistry, Observation

Patient presented for the placement of implants with the oral surgeon. Patient had a 3-unit bridge teeth #3-5, with a mesial bony defect on #5. After the bridge came off, area #4 and 5 was left edentulous and needed to be restored. The patient preferred implants for the area #4, 5 and 8.

The oral surgeon started the procedure by allocating where to place the implants. Then he took a #15 blade and created a flap through the crest of the alveolar ridge. Suctioning and irrigation were done during the whole implant placement procedure. The General Dentist who was going to restore the implants was assisting the Oral Surgeon which made the procedure even more efficient because the two specialists were able to coordinate the optimal placement of implants for the benefit of the patient. The implants were placed perpendicular to the occlusal plane. However, the anterior implant was placed more subgingival than the posterior implants, for esthetic reasons. The whole procedure was done under local anesthesia and nitrous oxide.

Although the patient was really anxious before the procedure, the good social and professional techniques of the oral surgeon made the procedure as smooth as placing a sealant on a tooth. After the placement of the implants was completed, the oral surgeon sutured the flap sites and achieved hemostasis. During this time the general dentist relined the patient’s existing flipper in order for it to fit the mouth well after implant placement. We took a PAN of the patient right after this procedure was completed.

Both the oral surgeon and the general dentist were satisfied with the way these implants looked on the PAN. The implants had nice angulations and stayed away from adjacent teeth and their roots. The oral surgeon commented that he used the indirect sinus lift technique when placing these implants by lightly hammering the #4 and 5 implants into the sinus in order to push some bone out because the surgeon knew from the previous PAN that we needed 2-3 mm more of bone at the implant apex in order for the implant apex not to be exposed in the sinus.

The patient was really happy to have been done with this stage of surgery and she was really pleased how we helped her get through this as a team.

R.F., New York University College of Dentistry, Observation

Today in the dental office there was a case that was very complex not only because of the dental work that was involved but because there was also issues of finance and patient management involved. The patients was chief financial officer of his company and had a lot of dental work that needed to be done. This patient was overweight as an adolescent and suffered from anorexia and bulimia. These two disorders ruined his upper teeth and neglect over many years worsened the situation. When he presented to the office the patient had almost no coronal tooth structure left on any of the maxillary teeth.

It was charted that 6-11 and 14 and 15 were restorable with guarded prognosis and any other root tips in the mouth were to be extracted. 6-11 and 14 and 15 were all to be treated with RCT in one visit and to be restored a few days later also in one visit with temporaries.

One of the main concerns with this patient was the loss of vertical dimension. After many years of going with the wrong vertical we were concerned that opening the bite again would cause stress to the TMJ. After endo and OS consults however it was deemed that restoration of the occlusion could be done immediately. It was also noted that this patient was very phobic and was pre-medicated prior to any treatment for the phobia.

The treatment time was about 4 hours in which 8 root canals, post space preparations, and impressions were done. The lab tech was on hand to observe the case so that he could process temps for the patient within 4 days when the post/cores are inserted. This is a case that would normally have taken months and a lot of patient visits but is going to be taken care of in a short span of time with specialist attention.

H.A., New York University College of Dentistry, Patient 10

Female patient presents to the dental office for an oral surgery consult for right mandibular pain and swelling. The patient filled out a TMJ pain form asking where her pain was. Oral surgeon performed a head and neck exam and specifically palpated the area of tenderness. Upon examination of the panoramic film, it was evident that there were two teeth present below the inferior alveolar nerve in the area of the angle of the ramus, which is probably causing the pain.

Patient informed she should have the teeth extracted by an oral surgeon, which should reduce the facial pain. Also noted was a loss of vertical dimension and deviation of the jaw upon closing.

N.S., New York University College of Dentistry, Patient 1 – part 2