246

CMEinfo presents
a definitive multimedia course

ORAL & MAXILLOFACIAL SURGERY:

PATIENT SAFETY AND
MANAGING COMPLICATIONS
Directed by Jeffrey Bennett, DMD, and Elie M. Ferneini, MD, DMD
 Oral and Maxillofacial Surgery –
Patient Safety and Managing Complications
Provided by:
Oakstone Publishing, LLC
_____________________________________________________________________________________________________________________
DATE OF ORIGINAL RELEASE: December 1, 2017
DATE CREDITS EXPIRE: December 1, 2020

TARGET AUDIENCE:
This educational activity was designed for practicing Oral and Maxillofacial Surgeons (in private
and academic settings), surgery residents, and fellows.

ESTIMATED TIME TO COMPLETE:

It is estimated that it should take the average learner 19 hours to complete the activity.

METHOD OF PARTICIPATION: Review Video/Audio program, complete the

comprehensive activity evaluation and score 70% or greater on the required posttest to assess the
knowledge gained from reviewing the program.

LEARNING OBJECTIVES:
At the conclusion of this activity, the participant will be able to:

 Outline an increased scientific and technical knowledge base in oral and maxillofacial
surgery.
 Describe current patterns of care to improve patient safety and prevent complications.
 Apply the information learned in his or her daily clinical practice.
 Use improved competence in recognizing and managing complications. Thus improving
patient outcomes and safety.

ACCREDITATION/DESIGNATION:
Oakstone Publishing, LLC is accredited by the Accreditation Council for Continuing Medical
Education (ACCME) to provide continuing medical education for physicians.

Oakstone Publishing, LLC designates this enduring material for a maximum of 19 AMA PRA
Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of
their participation in the activity.

Oakstone Publishing, LLC is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP does not approve or
endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards
of dentistry.
Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP
at www.ada/cerp.

246
____________________________________________________
Oakstone Publishing, LLC designates this activity for 19 continuing education credits.

Credit breakdown by unit:

UNIT 1: 7.25 AGD Code 310
UNIT 2: 6.75 AGD Code 310
UNIT 3: 5.00 AGD Code 310

Academy of General Dentistry

Approved PACE Program Provider
FAGD/MAGD Credit
Approval does not imply acceptance
by a state or provincial board of
dentistry or AGD endorsement.
(6/1/2005) to (5/31/2023)
Provider ID# 306382

FACULTY AFFILIATIONS DISCLOSURE:

Oakstone Publishing, LLC has assessed conflict of interest with its faculty, authors, editors, and
any individuals who were in a position to control the content of this CME activity. Any
identified relevant conflicts of interest were resolved for fair balance and scientific objectivity of
studies utilized in this activity. Oakstone Publishing’s planners, content reviewers, and editorial
staff disclose no relevant commercial interests.

Disclosure information for all individuals in control of the content of the activity is located
on the disclosure statement in the PDF and printed syllabus.

WARNING:
The copyright proprietor has licensed the picture contained on this recording for private
home use only and prohibits any other use, copying, reproduction, or performance in
public, in whole or in part (Title 17 USC Section 501 506).

CMEinfo is not responsible in any way for the accuracy, medical or legal content of this
recording. You should be aware that substantive developments in the medical field covered
by this recording may have occurred since the date of original release.

© 2017 Ebix, Inc. DBA Oakstone Publishing. LLC.

CMEinfo is a registered trademark of Oakstone Publishing, LLC.

246
 Oral & Maxillofacial Surgery:
Patient Safety & Managing Complications
Faculty List
____________________________________________________
COURSE DIRECTORS:

Jeffrey Bennett, DMD Elie M. Ferneini, MD, DMD, MHS, MBA,

Indianapolis, IN FACS
Associate Clinical Professor,
Division of Oral and Maxillofacial Surgery,
University of Connecticut,
Farmington, CT
Beau Visage Med Spa/Greater Waterbury
OMS
Cheshire, CT

FACULTY:

Mo Banki, MD, DMD, FACS Jasjit Dillon, DDS, MBBS, FDSRCS,

Medical Director FACS
Artistic Contours Clinical Associate Professor,
Warwick, RI Chief of Service & Program Director,
Clinical Faculty, Department of Surgery Department of Oral & Maxillofacial
Warren Alpert Medical School of Brown Surgery,
University University of Washington,
Providence, RI HarborView Medical Center,
Clinical faculty, Seattle, WA
Division of Oral and Maxillofacial Surgery,
University of Connecticut, Christy B. Durant, ESQ
Farmington, CT Attorney at Law,
Partner - Quinlan and Durant, LLC
Srinivasa R. Chandra, MD, BDS, Providence, RI
FDSRCS (Eng)
Assistant Professor in Head and Neck Thomas Flynn, DMD
Surgery, Division of OMFS, Retired Associate Professor,
Department of Surgery, Retired Director of Predoctoral
University of Nebraska Medical Center, Oral and Maxillofacial Surgery Education,
Omaha, NE Department of Oral & Maxillofacial
Surgery,
Harvard School of Dental Medicine,
Boston, MA
____________________________________________________
Deepak Krishnan, DDS, FACS David B. Powers, DMD, MD, FACS,
Associate Professor of Surgery, FRCS (Ed)
Residency Program Director, Associate Professor of Surgery,
Oral Maxillofacial Surgery, Director, Craniomaxillofacial Trauma
University of Cincinnati, Program,
Cincinnati, OH Division of Plastic, Maxillofacial & Oral
Surgery,
Pushkar Mehra, DMD, MS, FACS Duke University Medical Center,
Professor and Chair, Durham, NC
Department of Oral & Maxillofacial
Surgery, Eber Stevao, DDS, MSc, PhD
Boston University School of Medicine, President and Director,
Boston, MA Curitiba Institute of Orthognathic Surgery,
Curitiba, Brazil
Paul Moore, DMD, PhD, MPH
Professor, W. Bradford Williams, DMD, MD
Pharmacology, Dental Anesthesiology, and Kaiser Oakland Medical Center
Dental Public Health Department of Maxillofacial Surgery
University of Pittsburgh Oakland, CA
School of Dental Medicine,
Pittsburgh, PA Jennifer E. Woerner, DMD, MD, FACS
Assistant Professor,
Peter Moy, DMD Department of Oral & Maxillofacial
Nobel Biocare Endowed Chair, Surgery,
Surgical Implant Dentistry, Louisiana State University
Clinical Professor, Health Sciences Center,
Ronald Reagan Medical Center, Shreveport, LA
Oral & Maxillofacial Surgery,
UCLA, School of Dentistry,
Los Angeles, CA

Gregory Ness, DDS, FACS

DP Snyder Professor of Oral Surgery,
Oral & Maxillofacial Surgery and Dental
Anesthesiology,
The Ohio State University,
College of Dentistry,
Columbus, OH
 Oakstone Publishing, LLC
Oral & Maxillofacial Surgery:
Patient Safety and Managing Complications
December 1, 2017

Book
Topic/Speaker Page #
Patient Safety in Oral & Maxillofacial Surgery
1
Jeffrey Bennett, DMD
Anesthetic Complications
29
Deepak Krishnan, DDS, FACS
Legal Aspects Pertaining to the Management of Patients
105
Christy B. Durant, Esq.
Prescribing Controlled Substances, Pain Management, & the Opioid Epidemic
155
Paul Moore, DMD, PhD, MPH
Patient Safety in Antibiotic Therapy and Infection Management
201
Thomas Flynn, DMD
Navigational Surgery and Virtual Surgical Planning: It's Applications in Oral and
Maxillofacial Surgery 261
Jasjit K. Dillon, DDS, MBBS, FDSRCS, FACS
Dentoalveolar Complications
309
Gregory Ness, DDS, FACS
Complications in Dental Implants
344
Peter Moy, DMD
Complications in Orthognathic Surgery
432
W. Bradford Williams, DMD, MD
Complications in Reconstructive Surgery
517
Srinivasa R. Chandra, MD, BDS, FDSRCS (Eng)
Complications in Maxillofacial Trauma
550
David Powers, DMD, MD, FACS, FRCS (Ed)
Complications of TMJ Surgery
616
Pushkar Mehra, DMD, MS, FACS & Eber Stevao, DDS, MSc, PhD
Complications in Craniofacial Surgery
644
Jennifer Woerner, DMD, MD, FACS
Complications in Minimally Invasive Facial Cosmetic Surgery
661
Elie Ferneini, MD, DMD, MHS, MBA, FACS
Complications of Cosmetic Surgery
712
Mo Banki, MD, DMD, FACS
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

PATIENT SAFETY
STEPS TO MINIMIZE RISKS

JEFFREY BENNETT, DMD*

• Dr. Bennett has no

relationships to disclose

Medical error is the 3rd greatest

cause of death
Surgical care accounts for 2/3rds of
in-hospital deaths

HEALTHCARE IS HAZARDOUS

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“avoidance, prevention and amelioration of

adverse outcomes or injuries stemming from
the process of healthcare”

PATIENT SAFETY
National Patient Safety Foundation

Patient safety is the basis for good

patient care

WHY?

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BELL SHAPE CURVE

Intake errors
Diagnostic errors
Medication errors
Anesthetic errors
Surgical errors
Discharge / transference of care errors
Communication errors
Errors of the human-machine interface

MEDICAL ERRORS

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Risk officers
Quality control officers
Compliance officers

ORGANIZATIONAL STRUCTURE

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Education Anesthetic
team

Checklists &
Cognitive aids
Monitoring

ABOMS DAANCE

Patient Continuing
Safety education
Residency
Office
Simulation anesthetic
evaluation
Patient
Timeouts selection

Simulation &
mock drills
Anesthetic
depth Clinical
management

WHY CHANGE SOMETHING

THAT IS NOT BROKEN?

OR IS IT BROKEN & SIMPLY NOT

RECOGNIZED.

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Is there a problem?
Is there a “better” way?
What can be changed?
How can I make improvements?
Do these changes make a difference?
How will I know if the changes made a
difference?

Medical checklist
Review of systems

MEDICAL HISTORY

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Failure to diagnose
Delay in diagnosis
Misdiagnosis
Over-diagnosis

Pathology lab book

DIAGNOSTIC ERRORS

PEDIATRIC ANESTHESIA

Anatomic and physiologic development

What age defines a pediatric patient?

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Reconciliation
Adverse drug event
Polypharmacy
Altered drug efficacy
Continuance or discontinuance
oral anticoagulants

MEDICATION MANAGEMENT

Injury caused by medication use

Unpredictable: idiosyncratic or
allergic
Predictable: related to inherent
pharmacologic properties of
drug

ADVERSE DRUG EVENT

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Right patient
Right drug
Right dose
Right route
Right time

MEDICATION MANAGEMENT

Anesthesia related medication errors

occur at a rate of 1 for every 20
medication administrations
1/3 of these result in patient harm
Contributing factors
Drug shortages
Drug dilution
Infusion pumps

MEDICATIONS AND ANESTHESIA

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DRUG SHORTAGES

Laboratory study in which

drug required dilution prior
to delivery
15% correct calculation
61% significant error
50 x’s too low
56 x’s too high

ACCURACY OF CALCULATING
DRUG DILUTION
Avidan et al. J Clin Anest
2014

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5mcg/ml remifentanil:
10mg/mL propofol
Vial: 1 mg
2.5 mL of NS to 1 mg
remifentanil
0.25 mL contains 100mcg
remifentanil
Add 100 mcg remifentanil
to 20mL propofol

REMIFENTANIL – PROPOFOL INFUSION

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MINIMIZING MEDICATION ERRORS

Familiarity and knowledge

Verifying vial contains the correct drug concentration
Avoidance of stocking same drug at different concentrations
Avoidance of look-alike vials
Avoidance of using sound alike drugs
Stocking ready-to-use concentrations
Labeling syringes with name and concentration
Sterile technique
“one drug, one syringe, one patient”

Aids to determine dosing

Select “just the right” number of medications to
administer
Closed loop communication
Prevent distraction

MINIMIZING MEDICATION
ERRORS

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Ensure a patent continuous running IV

line
Connect a medication infusion to the
most proximal IV port

MINIMIZING MEDICATION
ERRORS

Electronic prescribing systems

Decision support
Bar code scanning

MINIMIZING MEDICATION
ERRORS

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Treatment Options
LA and oral premed +/- N2O/O2
Moderate IV sedation
Deep sedation/GA

Treatment location

PATIENT SELECTION
ANESTHETIC DEPTH

1541 closed claims anesthesia cases

34% of which were respiratory events
85% resulted in brain damage or
death
> 90% of which better monitoring
would have prevented the
outcome

ADVERSE RESPIRATORY EVENTS

Anesthesiology 72:828, 1990

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ASA 2009 database

Adverse respiratory events were
the primary contributing factors
resulting in death in out-of-
operating room locations
50% were associated with
monitored anesthetic care
(MAC).
Metzner J, Posner KL, Domino KB. The risk and safety of anesthesia aremote
locations: the US closed claims analysis. Cur Opin Anaesthesiol 2009;22:502-508

WHAT IS THE LIMITATION TO PULSE

OXIMETRY?
With supplemental O2 administration
Provides no indication of ventilation!

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50% of children who received

sedation in the PED had hypopnea &
were 6.6 times more likely to have
oxygen desaturations
Hypopnea occurred on average 3.7
minutes prior to oxygen desaturation

Langhan ML, Chen L, Marshall C, Santucci KA.

Detection of hypoventilation by capnography and its
association with hypoxia in children undergoing
sedation with ketamine. Pediatr Emerg Care
27:394;2011

RESPIRATORY DEPRESSION WAS 17.6

TIMES MORE LIKELY TO BE DETECTED
AMONG SEDATED PATIENTS WHO WERE
MONITORED WITH CAPNOGRAPHY
THAN WITH STANDARD MONITORING
ALONE

Waugh JB, Epps CA, Khodneva YA. Capnography enhances

surveillance of respiratory events during procedural sedation: a
meta-analysis. J Clin Anesth 23:189;2011

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Continuous auscultation of lung and heart sounds

Capnography

BENEFICIAL REDUNDANCY

VIDEO LARYNGOSCOPY

king

glidescope
Vivid trac

McGrath

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Gas plumbing
Anesthesia machines
Gas scavenging
Sterilization efficacy
Electrical safety and calibration
Monitoring device accuracy
Back-up power
Radiation safety

EQUIPMENT SAFETY

SURGICAL ERRORS

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High volume office

Complexity of the surgical site
Patient charting and treatment planning
Non-marked surgical site
Surgical site visualization
Multiple surgeons / pass-off miscommunication

CAUSES OF WRONG SITE

SURGERY

FACTORS CONTRIBUTING TO WRONG

TOOTH SURGERY

Nomenclature
Mounting
Migrating/drifting tooth
Ectopic position
Poor referral process and
documentation

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Period of interdisciplinary discussion

Communication
Everybody comprehends intended procedure
Minimizes misunderstanding
An “active” process

TIMEOUT

Simple standardized process

Anticipate errors
Intercept errors
Prevent harm
Forces a task to be performed

CHECKLIST

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Use at least two ways to identify

patients.
Make sure that correct surgery is done
on the correct patient and at the
correct place on the patient’s body
Mark the correct place on the patient’s
body where the surgery is to be done
Pause before the surgery to make sure
that a mistake is not being made

JOINT COMMISSION (2016)

Wrong patient
Wrong procedure
Wrong site surgery
Patient allergies identified
Imaging displayed
Antibiotics indicated and administered
Appropriate equipment available
Instrument count before and after procedure
Implantable biologics/devices documented
Specimens logged

GOAL OF TIMEOUT & CHECKLIST

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Decrease in death rate and complication rate

Culture

CHECKLIST & TIMEOUT

“YOU ARE ONLY AS GOOD AS

YOUR STAFF”

“GOOD CARE STARTS WITH GOOD

STAFF”

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WHO IS YOUR STAFF?

AAOMS DAANCE
Clinical skills

Knowledge & skill acquisition

Foundation
Maintenance
Crew resource management / team functionality
“One does best what one does often”

STAFF TRAINING

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Role delegation Leadership

Individual
responsibility Decision-making
Closed-loop Information
communication management
Collaboration
Knowledge sharing
Workload distribution
Situational awareness Staff member
empowerment

CREW RESOURCE
MANAGEMENT

Leading a “code”
Hospital versus office
Team leader
Colleagues
Nursing
Respiratory therapist
Pharmacy staff
Assistants?

THE NEED FOR SIMULATION

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Replicates the “real” event

Repetitive
No patient risk
Routine & emergent
Assess individual and team functionality
“One does best what one does often”

SIMULATION BASED TRAINING

Airway management
Bag-valve-mask ventilation
Oral & nasal airway placement
Supraglottic airway placement
Endotracheal intubation

TASK SIMULATORS

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Culture of safety
Structured protocol
Critical-care pathways
Cognitive aids & manuals

“BEST PRACTICE”

Where and when?

Problems
“weakest link”
Continuance of care
Miscommunication
Clinical disagreements

DISCHARGE & TRANSFERENCE

OF CARE

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Facility’s physical layout

Patient & personnel records Joint Commission

Peer review & quality Accreditation Association

assurance of Ambulatory Health Care

Operating room personnel American Association for

Accreditation of
Equipment Ambulatory Surgery
Operations and Facilities
management OAE
Environmental safety

DOES SITE ACCREDITATION

INCREASE SAFETY?

Avoiding reliance on memory

Access to information
Checklist
Timeout
Team collaboration
Patient participation
Design for recovery
Anticipate the unexpected

PATIENT SAFETY INTERVENTIONS

Barnsteiner. Online J Issues Nurs (2011)

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Evidence from randomized controlled trials is

important information, but it is not necessary for
acceptance of a safety practice and may be
counter-productive
For policy makers to wait for incontrovertible
proof of effectiveness before recommending a
practice would be a prescription for inaction

Leape LL, et al: What practices will most

improve safety? Evidence-based
medicine meets patient safety. JAMA
288:501;2002

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Intraoperative
Complications of General
Anesthesia
Deepak G Krishnan DDS, FACS
Associate Professor of Surgery
Residency Program Director
Oral Maxillofacial Surgery
University of Cincinnati

Disclosure

Dr. Deepak Krishnan has nothing to

disclose.

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

“The eyes do not see

what the mind does not know”

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Total In-Office Death/Brain

Damage
Cases Reported to OMSNIC
2000 - 2012

157

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Incidence of In-Office
Anesthesia Death & Brain
Damage Cases

157 cases = 1
36,272,094 procedures 231,033

Frequency of Office Anesthetic

Deaths 2000-2012

• 1 in every 528 OMS will experience an office anesthetic death per

year

• In a 30 year practice life 1 in 18 OMS will experience an office

anesthetic death

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 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Adverse Events in Outpatient Setting

• Pediatric Sedation
Research Consortium1 –
collection of data from 26
institutions, 30037
sedation/anesthesia
encounters July 2004 –
November 2005

Cravero J, Blike George T, et al. Incidence and Nature of Adverse Events During
Pediatric Sedation/Anesthesia for Procedures Outside the Operating Room: Report
From the Pediatric Sedation Research Consortium. Pediatrics. 2006;118:1087-1096.

Anesthesia Progress Fall 2017

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• Intolerance of the uncertainty

• Management of anxiety and pain
• Options for anesthesia - from local to general
• Safety
• Training in techniques, understanding of pharmacology, management
of potential complications
• High stakes, high risk

Current Paradigm

• Residency training
• Progressive exposure to anesthesia in the relevant setting
• A familiar drug cocktail, set of skills, crash cart, vague recollection of
ACLS
• OAE every five years by a peer
• Anesthesia CE credits

• Is that enough?

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Intent of OAE

• Since 1975
• “Each practicing AAOMS member maintained a properly equipped
office and was prepared to use accepted techniques for managing
emergencies and complications of anesthesia in the treatment of the
OMS patient in the office or outpatient setting”
• OAE manual is being revised for the next edition

Is that enough?

• Is it?
• ACLS retention with hi-fi Sim = 120 days
• Daily practice of routine technique

• Competent – mastery of a set of skills, knowledge

• Proficient – a measure of performance – a snapshot of success

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• Safety
• State Certification requirements
• Malpractice costs

• Advanced safer sedation and monitoring techniques

• Training

Vigilance at every step

• Appropriate patient selection

• Appropriate preparedness

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Vigilance at every step

Pre-Procedural Vigilance
• a documented pre-sedation medical evaluation,
including a focused airway exam
• an appropriate interval of fasting before sedation
• No sedative or anxiolytic medications without
supervision from skilled medical personnel (i.e., not
at home or by a technician)
• Sedative and anxiolytic medications should only be
administered by, or in the presence of individuals
skilled in airway management and cardiopulmonary
resuscitation

Vigilance at every step

Procedural Vigilance
• Age- and size-appropriate equipment and
appropriate medications
• Continuous and appropriate monitoring
• Designated anesthesia personnel to monitor the
patient’s cardiorespiratory status during and after
the procedure

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Vigilance at every step

Post - Procedural Vigilance

• Specific discharge criteria
• Children/ young adults sedated using medication
with a long half-life (e.g., chloral hydrate,
pentobarbital and chlorpromazine) may require
extended observation.
• Don’t hurry the D/C
• 2 responsible escorts

Vascular Access

• IV
• IO availability and training to use
• Safety Net

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• Top 5 reasons never to sedate in your practice

1. ___
2. ___
3. ___
4. ___
5. ___

ADSA Resources

• The Rollert Pediatric Dosing guide

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Emergency Drugs

• Succinylcholine
• Depolarizing muscle relaxant
• 30-60s onset time
• Duration <10min
• Children more susceptible than adults to
cardiac arrhythmias, hyperkalemia,
rhabdomyolysis, myoglobinemia following
succinylcholine

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Emergency Drugs

• Drugs via ETT

• N – naloxone – 0.2mg/kg
• A – atropine – 0.04mg/kg
• V – valium
• E – epinephrine – 0.1mg/kg
• L – lidocaine – 2.5mg/kg

Emergency Drugs

• IV Medications
• Adenosine 0.1 mg/kg, 0.2 mg/kg
• Amiodarone 5 mg/kg
• Atropine 0.02 mg/kg
• Epinephrine 0.01 mg/kg
• Flumazenil 0.01 mg/kg
• Lidocaine 1 mg/kg
• Naloxone 0.1mg/kg

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Outline
I. Airway
I. Ventilation
II. Oxygenation
II. Complications of intubation
III. Circulation
IV. Malignant Hyperthermia
V. LAST

Goal: safe care

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Airway Evaluation
•2 main attributes are oropharyngeal exam and
mental distance
•Mallampati – patient in a sitting position, w/
neck extended, tongue out, and phonating
–Class I – Soft palate, fauces, uvula, ant and post
tonsillar pillars
–Class II – Soft palate, fauces, uvula
–Class III –Soft palate, uvula
–Class IV – Soft palate only

Mallampati RS, Gatt SP, Gugino LD. A clinical sign to predict

difficult tracheal intubation: A prospective study. Can Anaesth
Soc J. 1985;32, 429

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Cormack-Lehane Laryngoscopy Grades

Correlating

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Airway Assessment
Can you intubate the patient?
Can you ventilate the patient?
• Mallampatti – Samsoon • Short neck
• Thyromental distance • Neck hyperextension
• Macroglossia • Neck circumference
• Retrognathia • Position of larynx
• Tonsillar hypertrophy • Prior tracheostomy
• Inter-incisal distance • Infection / mass
• Length of upper incisors • Obesity

Airway Assessment

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Airway Assessment

Change in Emphasis

• Old: “If you can’t INTUBATE

it…don’t sedate it”
• New: If you can’t VENTILATE
it…don’t sedate it
• Difficult to intubate does NOT
necessarily mean difficult to
ventilate
• Most studies do not investigate
“difficult to ventilate”

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Can You Ventilate The Patient?

• Facial hair • Skeletal abnormalities
• BMI > 26 kg/m2 • Poor Atlanto-occipital extension
• Edentulous • Lingual tonsil hypertrophy
• Age > 55 years • Facial burns
• H/o snoring • Heavy jaw muscles
• Macroglossia
• H/o OSA

The Pediatric Respiratory System

Not just a small adult….

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Airway

• Proportionally larger head and tongue

• Narrow nasal passages
• Anterior and more cephalad larynx (C4 versus C6 in adults
• Long epiglottis
• Short neck
• Short trachea, narrow cricoid, funnel shaped

D G Krishnan ODSA Nov 2016

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Geriatric Airway

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Geriatric Airway Changes

• Decreased pharyngeal muscular support

• Opening and/or maintaining the airway
• Cervical arthritis limits neck extension
• Increased risk for aspiration
• Depressed lower esophageal
sphincter tone
• Increased gastric emptying time
• Protective laryngeal reflexes are
diminished
• Decreased number and activity of
respiratory cilia

Pharyngeal Muscular Dilators

• Tensor palatini – soft palate - nasopharynx

• Genioglossus – tongue – oropharynx
• Hyoid muscles – epiglottis – laryngopharynx
• Geriatric dilator muscle tonus decreases, with obstruction tendency

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Geriatric Pulmonary Morbidity

• Ventilatory patterns
• Irregular / apneic spells
• Anesthesia
• Decreased resting PaO2
• Decreased ventilatory responses to hypoxia & hypercarbia
• Increased incidence of desaturation and apnea

Airway Setup
• Airway setup in each operatory
• Drugs
• Airway adjuncts
• Oxygen
• Suction

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Crash Cart

• Central area • Airway adjuncts

• Oxygen tank • Laryngoscope
• Regulator • Batteries
• BVM • Stylettes
• LMA/iGel
• Suction

Preparation!!!!

