Spring - Western Society of Oral and Maxillofacial Surgeons
Transcription
Spring - Western Society of Oral and Maxillofacial Surgeons
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 Page 4 - The Westerner - Spring 2014 WSOMS Officers 2014–2015 President: Dr. Jay Malmquist 5415 SW Westgate Drive # L-7 Portland, OR 97221 e-mail: Jmalmqu950@aol.com President-Elect: Dr. Steve Leighty 1240 High Street # 105 Auburn, CA 95603 e-mail: sleighty@gmail.com Vice President: Dr. Gabriel Kennedy 2266 Mission Street SE Salem, OR 97302 e-mail: salemoms@aol.com Secretary-Treasurer: Dr. Murray Jacobs Loma Linda University Loma Linda, CA 92350 e-mail: murrayjacobsoms@gmail.com Past President: Dr. Daniel Klemmedson 3150 N. Swan Road Tucson, AZ 85712 e-mail: dklemmedson@sazoms.com 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 e-mail: randallblazic@gmail.com (2014–2017) Dr. Paul Lambert 5398 N. Meadowbrook Way Boise, ID 83702 e-mail: plambert2008@live.com (2012–2015) Dr. Tracy Johnson 2040 Mitchell Road SE Port Orchard, WA 98366 e-mail: tjohnson13@wavecable.com (2012–2015) Dr. Keith Krueger 1475 SW Chandler Street # 101 Bend, OR 97702 e-mail: jawzdoc@aol.com (2012–2015) Dr. Elizabeth Kutcipal Seattle Children’s Hospital Seattle, WA 98105 e-mail: libbykuts@gmail.com (2014–2017) EX-OFFICIO BOARD Dr. A. Thomas Indresano (District VI Trustee) UOP School of Dentistry 2155 Webster Street # 522F San Francisco, CA 94115 e-mail: tindresano@pacific.edu Dr. Charles Walter (Caucus Chairman) 3400 Squalicum Parkway Bellingham, WA 98225 e-mail: c.walter@comcast.net Dr. Gerald MacDonald (Resident Fund Chairman) 3109 Budding Oaks Court Sparks, NV 89436 e-mail: macomfs@aol.com Dr. Daniel Orr II (Westerner Editor) 2040 W. Charleston Boulevard # 201 Las Vegas, NV 89102 e-mail: dlorrii@gmail.com Dr. John Bond (Nominating Committee Chairman) 5967 Post Oak Drive San Jose, CA 95120 e-mail: jsbond@johnsbonddmd.com The Westerner -Spring 2014- Page 5 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). Page 6 - The Westerner - Spring 2014 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 The Westerner -Spring 2014- Page 7 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 Page 8 - The Westerner - Spring 2014 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. The Westerner -Spring 2014- Page 9 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 Page 10 - The Westerner - Spring 2014 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. The Westerner -Spring 2014- Page 11 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 Page 12 - The Westerner - Spring 2014 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. The Westerner -Spring 2014- Page 13 Page 14 - The Westerner - Spring 2014 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 The Westerner -Spring 2014- Page 15 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 Page 16 - The Westerner - Spring 2014 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. The Westerner -Spring 2014- Page 17 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. Page 18 - The Westerner - Spring 2014 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 The Westerner -Spring 2014- Page 19 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 Page 20 - The Westerner - Spring 2014 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 The Westerner -Spring 2014- Page 21 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. Page 22 - The Westerner - Spring 2014 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 -Spring 2014- Page 23 The Westerner Western Society of Oral & Maxillofacial Surgeons 3109 Budding Oaks Court Sparks, NV 89436 JULY 17-21, 2015 WSOMS ANNUAL MEETING BENSON HOTEL, PORTLAND, OR DON’T FORGET TO MARK YOUR CALENDAR PRSRT STANDARD U.S. POSTAGE PAID RENO, NV PERMIT NO. 931