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Airway Bougies / Exchange Catheters

• Grades III & IV views

• Technique
• Blind or under-visualization
• “feel” bougie rubbing
tracheal rings
• Pass endotracheal tube
over bougie
• Cook airway exchange
catheters

Can you perform a Cricothyrotomy?

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Naso-pharyngeal Airway
• Up the nose with a rubber hose

Oro-pharyngeal Airway

• Measure airway from

commissure of the lip to the ear
lobe
• Open mouth with cross finger
technique
• Pull tongue forward & insert
device

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• Optimize visualization
• Minimize the angle between:
• Oral axis
• Pharyngeal axis
• Laryngeal axis

Miller Blade
• Small mandibular space
• Anterior larynx
• Long floppy epiglottis (peds)

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Macintosh Blade
• Little upper airway room
• Small narrow mouth
• Narrow palate
• Small oropharynx

• Less traumatic to teeth

• Curved blade does not touch epiglottis
• Pharyngeal surface of epiglottis innervated by
glossopharyngeal nerve
• Laryngeal surface of epiglottis innervated by
superior laryngeal nerve
• Stimulation of superior laryngeal nerve
• Laryngospasm & bronchospasm

A Different View

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Nasal Intubation
• Awake: Prepare nostril • Small endotracheal tube
(decongest/dilators) • Lubricated
• Anesthetize airway • Presoaked in warm water
• Spray / rinse oral pharynx
• Trans-tracheal block
• Orient tube such that tip is
• Glossopharyngeal nerve block against septum and bevel
• Recurrent laryngeal nerve block faces turbinate
• RAE (fixed flexion length
per diameter) Vs. “regular”
ET

A Difficult or Failed Intubation

• Tooth damage
• Soft tissue trauma
• Crico-arytenoid joint subluxation
• Assoc. with: chronic renal insufficiency, Crohn’s dx,
acromegaly
• S/S: voice changes, sore throat, pain on swallowing,
stridor, shortness of breath
• Early (better) Vs. late intervention

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Attempted Intubation – Action & Reactions

• Autonomic responses
• Tachycardia
• Hypertension
• Dysrhythmias
• Bronchospasm
• Hypotension & bradycardia
• Laryngospasm &/or bronchospasm
• In-folding of arytenoids
• Coughing & bucking
• Vomiting, regurgitation, aspiration

Supraglottic Airway Devices

• Minimally invasive device

• Inflatable mask fitted with a tube
• Occupies the hypo-pharyngeal space
• Forms a seal above the glottis
• Go to rescue airway

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LMA©

LMA Types

LMA Unique LMA Fastrach

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LMA Types

LMA ProSeal LMA Supreme

LMA Types

LMA C-trach LMA Flexible

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Laryngeal Mask Airway

• Muscle relaxation is unnecessary

• Laryngoscopy is circumvented
• Hemodynamic changes are minimized during insertion

LMA Contraindications
• Non-fasted patient
• Morbidly obese
• High inspiratory pressures
(>20 – 25 cm H2O)
• Hiatal hernia
• GERD

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LMA Complications
• Coughing
• Laryngospasm
• Labored breathing
• Complete airway obstruction
• Sore throat
• Dysarthria
• Hypoglossal nerve paralysis
• Inability to protect against pulmonary aspiration

iGel

• Anatomic gel seal. No inflation

• Ease of insertion
• Integral bite block
• Less laryngeal trauma
• Gastric suction possible
• Max airway pressures equivocal

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Supraglottic Airway Devices

• LMA/iGel
• King airway

• Combitube

Supraglottic Airway Devices

• Cobra perilaryngeal airway

• Cuffed oropharyngeal airway

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Video Laryngoscopy

king

Vivid trac
glidescope

McGrath

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Complications of Intubation
• Damage to maxillary incisors
• Esophageal placement
• Lingual nerve injury
• Aspiration

Aspiration

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Aspiration
• Obesity
• GERD
• Hiatal hernia
• Pregnancy
• Trauma patients

Adams JP, Murphy PG. Obesity in anesthesia

and intensive care. Br J Anaesth. 2000; 85: 91

• Increased intra-abdominal and intragastric pressures

• GERD and hiatal hernias common
• 8 hour fast: 85-90% morbidly obese patients gastric
volumes > 25mL and pH < 2.5
–H2 blocker and prokinetic agent 12 hours and 1-2
hours prior to surgery

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Aspiration - Sequelae
• Aspiration pneumonitis vs. pneumonia
• Physical obstruction
• Laryngospasm
• Bronchospasm

Aspiration - Treatment
Depends on aspirate and level of anesthesia

• Reflexes intact, cough, turn head to side, 100% O2, suction

when needed
• Cannot clear airway, Trendelenburg, head down 15 and
turned to right, suction, then intubate, 100% O2

• Cricothyrotomy or tracheostomy

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Aspiration Pneumonitis
• Acute lung injury after inhalation of regurgitated gastric
contents

• Approximately 1:3000 general anesthetics

• 10 – 30% of all deaths associated with anesthesia

Aspiration Pneumonitis
• Chemical burn of tracheobronchial tree and
pulmonary parenchyma
• Intense parenchymal inflammatory reaction
• Biphasic
–1-2 hours, direct caustic contact
–4-6 hours, inflammatory reaction

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Aspiration Pneumonitis
Gastric pH<2.5 and .3mL/kg aspirate
• No empiric Abx
–Gastric contents sterile

• Abx warranted:
–If not resolving in 48 hours
–If concern for gastric contents, pH>2.5
–Broad spectrum, Levaquin

Aspiration Pneumonia
• Inhalation of colonized oropharyngeal material
• Silent aspirates, people in nursing homes, neurologic
dysphagia
• Impairment of gag and/or swallowing
• Radiographic infiltrate

*Generally not associated with GA

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Pneumonia vs. Pneumonitis

Aspiration
• Prevention
• Recognize patient populations at risk
• RSI (rapid sequence induction)
• Sellick maneuver

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Aspiration
• Recommendations for office procedures are lacking
• Obese OR patients
–Ranitidine 150 mg po 12h and 2h prior
–Metoclopramide 10 mg 12h and 2h prior
–Bicitra 30 mL
• Cancel procedure if patient ate
• Current guidelines are 4-6h food, 2-4h water

Apnea and
Airway Obstruction

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Apnea vs. Obstruction

• YOU

• Opioids
• Benzodiazepines
• Inhalational agents

• Mechanical obstruction
–Tongue/soft tissue
–Sweetheart retractor
–Foreign object

Apnea-Treatment
• Jaw thrust
• Remove retractors
• Protrude tongue mechanically
• Hypercarbic drive
• May require PPV
–LMA
–Intubation

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Obstruction

Pharmacologic Treatment
• Lower/Stop inhalational agent
• Opioid overdose
–Narcan .4 mg IV q2-3 min
• Benzodiazepine overdose
–Flumazenil .2mg IV every 60 secs up to 1.0 mg

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Hypoxia

Hypoxia

Mechanical Intrapulmonary Surgical

100% O2 100% O2 100% O2

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100% O2

Ruptured
ETT cuff

Obstructed ET
ETT placement

Mechanical

Pulse
Circuit
oximeter

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Intrapulmonary
• Laryngospasm

• Bronchospasm

• Tension pneumothorax

Surgical Causes
• Hemorrhage
• Hypotension
• Compression vital structures
• V/Q mismatch
• PE
• Anemia
• Fat Embolism

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Hypoxia – What do you do?

There is so much that

can go wrong, How do
I figure out what it is?

Hypoxia
• Remember: 100% O2!!!
• Adequacy of ventilation assessed
• Hand ventilate patient
–Not intubated – Mask
–Not able to mask, oral/nasal airway
–Not working – supraglottic airway

–Intubated – Take off ventilator, bag

•*Now can assess multitude of variables

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Hypoxia
• FiO2 concentration

• Capnograph

• Peak pressures

• Ruptured ETT

Hypoxia – Poor Compliance

• Obstruction

• Bronchospasm

• Tension pneumothorax

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Hypoxia - Listen
• Is there a leak?
• Do you hear bilateral breath sounds?
• Are the breath sounds decreased?
• Are the breath sounds clear? Wheezing? Rales?

Hypoxia - Inspect
• ETT for kinks
• Plugging tube
• Circuit for mechanical problems
• O2 supply
• Pulse oximeter
• Perform laryngoscopy

*If in doubt of system, change it*

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Hypoxia
• Change faulty machinery
• Tension pneumothorax
–Needle decompression, followed by chest tube
• Dislodgement ETT
• Anemia, hemorrhage
–Blood, IV fluids

May need PEEP and/or PA catheter for further

diagnosis

Larnygospasm

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Laryngospasm
• Spasm of the vocal cords
• Usually direct airway stimulation (blood, secretions in
airway)
• GERD, irritable airways
• Light planes of anesthesia

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Laryngospasm - Recognition
• Incomplete laryngospasm
–Stridor
–Desaturate

• Complete laryngospasm
–No air movement = no breath sounds
–Desaturate

Laryngospasm - Treatment
• Usually self-limiting
• Support ventilation, PPV w/ 100% oxygen
• Deepen anesthesia
• .15-.3 mg/kg of succinylcholine (10-20 mg)
• If persists, intubating dose of 100mg succinylcholine
and intubation (Make sure pt. is adequately
anesthesized!!!)

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Negative Pressure Pulmonary

Edema
Sucking against a closed glottis

• Normal intrapleural pressure is -5 to -10 mmHg, may

rise to -50 to -100mmHG
–Increases transcapillary hydrostatic pressure
causing pulmonary edema

• Results in RV distension, leftward shift of

intraventricular septum, decreased L ventricular
compliance

Negative Pressure Pulmonary

Edema
• Fluid leaking from capillaries to alveolar space and
interstitium
• Hypoxia
• Pink, frothy sputum
• Stridor
• Accessory respiratory muscle use
• Wheezing as progresses

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Negative Pressure Pulmonary

Edema
• 100% O2
• Removal of obstruction
–Intubation
–Succinylcholine
• Correct hypoxemia
–May require PEEP
• Diuretics unless volume depleted

Bronchospasm

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Bronchospasm
• Abnormal contraction of bronchial smooth muscle
resulting in acute airway obstruction
• Results in excessive mucus secretions
• Asthma and chronic bronchitis are at increased risk

Bronchospasm - Recognition
• No air movement
• Unable to ventilate patient
• High PIP’s
• Decreasing O2 sat

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Bronchospasm - Treatment
• May need to deepen anesthetic – Ketamine
• Steroids
• B2 agonists
–Albuterol
–Epinephrine (Racemic - inhaled)
–Isoproterenol
• If unable to move air, may need SC or IV epi (.1mg -
.3mg)
–Epi pen or Epi Pen Jr.

Bronchospasm
• Best bet is prevention
• E.g. consider cancelling surgery if asthmatic patient
has concomant factors (bronchitis, URI)
• Consider steroids pre-operatively for decreased
mucus production, potentiate B2 agonist
• Consider giving anticholinergics for decrease
secretions
–Atropine, Atrovent

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Benefits of Smoking Cessation

• 12-24 hours of cessation, CO and nicotine levels
return to normal
• 2-3 weeks: bonchotracheal ciliary function improves
• >2 weeks: sputum volume decreases to normal
• 6-8 weeks: significant decrease in postoperative resp.
morbidity

Hypotension

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Hypotension
• Common!!!!
–N20, Propofol, inhaled anesthetics

• Surgical stimulation

• IV fluids…..more IV fluids

• Phenylephrine, Ephedrine

*Remember - generally not a hemorrhagic issue in

office procedures

Hypertension

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Hypertension
• Determine cause
–Preexisting disease
–Surgery
–Anesthetic
–Medication
–Other

Hypertension

• Preexisting disease
–Beta blockers
–Vasodilators
–Treatment guided by previous medications
• given and heart rate

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Hypertension
• Surgery
–Pain
–Tourniquet time
–Aortic cross clamping

Hypertension
• Related to anesthetic
–Inadequate depth anesthesia
–Hypoxia
–Hypervolemia
–Hypercarbia
–MH
–Shivering
–Inappropriate size BP cuff

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Hypertension
• Medication
–Rebound HTN
–Systemic absorption vasoconstrictors
–IV indigo carmine

Hypertension
• Others
–Bladder distension
–Hypothermia
–Hypoglycemia

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Hypertension - Treatment
•Guided by etiology
• Beta blockers
–Esmolol – ½ life 9 minutes
–Labetolol – non selective, alpha 1
• Peripheral vasodilators
–Hydralazine – reflex tachycardia
–Nitroprusside – afterload reducer, easily titrated,
short ½ life
• Narcotics

Malignant Hyperthermia

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Malignant Hyperthermia

• Inherited myopathy characterized by a

hypermetaolic state after exposure to appropriate
triggering agent
• Defect in SR causing decreased calcium reuptake
• Intracellular calcium increases 500-fold
• Causing sustained muscle contraction, glycolysis,
heat production
• 1 in 15,000 peds, 1 in 50,000 adults

Triggers

• Safe agents
• Local
• Propofol
• Ketamine*
• Non-depolarizing muscle relaxants*
• Anesthetic-related disease
• Succinylcholine
• Inhalation agents

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Recognition

• Increase end-tidal CO2*

• Decrease O2 saturation
• Tachycardia**
• Dysrhythmia
• Muscle rigidity*
• Masseter muscle
• Full blown case 20-30 min after MMR

*Some may cancel case in presence of MMR*

Treatment

• Stop all triggering agents (change circuit)

• Hyperventilate with 100% oxygen
• Dantrolene
• Cool patient
• Treat acidosis
• Maintain UOP (>2 ml/kg/hr)
• Treat hyperkalemia

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Dantrolene

• Mixture
• 20 mg dantrolene, 3 g mannitol, 60 mL H2O
• MOA: Impairs Ca dependent muscle contraction in SR
• Side effects
• Muscle weakness, hyperkalemia, GI upset, thrombophlebitis

Ryanodex

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Recovery and Discharge

• Complete recovery in recovery area
• Post-anesthetic laryngospasm in peds
• Recovery in lateral position to avoid secretions irritating chords
• State of consciousness, vitals, age appropriate ambulation, pain
control, absence of post-op N/V
• Car seat/ unattended recovery!

TWO ADULT ESCORTS MANDATORY

Local Anesthetic Systemic

Toxicity (LAST)

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LAST

• Overdosing, intra-venous injection, hyper-absorption

• CNS Symptoms - tinnitus, disorientation, and ultimately, seizures
• CVS Symptoms - hypotension, dysrhythmias, and cardiac arrest
• Dose dependent – CNS>CVS

LAST

• allergic reactions
• Methemoglobinemia
• Direct neural
• local tissue toxicity

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ASRA Guidelines

• ASRA.com
• Checklist for LAST

LAST Management

• Get Help
• Initial Focus
• Airway management: ventilate with 100% oxygen
• Seizure suppression: benzodiazepines are preferred - AVOID Propofol
in patients having signs of cardiovascular instability
• Alert the nearest facility having Cardiopulmonary bypass capability

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LAST Management

• Management of Cardiac Arrhythmias

• Basic and Pediatric Advanced Life Support (PALS)
• REDUCE individual epinephrine dose

Lipid Rescue Therapy

• Mechanism still largely unknown

• LA are lipophilic drugs
• free unbound LA in the circulation ->‘taken up’ by the lipid part of the
plasma
• ->thereby being sequestered from having its effect

• Paediatr Anaesth. 2012 Toxicity of local anesthetic drugs: a pediatric

perspective - Lönnqvist PA

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Complications at home

• Narcosis
• Aspiration
• Inadequate pain control
• PONV
• Thermoregulation events

Avoiding Substance Abuse

• Clearly define, verbally and in writing the time limited nature of

drug’s dose, frequency and duration
• One prescriber only
• Avoid negotiating
• Pain contract
• No replacement for “lost” drugs
• Length of time of prescription

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Conclusion
• Safe, effective
• Preparedness
• 100% O2
• Accepted complication rate*
–1-6% complication rate (eg laryngospasm)
–1/835,000 mortality rate

•*D’Eramo EM, Bookless SJ, Howard JB. Adverse

events with outpatient anesthesia in
Massachusetts. JOMS (61) 2003 July: 793-0

• Top 5 reasons never to sedate in your practice

1. ___
2. ___
3. ___
4. ___
5. ___

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The End
[email protected]

References

Adams JP, Murphy PG. Obesity in anesthesia and intensive

care. Br J Anaesth. 2000;85:91
Todd DW. Anesthetic considerations for the Obese and
Morbidly Obese Oral and Maxillofacial Surgery Patient. J of
Oral and Maxillofac. Sep 2005 (63). 1348-1353
Lange MS, Waite PD. Bilateral lingual nerve injury after
laryngoscopy for intubation. J of Oral and Maxillofac. Dec
2001 (59). 1497-1499
Davidson S, Guinn C, Gacharna D. Diagnosis and treatment of
negative pressure pulmonary edema in a pediatric patient: a case
report. AANA J 2003; 72(5): 337-338.
D’Eramo EM, Bookless SJ, Howard JB. Adverse events with outpatient
anesthesia in Massachusetts. JOMS (61) 2003 July: 793-0

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References

Butterell H, Riley RH. Life-threatening pulmonary edema

secondary to tracheal compression. Anaesth Intensive Care
2002;30(6)804-806.
Mallampati RS, Gatt SP, Gugino LD. A clinical sign to predict
difficult tracheal intubation: A prospective study. Can
Anaesth Soc J. 1985;32, 429
Sellick BA. Cricoid pressure to control regurgitation of
stomach contents during induction of anaesthesia. Lancet
1961; 2: 404-6.
Marik Paul E. Aspiration pneumonitis and Aspiration
pneumonia. NEJM (334) 2001: 665-70.
Holm SW, Cunningham LL, Bensdoum E, Madsen MJ.
Hypertension: Classification, Pathophysiology, and
Management During Outpatient Sedation and Local
Anesthesia. JOMS (64) 2006: 111-21

References

Cormack RS and Lehane J. Difficult tracheal intubation in

obstetrics. Anaesthesia 1984;39:1105-1111. Describes the
laryngoscopy grades and correlates with difficult intubation. Also
proposes a technique of attempting to intubate while intentionally
achieving a suboptimal (Class III) view.

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Legal Aspects Pertaining to the

Management of Patients

Christy B. Durant, Esq.

DISCLOSURE

Christy B. Durant has nothing to disclose

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ABSTRACT
Although a doctor’s primary focus should always be on
patient care and patient safety potential medico-legal
issues and liability consequences in the process of
providing such care must always be taken into
consideration. It is only with a well-documented
medical record containing all relevant information, a
written informed consent from the patient, and a strong
doctor/patient relationship built on trust and open
communication, that a provider will be able to
successfully defend him or herself in the unfortunate
situation of a legal event.

Topics Covered
• Doctor/Patient Relationship
– Legal and Clinical Relationship
– Effective Communication
– Medical History
– Risks/Benefits/Expectations
– Informed Consent

• Medical Record
– Effective Documentation
– Paper vs. EMR

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• Medical Record (con’t)

– HIPAA/HITECH
– Anesthesia Record
– Avoiding common pitfalls

• The Patient
– Dissatisfied patient
– Non-Compliant Patient

• Lawsuit/Claim
– Elements of Negligence
– Tips for a Safer Practice

ESTABLISHING THE
DOCTOR/PATIENT
RELATIONSHIP

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Establishing a healthy doctor/patient relationship is the

first step necessary to achieving a successful outcome
for both provider and patient.

• It is the foundation upon which all further

communications between the doctor and the patient
are based.

• Doctor/patient assessment begins immediately

including,
• Appearance
• Tone of Voice
• Perceived knowledge on subject matter
• Empathy
• Pattern of speech

A doctor must ALWAYS be cognizant of setting the stage

for the first encounter with a new patient.

More simply,

YOU NEVER GET A SECOND CHANCE TO MAKE A

FIRST IMPRESSION!!

This impression holds more weight than most give credence

too in forecasting the strength of doctor/patient relationship
moving forward.

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Why is a doctor’s rapport with a patient

so integral:
1. Effects a patient’s trust and confidence in a
doctor

2. Directly influences a patient’s willingness

and ability to effectively and adequately
communicate with their doctor.

3. Impacts a patient’s level of satisfaction which

can directly impact the likelihood of future
complaints, claims and/or legal action by the
patient.

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Legal and Clinical Relationship

Once established, the Doctor/Patient relationship
is not only a clinical relationship whereby the
doctor assumes the care and treatment of a
patient.

Legally, it is the first element required to

establish liability. It is a fiduciary relationship
thereby creating a legal obligation on behalf of
the doctor commonly known as a duty of care.

Duty of Care
• Doctor has a duty to possess the medical skill
and knowledge required of a reasonably
competent doctor practicing in the same field
or specialty.

• Doctor further carries a duty to exercise

reasonable care, skill and diligence as doctors
and surgeons in a similar field ordinarily
exercise.

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What does this mean?

• Failure to meet the duties of care is a setup for
malpractice.
• It is incumbent on a doctor to recognize if they
possess the needed training and skill to manage
the problem.
• They have an ethical obligation to ensure they are
capable of skillfully executing the surgical plan.
• Doctor must know when to seek assistance, make
a referral or obtain a consultation.

Effective Communication
• Maintaining open communication can only serve to
benefit the doctor and the patient both from a liability
standpoint as well as a quality of care measure.

• Research has clearly demonstrated that the more at ease

a patient feels in interacting with a clinician the more
open the lines of communication will be between the
parties.

• It also shows that strong communication skills are

imperative to being an effective healthcare provider.

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• Good doctor/patient communication has

been directly linked to:

• Improved patient satisfaction

• Better patient care
• Decrease in medical malpractice
suits

TRANSPARENCY
The most important part of effective communication in the
doctor/patient relationship is transparency.

Transparency by both a patient and a doctor,

1. Directly impacts patient safety

2. Directly impacts patient expectations and satisfaction
3. Provides essential information necessary to safely and
effectively perform surgery.

As a doctor, effective communication is the principal way to

establish trust with a patient.

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Unfortunately trust is not

automatic and must be earned

Valuable Tools in Communication

• Use non-scientific laymen's terms when speaking
to a patient.

• Allow sufficient time for a patient encounter.

• Make eye contact with the patient when speaking.

• Practice reflective listening.

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• Reflective Listening is a patient-centered

communication style and includes repeating or
paraphrasing the patient’s words back to them

• “What I hear you saying is…..”

• “So it sounds like you’re saying…”

• This key tool allows a patient to feel they

are being heard;

• Serves to alert the doctor to potential

misunderstandings; and

• Aides in eliminating confusion by the

patient and the doctor.

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Patient-Centered vs. Doctor-Centered

• The term “patient-centered” has become a quality
improvement buzzword.

• Patient-centered and doctor-centered behaviors have

emerged from communication research as a principal
characteristic about the doctor/patient relationship.

• Studies have shown that doctor’s practicing a patient-

centered communication style is associated with greater
patient satisfaction, better patient recall, and improved
adherence to medical recommendations. Therefore, it is
a preferred method of communication.

Back, M.D., Anthony; “Patient- Physician Communication in Oncology: What Does Evidence Show”;
Cancer Network, Volume 20, January 1. 2006.

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If you find yourself in this situation as a

doctor, changing your approach to
communication is imperative

Cautionary Advice
• Avoid making guarantees regarding an outcome.

• The use of certain language and even diagrams, drawings, or computer

projections can be interpreted from a legal standpoint as an express
warranty to a patient.
- Patients can reasonably rely on such language and illustrations, causing
a material departure from the results to potentially give rise to a breach
of contract claim by a patient.
- Avoid verbal representations that minimize certain risks of a procedure
or exaggerate the likely benefits.
- The critical distinction that courts seek to make is between statements
that fall within the category of “therapeutic reassurance” and statements
that cross the line into a guarantee for certain results or warranty of a
cure.

Evading gray areas is just another element in practicing effective

communication with a patient, particularly regarding the nature, risks and
benefits of a procedure.

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• While there may be many reasons for

filing a claim, legal precedent has shown
that dissatisfaction with some aspect of
communication with their doctor is a
strong underlying current to many claims

• The most frequent grievances expressed

by patients is that no one involved in
their care fully explained the potential for
adverse effects, that the doctor misled
them, that the doctor did not talk to them
or answer questions, and that the doctor
would not listen to their concerns.

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MEDICAL HISTORY
Obtaining an accurate medical history from a patient goes
directly to patient safety and obtaining the expected outcome
from any procedure.

It is based on the patient history and examination that the

diagnosis is made and the treatment plan is based.

An exact, legible record of the original consultation is further

essential to assess progress following the treatment.

Not having all the relevant facts about a patient’s medical

history due to a doctor’s ineffective communication or lack of
attention to the importance of certain information, is a direct
road to liability.

Why is a Medical History

important?
• To determine whether a patient can safely
undergo a planned procedure.
• To identify relevant information that may alter
the anticipated outcome of the planned
procedure.
• To identify relevant information that may
affect anesthetic plans.
• To identify potentially problematic patients,
both medically and psychologically.

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Obtaining Relevant Information

• Provide patient with thorough medical history questionnaire in
non-scientific language

– Inquire about physical history as well as social and

psychological history.

– Include a section for patient to write in their own words the

chief complaint or reason for visit.

– In compliance with the Health Insurance Portability and

Accountability Act (HIPAA), include a brief statement
informing the patient that all information disclosed on the
document will be kept confidential unless the patient
specifically authorizes disclosure to a third party.

– Allow for a space for patient to identify permitted third party

disclosures.

• Use open dialogue and effective

communication to review the questionnaire
answers with the patient.

• Allow sufficient time for patient questions.

• Use the interview process to illicit additional

information the patient may not deem
relevant by asking follow-up questions.

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INFORMED CONSENT

• The word “consent” means to give an

approval, assent or permission, and a voluntary
agreement to another proposition.

• In simple terms, the consent of a patient is an

instrument of mutual communication between
a doctor and a patient with an expression of
authorization/permission by the patient for the
doctor to act in a particular way, after
achieving an understanding of the relevant
medical facts and risks involved.

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An appropriately written and

signed informed consent from a
patient that includes potential
material risks and complications is
the cornerstone to a doctor
avoiding liability in a medical
malpractice action.

• Informed consent is based upon the principles of

autonomy and privacy and has become the
requirement at the center of morally valid decision
making in healthcare and research.

• Patient autonomy means that patients have the right to

participate with their doctor in their own healthcare
decision making.

• Under this ethical principle, the patient has the

freedom to decide what should or should not happen
to their own body and to gather information before
undergoing a test/procedure/surgery.

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There are seven (7) general criteria that have been defined for
an informed consent to be considered complete:

(1) competence of the patient to understand and to decide

(2) voluntary decision making

(3) disclosure of material information such as risks, benefits and alternative

forms of treatment

(4) recommendation of the plan

(5) comprehension of terms

(6) decision in favor of the plan, and

(7) authorization of the plan

• All seven (7) criteria must be met in order to

have a patient’s informed consent.
• Informed consent should always be in writing
and obtained in the presence of a witness.
• The informed consent form should be as
detailed and specific to the procedure as
possible. Avoid using a generic template for
all medical services.
• Informed consent must be obtained PRIOR to
treatment/surgery.

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Don’t let this be you

• Some states may have additional

requirements, either by statute or case
precedent, including the doctor’s obligation to
discuss alternative available treatment options
with a patient.

• It is imperative for every practitioner to be

familiar with their individual state’s
requirements.

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STANDARD FOR DISCLOSING RISKS,

BENEFITS AND COMPLICATIONS
• The ethical-legal process of informed consent, so fundamental to patient
autonomy, has been the subject of many legal cases.

• Recently, more than half the states in the United States have moved to adopt
the reasonable-patient standard for what doctors should inform patients
about the risks, benefits, and alternatives of treatment.

• This standard means that the information patients should be informed of is

no longer determined by what a responsible body of doctors deems
important, but rather by what a reasonable patient deems important.

• In these states where this standard has been adopted doctors and other
healthcare practitioners are required to disclose all relevant information
about the risks, benefits, and alternatives of a proposed treatment that an
objective patient would find material in making an intelligent and informed
decision about whether to proceed with the proposed treatment.

• Use of brochures and/or leaflets to provide a patient with

comprehensive, objective information for specific
procedures is a beneficial way for a doctor to make
additional information available to patients that they can
take home and further understand the discussed treatment
options.

• Document in the patient’s medical record when such

materials are provided to a patient as an added measure to
demonstrate that a full and thorough explanation of
treatment has been given.

• Always document in the patient record when an informed

consent was obtained with the written consent form itself
included in the chart as well. For offices using electronic
record keeping, having patients use an electronic signature
pad is another valid means to obtain and document consent.

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Advantages of Adequate Informed

Consent
1. Fulfills a legal obligation.

2. Having a patient that fully understands the

nature of their condition and has a sensible and
practical expectation is less likely to sue.

3. Provides valuable support to defending claims

based on misunderstanding or unrealistic
expectations of treatment.

• Claims based on lack of informed consent

are a staple in the medical malpractice arena
and can often be avoided.

• Patients challenge treatment rendered on the

grounds that adequate information was not
provided to the patient in order to make a
proper and knowledgeable decision.

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• The importance of providing accurate,

adequate and relevant information truthfully to
a patient in a simply written form using non-
scientific terms and language that the average
patient can understand cannot be overstressed.

• Finally, the doctor must thoroughly discuss

risks, benefits and alternatives with the patient
and should document in the medical record
that all questions and concerns have been
answered for the patient.

MEDICAL RECORD

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• Medical records are one of the most important

aspects and on which practically almost every
medico-legal battle is won or lost.

• The key to disposing most medical negligence

claims rests with the quality of the medical
records.

• A good medical record serves the interest of the

doctor as well as the patient as it is the solitary
document that explains all details about the
patient’s history, clinical findings, diagnostic test
results, pre-and postoperative care, patient’s
progress and medications.

Effective Documentation
• Medical record-keeping has evolved into a science and
takes a conscious effort by a doctor to master over time.

• The treating doctor should always have a legible and

concise medical record. If the entry can not be
interpreted it doesn’t do any good.

• Giving consideration to who may be a possible reader

of the medical record is one way for a doctor to achieve
sufficient clarity, avoid cryptic communication styles
and achieve the goals of the record in both patient care
and liability prevention.

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• In a medical negligence case, record maintenance is often the only

way for the doctor to prove that the treatment was carried out
properly.

• Given the length of time a patient has to file a medical negligence

claim, known as the statute of limitations, by the time a medical
negligence claim comes to fruition, the medical record is often the
only source of the truth and is likely far more reliable than
memory.

• In the legal system, clear and legible documentation is regarded as

an essential element, and is given much greater evidentiary
strength than the memories of the parties involved or any
witnesses.

• The failure to document relevant data is in itself considered a

significant breach of and deviation from the standard of care.

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Aside from the protections for legal jeopardy, a

well-documented legible record provides the
only lasting version of the care as it evolves over
time and serves as a reference of significant
value in emergency care as well as quality
assurance.

If dictating entries to the medical record be sure to

speak clearly and slowly. To ensure accuracy
ALWAYS review a dictated entry before it is finalized.

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What to Write in the Record

• Writing more does not mean it is a good medical record.

• Writing with greater efficiency and documenting what is

most relevant to the patient’s care is of far greater value.

• Do NOT write any personal comments or criticisms in the

record! Remember other people can review these records
including the patient themselves.

• Practitioners should focus on the following areas when

considering what to document in the medical record:

1. Risk-benefit analysis of important decisions in

the clinical care of the patient.

• The doctor should document even the most obvious

risks and benefits of a procedure or treatment plan. Must
give equal attention to benefit side of a decision and not
only focus on the risk side.

• Conducting this analysis holds true for all decision-

making regarding patient treatment and includes not
only documenting the risk benefit of a
treatment/procedure itself, but also any medications
prescribed, as well as postoperative treatment
recommendations.

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2. The use of clinical judgment at crucial decision

points.

• There are several reasons why documenting this essential

element is useful in liability prevention.

• One of those reasons and perhaps the most obvious, is the

exercise of clinical judgment which is based on both
objective and subjective clinician factors that emerges
from the actual patient encounter; no one else had direct
experience with the patient.

• To derive a benefit from the immediacy of these

observations, it is critical to identify and document the
decision-making process that goes into a treatment
decision. This is especially true if the surgeon finds it
necessary to deviate from their preoperative plans or the
customarily used technique.

3. The patient’s capacity to participate in his or her

own care.

• This includes making note of a patient’s ability to

understand all aspects of the treatment/procedure being
recommended for them, as well as understanding the
purpose of medications prescribed and discharge
instructions.

• It goes without saying, if you do not believe a patient

is competent, lacks capacity to understand or remains
confused about a treatment plan, DO NOT PROCEED.

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Keep personal comments or opinions out

of the record!

Paper vs. Electronic Record

• The debate continues among healthcare

providers as to which is better, the old
fashioned paper record vs. the new EMR
systems.

• There are pros/cons to each not only in the

clinical setting but also in a medical
negligence action.

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Paper Record – Pros

• Just like reading an actual paperback book vs. using a kindle or
other e-reader, a paper record allows you to physically hold a
patient’s medical history and the course of their medical services in
your hand. A doctor can flip back and forth between pages or place
them side by side.

• There is no need to rely on computer templates and restrictive

computer program protocols.

• It is generally more thorough and often more personable as it

requires more than the click of a button to complete.

• It is also considered safer in terms of unnecessary or unwanted

disclosure to third parties.

Paper Record - Cons

• The #1 issue with paper records is legibility.

• The common concern for an illegible record is medical

error and mistakes which ultimately affect patient
safety and continuity of care.

• Another issue is the sheer volume of a paper record and

a risk of losing actual papers inside.

• Finally, there is only one. If a patient’s paper record is

lost, stolen or destroyed there is a huge problem.

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Many are convinced this is taught in dental and

medical school!

Bottom Line on Paper Records

• If paper records are still being utilized, RULE 101 is they
must be legible, legible, legible.

• Any other healthcare provider should be able to pick up a

doctor’s record at any point during treatment and ascertain
sufficient information about the patient’s medical history,
treatment plan and any communications that transpired with
the original doctor.

• Practicing this mantra will significantly aide in adequately

maintaining patient safety and promoting effective
continuity of care.

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EMR Records - Pros

• There is no question that the use of electronic medical
records is becoming the “norm” among healthcare
providers.

• Many believe the use of an EMR is a huge step in

increasing patient safety and allows for a patient to
seamlessly transition between healthcare providers through
the shared access by providers to the patient’s medical
records.

• The EMR most definitely addresses the primary concern of

illegible records however still carries a risk of typing errors.

EMR Records – Cons

• With the increased use of the EMR studies are already being conducted to
highlight common trends among users and how those trends can either be
beneficial or detrimental to patient safety.

• The repeated use of a boilerplate progress note or similar entry by a

healthcare provider in a patient’s record seems to be at the forefront of
issues with EMR use.
– This practice can not only result in medical mistakes/errors but in turn
can directly impact a providers likelihood of a liability action.
– Just as would be required in a paper record, progress notes should be
individualized to the patient’s presentation on an exact day.

• The use of the EMR increases the likelihood of unwanted disclosure of

protected health information to third parties
– The responsibility of a healthcare provider to implement necessary
safeguards and security measures to prevent such disclosure is
significantly increased.

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HIPAA and HITECH Compliance

The Health Insurance Portability and Accountability Act (HIPAA) was passed
by the U.S. Congress in August 1996.

• It is the first comprehensive federal protection of the privacy of health

information. The primary purposes of the Act are to improve the efficiency
and effectiveness of healthcare delivery by creating a national framework for
health privacy protection, as well as to protect and enhance the rights of
patients by providing them access to their health information, and controlling
inappropriate use or disclosure of that information, while helping to improve
the quality of healthcare by restoring trust in the healthcare system among all
those involved.

• The core principal of the HIPAA Privacy Rule is the protection, use, and
disclosure of protected health information (“PHI”).

Protected health information means individually identifiable health information that

is transmitted or maintained by electronic or other media, such as computer storage
devices. The privacy rule protects all PHI held or transmitted by a covered entity,
which includes healthcare providers, health plans, and healthcare clearinghouses.
Figure 1 Individually Identifiable Health Information

I. Name
II. Home address
III. Phone numbers
IV. Fax numbers
V. Dates (birth, death,
admission, discharge, etc.)
VI. Social Security Number
VII. E-mail address(es)
VIII. Medical record numbers
IX. Health plan beneficiary
numbers
X. Account numbers
XI. Certificate or license
numbers
XII. Vehicle identifiers and
serial numbers, including
license plate numbers
XIII. Web Universal Resource
Locators (URLs)
XIV. Internet Protocol (IP)
address numbers

Pandit MS. Medical Negligence: Coverage of the profession, duties, ethics, case law, and
enlightened defense- a legal perspective. Indian J. Urol. 2009;25(3) :372-8.

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Use and disclosure are the two fundamental concepts in the HIPAA Privacy Rule. Under HIPAA, “use”
limits the sharing of information within a covered entity, while “disclosure” restricts the sharing of
information outside the entity holding the information. A written authorization must be obtained from
a patient before sharing that information with anyone, unless the disclosure falls into one of the limited
exceptions when patient information may be disclosed without authorization (Figure 2). The Privacy
Rule is designed to provide strong privacy protections that do not interfere with patient access to health
care or the quality of healthcare delivery.

Pandit MS. Medical Negligence: Coverage of the profession, duties, ethics, case law, and enlightened
defense- a legal perspective. Indian J. Urol. 2009;25(3) :372-8.

Patient Notification
• All patients must be provided with a written document called
the Notice of Privacy Practices which sets forth in plain and
simple language how patient’s medical information may be
used and disclosed as well as how to get access to the
information.

• A copy of the Notice of Privacy Practices should be posted in

the doctor’s office where it can be easily seen by all patients.

• An easy way for practitioners to protect themselves and ensure

that patients are aware of an office’s use and disclosure of
protected health information is to have patients sign and
acknowledge that they have been informed and provided a
copy (or advised where it is available to access) the Notice of
Privacy Practices.

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Protecting Information
• The privacy and protection of patients’ identifiable healthcare information has been
made a top priority not only by the federal government but by individual states over
the last 10 years.

• Healthcare providers must not only be aware of the HIPAA privacy laws and the
ramifications for breach thereof, but administrative and clinical staff must be
trained on this subject as well.

• A doctor is required to take reasonable administrative, physical and technical

safeguards to protect an individual’s health information from incidental disclosure
to third parties.

• These safeguards have most recently extended to any and all business associates of
a covered entity that may have access to confidential patient information.
Therefore, healthcare providers MUST update all business associate agreements
with their vendors who have access to PHI.

What do I need to do?

• Offices are required to appoint a security officer who is responsible for the
doctor’s office’s security and to perform a risk analysis to determine
information security risks and vulnerabilities.

• Established policies and procedures must be in place to allow access to

protected health information on a need to know basis only.

• Staff training should be done to ensure awareness about the significance of

maintaining patient confidentiality.

• An office must have written policies and procedures regarding how to

address a HIPAA breach, as well as a disciplinary policy in the employee
manual in the event of an employee’s violation of HIPAA.

• Must be familiar with individual state laws.

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HITECH and EMR

• The HIPAA security role specifies how patient information is
protected on computer displays, computer networks, the Internet,
discs and other storage media extranet.

• The Health Information Technology for Economic and Clinical

Health (HITECH) Act, enacted as part of the American Recovery
and Reinvestment Act of 2009, was signed into law on February 17,
2009, to promote the adoption and meaningful use of health
information technology.
– Subtitle D of the HITECH Act addresses the privacy and security
concerns associated with the electronic transmission of health
information, in part, through several provisions that strengthen the civil
and criminal enforcement of the HIPAA rules.
– Offices that utilize electronic medical records should be familiar with
requirements set forth in Subtitle D of HITECH which enforces the
privacy protections necessary for handling and transmitting electronic
medical records.

Why is Protection So Important?

• Building patient trust.

• A breach of protected healthcare information can result not

only in monetary damages to rectify the problem, but in
some states patients have been permitted to file malpractice
actions on a HIPAA breach alone.

• The Office of Civil Rights under the federal Department of

Health and Human Services is increasing its audits on
healthcare facilities and individual practices; not having the
appropriate safeguards, and policies and procedures in place
to limit the incidence of a healthcare breach, can result in
huge monetary fines.

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Anesthesia Record
• With the increased attention being given to the administration
of anesthesia by dentists and oral and maxillofacial surgeons,
particularly in an office setting, the importance of a complete
and legible anesthesia record cannot be over emphasized.

• When it comes to documenting the elements of anesthesia

administration to a patient, the more information written the
better.

• In the unfortunate circumstance of an adverse event relating

to the administration of anesthesia, the anesthesia record will
serve as a key piece of evidence to the defense to demonstrate
exactly what occurred during an operative procedure.

What Should Be in the Anesthesia Record?

• In addition to general patient identifiers (ex. name, date of birth, height and weight,
BMI, and Mallampatti score), the anesthesia record should contain, at a minimum,
the name and dosage of all anesthetic medication provided to a patient, the time
each medication was administered, and the patient’s vital signs, not only at the start
and stop of a procedure but at intervals throughout.

• The anesthesia record should also document, either by initials or name, everyone
that was present during the operative procedure.

• It should further document the start and stop time of anesthesia.

• Must be signed by the anesthesia provider.

• To the extent that any patient monitors are used during an operative procedure that
have the capacity to print a record of the patient’s vital signs, the printed strips
should be attached to the anesthesia record and placed in the patient’s medical
record. Such strips are particularly important if they document any problematic
periods while the patient was under anesthesia.

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Discharge Notes and Instructions

• Do not underestimate the importance of making a proper discharge note in the
medical record, as well as preparing adequate written discharge instructions for
the patient.

• Post procedure care and patient responsibilities should be communicated clearly

to the patient in both verbal and written forms. Documentation of the advice
given to a patient is as important as the verbal communication.

• Ensuring that a patient thoroughly understands post-operative care instructions is

vital to preventing the occurrence of a non-compliant patient due to confusion or
lack of information.

• A doctor should have strict discharge criteria in place as to the parameters

required before a patient may be discharged. In the hospital environment the
post-anesthesia care unit may have discharge criteria in place as standard
protocol.

• Remember a doctor can be held negligent if proper instructions are not given to
a patient upon discharge regarding medications to be taken, physical care
required, the need for urgent reporting if any untoward complication happen,
and advised follow-up appointment.

• Discharge instructions should be written in simple,

non-scientific terms that are set forth in a concise
and legible manner.

• A doctor should also have the patient sign a copy

of the discharge instructions, to be placed in the
medical record, to document both understanding
of the instructions and receipt of the same.

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Avoiding Common Pitfalls

• Do not alter the records from their original form
• Corrections or amendments to the record should be done by creating a new entry with the
current date and indication that it is an addendum to the original entry.
• Practitioners should at all times avoid making cross outs, insertions and using arrows to
rectify an error. In the event that a strike through of a word or phrase is made, be certain
that the original text is still visible to a reader and initial and date the correction.
• The applies to and EMR as computer forensics can reveal when and what changes have
been made to an electronic record.

• “If it’s not in the record it didn’t happen.” Put another way, poor records mean a poor defense
and no records mean no defense. Document even the obvious. This includes specific patient
questions and concerns as well as answers given to the patient.
• Regardless of what a doctor recalls of the circumstances involving a patient, in the event
of an adverse outcome, it is the medical record that will serve as the primary and most
trusted source of information in the view of judges and juries.

• If you develop written policies regarding HIPAA safeguards and office practices, follow them.

The Patient and Unanticipated

Outcomes

It goes without saying that unanticipated outcomes are inevitable when

performing surgery, especially maxillofacial surgery, where the results
may directly impact the physical appearance of a patient and where
success or failure is almost solely determined by the patient’s own
perception.

Whether the unanticipated outcome is a dissatisfied patient, a non-

compliant patient or a clinical error occurred on the part of the doctor,
all of these scenarios should be addressed promptly and efficiently by
the doctor and his/her staff.

Turning a blind eye to an unforeseen outcome, regardless of how minor

or complicated, will almost certainly have a negative result for the
doctor and frequently is the main trigger of a lawsuit.

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Dissatisfied Patient
Even the most experienced and skilled surgeon can have a dissatisfied patient,
particularly one undergoing a procedure where the motivations for having
treatment/surgery may be exceedingly personal.

History has shown that there is a higher incidence of patient dissatisfaction in those
with underlying psychological profiles.

This is why with an effective and thorough initial patient consultation and medical
examination, hopefully a doctor has already identified those individuals with a
psychological background that may be more likely to contribute to the feelings of
dissatisfaction or frustration with the outcome of a procedure/treatment even if
everything went according to the plan.

A doctor should be cognizant of the those patients that hint at unrealistic

expectations as to what can be achieved from their treatment and therefore are
almost impossible to appease.

Selecting the right patient for a procedure/treatment is integral to avoiding a

malpractice claim later on by a patient who is dissatisfied.

How to Handle a Dissatisfied Patient

Should a doctor encounter a dissatisfied patient; it is imperative for the
doctor to listen carefully to the patient’s concerns.

In most cases where a patient expresses dissatisfaction, the doctor and the
patient can reach a mutual understanding on how to rectify the situation
and the patient ultimately walks away happy.

This is where having the foundation of a strong and healthy doctor/patient

relationship can serve to help remedy unsatisfactory outcomes.

A patient is more likely to sue if the patient perceives that his/her doctor
is lacking empathy and communication skills, particularly in addressing a
patient’s unhappiness of a procedure.

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Non-Compliant Patient
• This is the patient that can be described as the one that does not listen.

• The patient’s inability or refusal to comply with post-operative care instructions is

more likely to result in a poor clinical outcome for the patient, as well as, increase the
risk for post-operative/treatment complications, including most significantly, infection.
• However, the doctor must insure that a patient’s non-compliance is not the result
of confusion with the discharge instructions or simply a lack of attention by the
doctor to appropriately inform a patient about necessary post-operative care.

• If a patient is non-compliant due to their own negligence or lack of caring, it is

imperative that the doctor continue to reinforce to the patient the importance of
following medical instructions and complying with all post-operative care obligations
to avoid complications and carefully document the non-compliant behavior.
• Ideally, this should be conveyed to the patient both in writing and orally.
• The doctor should further document in the patient’s medical record each time
these conversations occur, including the instructions that were provided to the
patient and the doctor’s concerns with the potential of a patient’s non-compliance.

• These key steps, although seemingly minor, can serve to protect the doctor should a
liability claim be asserted. The primary ways to handle these patients is through
continuous communication and documentation.

MEDICAL NEGLIGENCE
AND WHAT TO DO ABOUT IT
Patients file malpractice lawsuits for a variety of reasons, including poor
relationships with their doctor that preempt the alleged malpractice, medical
advice to seek a legal remedy, and media advertising.

The unfortunate fact is that most surgeons will be involved in a medical

malpractice case sometime in their career in one of several capacities, such
as the defendant treating surgeon, a fact witness, or an expert witness.

Regardless of the circumstances surrounding a lawsuit, it is helpful to be

able to put malpractice claims in context and to understand the elements of
malpractice.

The laws of malpractice, the procedures involved, and the judicial process
vary from state to state and from country to country.

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The most common types of medical malpractice

litigation, ranked in order of frequency are:

(1) lack of due care;

(2) lack of informed consent/battery;

(3) vicarious liability/respondent superior/negligent supervision;

(4) injury to third parties; and

(5) abandonment

Elements of Negligence
In any medical malpractice or medical negligence case, an affected
patient will need to prove four things to the court in order to prevail:

(1) that the doctor, owed them a duty of care;

(2) that the doctor breached that duty of care, via some type of
negligence;

(3) that the negligence caused the harm from which they claim to be
suffering, and

(4) that the harm is sufficiently severe to merit the awarding of

damages (compensation).

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To rebut those allegations, the doctor must provide evidence

that shows either:

(1) the doctor owed the patient no such duty;

(2) the doctor was not negligent in rendering medical services;

(3) that the harm the patient is claiming to have suffered was
not a direct result of any of the doctor’s actions, or

(4) that the damage are of an insignificant magnitude to merit a

damage award.

In simple terms, the person making the claim for

medical negligence or malpractice must establish
that it was more likely than not that the
negligence occurred by the doctor and further,
that negligence was the direct cause of their
injuries and if serious enough to deserve
compensation.

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Patient’s Burden
• A majority of claims for medical negligence do not succeed
because the plaintiff (patient, in this scenario) cannot
establish that harm has occurred as a direct result of a
negligent act or a failure to act, as the case may be.

• Negligence cannot merely be inferred from the existence of

a bad result as adverse results are a risk of any procedure.

• Unless the patient can prove that their bad result was
directly linked to a doctor’s negligence, that is the duty to
treat the patient with the skill and judgment that would be
exercised by other surgeons under similar circumstances,
the case will be dismissed as a matter of law.

• An exception to this rule would be a theory of

negligence called “res ipsa loquitor.”

• In such a case, evidence presented may reflect

that the doctor in question was not the direct
cause of the injury in question; however, it may
be determined that the injury could not have just
resulted “on its own,” and would have had to have
happened due to some sort of negligence in the
procedure.

• In this instance a doctor may be still be liable for

a patient’s injuries.

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What is the Standard of Care?

• In the United States, doctors are generally held to
a national standard of care. This means that any
particular doctor’s actions are held to what a
reasonable doctor in like or similar circumstances
would do.

• Therefore, a breach of this duty would be a

diversion from the national standard of care, or to
put it in like terms, a diversion from what a
reasonable doctor would do in the same or similar
circumstances.

What if it Happens to You

• Contact your malpractice carrier to put them on notice of the receipt of
either a claim letter or an actual legal complaint
– It is a safe practice to promptly notify your malpractice insurance of any
significant adverse event even prior to a patient taking legal action

• Secure the relevant patient’s medical record so that it remains in its

original form.

• Promptly secure any other relevant materials, documents or equipment

that is pertinent to the adverse event.

• Do not speak with others about the incident and wait for the appointment
or advice of legal counsel.

• Stay calm and remember that the filing of a lawsuit or a claim does not in
and of itself mean there was negligence.

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Tips for a Safer Practice

We all know that regardless of the amount of diligence afforded to the
practice of medicine and seemingly doing everything according to plan, we
live in a very litigious society where doctors, particularly surgeons, are
vulnerable to claims of liability.

The unfortunate circumstance of being involved in a medical malpractice

action is never anticipated nor an easy process for anyone involved.

The rule of thumb is not to wait until you find yourself in the midst of a
malpractice action to recognize that you have to make changes to the way
you practice medicine.

Following the below tips are just a few ways to help avoid liability and
prepare your defense in the event it happens.

• BE TRANSPARENT

Not only with patients but staff as well.

Transparency and effective communication will
contribute to establishing a strong doctor/patient
relationship and create a healthy and safe work
environment.

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• GIVE OF YOUR TIME

Give each individual patient and each case the

attention it deserves. Regardless of how busy your
schedule and how full the waiting room, recognize
each patient is seeking your professional advice and
experience on what can be a very personal issue.

• DOCUMENT

Adequately document in the medical record all relevant

aspects of a surgical procedure from patient evaluation all the
way through post- operative assessments. Consider the medical
record as an individual diary for the patient that should identify
both risks and benefits of a procedure, a patient’s candidacy for
treatment, alternatives of treatment, as well as the anticipated
outcome and complications encountered.

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• BE HONEST

Don’t be afraid to tell a patient “No”. A

doctor should never lose sight of their ethical
obligations to a patient and providing safe,
quality care in lieu of financial gain.

• USE SOUND JUDGMENT

Trust your instinct. If there is any factor in

evaluating a patient for treatment, whether surgical
or not, that gives you pause, causes unease or
raises a potential concern, do not proceed with
treatment. A doctor should never underestimate the
importance of clinical judgment in their decision
making. It is always better to pass up a potential
surgery than second guess your decision down the
road, especially in the face of liability.

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• BE HUMBLE

Be cognizant of your limitations and never be

afraid to ask for help. A continuous theme in
medical malpractice cases includes practitioners
acting beyond the scope of their experience and
expertise and failing to seek a consultation or
second opinion. There is no shame in asking for
a second opinion or requesting a consultation.

• PREPARE

If you are performing office based surgical procedures, be

prepared for a patient emergency in the office setting before it
happens. This includes: having an adequate written
policy/plan in place that sets forth protocol and procedures
that can be followed by all staff in the event of a surgical
emergency; orient staff to the policy/plan so they are familiar
with everyone’s role; periodically run emergency drills and
subsequent debriefing with office staff including assignment
of both live and post-event documentation in the medical
record (particularly adverse anesthesia events); and finally,
actually follow the policy/plan. Remember, it is better to have
no policy at all than for an office to have written policies that
are not followed.

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• KNOW THE LAW

Be familiar with your individual state laws, as

well as the rules and regulations of state and
federal regulating agencies regarding any and
all necessary licensing, permitting and
certifications that are applicable to your office
practice and the types of cosmetic procedures
performed.

• UPDATE

Have a set schedule for the year establishing designated

time periods for reviewing, revising and updating office
policies/procedures, patient forms, and any informational
brochures or leaflets. Add to this schedule specific dates
for reviewing and inspecting office equipment, including
any and all patient monitors, radiographic equipment as
well as emergency equipment. Stay up to date on new
HIPAA/HITECH laws and implementing effective
safeguards.

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Conclusion
As previously stated, most surgeons will be involved in a
claim or medical malpractice action, in some capacity, during
their career.

The purpose of this presentation is to remind you of the key

areas within healthcare where knowledge and attention is
necessary to prevent preventable mistakes from happening that
can directly impact patient safety and the likelihood of a
liability action.

Hopefully this lecture provides you with some simple

guidelines to integrated into your practice that can serve to
better protect you and the patient from an unfortunate event.

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Oral and Maxillofacial Surgery

Patient Safety and Managing Complications

Paul A. Moore DMD, PhD, MPH

Professor: University of Pittsburgh
School of Dental Medicine

[email protected]

Oral and Maxillofacial Surgery

Patient Safety and Managing Complications

Prescribing Controlled Substances,

Pain Management, and the
Opioid Epidemic

Paul A. Moore DMD, PhD, MPH

Professor: University of Pittsburgh
School of Dental Medicine

[email protected]

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Disclosure: Paul A. Moore

Dr. Moore Reports no relationships with a

commercial interest.

Paul A. Moore

USS Homestead Mill - 1966

http://pgdigs.tumblr.com/

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Broadening our Responsibilities

• Antibiotic Stewardship
– Narrow spectrum
– D/C after 2-3 days symptom free
– Bacterial infections only
• Mercury Waste: EPA/ADA requirements
– Amalgam separators
– Prohibits flushing
– Avoid bleach and chorine cleaners
• Opioid Prescribing: ADA guidelines
– Nausea / vomiting and constipation
– Respiratory depression with alcohol and drug interactions
– Misuse and abuse of unused opioid medications

Fluent MT, Jacobsen PL, Hicks LA: Considerations for responsible antibiotic use in dentistry. J Am
Dent Assoc 147:683-686, 2016
Paul A. Moore

Opioids and Acute Pain Management

Opioid Epidemic: From Prescriptions to Illicit Drugs.
Opioid Prescribing Practices in Dentistry.
Changing Landscape in Analgesic Therapeutics.
Propoxyphene, Codeine, Vicodin, Acetaminophen, Buprenorphine, Naloxone.

Changing guidelines and regulations:

ADA, FDA, CDC, State Licensure, DEA

Opioid-sparing strategies for post-op pain management.

Stepwise prescribing: APAP combined with Ibuprofen.
Dentistry’s responsibility for safe prescribing.

Paul A. Moore

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Heath Ledger’s Overdose

Feb 6, 2008 -- A deadly cocktail of mostly
prescription drugs killed Heath Ledger.
The deadly drug cocktail included:
Oxycodone, also known under brand name OXYCOTIN,
a potent painkiller.
Hydrocodone, an ingredient in VICODIN, other
painkillers, and some cough suppressants.
Diazepam or VALIUM, an antianxiety drug sometimes
prescribed as a muscle relaxant
Alprazolam or XANAX, prescribed for panic attacks
Temazepam or RESTORIL, prescribed for insomnia
Paul A. Moore

Michael Jackson’s Overdose

June 25, 2009 -- Michael Jackson died of acute
propofol and benzodiazepine intoxication at his
home in Los Angeles.
His personal physician was convicted of
involuntary manslaughter in 2011.
The combination of drugs in his body included:
The anesthetic propofol (DIPROVAN).
The benzodiazepines lorazepam (ATIVAN),
midazolam (VERSED) and diazepam (VALIUM).

Paul A. Moore

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Prince’s Overdose
April 21, 2016 – An accidental self-
administered overdose of fentanyl killed
Prince.
The week before his death, Prince’s plane
reportedly made an emergency landing at
Quad City International Airport in Moline,
Illinois, as the singer was en route home from
a concert in Atlanta. He was reportedly treated
for an overdose of the opioid painkiller
PERCOCET.
Paul A. Moore

Tiger Woods

On May 31, 2017, Tiger Woods

fell asleep behind the wheel of
his Mercedes, and failed a sobriety
field test. Toxicology reports found
five drugs in his system:
VICODIN, DILAUDID, XANAX,
AMBIEN AND THC.

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Unintentional Drug Overdose: 1999-2010

Paul A. Moore

Monitoring the Future

Monitoring the Future, National Survey Results on Adolescent Drug Use, 2005.

Richard A. Friedman, NEJM 354:14, 2006 Paul A. Moore

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Drugs, Guns and Automobiles

Paul A. Moore

Decreasing Prescriptions Rates

• Amount of prescription opioids peaked in 2010 (782

MME) per capita (156 Vicodin per person).
• Prescription rates plateau 2010 – 2012 and have declined
since.
• Still, the amount prescribed in 2015 is four times higher
than Europe.
• Declines are due to State legislation, Federal laws, CDC
reports, education and use of PDMPs.
• Overdose deaths continue, primarily due to illicit opioids
(heroin and fentanyl).

Schular A et al. CDC report. JAMA July 6, 2017

Paul A. Moore

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Prescriptions vs Heroin

Paul A. Moore

How did we get here??

Paul A. Moore

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Opioid Epidemic: Why Now?

The American Pain Society and the Joint Commission’s

recommendation: pain should be the “Fifth Vital Sign”
1996 Purdue Pharm introduces MS Contin and OxyContin.
Porter and Jick: NEJM Opioid letter 1980.
2007-2012: 740 million Vicodin and OxyContin pills sold in
WV: 433 pills per resident.
The “Great Recession”.
Economics:
One (1) OxyContin pill = $80.00
One (1) bag of heroin = $10.00

2010 OxyContin reformulated as abuse deterrent.

Paul A. Moore

ADDICTION RARE IN PATIENTS TREATED WITH NARCOTICS

To the Editor: Recently, we examined our current files to determine

the incidence of narcotic addiction in 39,946 hospitalized medical
patients' who were monitored consecutively. Although there were
11,882 patients who received at least one narcotic preparation, there
were only four cases of reasonably well documented addiction in
patients who had a history of addiction. The addiction was considered
major in only one instance. The drugs implicated were meperidine in
two patients, Percodan in one, and hydromorphone in one.
We conclude that despite widespread use of narcotic drugs in hospitals,
the development of addiction is rare in medical patients with no
history of addiction.

JANE PORTER
HERSHEL JICK, M.D.
Boston Collaborative Drug Surveillance Program
Boston University Medical Center
Waltham, MA 02154

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“ADDICTION RARE IN PATIENTS TREATED WITH NARCOTICS”

A 1990 article in Scientific American, where it was called
"an extensive study;"
A 1995 article in Canadian Family Physician, where it was
called "persuasive"
A 2001 Time Magazine feature, which said it was a
"landmark study" demonstrating that the "exaggerated fear
that patients would become addicted" to opiates was
"basically unwarranted;"
A 1989 monograph for the National Institutes of Health
which asked readers to "consider the work of Porter and
Jick."
As of May 24, 2016, the Porter and Jick letter has been
cited 901 times in scholarly papers, according to a Google
Scholar search.
“Dreamland”. authored by Sam Quinones

Trends for Opioids Misuse

Prescription drugs (primarily opioids) are

second to marijuana in categories of abused
drugs.
For first time users, friends and family were
the primary source: “the AT&T plan”.

Responding to America’s Prescription Drug Abuse Crisis. US Surgeon General report 2010
Paul A. Moore

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Trends for Opioids: Overdose

Between 1999 and 2015, more than 560,000
Americans have died from drug overdose.
Today, 130 deaths per day occur in the US
resulting from opioid drug misuse and abuse.
There were 3,383 drug-related overdose deaths
were reported in Pennsylvania in 2015, an
increase of 23.4 percent from the total number of
overdose deaths (2,742) reported in 2014.

JAMA 2012;307:19. and Pa Dept of Health 2015.

Paul A. Moore

Opioid Market: Chronic Pain

Paul A. Moore

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Opioid Prescriptions by Dentists

Paul A. Moore

Opioid Prescriptions in Dentistry

Trends in Opioid Analgesic-

Prescribing Rates by Specially
U.S., 2007-2012

Benjamin Levy et al.

Am J Prev Med 2015;49(3):409–413

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Trends: Opioid Prescribing in Dentistry

A total of 9.4 billion units of opioids were sold in in
the U.S. in 2007. (80% of total world prescriptions).

Estimated that 15% are diverted for sale on the street.

12.2% of immediate-release opioids are prescribed by

dentists.

Dentists and OMFSs often prescribe opioid analgesics

to adolescents and young adults for the first time in
their lives (3-4 million wisdom teeth extractions).

Golubic et al. Opioid prescribing in dentistry. Compend CE Dent 2011.

Paul A. Moore

Developing Adolescent Brain

A balance exists between “pleasure centers” (Nucleus Acumbens)
and “judgement centers” (Prefrontal Cortex).

Pathways controlling this balance

are not completely developed
until 20-25 years of age.

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Monitoring the Future

Data come from the Monitoring the Future study, U of Michigan.
Nationally representative sample of 6,220 individuals surveyed in High
School in 12th grade
Followed up through age 23. Analyses are stratified by predicted
future opioid misuse as measured in 12th grade on the basis of known
risk factors. The main outcome is nonmedical use of a prescription
opioid at ages 19 to 23.
Predictors include use of a legitimate prescription by 12th grade, as
well as baseline history of drug use and baseline attitudes toward
illegal drug use.
RESULTS: Legitimate opioid use before high school graduation is
independently associated with a 33% increase in the risk of future
opioid misuse after high school.

Richard Miech, Lloyd Johnston, Patrick M. O’Malley, Katherine M. Keyes, Kennon Heard
Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics 2017;139(6)
Paul A. Moore

Steeler Cheerleaders-1961

http://pgdigs.tumblr.com/

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Comprehensive National Survey

Random national sample

Current practicing OMFS
3rd molar extractions
Pain control practices

Paul A. Moore

Therapeutic Topics of Interest

Anesthesia Practices
• General Anesthesia
• Intravenous Conscious Sedation
• N2O/O2 Inhalational Sedation
• Oral Sedation

Preferred Agents
• Anesthetics and Sedatives
• Local Anesthetics
–Surgical and Post-op pain management
• Antibiotics and Corticosteroids
• Post-operative Analgesics
–Peripherally and Centrally-Acting

Paul A. Moore

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Questionnaire Design

Random national sample of 850 currently

active practicing oral and maxillofacial
in U.S. (5,542)*
Survey included practitioners from eight
geographic census regions.
Questionnaire designed with expert panel
and pilot testing.
Initial and two follow-up mailings.

*ADA Survey Center’s Distribution of Dentists in the United States by Region and State, 2000.
Paul A. Moore

Third Molar Surgeries/Year

“ On average, how many third molar extraction surgery cases
do you perform each month? ________Patients/Month”

Geographic Region Cases/Month # OMFS Cases/year

New England: 44.9 (+ 4.9) 416 224,141

Middle Atlantic: 46.8 (+ 3.4) 1,061 595,858
South Atlantic: 51.2 (+ 3.0) 996 611,942
East South Central: 45.9 (+ 6.7) 294 161,935
East North Central: 54.1 (+ 3.5) 875 568,050
West North Central: 68.5 (+ 4.8) 329 270,438
West South Central: 48.9 (+ 3.9) 496 291,053
Mountain: 66.5 (+ 6.1) 298 237,804
Pacific: 55.7 (+ 3.7) 777 519,347

U.S. Overall 52.7 (+ 1.4) 5,542 3,504,761

Paul A. Moore

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Outpatient Anesthesia Modalities

“How often do you use the following anesthetic modalities for
pain and anxiety control when extracting third molars?”
Geographic Region GA* IV CS * Oral N2O* Local*

New England: 52.1% 26.8% 2.2% 8.0% 11.2%

Middle Atlantic: 39.1% 27.0% 2.5% 9.3% 22.2%
South Atlantic: 38.0% 40.4% 2.2% 6.2% 13.5%
East South Central: 48.4% 44.2% 0.1% 2.2% 3.3%
East North Central: 45.2% 36.4% 0.6% 6.1% 12.3%
West North Central: 52.1% 27.3% 2.6% 5.8% 11.9%
West South Central: 39.6% 48.5% 2.4% 2.4% 7.6%
Mountain: 56.1% 36.3% 0.5% 4.4% 4.6%
Pacific: 62.8% 16.6% 1.1% 4.2% 15.2%

U.S. Overall 46.3% 33.4% 1.7% 5.8% 13.0%

* p>0.01
Paul A. Moore

U.S. Anesthesia Practices: Summary

3.5 million third molar surgery

cases/year
2.8 million required general
anesthesia or deep sedation.
3.0 million received opioid
analgesic prescriptions

Paul A. Moore

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Preferred Peripherally-Acting Analgesics

“Please complete the following prescription for the peripherally-
analgesic you have recommended most often in the past month.”

Ibuprofen (Advil, Motrin) 73.5% (312)

Rofecoxib (Vioxx) 6.1% (26)
Naproxen (Aleve, Naproxen) 4.9% (21)
Etolorac (Lodine) 4.5% (19)
Ketorolac (Toradol) 2.3% (10)
Valdecoxib (Bextra) 1.9% (8)
Acetaminophen (Tylenol) 1.7% (7)

Paul A. Moore

Ibuprofen
randomized
double-blind
1.0 clinical trial
3rd molar extractions
192 subjects
.80 ibuprofen 400 mg
ibuprofen 200 mg
Pain Relief (PID)

.60
ASA 650 mg

.40
ASA 325 mg

.20

Placebo

1 2 3 4

Time (hours)
Paul A. Moore

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Ibuprofen vs APAP

Ibuprofen 400 mg
APAP 1000 mg
Placebo

Cooper SA et al.: J Clin Pharmacol 1989 29:1026 Paul A. Moore

Centrally-Acting Analgesics
“What percentage of patients do you prescribe centrally-acting
analgesics (narcotic) following third molar extractions? “

Rarely (1-20%) 2.9%

Sometimes (21-40%) 1.5%
Half the time (41-60%) 1.9%
Often (61-80%) 8.6%
Almost always (81-100%) 85.1%

Paul A. Moore

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Preferred Centrally-Acting Analgesics

“Please complete the following prescription for the centrally-acting
analgesic you prescribed most often in the past month.”

Hydrocodone / APAP 64.0%

Oxycodone / APAP 20.2%
Hydrocodone / ibuprofen 4.6%
Codeine / APAP 4.3%
Promethazine / meperidine 3.7%
Propoxyphene / APAP 1.2%

Paul A. Moore

Top Prescription Analgesics

Vicodin hydrocodone/APAP #3
Motrin ibuprofen #20
Darvocet propoxyphene/APAP #24*
Perocet oxycodone/APAP #30
Ultram tramadol #44
Tylenol #3 codeine/APAP #48
Naproxen naproxen #61
Celebrex celecoxib #76
Oxycontin oxycodone #100

Verispan Scott-Levin, SPA

Paul A. Moore

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Summary: Analgesics

OMFS’s prescribe opioid analgesic almost always (85%)

following third molar extraction surgery (3.0 million)
Hydrocodone /APAP is the preferred combination
analgesics. (efficacy, flexibility, marketing, side effects?)
Instructions recommend “take as needed for pain” by
96% OMFS.
Median dispensing of hydrocodone/APAP: 20 tabs
(range 8-40).

Paul A. Moore

Prescribing vs Utilization

“Postoperative Pain, Prescription Analgesic Use,

and Complications Following Third Molar
Extractions” Welland Breanna et al.
Forty-eight patient interviews (1-day, 7-days).
Age: 18.8 yrs (15-30)
Female = 22 / Males =13
20 Vicodin® prescribed / 8 consumed at 7-days.
Nausea/vomiting at 7-days interview: 24%.

Paul A. Moore

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Southside & Hazelwood 1967

http://pgdigs.tumblr.com/

Darvocet and Darvon Withdrawal

Mild opioid analgesic: Schedule IV
Propoxyphene, the active component, puts
patients at risk of potentially serious or fatal
heart rhythm abnormalities.
Propoxyphene has a poor benefit to risk
profile.
November 2010, withdrawn by Elli Lilly.

Paul A. Moore

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Acetaminophen Toxicity

Acetaminophen has had a long

history of safety, but concerns
have been growing related
to liver toxicity.

Paul A. Moore

APAP and Acute Liver Failure

42% of all acute liver failures (ALF) are

due to acetaminophen (APAP) overdoses.
The majority of these APAP overdoses
were unintentional (two or more APAP
formulations).
Even with treatment (N-acetylcysteine),
27% died.
Paul A. Moore
Larson et al. Hepatology 2005;42 (6)

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Acetaminophen and Acute Liver Failure

In Jan. 2011, FDA requested limiting

APAP dose to 325 mg in opioid
combination formulations such as
Vicodin® and Percocet®.
FDA labeling requirement to include a box
warning for liver toxicity.
Labeling of Tylenol® indicates a change in
daily maximum of APAP from 4.0 grams to
3.0 grams.
Decrease units for sale OTC (16 tablets in
Great Britain) Larson et al. Hepatology 2005;42 (6)
Paul A. Moore

US Sales of APAP

Paul A. Moore

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Hydrocodone Formulations -2011

Vicodan
hydrocodone 5.0mg / APAP 500 mg
hydrocodone 7.5mg / APAP 750 mg (ES)
hydrocodone 10mg / APAP 660 mg (HP)

Lorcet
hydrocodone 5.0mg / APAP 500 mg (HD)
hydrocodone 7.5mg / APAP 650 mg (PLUS)
hydrocodone 10mg / APAP 650 mg (10/650)

Paul A. Moore

Abbott’s Reformulations of Vicodin

Vicodin® 5 mg hydrocodone
bitartrate / 300 mg acetaminophen
Vicodin ES® 7.5 mg hydrocodone
bitartrate / 300 mg acetaminophen
Vicodin HP® 10 mg hydrocodone
bitartrate / 300 mg acetaminophen

Paul A. Moore

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Boxed Warning for Vicodin

HEPATOTOXICITY: ACETAMINOPHEN HAS
BEEN ASSOCIATED WITH CASES OF ACUTE
LIVER FAILURE, AT TIMES RESULTING IN
LIVER TRANSPLANT AND DEATH. MOST OF
THE CASES OF LIVER INJURY ARE
ASSOCIATED WITH THE USE OF
ACETAMINOPHEN AT DOSES THAT
EXCEED 4000 MILLIGRAMS PER DAY, AND
OFTEN INVOLVE MORE THAN ONE
ACETAMINOPHEN -CONTAINING PRODUCT.

Tylenol OTC Labeling

Reducing the maximum daily dose from 8

pills (4,000 mg) per day to 6 pills (3,000
mg) per day

Changing the dosing interval from every 4-

6 hours to every 6 hours.

Paul A. Moore

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ASA vs. Codeine vs. Placebo

2.0
ASA
PAIN RELIEF SCORE (PID)
1.5

CODEINE
1.0

PLACEBO
.5

1 2 3 4
TIME (HR)
Paul A. Moore

Codeine Demethylation
Codeine is a prodrug being metabolized to morphine thru
CYP2D6 demethylation.

Inhibited by fluoxetine (Prozac®) and paroxetine (Paxil®).

Augmented by rifampin through enzyme induction.

Polymorphism of CYP2D6 very from slow to ultra-rapid.

Risk for overdose following

tonsillectomies include:
1. Young Children
2. Obstructive Sleep Apnea
3. Ultra-rapid phenotype
Paul A. Moore

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Codeine Demethylation
We report on the case of a healthy 2-year-old boy weighing 13
kg, with a history of snoring and sleep-study–confirmed sleep
apnea, who underwent elective adenotonsillectomy. The
outpatient surgery was uncomplicated, and 6 hours after
surgery the boy received 10 mg of meperidine and 12.5 mg of
dimenhydrinate intramuscularly and was sent home with
instructions for 10 to 12.5 mg of codeine and 120 mg of
acetaminophen syrup to be administered orally every 4 to 6
hours as needed. On the second evening after surgery, fever
and wheezing developed in the child. At 9 a.m. the next day,
the child's vital signs were absent, and resuscitation efforts
failed. NEJM 2014

Paul A. Moore

Children’s Motrin

• Stability in Solution
• Alternative to ASA
• Demonstration of Efficacy
• Pain assessment in Children

Paul A. Moore

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Analgesics in Pediatric Dentistry

Placebo
moderate pain Acetaminophen (APAP)
APAP with Codeine
Ibuprofen

mild pain

no pain
0 1 2 3 4
Single & multiple extractions
Hours after medicating
154 children 5-12 y.o.
39 did not require analgesics
Mother’s pain report Moore PA, Acs G and Hargreaves JA: Post extraction pain relief in
children: a clinical trial of liquid analgesics. Int J Clin Pharm 23:573-577.

Paul A. Moore

Opioid Induced Nausea and Vomiting

Paul A. Moore

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Limiting Opioid NV – CL108

Combination of
Immediate-release promethazine 12.5 mg
Hydrocodone 7.5 mg
Acetaminophen 325 mg
Significantly reduces opioid-induced nausea
and vomiting (OINV) following third molar
extractions.
Pivotal Phase III Clinical Trials have been
completed.
Paul A. Moore

Opioids and Anti-Constipation

MOVANTIK (naloxegol), an opioid antagonist, contains
naloxegol oxalate as the active ingredient.

Opioid antagonist indicated for the treatment of opioid-

induced constipation (OIC) in adult patients with chronic
non-cancer pain

At recommended doses, functions peripherally in GI

tissues with limited CNS penetration.

Metabolized via CYP3A isoenzymes; dose adjustments are

recommended when taking CYP3A4 inhibitors/inducers

Paul A. Moore

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Medication Assisted Treatment: MAT

Buprenorphine (Subutex®)
Buprenorphine + Naloxone (Suboxone®)
Methadone
Naltrexone (Vivitrol®)
Naloxone (Narcan®)

Paul A. Moore

National Issues in Opioid Therapeutics

Expand take-back programs.
Educational requirements for DEA registration.
REMS: Opioid Risk Evaluation and Mitigation
Strategies.
Expand dental school accreditation curriculums in
anesthesia and pain control.
PDMPs: Electronic State sponsored prescription
drug monitoring programs.
Revise opioid formulation and DEA scheduling.

Paul A. Moore

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Drug Enforcement Administration

• Scheduling Changes
• Continuing Educational requirements
• Broadening Take-back programs

Paul A. Moore

Definition of Controlled Substance Schedules

Schedule I High abuse potential, no acceptable medical use.

Examples: heroin, LSD, peyote, marijuana

Schedule II High abuse potential, may lead to severe dependence

Examples: codeine, morphine, cocaine, amphetamines, fentanyl,
meperidine, oxycodone (Percocet®, Oxycontin®),
APAP/hydrocodone (Vicodin®)

Schedule III Less abuse potential, risk of moderate dependence

Examples: ASA/codeine, APAP/codeine

Schedule IV Low abuse potential

Examples: barbiturates, alprazolam (Xanax®), carisoprodol
(Soma®), triazolam (Halcion®), tramadol (Ultram®)

Schedule V Abuse potential less IV, limited amount of narcotics

Examples: Cough prep. with codeine (Robitussin AC®)

http://www.deadiversion.usdoj.gov/schedules/index.html#list
Paul A. Moore

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CDC Prescribing Opioids for Chronic Pain

The CDC expert panel recognized that long-term opioid use

often begins with treatment of acute pain.

“Three days or less will often be sufficient; more

than seven days will rarely be needed.”

“Extended release and long-acting opioids, such as

methadone, fentanyl patches, or extended release versions of opioids
such as oxycodone, oxymorphone, or morphine, should not be
prescribed for the treatment of acute pain.”

Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain -United States, 2016. MMWR
Recommend Rep 2016;65:1–49.

Paul A. Moore

ADA Advocacy and Education

Revised “Use of Opioids” Statement, 2016
PCSS-O Webinars (2012-2017)
JADA Articles and Practical Guide
Support of National Agenda
Continuing Education
Wellness Committee

List of ADA opioid webinar is here:

http://pcss-o.org/calendar-of-events/list/?tribe_paged=1&tribe_event
_display=past&tribe_organizers%5B%5D=3854&tribe_eventcategory%5B%5D=87

Or search ada.org for “opioid advocacy”

Paul A. Moore

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ADA Statement for Opioids in Acute Pain

The American Dental Association revised its statement

on the Use of Opioids in the Treatment of Dental Pain.*

“Dentists should consider nonsteroidal anti-

inflammatory analgesics (NSAIDs) as the first-line
therapy for acute pain management.

*Adopted by the House of Delegates 2016

Paul A. Moore

Food and Drug Administration

• Labeling: “Black Box Warnings”

• REMS for extended release opioids
• Approval of NARCAN formulations
• Abuse-deterrent opioid formulation

Paul A. Moore

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PA State: Act 126

• Act 126: Prescribing to minors requires signed consent and
limits to seven days, discuees risks of addiction and
overdose.
• Act 125: Required curriculum for medical/dental schools.
Licensure renewal requires two hours of CE.
• Act 124: requires a check of the PDMP for every
prescription of an opioid or benzodiazepine. Dispenser
input required within 24 hours.
• Act 122: Emergency departments limit to seven day
prescriptions of opioids.
• No early refills.
• Act 123: Broadens drop-off locations to include
pharmacies. Paul A. Moore

Frank E. Bingaman

http://www.carnegielibrary.org/exhibit/photog.html

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Bupivacaine
C C C C C
O
N
N C

C
• Marketed as Marcaine® and Vivacaine®
• Provides prolonged duration of soft tissue anesthesia to
delay the postoperative pain (6-8 hours).
• 0.5% bupivacaine, 1:200,000 epinephrine.
• Onset time is longer (8 min. vs 4 min.) than other LA
drugs b/c of elevated pKa
• Long duration due to binding to tissue proteins.

Paul A. Moore

Local Anesthetics for Oral Surgery

“Which one of the following local anesthetics do you administer most
frequently for anesthesia when extracting third molars?”

Local Anesthetic Formulation Frequency

2% lidocaine, 1:100,000 epinephrine 70.4%

0.5% bupivacaine, 1:200,000 epinephrine 11.3%
4% articaine, 1:100,000 epinephrine 7.3%
4% prilocaine, 1:200,000 epinephrine 3.1%
2% mepivacaine, 1:20,000 levonordefrin 1.9%
2% lidocaine, 1:50,000 epinephrine 1.8%
3% mepivacaine 0.7%
1.5% etiodocaine, 1:200,000 epinephrine 0.5%
4% prilocaine 0.2%
Do not use local anesthetics 2.8%
Moore PA, Nahouraii HS, Zovko J, Wisniewski SR. Gen Dent 2006; 54(2):92-98.
Paul A. Moore

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Long-Acting Local Anesthetics

“How often do you use long-acting local anesthetics to manage the post-
operative pain of third molar extractions? Check ONE box”

Never 20.2%
Rarely 19.6%
Sometimes 8.0%
Half the time 5.7%
Often 10.6%
Almost always 35.8%

“95% of OMFS selected 0.5% bupivacaine, 1:200,000 epinephrine”

Moore PA, Nahouraii HS, Zovko J, Wisniewski SR. Gen Dent 2006; 54(2):92-98.
Paul A. Moore

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This image This image
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T ed.

0.5% Marcaine
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Post-Extraction Pain

Analgesics Following Third Molar Extractions

3% mepivacaine

bupivacaine / epi

1 2 3 4 5
Analgesic Tablets
Trieger N and Gillen GH. Anesth Prog 20:23-27, 1979.

Paul A. Moore

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Ibuprofen Pretreatment

Pain onset Severity

Pretreatment (min) Severe Moderate Mild

Placebo 137 ± 8 16 29 0
Ibuprofen 238 ± 20 8 34 3

Dionne and Cooper; Oral Surg 45:851

Paul A. Moore

Corticosteroid Use: 3rd molars

“How often do you use corticosteroids as part of your post-operative management?”

Never 20.0%
Rarely 7.9%
Sometimes 6.2%
Half the time 5.1%
Often 22.8%
Almost always 38.0%

“90.2% of OMFS selected dexamethasone”

Paul A. Moore

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Dexamethasone and Third Molar Surgery

Moore PA, Brar P, Smiga ER, Costello BJ: Prevention of Pain and Trismus Following
Third Molar Surgery: Rofecoxib vs. Dexamethasone. OOO 2005;99(2) E1-E7.

Oral Surgery Model: Opioid Combinations

Paul A. Moore

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Ibuprofen and APAP

Paul A. Moore

NNTs for Analgesic Agents

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NNTs for Dental Analgesics

Drug Formulation Trials/Subjects NNT (C.I.)

Aspirin 600/650 mg 45/3581 4.5 (4.0-5.2)

Aspirin 1,000 mg 4/436 4.2 (3.2-6.0)
Acetaminophen 1,000 mg 19/2157 3.2 (2.9-3.6)
Ibuprofen 200 mg 18/2470 2.7 (2.5-3.0)
Celecoxib 400 mg 4/620 2.5 (2.2-2.9)
Ibuprofen 400 mg 49/5428 2.3 (2.2-2.4)
Oxycodone 10 mg plus
Acetaminophen 650 mg 6/673 2.3 (2.0-6.4)
Codeine 60 mg plus
APAP 1000 mg 26/2295 2.2 (1.8-2.9)
Naproxen 500/550 mg 5/402 1.8 (1.6-2.1)
Ibuprofen 200 mg plus
Acetaminophen 500 mg 2/280 1.6 (1.4-1.8)

Stepwise Guidelines
Mild Pain
Ibuprofen 200-400 mg
q 4-6 hours: as needed (p.r.n.) pain

Mild-Moderate Pain
Ibuprofen 400-600 mg
q 4-6 hours: fixed interval for 24 hours

Moderate - Severe Pain

Ibuprofen 400-600 mg plus APAP 500 mg
q 6 hours: fixed interval for 24 hours

Severe Pain
Ibuprofen 400 mg plus APAP 650/hydrocodone 10 mg
q 6 hours: fixed interval for 24-48 hours
Paul A. Moore

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Luke Swank

Issues in Therapeutics
Changes in drug therapy for post-operative dental
pain management.
• No longer prescribing Darvocet.
• Limiting dose of APAP in combination analgesics.
• Long-acting local anesthetics i.e. Marcaine
• High efficacy of NSAIDs in dental post-op pain.
• Steroids as an antiemetic and an anti-inflammatory.
• Prophylactic NSAID’s.
• APAP-Ibuprofen as a first-line therapy.
Balancing pain management and potential
misuse.
Paul A. Moore

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Dentist’s Responsibilities

Drug use and abuse histories of patient and family.

Consider risks regarding patient’s mental health.
Use PDMP when writing for opioid analgesics.
Determine potential drug interactions re. opioids.
Limiting prescriptions with fewer units of opioids.
(0, 8 units?, 20 units?, 40 units?)
Counsel patients of expectations and dangers.
This may be our most important as a “teaching opportunity”
for first time users of opioid analgesic drugs.

Paul A. Moore

New York Mandatory PDMP

Prescription Drug Monitoring Programs (PDMPs)

have dramatically decreased “doctor shopping”.

New York State instituted a mandatory PDMP

program for prescribing opioid analgesics in 2014.

Assessing the impact of the program within a

dental urgent care center, during a three month
period, investigators found a 78% reduction in the
quantity of opioid pills.
Rasubala l, Pernapati L, Velasquez X, Burk j and Ren YF. Impact of a Mandatory
Prescription Drug Monitoring Program on Prescription of Opioid Analgesics by
Dentist. PLoS ONE 10(8): e0135957. Doii:10.1371/journal.pone Paul A. Moore

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Patient Issues with Opioid Therapy

Re-enforce parent’s responsibility as the

“gatekeeper” to monitor pain and analgesia needs.
Prepare for patients for possible ADR’s i.e.
nausea, vomiting, and constipation.
Understand the potential of opioid prescriptions
for drug misuse, abuse and addiction.
Recommend strategies to secure prescriptions.
Indicate local drug take-back programs.
Describe procedures for disposal of unused drug.

Paul A. Moore

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Disposal of Prescription Drugs

Take them out of their original containers and mix them with an undesirable substance,
such as used coffee grounds or kitty litter. The medication will be less appealing to
children and pets, and unrecognizable to people who may intentionally go through your
trash. Put them in a sealable bag, empty can, or other container to prevent the
medication from leaking or breaking out of a garbage bag.

• Cat litter
• Coffee grinds
• Disposal Pouches: Deterra
• Take back programs
• Flush it.

Paul A. Moore

Prescription Drug Disposal: Flushing

Fentanyl: Duragesic, patch (extended release)
Methylphenidate
Meperidine: Demerol, tablets
Diazepam
Hydromorphone HCl: Dilaudid, tablets, oral liquid
Methadone: Dolophine Hydrochloride, tablets
Morphine: Embeda, capsules (extended release)
Hydromorphone Hydrochloride
Methadose, tablets
Morphine Sulfate, tablets (immediate release)
Oxycontin, tablets
Percocet, tablets & Percodan, tablets

Paul A. Moore

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Thankyou for your attention

Aaron Huey, NatGeo Photographer

Paul A. Moore

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PATIENT SAFETY IN ANTIBIOTIC

THERAPY AND SURGERY OF
ORAL AND MAXILLOFACIAL
INFECTIONS

Thomas R. Flynn, D.M.D., Reno, NV

[email protected]

DISCLOSURE

Dr. Flynn has no commercial interest in

any of the topics, procedures, or
medications discussed in this
lecture.

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Objectives: Better Practice

1. Pitfalls in the diagnosis of OMF infections

2. Safe practices in the management of OMF infections
3. Principles of safe use of antibiotics in a changing
environment

PRINCIPLES OF MANAGEMENT
OF DEEP SPACE INFECTIONS
1. DETERMINE SEVERITY
2. EVALUATE HOST DEFENSES
3. DECIDE: INPATIENT VS. OUTPATIENT
4. TREAT SURGICALLY
5. SUPPORT MEDICALLY
6. CHOOSE ANTIBIOTIC APPROPRIATELY
7. ADMINISTER ANTIBIOTIC
APPROPRIATELY
8. REEVALUATE FREQUENTLY

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STEP 1: DETERMINE THE

SEVERITY OF INFECTION

• ANATOMIC LOCATION
• RATE OF PROGRESSION
• AIRWAY COMPROMISE

DETERMINE THE SEVERITY

OF INFECTION
ANATOMIC LOCATION
– Low: Buccal, infraorbital, vestibular,
subperiosteal
– Moderate: masticator, submandibular,
submental, sublingual
– High: Ludwig’s, lateral or retropharyngeal,
danger space, mediastinum, cavernous
sinus

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DETERMINE THE SEVERITY

OF INFECTION
LOW SEVERITY

Vestibular space Space of body of mandible

DETERMINE THE SEVERITY

OF INFECTION
MODERATE SEVERITY

Submasseteric Submental + Submandibular

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DETERMINE THE SEVERITY

OF INFECTION
HIGH SEVERITY

Lateral Pharyngeal Mediastinitis

DETERMINE THE SEVERITY

OF INFECTION
RATE OF PROGRESSION

8 p.m. 12 midnight

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SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME
SIRS IS > 2 OF: LOOK FOR ORGAN
DAMAGE:
360C < T > 380C
P > 90 KIDNEYS
R > 20 or CO2 < 32 LIVER
MAP < 32 LUNGS
4 < WBC > 12 BRAIN
BANDS > 10% EXTREMITIES

DETERMINE THE SEVERITY

OF INFECTION
NECROTIZING FASCIITIS

2 d postop 5 d postop

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DETERMINE THE SEVERITY

OF INFECTION
AIRWAY COMPROMISE
– RECENT HISTORY
– PHYSICAL EXAMINATION
• POSTURE AND ACCESSORY MUSCLES
• VOICE QUALITY AND VOLUME
• CONTROL OF SECRETIONS
• TRISMUS AND VIEW OF PHARYNX
• RESPIRATIONS AND O2 SATURATION
– CT, IF PRUDENT
– AIRWAY MANAGEMENT PLAN

DETERMINE THE SEVERITY

OF INFECTION
AIRWAY COMPROMISE: POSTURE

Left lateral pharyngeal space

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DETERMINE THE SEVERITY

OF INFECTION
AIRWAY COMPROMISE: Lightspeed CT

Pterygomandibular, LPS, RPS compressing airway

STEP 2: EVALUATE HOST DEFENSES

DIABETES

• Zheng L, et al., JOMS, 2011

Diabetic patients had infections that
involved more spaces, longer
hospital stays, and more frequent
complications

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STEP 3: DECIDE ON THE

SETTING OF CARE

ERR ON THE SIDE OF ADMISSION

• AIRWAY SECURITY
• CONSULTATION AND CT AVAILABLE

STEP 4: TREAT SURGICALLY

WHEN TO GO TO THE OR

• FOR AIRWAY SECURITY

• MODERATE-HIGH ANATOMIC SEVERITY
• MULTIPLE SPACE INVOLVEMENT
• RAPIDLY PROGRESSING INFECTION
• NEED FOR GA

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MOST COMMON ERRORS AT SURGERY

• Insecure airway (sutured nasotracheal tube)
• Premature extubation (swelling will worsen)
• Inadequate surgery
– Draining radiographic abscesses only
– Avoiding unfamiliar spaces (lateral and
retropharyngeal spaces)
– Consider and evaluate for osteomyelitis
• Inadequate cultures
– Aerobic only
– Expired culturettes
– Not culturing cellulitis

Mortality due to
Ludwig’s Angina
• Williams (1940) – 54%
emergent tracheotomy
• Williams and Guralnick (1943) – 10%
early intubation or tracheotomy
• Hought, Fitzgerald, et al. (1980) – 4%
medical compromise implicated

AIRWAY SECURITY AND AGGRESSIVE SURGERY

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SURGEON’S ROLE IN
AIRWAY MANAGEMENT
• RESPECT THE
JUDGEMENT OF AN
EXPERIENCED
ANESTHESIOLOGIST,
BUT COMMUNICATE
• BE SCRUBBED AND
READY TO TRACH
• NEEDLE
DECOMPRESSION

REASONS FOR
TREATMENT FAILURE
• INADEQUATE SURGERY
• DEPRESSED HOST DEFENSES
• FOREIGN BODY
• ANTIBIOTIC PROBLEMS: RESISTANCE,
COMPLIANCE, ABSORPTION, DOSAGE,
ALLERGY, TOXICITY
• SUPERINFECTION
• CHANGE IN FLORA: RECULTURE

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2 Patients, 4 days postop

INADEQUATE SURGERY ANTIBIOTIC PROBLEMS

WHEN TO CHANGE
ANTIBIOTICS
• ALLERGY OR TOXIC REACTION
• AT LEAST 48 h OF I.V. ANTIBIOTIC (72 h
FOR ORAL)
• DETERIORATION AFTER REPEAT I&D
AND/OR POSTOP CT
• C&S REPORT INDICATING RESISTANCE
• NECROTIZING FASCIITIS

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EXTUBATION TECHNIQUE
• CONSIDER OR
• TRACH SET READY
• SUCTION ETT AND
PHARYNX
• LIDOCAINE
• DEFLATE CUFF
• AIR LEAK
• OXYGENATE
• EXTUBATE OVER
STYLET
Especially consider this in the severe case/difficult airway/obese pt.

UNUSUAL
MAXILLOFACIAL INFECTIONS
AND COMPLICATIONS

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NECROTIZING FASCIITIS
• DUSKY, PARESTHETIC SKIN
• VESICLES EARLY, NECROSIS LATE
• DISSECTION ALONG PLATYSMA
• FASCIOTOMY, WIDE UNDERMINING, WOUND
PACKING, BIOPSY FASCIA, GRAM STAIN, C&S
• REPEAT SURGERY
• MEDICAL MANAGEMENT
– BROAD-SPECTRUM AB’S, FLUIDS, CALCIUM,
BLOOD, CONTROL PREDISPOSING DISEASE

NECROTIZING FASCIITIS

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NECROTIZING FASCIITIS

NECROTIZING FASCIITIS

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NECROTIZING FASCIITIS
LITERATURE REVIEW
• IMMUNOCOMPROMISE 22-64%
• GAS ON CT SCAN 55%
• REOPERATION 80%
• MORTALITY 0-19%
• FACTORS INCREASING MORTALITY
– IMMUNOCOMPROMISE
– DELAY IN SURGERY > 24h
– MEDIASTINITIS + SEPSIS = 64%

Yiu, et al. JOMS 58:1347, 2000; Umeda, et al. OOO 95:283, 2003;
Sandner, et al. J Oral Maxillofac Surg 73:2319-2333, 2015

NECROTIZING FASCIITIS
LRINEC SCORE
(Laboratory Risk Indicators for NECrotizing fasciitis)
Variable Score
CRP > 150 4
WBC 15-25 1
WBC > 25 2
Hgb 11-13.5 1
Hgb < 11 2
Na+ < 135 2
Creatinine > 1.6 2
Glucose > 180 1

Maximum score = 13; > 6 is suspicious for NF; > 8 is

strongly predictive of NF.

Sandner, et al. J Oral Maxillofac Surg 73:2319-2333, 2015

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INVASIVE STREPTOCOCCAL
INFECTIONS
GROUP A β-HEMOLYTIC STREPTOCOCCI

• 3.5 cases per 100,000 in US

– ↑ in extremes of age, African-Americans
• Streptococcal pyrogenic exotoxin (SpeB)
degrades C3b, interfering with opsonization,
phagocytosis, and chemotaxis
• Biopsy: no WBC’s near Gm+ cocci
• Mortality 14%: 36% with STSS, 30-50% with NF
• Prevention: Strep A vaccine?, not AB’s
O’Laughlin, et al. CID 45:853, 2007;
Terao, et al. J Biol Chem 283:6253, 2008

MEDIASTINITIS

Orange
arrows =
gas
producing
infection

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MEDIASTINITIS
OPEN THORACOTOMY IS BECOMING STANDARD

• 47% MORTALITY WITH CERVICAL APPROACH

• 19% MORTALITY WITH OPEN THORACOTOMY AND
DIRECT DEPENDENT MEDIASTINAL DRAINAGE
(CORSTEN)

• DELAY A FACTOR IN MORTALITY (MARTY-ANE)

• 0% MORTALITY WITH CT 2-3d POSTOP OR WITH

DETERIORATION (FREEMAN)
– 6 + 2 SURGERIES PER PATIENT (N=10)
– 4 + 1 CERVICAL I&D’S; 2 + 1 THORACIC I&D’S; 6 + 4 CT’S
– 30% REQUIRED LAPAROTOMY; 40% TRACHEOTOMY
– LOS = 46 + 30 (14-113) DAYS
Corsten, et al., Thorax 52:702, 1997; Marty-Ane, et al., Ann Thorac Surg 68:212, 1999
Freeman et al., J Thorac Cardiovasc Surg, 119:260, 2000; Roccia et al., JOMS 65:1716, 2007;
Chen, et al., J Thorac Cardiovasc Surg, 136:191, 2008

SUBPERIOSTEAL
ORBITAL ABSCESS

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CAVERNOUS SINUS
THROMBOSIS
MODERN CAUSATION
• Antibiotics have greatly decreased incidence of dental
and facial causes
• Most common modern cause: sphenoid sinusitis
• Sphenoid sinusitis-associated CST difficult to diagnose
– 50% morbidity
– 50% mortality
• Other causes of CST: orbital, pulmonary, vascular,
idiopathic
Ebright JR, et al: Arch Intern Med 161:2671, 2001;
DiNubile MJ. Arch Neurol 45:567, 1988.

CAVERNOUS SINUS THROMBOSIS

DIAGNOSIS
• Contrast-enhanced CT

– Filling defect in affected cavernous

sinus (curved arrow)

– Bulging of lateral sinus wall (small

straight arrow)

– Narrowing of intracavernous carotid

artery

• Magnetic resonance venogram (MRV)

– Similar findings to CT; more sensitive?

• Ophthalmic findings

– contralateral dilated retinal veins

– proptosis, bilateral orbital swelling

• Cranial nerve defects: VI, then II-V

MRV from Ebright, 2001

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SUSPECT OSTEOMYELITIS

Increased suspicion in extraction socket with:

1. Symptoms longer than 2 weeks
2. Infection not responding or recurring after soft tissue I&D
3. New onset of paresthesia

OSTEOMYELITIS
CONSERVATIVE SURGERY LESS FREQUENTLY
CURATIVE
• OLDER PATIENTS (40’S AND 50’S), N = 24
• DENTAL CAUSATION MOST FREQUENT
• PARESTHESIA IN 29% OF CASES
• HYPERTENSION AND DIABETES
• CT MOST USEFUL; MRI – DECREASED MARROW VASCULARITY
• USUAL ORAL PATHOGENS
• DURATION OF ANTIBIOTIC TX DEPENDENT ON CLINICAL COURSE
AND LABS (WBC, SED RATE, CRP)
• MARGINAL RESECTION OF MANDIBLE – 50% FAILURE (N=6)
• SEGMENTAL RESECTION OF MANDIBLE – 6% FAILURE (N=18)

Baur, et al: JOMS 73:655, 2015

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PRINCIPLES OF ANTIBIOTIC
THERAPY – according to me
1. Surgery to remove the cause and establish drainage
is primary; antibiotics are adjunctive treatment.
2. Use therapeutic antibiotics only when clinically
indicated.
3. Use specific antibiotic therapy as soon as possible,
based on culture and sensitivity testing.
4. Use the narrowest spectrum empiric antibiotic
effective against the most likely pathogens.
5. Avoid the use of combination antibiotics, except in
specific situations where they are shown to be
necessary.

PRINCIPLES OF ANTIBIOTIC
THERAPY (cont.)
6. Use the least toxic indicated antibiotic, considering
interaction with concurrent medications.
7. Minimize the duration of antibiotic therapy, as
appropriate to the presenting type of infection.
8. Use the most cost-effective appropriate antibiotic.
9. Use prophylactic antibiotics only where proved
effective or according to professional guidelines.
10. Follow the guidance of evidence-based
recommendations and professional guidelines when
they are available.

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Principle 1: Surgery to remove

the cause and establish drainage
is primary; antibiotics are
adjunctive treatment.
• Source control = Surgery
– Abscess-forming bacteria in odontogenic
infections
– Closed cavities: fascial spaces, sinuses,
teeth, bone
– Extraction, I&D, Debridement,
Reestablishing natural drainage pathways
• Antibiotic Therapy

Mortality due to
Ludwig’s Angina
• Williams (1940) – 54%
emergent tracheotomy
• Williams and Guralnick (1943) – 10%
early intubation or tracheotomy
• Hought, Fitzgerald, et al. (1980) – 4%
medical compromise implicated

AIRWAY SECURITY AND AGGRESSIVE SURGERY

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EXTRACTION HELPS!
• Extraction vs. Non-extraction in
severe infections (N=179)
• Non-restorable = extraction group
• Restorable = non-extraction group
• T, WBC, CRP significantly less in
extraction group on POD2
• LOS in hospital significantly less in
extraction group
Igoumenakis, et al: JOMS 73:1254, 2015

Does an antibiotic prescription prevent

severe infection?
In patients with toothache
• Randomized clinical trial of Penicillin V or placebo in patients
presenting to ER with toothache (Vicodin given for pain
relief)
13 of 134 patients with toothache developed severe infection
(swelling, fever, pus drainage, or trismus) = 10%
No difference between PCN and placebo groups for these
parameters
No difference in pain between antibiotic and placebo groups
Positive correlation with developing severe infection: Existing
amalgam, PAP > 1.5 mm
• Conclusion: Definitive dental treatment for toothache with
existing amalgam and large PAP within 5-7d, not antibiotics
(Grade A)
Brennan, et al: JADA 137:62-66, 2006

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I&D IS MORE IMPORTANT THAN

ANTIBIOTICS
2 Emergency Medicine Meta-analyses

• No difference in outcome of soft tissue infections treated

with I&D between patients treated with effective vs.
ineffective or no antibiotic. Fahimi, et al. CJEM. 17:420-32,
2015
• No difference in outcome of soft tissue infections treated
with I&D between patients treated with antibiotic vs. no
antibiotic. Singer and Thode. Emerg Med J. 31:576-578,
2014

DRAINING A CELLULITIS

• Aborts spread of infection (Montefiore

study experience)
• Length of stay not significantly longer
– 4.7 + 2.7 d vs. 6.1 + 3.6 d
– Severity greater in cellulitis group
• Good specimens obtained

Flynn, et al: JOMS 2006;64:1093-1103 and 1104-1113

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Principle 2: Use therapeutic antibiotics

only when clinically indicated.
• Fever
• Swelling
• Lymphadenopathy
• Sinusitis
– not responsive to decongestants > 10 d
– spreading beyond sinuses
• Prophylactic antibiotics
– Established guidelines for SBE, LPJI
– SSI when supported by evidence
– Immune compromise

Effect of antibiotic therapy on

PCN resistance in
upper respiratory tract infections
% resistant
PCN treatment for pharyngitis (7days)
(cases)

Before treatment 12

End of Treatment: Patient 46

End of Treatment: Parents and sibs 45

3 months after treatment 27

Brook, Arch Otolaryngol Head Neck Surg 114:667, 1988

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Effect of antibiotic therapy on

PCN resistance
in upper respiratory tract infections

Throat swab cultures in

% PCN
children:
resistant
Monthly variation in PCN
(cases)
resistance
September (trough) 13

April (peak) 60

Brook, et al., Pediatr Infect Dis J 16:255, 1997

INCREASING ANTIBIOTIC RESISTANCE

RATES IN ODONTOGENIC INFECTIONS
Year % of Cases PCN Country
Resistant

1991 (Brook, et al.) 33 USA

1992 (von Konow, et al.) 38 Sweden

1995 (Lewis, et al.) 55 UK

1999 (Flynn, et al.) 54 USA

2017 (Kim et al.) 63 USA

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CONCLUSIONS
1. ONLY PRESCRIBE THERAPEUTIC ANTIBIOTICS
FOR:
– Swelling
– Fever
– Lymphadenopathy
– Immune system compromise
2. Choice of antibiotic is not crucial to the outcome
– use narrow spectrum antibiotics
3. Definitive surgical/dental treatment is the most
effective measure
4. 3-4 day course of antibiotic is adequate

Principle 3: Use specific antibiotic

therapy as soon as possible, based
on culture and sensitivity testing.
• Culture Methods
– Indications for cultures
– Aerobic and anaerobic
– Osteomyelitis
• Molecular methods may soon allow rapid
identification of pathogens
– Flynn, et al. JOMS 70:1854, 2012 (odontogenic
abscesses)
– Mansfield, et al: JOMS 70:1507-1514, 2012
(pericoronitis)

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When is Culturing Necessary?

• Serious, potentially life-threatening
infections
• Chronic, recalcitrant infections
• Previous, multiple antibiotic therapy
• Immunocompromised patient
– Diabetes
– IVDA
– HIV

Culturettes

• Aerobic and
anaerobic
– watch expiration
dates
• More practical for the
office than syringes

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“Normal Oral Flora”

- So what??
• Medicolegal protection
• Empiric antibiotics should be effective
• Severe (hospitalized) cases:
– Eikenella corrodens grows on clindamycin
– Penicillin-resistant strains in 63% of cases
– Penicillin failure in 21% of cases
– Clindamycin-resistant strains in 32% of cases

Principle 4: Use the narrowest

spectrum empiric antibiotic effective
against the most likely pathogens.
• Narrow spectrum antibiotics decrease:
– Antibiotic resistance
– Superinfection
– Pharmacologic toxicity
– Cost
• Most likely pathogens of head and neck
infections
• Comparing antibiotic effectiveness
• Empiric antibiotics of choice

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MAJOR PATHOGENS OF
OROFACIAL INFECTIONS
Type of Infection Microorganism
Early Lesions Streptococcus milleri group

Mature Lesions S. viridans group

Peptostreptococcus spp
Prevotella spp
Fusobacterium spp

MICROBIOLOGY OF
OTHER HEAD AND NECK
INFECTIONS
Brook, et al.

• Cellulitis – streps and staph, still some

anaerobes, esp. head and neck
• Odontogenic sinusitis – same organisms but
fewer
• Rhinogenic orbital infections – same
organisms but fewer

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MICROBIOLOGY OF
MEDIASTINITIS
Brook, et al.

• Post-sternotomy
– Staph aureus

• Other mediastinitis
(odontogenic, gunshot
wounds)
– Same as orofacial
pathogens

MICROBIOLOGY OF
NECROTIZING FASCIITIS
Brook, et al.

• Polymicrobial (Local flora)

– 4.6 isolates per case
– Head and neck:
orofacial pathogens
– Perineal: abdominal
and G-U pathogens
• Group A beta-hemolytic
streptococci
• Clostridial
• MRSA
• Klebsiella

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Microbiology of Infections in
Immunocompromise
• Diabetes – Klebsiella*
• I.V. Drug Abuse – MRSA
• HIV - Intracellular pathogens (M. avium)
– Multi drug resistant TB
– HIV-P and HIV-G (same flora as periodontitis)
• Chemoradiotherapy – Non-albicans Candida 2X more frequent
than albicansǂ
• Increased virulence of Candida spp. in digestive tract cancers§

*Huang TT, et al. Acta Otolaryngol 126:396, 2006

*Lee, et al.: Yongsei Med J 2007:48:55-62
ǂSingh, et al.: J Egypt Natl Canc Inst. 2017:29:33-37
§ DeSousa, et al.: BMC Infect Dis. 2016 Feb 23;16:86

Systematic Review
Trials of Antibiotics in Odontogenic Infections

Randomized Clinical Trial Antibiotics Tested Result

Gilmore WC, Jacobus NV, Gorbach SL, et al. 1988 PEN V v. CLINDA NSD

von Konow L, Nord CE, 1983 ORNIDAZOLE v. PEN V NSD

Mangundjaja S, Hardjawinata K, 1990 CLINDA v. AMPICILLIN NSD

Lewis MA, Carmichael F, MacFarlane TW, et al., 1993 AMOX/CLAV v. PEN V NSD

Davis WM Jr, Balcom JH 3rd, 1969 LINCO (im&po) v. PCNG (im&po) NSD

NSD - Antibiotic groups

Matijević S, Lazić Z, Kuljić-Kapulica N, , et al., 2009 AMOXICILLIN v. CEPHALEXIN had shorter treatment time
than surgery alone (NSD)

Ingham HR, Hood FJ, Bradnum P, , et al., 1977 METRONIDAZOLE v. PENG (IM QD) NSD

Al-Nawas B, Walter C, Morbach T, et al., 2009 MOXIFLOXACIN v. AMOX/CLAV NSD

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Systematic Review of Antibiotic

Effectiveness
Conclusions
1. The usual antibiotic choices are generally
equally effective, given appropriate
surgery
2. Antibiotic selection is appropriately based
on pharmacologic safety, cost, and past
medical history.
3. Surgery alone may be effective, but time
to cure may be shorter when antibiotics
are used.
Flynn: OMS Clinics N. America, Nov. 2011

Empiric Antibiotics of Choice

Outpatient Infections Amoxicillin

Clindamycin
Azithromycin

Inpatient Infections Ampicillin + Sulbactam

Clindamycin
Ampicillin +
Metronidazole

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Empiric Antibiotics of Choice

Penicillin Allergy

Outpatient Infections Clindamycin

Azithromycin
Moxifloxacin

Inpatient Infections Clindamycin

Ceftriaxone
Moxifloxacin (E. corrodens)
Vanco + Levo + Metronidazole?

ANTIBIOTICS FOR SEVERE

ODONTOGENIC INFECTIONS

• AMPICILLIN + SULBACTAM
• CLINDAMYCIN
• CEFTRIAXONE (Rocephin®)
• MOXIFLOXACIN
• VANCOMYCIN + METRONIDAZOLE

Considerations: Blood-brain barrier, IV vs. PO absorption,

Resistance, Drug interactions

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ANTIBIOTICS FOR NECROTIZING

FASCIITIS
• POLYMICROBIAL (odontogenic)
– Carbapenem (imi-, mero-, doripenem)

EMPIRIC • STREPTOCOCCAL (Group A, C, G)

THERAPY: – Penicillin G + Clinda?
Gram stain
+ C&S + Bx • CLOSTRIDIAL
Carbapenem – Penicillin G + Clinda
+ Vancomycin
• MRSA
– Imipenem + vanco- or daptomycin

• KLEBSIELLA
– Carbapenem (+ Colistin if KPC/ESBL+)

Gilbert, et al: Sanford Guide to Antimicrobial Therapy, 2017

ANTIBIOTICS FOR
OSTEOMYELITIS
BASED ON BONE CULTURES
• BONE SPECIMENS FOR CULTURE
– Extraoral harvest ideal
– Culturettes or sterile cup
• LONG TERM ANTIBIOTICS (6 weeks?)
– Fluoroquinolones, Augmentin helpful in avoiding PICC
line, e.g. in IVDA
– Decreasing urine Lysylpyridinoline (LP) → treatment
success
– Normalization of CRP?, ESR?
• REALLY LONG TERM FOR ACTINOMYCOSIS
(6 months)
*Springer, et al: IJOMS 2007;36:527-32

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Principle 5: Avoid the use of combination

antibiotics, except in specific situations where
they are shown to be necessary.
• Increased antibiotic resistance, toxicities, drug
interactions, and allergies
• Increased cost, especially with IV administration
• Bactericidal plus bacteriostatic
• Exceptions in head and neck infections
– When more effective
• Invasive Streptococcal infections
– To prevent resistance: e.g., staph osteo
– Life-threatening infection with unknown
pathogens

ANTIBIOTICS THAT
ANTAGONIZE EACH
OTHER
•Clindamycin and Erythromycin
•Linezolid and Vancomycin

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BACTERICIDAL VS. BACTERIOSTATIC

Bactericidal Bacteriostatic
Betalactams Macrolides
Penicillins Erythromycin
Cephalosporins Clarithromycin
Carbapenems Azithromycin
Monobactams Clindamycin
Aminoglycosides Tetracyclines
Glycopeptides Doxycycline
Vancomycin Tigecycline
Telavancin Sulfa antibiotics
Metronidazole Oxazolidenones
Fluoroquinolones Linezolid
Ciprofloxacin Tedizolid
Moxifloxacin
Daptomycin

ANTIBIOTICS FOR NECROTIZING

FASCIITIS
• POLYMICROBIAL (odontogenic)
– Carbapenem (imi-, mero-, doripenem)

EMPIRIC • STREPTOCOCCAL (Group A, C, G)

THERAPY: – Penicillin G
Gram stain
+ C&S + Bx • CLOSTRIDIAL
Carbapenem
– Penicillin G + Clinda
+ Vancomycin
• MRSA
– Imipenem + vanco- or daptomycin

• KLEBSIELLA
– Carbapenem (+ Colistin if KPC/ESBL+)

Gilbert, et al: Sanford Guide to Antimicrobial Therapy, 2017

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ANTIBIOTICS FOR COMMUNITY-

ACQUIRED MRSA
Outpatient, + Fever Bacteremia/Sepsis or
Endocarditis or no Treatment Failure
Immunocompetent* response > 3d
Daptomycin + Naf-
TMP/SMX- DS (160 – 320 bid) Vancomycin (IV) **
Oxacillin **
Ceftaroline or
Linezolid (not
Clindamycin (300-450 tid) Daptomycin (IV) ** for endocarditis)
**

Oritavancin or Dalbovancin ** Based on C&S testing Telavancin **

•If Abscess, I&D is most important

Gilbert, et al: Sanford Guide to Antimicrobial Therapy, 2017

ANTIBIOTIC STRATEGY IN
FEBRILE NEUTROPENIA
Absolute Neutrophil Count < 500; T > 38o C
• Low risk (no mucositis)
– Cipro + Augmentin
• High risk and children (with mucositis)
– Cefepime, carbapenem, piperacillin-
tazobactam, or
– Add vanco for central line or severe
mucositis, pneumonia, MRSA
– Add vanco- + tobramycin + echinocandin
for sepsis/shock
• Persistent fever > 5d (think fungi)
– Add echinocandin or voriconazole
Gilbert, et al: Sanford Guide to Antimicrobial Therapy, 2017

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Principle 6: Use the least toxic indicated

antibiotic, considering interaction with
concurrent medications.

• Relative toxicity
– of antibiotic families
– within antibiotic families
• Antibiotic associated colitis
• Drug interactions

Relative toxicity of antibiotic

families
Antibiotic Family Major Toxicity
Penicillins Allergy
Cephalosporins Allergy, Superinfection
Carbapenems Seizures
Oxazolidinones Serotonin Syndrome,
Thrombocytopenia

Macrolides Drug Interactions, ↑QT

Fluoroquinolones Drug Interactions, ↑QT,
Chondrotoxicity

Glycopeptides Nephro/Ototoxicity
Aminoglycosides Nephro/Ototoxicity

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GI ISSUES
• Cephalosporins generally well tolerated, but
less effective against anaerobes
• Azithromycin vs. Erythromycin
• Augmentin: take at the beginning of a meal
for ↑ absorption, ↓ GI upset
• Fluoroquinolones: avoid dairy, Ca++
• No known benefit of antacids, bismuth, H2-
blockers

CEFTRIAXONE (Rocephin®)

• Third generation
• Parenteral only
• Streps, anaerobes
• Cross-allergy with penicillins
• Crosses blood-brain barrier
• Pseudocholelithiasis (sludging)

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CLARITHROMYCIN vs.
AZITHROMYCIN
• MACROLIDE ANTIBIOTICS (Biaxin® & Zithromax®)
• LESS GI UPSET THAN ERYTHROMYCIN
• ONCE OR TWICE PER DAY DOSING
• BACTERIOSTATIC OR – CIDAL PROTEIN SYNTHESIS INHIBITOR
– AZITHROMYCIN CONCENTRATES IN PHAGOCYTES 10-15X
• CYP3A4 DRUG INTERACTIONS WITH BIAXIN ONLY
• AZITHROMYCIN MORE EFFECTIVE FOR PEPTOSTREPTOCOCCI
• AZITHROMYCIN EFFECTIVE IN OMF INFECTIONS*

* Al-Belasy, et al. JOMS 61:310, 2003

IMIPENEM, MEROPENEM, ERTAPENEM

& DORIPENEM
Primaxin, Merrem, Invanz, & Doribax®

• Carbapenem antibiotics
• Bactericidal cell wall disruptor
• P. Aeruginosa becomes resistant during treatment
• Rare cross-allergy with penicillin (1%)
• Seizures at high doses of imi-, doripenem
• Cilastatin added to decrease renal excretion of
imipenem
• Doripenem not approved in pneumonia
• Meropenem safest, crosses BBB (not erta- and dori-)

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MOXIFLOXACIN (AVELOX®)
• NEW 4th GENERATION FLUOROQUINOLONE (w/ gemi-,
sparfloxacin)
• STREPS, ANAEROBES, EIKENELLA
• ONCE PER DAY DOSING PO AND IV; WELL
ABSORBED: AVOID ANTACIDS, DAIRY, IRON
• LIGHTHEADEDNESS, CONFUSION, SEIZURES, N &V
• INSULIN RELEASE IN NIDDM: HYPOGLYCEMIA
• PREGNANCY CATEGORY C AND CHONDROTOXIC:
AVOID IN CHILDREN

Culley C, et al.: Am J Health Syst Pharm 58:379-388, 2001

MOXIFLOXACIN (AVELOX®)
• DRUG INTERACTIONS: PROLONGS QT
INTERVAL IN 48%* (TORSADES)
– ANTIBIOTICS: MACROLIDES,
PENTAMIDINE, et al.
– ANTIARRHYTHMICS: AMIODARONE,
PROCAINAMIDE, SOTALOL, et al.
– OTHER DRUGS: TCA’S, SSRI’S, HALO-,
RIS-, DROPERIDOL, TAMOXIFEN
• AS EFFECTIVE AS CEFUROXIME IN SINUSITIS

*Ng T, et al.: Crit Care Med 32SupplA:40, 2004

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LINEZOLID
(Zyvox®)
• Oxazolidinones: new family of peptide AB’s
– Protein synthesis inhibitor at 50S ribosomal RNA
– Gm+ aerobes, including streps and enterococci
– MRSA, VRE (including E. faecalis)
– S. viridans, Fusobacterium, Peptostreptococcus, Prevotella
– Twice-daily dosing: 600 mg BID po or IV
– Absorbed well po and IV, crosses BBB
– Myelosuppression, thrombocytopenia
– Reduce epinephrine; confusion, tremor with SSRI’s, MAOI’s

Paladino JP: Am J Health Syst Pharm 59:2413-2425, 2002

TEDIZOLID
(Sivextro®)
• 2nd generation oxazolidinone: peptide AB’s
– Bacteriostatic: protein synthesis inhibitor at 50S ribosomal
RNA
– Gm+ aerobes, including S. pyogenes and E. faecalis
– 4-16 X more potent than linezolid against Staph, Enterococci
– S. milleri group, anaerobes?
– Once-daily dosing: 200 mg QD po or IV (over 18 yoa), X 6d
– Absorbed well po and IV, crosses BBB
– Myelosuppression, peripheral and optic neuropathy
– Weak inhibitor of MAO – less serotonin syndrome than
linezolid
– GAIN Act drug: accelerated approval; 5 years longer patent

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New Antibiotics
Less Useful to OMS

• 4th and 5th Generation

Cephalosporins:
– Cefipime, cefpirome, ceftaroline,
ceftobiprole, ceftolozane-
tazobactam
• Daptomycin (Cubicin ®) – for MRSA
• Fidoxamicin – for C. difficile colitis
• Polymixin B/E (Colistin®) – for HROs

New Antibiotics
Less Useful to OMS

• Tela-, orita- dalbavancin (for VRSA)

• Synercid® (for VRE) - ?effectiveness
• Tigecycline [Tygacil®] - MRSA, E.
faecalis, Streps, Klebsiella.
– Increased mortality
– Pregnancy D

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Even Newer Antibiotics

Not yet approved by FDA

• Ketolide: Solithromycin for CAP,

gonorrhea
• Oxazolidinone: Posizolid for Gm+
• Fluorocycline: Eravacycline for HROs
• AFN-1252 - Antistaphylococcal

ANTIBIOTIC ASSOCIATED COLITIS

RISK FACTORS FOR AAC

• Antibiotic therapy
• G.I. surgery
• Hospitalized patient
• Female
• Inflammatory bowel disease
• Cancer chemotherapy
• Renal disease

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ANTIBIOTIC ASSOCIATED
COLITIS
C. difficile most frequent cause of nosocomial
diaharrhea
• Clostridium difficile exotoxin assay X3
• Colonoscopy
• Discontinue antibiotic
• Vancomycin or metronidazole
• Fidoxamicin (frequent allergy, but lower
relapse, extremely expensive)

ANTIBIOTIC ASSOCIATED COLITIS

Fulminant AAC
• ~ 5% of cases - hypervirulent strains:
– NAP1/B1/027
• Fidoxamicin effective against NAP1/B1/027
• Elderly, hospitalized, operated patient
• Rapid onset of acute abdomen
• WBC > 18,000
• Total colectomy lifesaving in 60%; Diverting loop
ileostomy with colonic lavage in 80% (new procedure)*

Kazanowski M, et al. Tech Coloproctol. 18:223, 2014

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Antibiotics With Significant Risk

in Pregnancy

• Category D: Evidence of human risk

– Tetracyclines, tigecycline
– Aminoglycosides
– Voriconazole
• Category X: Risk outweighs benefit
– Thalidomide

Antibiotics With Significant Risk in

Pregnancy (cont.)
• Category C: Animal toxicity; human studies
inadequate
– Clarithromycin (Biaxin®), not Azithromycin
– Fluoroquinolones (Cipro®, moxifloxacin, etc.)
– Sulfonamides/trimethoprim
– Vancomycin, tela-, dalbavancin
– Imipenem/cilastatin
– Telithromycin
– Flu- Itra- Ketoconazole
– Echinocandins

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Antibiotics Not Approved for

Pediatric Use

• Fluoroquinolones
(moxi-, ciprofloxacin, etc.)

• Tetracyclines

DRUGS THAT PROLONG QT

Potential for Torsades and V. Fib.

• Antibiotics: macrolides, fluoroquinolones, TMP-SMX, flu-, itra-,

ketoconazole, pentamidine, quinine
• Antiarrhythmics: amiodarone, procainamide, sotalol,
disopyramide, quinidine
• Psychiatric drugs: TCA’s, SSRI’s, phenothiazines, lithium,
butyrophenones (Haldol, Risperdal)
• Anticonvulsants: felbamate, fosphenytoin
• Miscellaneous: diphenhydramine, droperidol, tacrolimus,
tamoxifen, serotonin receptor agonists (Imatrex, Zomig) smoking

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Antibiotic Drug
Interactions

Macrolide-Drug Interactions
Azithromycin not included in most of them
Other Drug Effect Result
Theophylline ↑ Theophylline Seizures, apnea,
N&V
Lova-, simvastatin ↑ Statin Rhabdomyolysis

Warfarin ↑ Warfarin INR

Carbamazepine ↑Carbamazepine Nystagmus, ataxia,

N&V
Pimozide (Orap) ↑ QT interval Torsades (V. fib)
(Azithromycin
AVOID
included)
Gilbert DN, Chambers, HF, et al: Sanford Guide to Antimicrobial Therapy, 2017

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Moxifloxacin-Drug Interactions
Other Drug Effect Result
Cations (dairy, antacids, vitamins) ↓ Moxifloxacin ↓ Antibiotic effect

Oral hypoglycemics Hypoglycemia

↑Hypoglycemc
Antimicrobials (macrolides, ↑ QT interval Torsades (V. fib)
pentamidine)

Antiarrhythmics (procainamide, ↑ QT interval Torsades (V. fib)

amiodarone, sotalol)

Other drugs (TCA’s, SSRI’s ↑ QT interval Torsades (V. fib)

butyrophenones, tamoxifen,
serotonin agonists)
Gilbert DN, Chambers, HF, et al: Sanford Guide to Antimicrobial Therapy, 2017

Linezolid-Drug Interactions
Other Drug Effect Result
Adrenergic agents ↑ Sympathetic Hypertension
(epinephrine) effect

Serotonergic drugs ↑ Serotonin Serotonin

(SSRI’s, MAOI’s) syndrome
(confusion, tremor,
sweating, fever)
Aged, fermented, ↑ Tyramine Hypertension
pickled, or smoked
foods

Gilbert DN, Chambers, HF, et al: Sanford Guide to Antimicrobial Therapy, 2017

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Miscellaneous Antibiotic-Drug
Interactions
Antibiotic Other Drug Effect
Clindamycin Muscle relaxants ↑ Duration of paralysis

Doxycycline Sunlight Photosensitivity

Doxycycline Warfarin ↑ INR

Tetracyclines Digoxin Digitalis toxicity

(prolonged in 10%)
Metronidazole Alcohol Antabuse effect

Metronidazole Warfarin ↑ INR

Metronidazole Hydantoins CNS depression

Gilbert DN, Chambers, HF, et al: Sanford Guide to Antimicrobial Therapy, 2017

Azole-Drug Interactions
Flu-, Itra-, and Ketoconazole
Other Drug Effect Result
Phenytoin, Dilantin ↑ Phenytoin CNS depression

Midazolam ↑ Midazolam Oversedation

Warfarin ↑ Warfarin Nystagmus, ataxia, N&V

Calcium channel ↑ Ca++ blocker Hypotension,

blockers bradycardia
Lova-, simvastatin ↑ Statin Rhabdomyolysis
(itraconazole only)
Oral hypoglycemics ↑ Hypoglycemic Hypoglycemia
(not ketoconazole)
Protease Inhibitors (not ↑ Protease Inhibitor Specific toxicity
fluconazole)
Gilbert DN, Chambers, HF, et al: Sanford Guide to Antimicrobial Therapy, 2017

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Principle 7: Minimize the duration of

antibiotic therapy, as appropriate to
the presenting type of infection.
• Decreases resistance
• Increases compliance
• Short courses effective
when combined with surgery

DURATION OF ANTIBIOTIC
THERAPY
SHORT COURSES MINIMIZE RESISTANCE

Type of Infection Duration of Antibiotic

Odontogenic 3-4d
Sinusitis 5d (adults) - 10 d (kids)
Osteomyelitis 42 d (until ESR WNL?)
Actinomycosis 180 d

Amoxicillin: 3d vs. 7d course had equally good results.

Chardin, et al.: J Med Microbiol 2009;58:1092-7

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Principle 8: Use the most cost-

effective appropriate antibiotic.

• Oral
• Intravenous
– Cost of administration
– Long dosage intervals
– Avoid combinations

Comparative Costs of Oral Antibiotics

Amoxicillin Cost
Antibiotic Cost per week
Ratio
Amoxicillin 500 tid $11.99 1.00
Penicillin V 500 qid $15.99 1.33
Augmentin 875 bid $69.99 5.84
Ceftin® 500 tid $85.99 7.17
Clindamycin 150x2 qid $43.99 3.67
Metronidazole 500 qid $30.99 2.58
Moxifloxacin 400 qd $107.99 9.01
Linezolid 600 bid $2,223.99 185.49

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Comparative Costs of I.V. Antibiotics

Antibiotic Cost per week Clinda Cost Ratio
Pen G 2 m.u. q4h $721.89 3.11
Ampicillin 1 g q6h $345.24 1.49
Unasyn 3 g q6h $656.88 2.83
Ceftriaxone 1 g q24h $57.26 0.25
Clindamycin 900 q8h $231.91 1.00
Metronidazole 500 q6h $182.00 0.78
Moxifloxacin 400 qd $322.00 1.39
Vancomycin 1g q12h $159.88 0.69
Linezolid 600 q12h $1,757.34 7.49
Includes $4.00 per dose I.V. administration cost

Principle 9: Use prophylactic antibiotics

only where proved effective or according
to professional guidelines.

• Principles of Antibiotic Prophylaxis

• Third Molar Surgery

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Principles of Antibiotic
Prophylaxis for
Wound Infection
1. Risk of infection must be significant
2. Correct narrow-spectrum antibiotic must
be chosen
3. Antibiotic level must be high
4. Antibiotic must be in the target tissue
before surgery
5. Use the shortest effective antibiotic
exposure

A QUESTION FOR YOU

WHEN DO YOU USE ANTIBIOTICS FOR

3M SURGERY?
A. H/o pericoronitis
B. Difficult impactions
C. A and B
D. Always
E. Never

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A QUESTION FOR YOU

WHEN DO YOU START ANTIBIOTICS

FOR 3M SURGERY?
A. 2 days or more preop
B. Orally, 2h or less preop
C. At start of the IV
D. Take-home prescription
E. Not unless infection develops postop

EVIDENCE BASE FOR PROPHYLACTIC

ANTIBIOTICS IN 3M SURGERY
• Prior pericoronitis increases infection risk
• Topical tetracycline decreases risk of infection and
dry socket
• Preop antibiotic decreases infection risk (NNT = 12 –
40* - 143**)
• Short postop course slightly decreases infection risk
1. Ren, et al. Antibiotic Prophylaxis in Third Molar Surgery. JOMS 65:1909-21 2007.
2. Halpern, et al. Inflammatory Complications After Third Molar Surgery. JOMS 65:177, 2007.
3. Lodi G, et al. Antibiotics to prevent complications following tooth extractions. Cochrane
Database Syst Rev. 2012 Nov 14;11:CD003811
4. * Moreno-Drada JA, et al. Effectiveness of antimicrobial prophylaxis in preventing the
spread of infection… A systematic review and meta-analysis. JOMS 74:1313, 2016
5. * Marcussen KB, et al. A systematic review on effect of single-dose preoperative
antibiotics at surgical osteotomy extraction of lower 3Ms. JOMS 74:693, 2016
6. * * Lang, et al. Do Antibiotics Decrease the Risk of Inflammatory Complications After
Third Molar Removal in Community Practices? J Oral Maxillofac Surg 75:249-255, 2017

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Principle 10: Follow the guidance of

evidence-based recommendations
and professional guidelines when
they are available.
• Endocarditis
• Late Prosthetic Joint Infections
– New ADA Guidelines 2015

Endocarditis Guidelines
WHO?
• Prosthetic cardiac valve
• Previous infective endocarditis
• Congenital heart defects (CHD) with residua
– Unrepaired cyanotic CHD, including palliative shunts, conduits
– Completely repaired CHD with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the
first six months after the procedure
– Repaired CHD with residual defects at the site or adjacent to the
site of a prosthetic patch or prosthetic device (which inhibit
endothelialization)

• Cardiac transplantation recipients who develop cardiac

valvulopathy

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Endocarditis Guidelines
HOW?
Situation Agent Regimen 30-60 minutes
before procedure
Adults Children
Oral Amoxicillin 2 gm 50 mg/kg
Parenteral Ampicillin 2 g IM or IV 50 mg/kg IM or IV
Cefazolin/ceftriaxone 1 g IM or IV 50 mg/kg IM or IV

PCN Cephalexin 2 gm 50 mg/kg

allergy, Clindamycin 600 mg 20 mg/kg
oral Azithro/clarithromycin 500 mg 15 mg/kg

PCN Cefazolin/ceftriaxone 1 g IM or IV 50 mg/kg IM or IV

allergy, Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
parenteral

REVISED ADA GUIDELINES ON

LPJI: 2015
Sollecito, et al. JADA 2015:146(1):11-16.

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WEAKNESSES OF STUDIES ON
LPJI
• TWO RECENT CASE CONTROL STUDIES:
– Dental Procedures + Antibiotic Prophylaxis followed by LPJI
– OUTCOME VARIABLE = ALL CASES OF LPJI
– No significant difference between cases with and without prophylaxis
• INFECTING BACTERIA IN THE SUBSEQUENT LPJI:
– Staphylococci = 58%
– Oral flora = 15%
• SUBSET OF LPJI DUE TO ORAL BACTERIA – INSUFFICIENT DATA
– No microbiologic data in JADA study (Medicare data set)
– Insufficient statistical power in CID study
• IT IS UNFAIR TO EXPECT AMOXICILLIN OR CLINDAMYCIN TO PREVENT LPJI
DUE TO RESISTANT BACTERIA!
Skaar DD, et al.: JADA 142:1343, 2011;
Berbari EF, et al: Clinical Infectious Diseases 50:8, 2010.

A QUESTION FOR YOU

WHEN WILL YOU USE PROPHYLACTIC
ANTIBIOTICS IN PATIENTS WITH
PROSTHETIC JOINTS?
A. With h/o LPJI
B. In immunocompromised patients
C. For joints < 2 years old
D. A, B, and C
E. Never

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THE END

THANK YOU VERY MUCH!

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Navigational Surgery and

Virtual Surgical Planning:
It's Applications in Oral
and Maxillofacial Surgery
Jasjit Dillon MBBS, DDS, FDSRCS, FACS
Clinical Associate Professor
Program Director, Acting Chief of Service
Department of Oral & Maxillofacial Surgery
Harborview Medical Center, University of Washington, Seattle

• Nothing to disclose
• Speaker Honorarium
• Products shown are for educational purposes only
• Patients have provided written consent

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Educational goals
• Why do we need intraoperative CT guided navigation?
• What is it?
• Surgical set up
• Applications in Oral & Maxillofacial Surgery
• Cost analysis

Why do we need it?

• Maxillofacial region – unique challenges

• Complex anatomy
• Facial esthetics
• Surgical incisions
• Errors are unforgiving
• The Future is ‘now’
• Patient specific implants
• Facial transplants
• Tissue engineering

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Why do we need it?

OIF

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Intraoperative Imaging

What is Navigation?
• Guidance system
• Accurately and precisely perform surgery
• STATIC – surgical guides, no ability to change
• DYNAMIC

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What is image guided navigation?

• ‘GPS in the OR’
• Computer-Aided Design/Computer-Aided
Modeling software
• Digital Imaging and Communications in
Medicine format

How has it evolved?

• 1) computer-aided preoperative planning
• 2) intraoperative navigation
• 3) intraoperative CT/magnetic resonance imaging

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How has it evolved?

• Computer-Aided Design/Computer-Aided Modeling

software
• Digital Imaging and Communications in Medicine
format

Navigation Components: ‘GPS’

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Registration techniques
• Marker based registration
• Self adhesive reference markers – mask
• Referencing dental splint
• Percutaneously inserted implants
• Marker free registration
• Laser surface scanning

Comparison of different registration methods for surgical navigation in cranio-maxillofacial surgery. Luebbers at al:
Journal of Cranio-Maxillofacial Surgery (2008) 36, 109e116

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Create Boundaries
• Visual and audible warnings when instrumentation
is too close to vital structures

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Video courtesy Dr David Powers DDS, MD

Uses in Oral & Maxillofacial Surgery

• Trauma
• Pathology
• Implants
• Orthognathic
• TMJ
• Foreign body retrieval
• Important education tool for trainees

Surgical Navigation: A Systematic Review of Indications, Treatments, and Outcomes in Oral and Maxillofacial Surgery. Azarmehr et al :JOMS 1-19, 2017

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Orbits

1 wall - floor

Computer-Assisted Navigational Surgery Improves Outcomes in Orbital Reconstructive Surgery: Cai et al 2012 J. Craniofacial Surgery

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4 years post op

Large medial wall

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Post op – no long term issues

2 wall defects

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1.5 years post op

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4 wall defect

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Rt ZOMC, 4 wall orbital

fracture. Type III NOE

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6 wks post-op

Panfacial

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Implants

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Implant Placement Accuracy Using Dynamic Navigation. Int J Oral Maxillofac Implants. 2017 Jan/Feb;32(1):92-99.

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Pathology

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Orthognathic

Computer planning and intraoperative navigation in orthognathic surgery. Bell: JOMS 69:592-605, 2011

Computer planning and intraoperative navigation in orthognathic surgery. Bell: JOMS 69:592-605, 2011

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Computer planning and intraoperative navigation in orthognathic surgery. Bell: JOMS 69:592-605, 2011

TMJ

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Navigation-guided gap arthroplasty in the treatment of temporomandibular joint

Ankylosis. Yu et al: Int. J. Oral Maxillofac. Surg. 2009; 38: 1030–1035

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Increased Costs
•Platform
•$4500 - $300,000
•CAD/CAM CMF Software
•$35,000 - $90,000

Increased Costs
•Operating room costs
•Mid-Atlantic & Southeastern US Academic Hospitals
•$2551 - $2968 per hour data from Dr David
Powers
•Pacific North West trauma hospital
•$5060 per hour
•Cost Savings
•$150+ per minute
•$10,000 + for return to OR
•Time is money
Computer assisted navigational surgery improves outcomes in orbital reconstructive surgery. Cai et al: J. of Craniofacial Surg 2012

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Increased Costs
• Anesthesia costs
• $400 - $1000 per hour
• Variable costs
• Nursing staff
• Operating room technicians

Increased Costs
• CPT 20985
• Computer assisted intra-operative imaging
• $1500 - $2000
• Need for post-operative CT scan
• $350 - $1000
• Knowing you absolutely have the plate in the right spot
• “Priceless”

Slide courtesy Dr David Powers DDS, MD

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Summary
• Intraoperative image guided navigation
• Future is now
• Enhanced accuracy
• Reduced need for revisions/return to OR
• Applications - limitless

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COMPLICATIONS OF
DENTOALVEOLAR
SURGERY
Gregory Ness, DDS FACS
Oral and Maxillofacial Surgery
The Ohio State University

Disclosure
• Dr. Ness has nothing to disclose

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Lecture Outline
• Introduction
• Reducing the Risk of Complications
• Things That Go Wrong With Third Molar Removal (and
other teeth, too)
• Local Complications of Local Anesthetics
• Other Soft Tissue Injuries

A Few Important Things We Will Omit

• Osteonecrosis/Osteoradionecrosis (MRONJ, ORN)

• Complications of dental implant surgery (including
grafting)
• Surgical management of peripheral nerve injury
• Systemic complications of local anesthetics or other drugs
• Specific poor outcomes

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Staying Out Of Trouble:

Cultivate A Culture of Safety

1 2 3
Do only what Be clear on Prepare for
you know how your goals likely problems
to do before they
occur

“Because it’s there…?”

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DISPLACED TOOTH OR
FRAGMENT

Maxillary Third Molar Displacement

• Possible places
• Sinus
• Deep Temporal Space
• Buccally, under flap
• Initial management
• Locate
• Consider last force applied
• Retract, suction socket clean, inspect
• Radiographs if unable to see likely direction of displacement
• Attempt to retrieve tooth/fragment
• If unsuccessful, document events and location, inform patient

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Displacement into Maxillary Sinus

• Most common site – other tooth roots may also go there
• Sinus communication itself is a second consideration
• Must be retrieved, usually best done immediately
• If access allows, attempt to grasp, suction or irrigate out through
socket
• Otherwise, anterior maxillary antrostomy allows quick, low
morbidity access
• Sinus precautions
• Consider postop reevaluation in a week

Displacement Posteriorly
• Much less likely
• Minimize risk with adequate soft tissue flap, elevator
behind tuberosity during elevation
• Cautious retrieval attempt is best
• If access allows, attempt to grasp, suction or irrigate out through
socket without displacing farther posteriorly
• If unsuccessful
• Antibiotic coverage for oral flora
• Arrange for imaging (medical CT)
• Reevaluate at 1 week and until stable or removed
• Consider leaving in place if asymptomatic, immobile, uninfected

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Mandibular Third Molar - Lingual

Displacement
• Palpate lingually
• Inspect through socket
• Locate radiographically
• Panorex plus Occlusal
• CBCT
• Floor of mouth
• Reflect lingual flap
• Submandibular
• retrieval through socket

Huang, Wu, and Worthington. Accidentally Displaced

Lower Third Molar. J Oral Maxillofac Surg 2007

Mandibular Third Molar –

Posteromedial Displacement

Gerald Alexander, Hany Attia, Oral Maxillofacial Surgery

Displacement Complications, Oral and Maxillofacial Surgery Clinics of
North America, Volume 23, Issue 3, August 2011

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Management
• Attempt immediate retrieval
• Finger pressure to bring forward
• Cautious lingual flap or expansion of bony window through socket
• Localize radiographically
• Inform patient
• Antibiotic prophylaxis
• Reassess in 1 week
• Assess for symptoms, movement of fragment
• If none, reassess in another 3-4 weeks
• If still stable, consider leaving
• Otherwise, plan removal based on 3-D imaging

Posteromedial Displacement – lateral

pharyngeal space

Gerald Alexander, Hany Attia, Oral Maxillofacial Surgery Displacement Complications, Oral and Maxillofacial Surgery Clinics of North America,
Volume 23, Issue 3, August 2011

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Management

• Inform patient
• Localize
radiographically
(CT)
• Remove via
transoral incision
over location
• An OR procedure
with airway
protection
Gerald Alexander, Hany Attia, Oral Maxillofacial Surgery Displacement Complications, Oral and Maxillofacial
Surgery Clinics of North America, Volume 23, Issue 3, August 2011

Displaced into the Pharynx: Ingested Tooth

• Swallowed vs. aspirated?
• Patient may be mistaken!
• Verify that it is not still in the mouth or on drapes
• Assess for respiratory symptoms
• Arrange immediate imaging
• Further management is guided by imaging result

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Ingested Tooth Imaging

• PA chest radiograph
• If no is tooth visible, obtain abdominal view (KUB)
• Verify that tooth is below diaphragm
• If tooth is seen above diaphragm, obtain lateral chest film
• Identify whether the tooth is in lung or esophagus

Treatment According to Location

• Lung
• urgent consultation for bronchoscopic retrieval
• Esophagus
• consider attempt to complete swallowing (i.e. food, drink) and
recheck
• Stomach or beyond
• re-image every 2-3 days until tooth passes
• Or, the patient may return with the tooth in hand

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SINUS COMMUNICATION
(OROANTRAL FISTULA)

Sinus Communication
• Initial management at extraction
• Assess size
• <2mm, observe; >6mm likely to persist
• Consider soft tissue closure
• But preserve alveolar bone height
• Image site
• Instruct patient in sinus precautions
• Consider antibiotic coverage – for oral flora
• Reassess
• Ensure sinus health before surgical closure
• Normal drainage path must be present

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Options For Closure

Visscher, van Minnen, and Bos. Closure of Oroantral Communications. J Oral Maxillofac Surg 2010.

Common Flaps to consider

• Buccal mucosa
• Simple, successful, but reduces vestibular depth
• Buccal fat pad
• Adds vascularized bulk, little morbidity
• Palatal mucosa
• Thick, well-vascularized flap, more early donor site morbidity
• Tongue
• Very robust, reserve for challenging cases

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https://www.slideshare.net/NaveedIqbal12/oroantral-fistula

https://www.slideshare.net/NaveedIqbal12/oroantral-fistula

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Correcting Dog Ear in Flap

Guhan Dergin, Yusuf Emes, Cagrı Delilbası and Gokhan Gurler (2016). Management of the Oroantral Fistula, A Textbook of Advanced Oral
and Maxillofacial Surgery Volume 3, Prof. Mohammad Hosein Kalantar Motamedi (Ed.), InTech,

EXTRACTION-RELATED
FRACTURES

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Alveolus
• Buccal plate
• Maxillary or anterior mandibular teeth
• Negative consequence for implant sites

• Segmental
• If all teeth involved are being removed, no consequence
• If a tooth being preserved is involved, treat like traumatic
dentoalveolar fracture
• Rigid fixation for 4-6 weeks

• When bone is lost, are adjacent tooth roots exposed?

• Attempt to retain bone still attached to periosteum
• Consider periodontal therapy

Tuberosity Fracture
• Often includes a
palatal tear
• “Textbook” solution
is to preserve it
• Loss is rarely
consequential
• Denture seal is
preserved if soft
tissue tuberosity http://www.identalhub.com/dental-complications-during-tooth-extraction-880.aspx

persists
• Soft tissue
management is
therefore most
essential goal

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Mandible Fracture
• More common: A consequence of deep 3rd molar or large
cyst/tumor
• Predictable, patient is usually apprised of risk
• Event may occur during or after surgery
• Consider prophylactic archbars, access to fixation hardware
• Manage following the usual principles
• Less common: Consequence of inappropriate force
• Excess torque with Cryer elevator, e.g.
• Unexpected, rarely emphasized in consent
• Fracture management is completely routine
• Patient management is a significant challenge!
• It is hard when little things turn into big things

INJURY TO ADJACENT
TEETH

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Risk Factors in Adjacent Teeth

• Damage to crown
• Large restorations
• Caries
• Crowding, tipping
• Cusp fractures in opposing teeth
• Excessive traction force
• Avulsion
• Periodontal disease
• Crowding, tipping
• Fractured root – maxillary 3rd molar removal
• 3rd molar close to distobuccal root of 2nd molar

Preventative Management
• Identify risk factors and inform patient before the
procedure
• Relying on the written consent form is not sufficient
• Once an injury occurs, you are backpedaling!
• Include the possibility of restoration and root canal treatment
• Avoid instruments/techniques that put force (or even
contact) on teeth at risk
• Little or no luxation where neighboring tooth is compromised
• Consider dividing tooth being removed
• Consider early surgical technique
• Never “pull” teeth – uncontrolled traction can damage
opposing teeth (a “never” event)

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If Harm Occurs
• Inform patient
• Tooth damage
• Temporize vital tooth if necessary to keep comfortable
• Arrange definitive dental care
• Avulsed or mobile teeth
• Reimplant/splint immediately (semirigid, 2 weeks)

FRACTURED ROOT OR
ROOT TIP

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Fractured Root or Root Tip

• What’s the difference?

Root Tip Root

http://www.endoexperience.com/pro_caseMay03.html http://www.wayneleedds.com/smile-gallery/

To Retrieve or Not to Retrieve?

• Classic “textbook” emphasis: Remove the whole tooth!
• But in pre-implant era, bone removal was less consequential
• Techniques emphasized wide exposure and buccal bone removal
• Contemporary expectations include healing with a tall,
wide alveolar ridge
• Bone grafting is common
• Buccal slope of 2-3mm has repercussions for dental implants
• Newer approaches may allow both objectives
• Preserve buccal bone height and thickness
• Retrieve roots and root tips

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To Retrieve or Not to Retrieve?

• Get it out if
• Orthodontic movement will put a tooth in the site
• An implant is planned for the site
• The tooth was acutely symptomatic
• Radiographs show pathology at the apex
• Leave it if
• Above conditions do not exist
• Removal would
• Jeopardize vital adjacent structures
• Require significant bone removal
• If it is left in place
• Postsurgical radiograph
• Inform patient
• Consider postoperative visit to ensure normal healing

Techniques to Spare Alveolar Bone

• Fine fissure bur to remove bone within alveolus
• Take care to avoid adjacent roots
• Periotome carefully tapped into periodontal ligament
space
• If tooth was not acutely symptomatic, consider deferring
root fragment removal for 1-2 weeks
• Allow granulation tissue to form and loosen fragment
• If normal healing occurs, consider leaving in place unless it will be
in the way

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NERVE INJURY

IAN Proximity to 3rd Molar: Indicators

• Absence of (superior) canal wall crossing tooth*
• Darkening of root where crossed by IAN canal*
• Diversion of canal where it crosses the tooth*
• Deflection (dilaceration) of tooth roots around canal
• Narrowing of root where the canal crosses tooth
• Narrowing of canal where it crosses tooth
• Bifid root apex

*Combination of these 3 has best predictive value

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Options for High Risk Surgery

• Avoid surgery for prophylaxis if the tooth is low-risk
• Unexposed
• Normal probing depth distal of 2nd molar
• Patient understands need for routine dental care and careful
attention to hygiene in area
• Perform Coronectomy instead of extraction

Coronectomy Considerations
• Indications
• Moderate or high risk for IAN injury based on imaging
• Special risk (“professional wind instrument player”)
• Older patient (>25 years)
• Contraindications
• Horizontal impaction
• Pathology (infection, caries) present in 3rd molar
• Unable to remove all enamel
• Plan to distalize 2nd molar

Pogrel MA. Coronectomy: Partial Odontectomy or Intentional Root

Retention. Oral Maxillofac Surg Clin North Am. 2015 Aug

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Coronectomy technique
• Expose tooth as usual
• Section crown from root
• Remove additional tooth
to minimum 2-3mm
below alveolar bone
crest
• More may be better
• Ensure removal of all
Pogrel MA. Coronectomy: Partial Odontectomy or Intentional
enamel Root Retention. Oral Maxillofac Surg Clin North Am. 2015 Aug

Coronectomy Immediate Postop

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Outcomes
• Early (6-12 months) root migration is common
• Usually stabilizes below bone level
• Migration to exposure requires subsequent removal, usually (but
not always!) with less IAN risk
• Very low incidence of
• Infection
• Caries in 3rd molar
• Persistent defect distal to 2nd molar
• IAN injury

BLEEDING

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Preparation – Assess for Medical Causes

• Congenital coagulopathy
• von Willebrand Disease, Hemophilia A, B
• Acquired coagulopathy
• Liver disease
• Anticoagulation – coumadin vs. NOACs
• Platelet dysfunction/low count
• Congenital disease
• Liver disease (consider MELD score vs. INR alone)
• Anti-platelet drugs
• For known primary coagulopathy patients, hematology
consultation is essential

Avoid “Surgical” Bleeding

• Use local anesthetic with vasoconstrictor in inflamed
tissues
• Remove granulation tissue from socket
• Control extraction site bleeding primarily with pressure
• Avoid incisions near larger vessels
• Use local hemostatic measures when indicated

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Classic Local Hemostatic Measures

• Thrombin
• Gelatin foam (e.g. Gelfoam)
• Oxidated cellulose (e.g. Surgicel)
• Collagen sheets or plugs
• Fibrin preparations – “glue”
• Platelet-rich plasma

Other Bleeding Control Agents

• Aminocaproic acid oral solution (Amicar®)
• Inhibitor of fibrinolysis
• Effective for mild-moderate vWD, hemophilia, thrombocytopenia
• Desmopressin (DDAVP, Stimate®)
• Increases availability of Factor VIII, vWF
• Effective for mild-moderate vWD, hemophilia A (but not B),
thrombocytopenia

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Newer Hemostatic Agents

• Floseal®
• “Engineered” gelatin beads and thrombin concentrate
• HemCon®
• Military origin
• Chitosan, a shell-derived (but non-allergenic) polysaccharide

Floseal® Hemostatic Matrix

http://www.floseal.com/us/about.html

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HemCon® Dental Dressing

• Surface dressing
• Adherent – no suturing
• Antibacterial properties
• Hemostasis independent of clotting
cascade
• Evidence for
• Good hemostasis in anticoagulated
patients (INR>3)
• Compared to collagen plug
• Less postoperative pain
• Better soft tissue healing

https://www.hemcondental.com/

DRY SOCKET

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Prevention
• Numerous strategies have been published
• High-level evidence is lacking for most of them
• Chlorhexidine is the best documented
• Preoperative rinse, topical gel, 7-day postop regime
• Topical antibiotic to socket also well-supported
• Tetracycline or doxycycline
• Neurotoxicity has been a concern, but no evidence of significant
clinical risk
• Oral antibiotics: the controversy that won’t go away

Treatment
• As in prevention, options abound
• Goal is palliation during healing
• Consider
• Patient’s ability to return to office
• Ability to self-treat
• Pain experience/tolerance
• Removable dressing (i.e. gauze) must have radiopaque
marker
• Be aware of your dry socket dressing and state law
• “Compounding” may require additional licensure

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WRONG TOOTH

Easy Mistakes to Make

• Partially impacted 2nd molar looks like 3rd molar
• Wrong premolar for orthodontic purposes
• Wrong adjacent “bad” tooth
• Near full-mouth extraction becomes full-mouth
• Confusing multiple impactions +/- supernumeraries
• Are you and referring dentist naming them the same way?
• Retained decidous 2nd molar looks like permanent 1st
molar so counting erupted molars is wrong

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Management
• Healthy tooth: Treat like a traumatic avulsion
• Replace immediately
• Semi-rigid splint for 2 weeks
• Antibiotic coverage
• Check tetanus booster status
• Endodontic treatment in 7-10 days
• Caries, periodontal disease, immunocompromise
• Leave tooth out
• Consider socket preservation and eventual replacement for tooth

BROKEN NEEDLE

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Broken Anesthetic Needles

• A rare complication
• Incidence dropped to almost zero decades ago when disposable
needles were introduced
• Recent upturn for no clear reason
• Possible risk factors
• Burying needle to hub
• Bending needle (repeatedly?)
• Patient movement
• Small diameter, long needle (30ga long needle for IAN block)

• Is a retained needle a risk?

• Probably!

Needle Migration

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Retrieval of Broken Needle

• Emergent recovery attempt should be avoided
• If break happened in your own chair, a short, quick exploration may
be attempted
• Urgency is not justified
• No immediate consequence is likely to result
• But exploring the site may be very morbid
• Allow the patient to recover
• Prevents obscuring responsibility for other consequences
• Prolonged numbness
• Infection
• Pain

Retrieval of Broken Needle

• Treat like other foreign bodies
• Antibiotic coverage
• Image in 3-D
• Plan to remove under controlled circumstances
• Secure airway, magnification, time, bleeding control
• Consider using intraoperative image-guided navigation
• Scan immediately before surgery
• Anticipate legal entanglement
• Preserve needle once retrieved
• Keep impeccable records

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3-D Image-guided Localization

SOFT TISSUE INJURIES

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Soft Tissue Injuries

Handpiece Burn Prevention

• Proper maintenance
• Avoid overheating bur guard bearings
• Avoid long bur shafts
• Good retraction and soft tissue protection
• Assistant awareness

• Management
• Varies with depth, site

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Punctures and Lacerations

• Use controlled force!
• Be careful with blades away from the surgical site

• Management
• Repair lacerations immediately
• Leave deep punctures open
• Refer liberally for periodontal, cosmetic defects

Concluding Principles
• Culture of Patient Safety
• Recognize incident and inform patient
• Actively manage the complication
• Document well
• Learn from errors
• Discuss near misses and actual errors with staff, in a collegial,
analytical way
• Peer review and privileged information is a difficult legal matter
• Protection from discoverability varies by state
• Hospital care is usually protected, but office quality review is more
complex

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Complications in Dental Implant Surgery

Complications in Dental
Implant Surgery

Peter K. Moy, DMD

Surgical Implant Dentistry
UCLA, School of Dentistry

Oral and Maxillofacial Surgery Update

Complications in Dental Implant Surgery

Peter K. Moy, DMD
Endowed Chair, Surgical Implant
Dentistry
UCLA, School of Dentistry
Disclosure:
1. Endowed Chair, funded by Nobel Biocare, Inc.
2. Consultant, Nobel Biocare, Inc.
3. Director of Straumann Dental Clinic, funding by
Straumann
4. Speaker, X-Nav Corp. (Surgical navigation system)
5. Chair, Board of Directors, OsteoScience
Foundation (Geistlich Co.)

Oral and Maxillofacial Surgery Update

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Complications in Dental Implant Surgery

“Complications in Dental Implant

Surgery”
Learning From and Managing Failures

Patient Safety and Managing Complications

Complications in Dental Implant Surgery

9-30-93
Lifelong
Osseointegration
4-13-94
4-04-96
3-03-98
6-29-04
2 months

6 months

2.5 years
4.5 years
11 years

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Complications in Dental Implant Surgery

Increased Patient Demands

Awareness
• Increased focus on health and appearance
• Increased awareness of treatment modalities among patients
through media
Immediate Results
• Beautiful smile sooner, faster, or immediate!
Comfort
• Patients want minimal discomfort and a fixed prosthesis
At minimum cost

Complications in Dental Implant Surgery

Failures Occur in Three Categories:

1. Failure to Osseointegrate
2. Functional Failure
3. Esthetic failure

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Complications in Dental Implant Surgery

Medical-Legal Issues
1. Did you perform the procedure within the
“Standard of Care”?
2. Did you obtain “Informed Consent & Refusal”?
3. “Patient - Doctor” Communication &
Relationship.
4. Doctor showing “Compassion”.
5. Inform your patient of treatment alternatives to
deal with failures.

Complications in Dental Implant Surgery

I. Failure to Osseointegrate

Timing: Early Failures (Surgical)

Failure to establish initial stability

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Complications in Dental Implant Surgery

I. Failure to Osseointegrate

Early Failures (lack of adequate initial

stability) due to:
• Lack of bone volume
• Lack of bone quality (density)

Complications in Dental Implant Surgery

Lack of Bone Volume

Bone Grafting Techniques
for Site Development of Deficient Ridges
to Improve Function and Implant Success

Alveolar Ridge Preservation via Augmentation

Sinus Floor Grafts to Increase Total Volume

Block Bone Grafts to Correct Contour Deficits

Distraction Osteogenesis for Vertical Augmentation

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Complications in Dental Implant Surgery

Does grafting the socket at time of extraction:

• Improve healing time?
• Improve quality of healing?
• Support soft tissue?
• Prevent bone loss and preserve the ridge?

Socket augmentation
(Socket preservation)
Ridge preservation
Lack of Bone Volume

Complications in Dental Implant Surgery

Remodeling occurs after extraction

• Buccal bone loss, narrow horizontal dimensions
• Cortical bone replaced by trabecular bone and
bone marrow
Pietrokovski, 1967
Cardaropoli, 2003
Botticelli, 2004
Araujo, 2005

Lack of Bone Volume

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Complications in Dental Implant Surgery

Alloplasts improve alveolar dimensions over

membranes alone
• 16 patients split mouth membrane with
alloplast vs. membrane alone
• 6 month reentry significantly more bone fill
with augmented group
• Less vertical resorption in augmented group;
similar horizontal resorption

Camargo et al. OOO 90(5):581, 2000

Lack of Bone Volume

Complications in Dental Implant Surgery

Fate of buccal bone

• 36 maxillary anterior extracted teeth
• 19 sockets were augmented and 17 controls
• 21% augmented sockets lost >20% of buccal
dimension
• 71% control sockets lost >20%
• Clinicians could not predict which sockets
should be augmented at time of extraction

Nevins et al. Int J Perio Res Dent

6(1):19, 2006

Lack of Bone Volume

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Complications in Dental Implant Surgery

Socket
Augmentation
(Atraumatic extraction)

Lack of Bone Volume

Complications in Dental Implant Surgery

Lack of Bone Volume

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Complications in Dental Implant Surgery

Socket Augmentation

Immediate Post-extraction 1-week Post-extraction

Lack of Bone Volume

Complications in Dental Implant Surgery

1-week Post Extraction

Lack of Bone Volume

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Complications in Dental Implant Surgery

2-mos. Post Extraction

1-month Post-
extraction Lack of Bone Volume

Complications in Dental Implant Surgery

2-mos. Post Extraction

2-months Post-
extraction

Lack of Bone Volume

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Complications in Dental Implant Surgery

Socket Augmentation

Lack of Bone Volume

Complications in Dental Implant Surgery

Lack of Bone Volume

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Complications in Dental Implant Surgery

2-months Post-extraction

Lack of Bone Volume

Complications in Dental Implant Surgery

Immediate Post-placement 1-week Post-placement 2-months Post-placement

Lack of Bone Volume

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Complications in Dental Implant Surgery

Time of placement 2-months Post-placement

ISQ Value @ Implant Insertion ISQ Value @ 2-mos. Healing
Lack of Bone Volume

Complications in Dental Implant Surgery

1-Year
Post-loading

Lack of Bone Volume

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Complications in Dental Implant Surgery

2-Years
Post-loading

Socket Augmentation

Complications in Dental Implant Surgery

Benefits of delayed Limitations of delayed

implant placement implant placement
• Grafting not required at • Longer treatment time
time of implant placement • Requires second surgical
• Less difficult primary procedure
closure • Perceived decreased
• Less difficult primary patient satisfaction
stability
• Less potential for
compromised implant
positioning

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Complications in Dental Implant Surgery

Important unanswered questions

• When is the best time for implant placement
after extraction?

• Is extraction socket healing different when an

implant is placed immediately or when the
socket is grafted?

• Are specific grafting materials better than

others for socket augmentation?

Complications in Dental Implant Surgery

Extraction with Immediate Implant Placement and Immediate

Provisionalization

10-days

2-weeks 6-mos 1-yr 3-yrs

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Complications in Dental Implant Surgery

Extraction with Immediate Implant Placement

6-months after immediate - placement and immediate - loading

Complications in Dental Implant Surgery

Benefits of immediate Limitations of immediate

implant placement implant placement

• Higher patient satisfaction • Implant position may be

compromised
• Reduces treatment time
• Grafting is required to fill
• Possibility for patient to the “gap”
have immediate • Patient may have to wear
provisionalization an interim prosthesis
• Maintenance of hard and (removable)
soft tissue contours • Higher risk of gingival
recession

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Complications in Dental Implant Surgery

Limitations with immediate implants

• Require simultaneous bone grafting with or without
membrane
• Depends on bone morphology after extraction
• Potential compromised implant position
• Potential difficulty with primary stability
• Loss of buccal bone width
• Risk of marginal recession around implant

Botticelli et al., 2004

Chen et al., 2007

Complications in Dental Implant Surgery

Missing Single Tooth
MODERN TECHNOLOGIES HAVE HELPED THIS GROUP OF PATIENTS
MOST DUE TO:
1. The
surgeon’s ability to visualize alveolar contours via
CBCT
2. Thevariety of components to allow the surgeon to use an
appropriate implant design and positioning to achieve initial
stability predictably
3. Development of algorithms that will provide high
success/survival rates
4. Ability
to prevent collapse of hard and more importantly, soft
tissues through use of properly shaped immediate
provisional restoration to support these tissues

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Complications in Dental Implant Surgery

Missing Single-tooth in Esthetic Zone

• For the patient missing a single tooth in the Esthetic

Zone, surgical and prosthetic emphasis should be to
avoid loss of architecture/contours of the alveolar
ridge.

• Once esthetics is compromised, it will require

additional, more aggressive soft tissue management
and augmentation procedures (which are less
predictable around implants) to achieve acceptable
outcomes.

Complications in Dental Implant Surgery

Summary for Establishing Personal Algorithm for

Hard & Soft Tissue Augmentation Procedures
1. Select the appropriate augmentation technique for
correction of the clinical defect.
2. Select the appropriate donor material based on
patient’s decision/selection and evidence-based
science, not based on availability of the material.
3. Know the biology of bone/soft tissue and the graft
material(s) you are using.
4. Soft tissue, soft tissue, soft tissue!

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Complications in Dental Implant Surgery

I. Failure to Osseointegrate

Timing: Medium-term Failures (Patient)

Failure to form new bone

Complications in Dental Implant Surgery

Medium-term Failures due to:

• Slow or Lack of bone response (formation)

• Infectious event
• Premature loading

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Complications in Dental Implant Surgery

Implants
• No significant association between BMD and
implant survival (Holahan, IJOMI, 2008)
• More maxillary implant failures (compromised
healing) in post-menopausal women; reduced
by 41% when on HRT (August, JOMS, 2001)
• No correlation between ulna/radius bone
density measurement and implant failure (Becker, J
Periodontol, 2000)

Complications in Dental Implant Surgery

Concomitant factors that affect healing

(steroids, chemotherapy, smoking, diabetes)
Past Medical History (PMHx) & Meds
• Positive findings to be aware of:
o A history of radiation or chemotherapy
o Diabetes, Autoimmune disease, prolonged
Steroid therapy
o Meds: Anti-resorptive medications
o Social habits: SMOKING

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Complications in Dental Implant Surgery

Dental Risk Factors

• Extractions
• Why are teeth extracted?
• Poorer oral hygiene, more advanced dental
caries, more advanced periodontal disease
are associated with ONJ vs. control
• Statistically significant decrease in ONJ with
preventive measures
Marx RE et al. JOMS, 2005
Dimopoulos et al. , 2009
Oteri et al. J Osteoporosis, 2013
Kos. Arch Med Sci, 2014
AAOMS Position Paper JOMS 2007, 2009, 2014

Complications in Dental Implant Surgery

Risk Factors for ONJ

• Dental extractions or dental trauma
• Concomitant factors that affect healing (steroids,
chemotherapy, smoking, diabetes, etc.)
• Duration of bisphosphonate therapy

AAOMS Position Paper J Oral Maxillofac Surg 2007, 2009, 2014

ADA Council on Scientific Affairs, JADA, 2006
Marx RE. Quintessence 2007
ASBMR Task Force Report, J Bone Miner Res 2007

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Complications in Dental Implant Surgery

Position Paper
JADA, Vol. 139, Jan. 2008

Conclusion: Mode of bisphosphonate use

results in different risk profiles for adverse
jaw outcomes. While the authors
documented an increased risk of
inflammatory conditions and surgical
procedures of the jaw for users of IV BPs,
they did not find these observed increases for
users of oral bisphosphonates.

Complications in Dental Implant Surgery

History of taking Fosamax for 25+ years prior to implant

placements:

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Complications in Dental Implant Surgery

What is the Initiating Factor?

Marx RE: Oral & IV Bisphosphonate-Induced Osteonecrosis of the Jaws:

History, Etiology, Prevention, and Treatment. Quintessence 2007

• 152 cases with IV bisphosphonate

• Half occurred after procedure (36% ext, 9% perio surg, 3% implant, 1%
apico)
• Half occurred spontaneously, but half of these due to sig. perio disease
• Maybe up to 75% of cases are preventable

Complications in Dental Implant Surgery

Bisphosphonate indications
• Primary bone cancers
• Multiple myeloma
• Reduce spread of disease
• Reduce bone pain
• Minimize spontaneous
fracture
• Metastatic cancers
• Breast
• Prostate
• Hypercalcemia of malignancy
• Osteoporosis
• Other bone diseases
• Paget’s disease

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Complications in Dental Implant Surgery

Antiresorptive Medications
• Malignancy • Osteoporosis
– Fosamax (Alendronate)
• Aredia (Pamidronate) • Merck-1997
• Novartis-1991
– Actonel (Risedronate)
• Zometa (Zoledronate) • Proctor and Gamble-1998
• Novartis-2001 – Boniva (Ibandronate)
• Xgeva (Denosumab) • Roche-2005
• Amgen- 2010 – Reclast (Zoledronate)
• Novartis-2007
– Prolia (Denosumab)
• Amgen (2010)

Complications in Dental Implant Surgery

Denosumab
• Human monoclonal antibody binds to RANKL,
inhibiting its binding to RANK on osteoclasts
to induce bone resorption
• Osteoporosis, multiple myeloma, giant cell
tumor, bone metastases
• Temporary effect; no bone binding
• Jaw remodeling resumed when discontinued
(Otto et al. J Craniomaxillofac Surg 2013)
• Prolia subcutaneous injection every 6 mos

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Complications in Dental Implant Surgery

Denosumab
• Rodent study of OPG-Fc vs. ZA
discontinuation after periapical disease
induction
• OPG-Fc (antibody to OPG, like
denosumab), not ZA, discontinuation
reverses radiographic and histologic
features of ONJ in mice
• May decrease risk with drug holiday
• May heal faster with drug
discontinuation

De Molon et al. J Bone Miner Res, 2014

Complications in Dental Implant Surgery

Bisphosphonate Comparisons

Zahrowski JJ.
J Oral Maxillofac Surg 2007

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Complications in Dental Implant Surgery

Staging of MRONJ
At Risk Category Stage 0
• No apparent necrotic No clinical evidence of
bone in patients who necrotic bone; non-
have been treated either specific clinical findings
with oral or IV and symptoms
bisphosphonates

Complications in Dental Implant Surgery

Staging of MRONJ
Stage 1
• Characterized by
exposed bone that is
asymptomatic with no
evidence significant soft
tissue infection

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Complications in Dental Implant Surgery

Staging of MRONJ
Stage 2
• Exposed bone
associated with pain,
soft tissue and/or bone
infection

Complications in Dental Implant Surgery

Staging of MRONJ
Stage 3
• Exposed bone
associated with soft
tissue infection or pain
that is not manageable
with antibiotics due to
the large volume of
necrotic bone
• Pathologic fracture

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Complications in Dental Implant Surgery

Implants and Bisphosphonates

• No significant difference in complications in BP vs. control group with implants (Jeffcoat,
2006)
• Case series demonstrates high implant survival in patients on oral BPs (Fugazzotto, 2007)
• No increase in failures in patients on oral BPs (Grant, 2008)
• Decreased implant survival in patients on oral BPs (Kasai, 2009)
• No absolute contraindications to implant placement with IV or oral bisphosponates
(Chadha, 2013)
• High implant survival, minimal marginal bone loss, no ONJ (Tallarico, 2015)

Complications in Dental Implant Surgery

Implants

At Risk Category Stage 0

• No apparent necrotic bone in • No clinical evidence of
patients who have been necrotic bone; non-specific
treated either with oral or IV clinical findings and
bisphosphonates symptoms; BOP

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Complications in Dental Implant Surgery

Implants

Stage 2
• Exposed bone associated with pain, soft tissue and/or
bone infection

Complications in Dental Implant Surgery

MRONJ-related Implant Failures:

Stage 3
• Exposed bone associated with soft tissue infection or pain
that is not manageable with antibiotics due to the large
volume of necrotic bone

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Complications in Dental Implant Surgery

MRONJ-related Implant Failures:

Complications in Dental Implant Surgery

MRONJ-related Implant Failures:

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Complications in Dental Implant Surgery

MRONJ-related Implant Failures:

Complications in Dental Implant Surgery

MRONJ-related Implant Failures:

rH-BMP-2

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Complications in Dental Implant Surgery

MRONJ-related Implant Failures:

Complications in Dental Implant Surgery

Staging & Treatment Recommendations

• Stage 0
• Monitor, identify extent of disease; may progress
• Stage 1
• Aggressive home wound care with chlorhexidine
• Close follow-up
• Review indications for antiresorptive with patient
and/or PMD
• Stage 2
• Consider pain medication
• Antibiotics- Penicillin, Doxycycline vs. Clindamycin if
allergic
• Aggressive home wound care
• Consider debridement Consider alternative
• Review indications for antiresorptive with patient modalities such as
and/or PMD
parathyroid
• Stage 3 hormone
• Antibiotic therapy and pain control
• Consider debridement or resection
• Review indications for antiresorptive with PMD

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Complications in Dental Implant Surgery

For more information on MRONJ:

• www.ada.org/prof/resources/topics/osteonecrosis

or

• www.AAOMS.org/docs/position_papers/osteonecrosis

Complications in Dental Implant Surgery

Treatments under investigation

for MRONJ
• Vitamin E and Pentoxifylline
– Antioxidant and anti-inflammatory
• Parathyroid hormone
– Increase bone turnover
• Hyperbaric oxygen
– Increase vascularity and oxygenation
• Platelet-rich plasma/Platelet-rich Fibrin
– Growth factors; soft tissue healing
• Ozone
– Antimicrobial and wound healing properties
• Laser therapy
• Aggressive surgery
– Vascularized fibula flap

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Complications in Dental Implant Surgery

Parathyroid Hormone
• Animal studies: increased osteoblastic bone formation;
suppresses inflammation; increases collagen synthesis;
suppresses osteoclasts
• Overall promotion of soft and hard tissue healing wounds
• Increases BMD and bone remodeling in favor of bone
formation
• Contraindicated in patients with cancer
• Risk of osteosarcoma after 2 years of therapy
• Improved symptoms in ONJ patients (Stage 2 and 3)
when PTH utilized
• Several case reports and series

Kuroshima et al. J Periodontol 2014

Kakehashi et al. Int J Oral Max Surg 2015

Complications in Dental Implant Surgery

Take Home Points

• Pre-anti-resorptive preventive dentistry
• Encourage regular or increased dental
maintenance
• Consider drug holiday
• Extractions, implants, grafting, perio surgery
• Focused informed consent with risks
• No bone turnover marker evaluation (CTx)
• Continued research may change future
recommendation
• Patient education
• Diagnose and treat MRONJ early
• Therapies still much controversy

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Complications in Dental Implant Surgery

Acknowledgements
• Dr. Sotirios Tetradis NIH/NIDCR DE019465
• Olga Bezouglaia Oral and Maxillofacial
Surgery Foundation
• Dr. Flavia Pirih
UCLA’s Jonsson Cancer
• Dr. Alan Felsenfeld Center Foundation
• Dr. Earl Freymiller (JCCF)
• Dr. Tara Aghaloo UCLA Older Americans
Independence Center,
NIH/NIA Grant P30-
AG028748

Complications in Dental Implant Surgery

I. Failure to Osseointegrate

Timing: Late Failures (Decision-making)

Failure due to loading before

adequate integration of implant
(Premature Loading of implant)

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Complications in Dental Implant Surgery

Late Failures due to:

• Inappropriate loading of implant
• Excessive bone loss after loading
• Malposition of implant

Complications in Dental Implant Surgery

How do you determine implant stability?

Insertion Torque/
Percussion test
tactile feeling

Sound

Non-repeatable and Operator dependent.

subjective. Second stage Low sensitivity.
Touch torque test could be invasive.

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Complications in Dental Implant Surgery

How should implant stability be assessed?

The ISQ measures Insertion Torque
resistance to lateral measures resistance to
movement shear forces

Complications in Dental Implant Surgery

How does RFA work?

• Magnetic Waves (Resonance)

• Assigns numerical value

reflecting implant stability at the
bone-implant interface

• ISQ = Implant Stability Quotient

• 0 – 100

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Complications in Dental Implant Surgery

Why do I use the ISQ measurement?

• Optimal loading decisions

• Early warnings – take appropriate

response to potential causes of implant
failure

• Quality assurance
- Case documentation
- Communication
- Choice of methods and products
- Medical-legal aspects

Complications in Dental Implant Surgery

When to load? High initial stability (ISQ values

70 and above) tends to not
increase with time, even if the
high mechanical stability will
decrease to be replaced by a
developed biological stability.

Lower initial stability will

normally increase with time due
to the lower mechanical stability
being enforced by the bone
remodeling process
(osseointegration)

Values such as ISQ 55 or lower

should be taken as a warning
sign and actions to improve the
* Implant stability measurements using Resonance Frequency stability might be considered
Analysis. Biological and biomechanical aspects and clinical (larger implant diameter, longer
implications. Periodontology 2000, 2008. Sennerby & Meredith
healing time etc.)*

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Complications in Dental Implant Surgery

Early warning! The overall average value

of all implants over time is
approximately 70 ISQ.

If the initial ISQ value is

high, a small drop in
stability normally levels
out with time.

Lower values are expected

to be higher after the
healing period. The
opposite could be a sign
of an unsuccessful
implant.

A big drop in value or a

continuing decrease
should be taken as a
* Implant stability measurements using Resonance Frequency
warning sign and
Analysis. Biological and biomechanical aspects and clinical appropriate actions
implications. Periodontology 2000, 2008. Sennerby & Meredith
should be considered.

Complications in Dental Implant Surgery

Loading Protocol: Completely Edentulous

Cross-arch Splinting Individual Units

Fixed Provisional or ISQ < 59 ISQ > 60

Definitive Prosthesis

2-Stage Immediate
(Maxilla) Load with
2-Stage Overdenture
(Mandible)

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Complications in Dental Implant Surgery

Loading Protocol: Partially

Dentated

Hounsfield Units < 500 Hounsfield Units > 500 Hounsfield Units > 500
ISQ < 55 56 > ISQ < 65 ISQ > 66

2-Staging 1-Staging with Immediate

healing abutment Provisionalization

Complications in Dental Implant Surgery

Loading Protocol: Single-missing

Tooth

ISQ < 59 60 > ISQ < 65 ISQ > 66

2-Staging 1-Staging with Immediate

healing abutment Provisionalization
torque abutment to
25 Ncm

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Complications in Dental Implant Surgery

II. Functional Failures

Late Failures (Prosthodontic & Oral
Hygiene Maintenance)

Failure to position implants

in proper position

Complications in Dental Implant Surgery

Prosthodontic Failures due to:

• Inability to achieve a passive fit
• Constant prosthetic screw loosening
• Failure to inspect occlusion
• Failure to control lateral
interferences

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Complications in Dental Implant Surgery

Prosthodontic Failures

Horizontal
Cantilever

Complications in Dental Implant Surgery

Prosthodontic Failures

Vertical
Cantilever

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Complications in Dental Implant Surgery

Prosthodontic Failures

Prosthetic
component
loosening

Complications in Dental Implant Surgery

To Avoid Prosthodontic Failures:

Guided Surgical Planning
Prosthetically- directed Surgical Placement of
Implants

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Complications in Dental Implant Surgery

CAD/CAM Surgical Guide Cast fabrication

Complications in Dental Implant Surgery

Prosthesis fabricated PRIOR TO implant

placement

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Complications in Dental Implant Surgery

7 Day post op

Complications in Dental Implant Surgery

Benefits of
"Guided Approach"

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Complications in Dental Implant Surgery

Complications in Dental Implant Surgery

Fixture survival rate - 89%

Maxilla - 92%
Mandible - 83%
Surgical or Technical complications -
42%
Misfit of abut/bridge - 5 cases -
31%
Extensive adjustments required - 10%

Follow-up Period - 44 months

Why are there so many

technical, surgical, and
prosthodontic
complications?

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Complications in Dental Implant Surgery

II. Functional Failures

Why are there so many complications
associated with Guided approach to planning,
surgery, and prosthetic reconstruction?

1. Improper or inaccurate planning.

2. Poorly designed surgical template.
3. Poor execution of the surgical procedure.
4. Poorly designed prosthetic reconstruction.
5. Improper management of post-loading
prosthesis.

Complications in Dental Implant Surgery

Guided Surgical Planning – Prosthetically-

directed Surgical Placement of Implants

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Complications in Dental Implant Surgery

Managing Complications with Current

CAD/CAM Technology
• Improved accuracy, restoratively and surgically

• Clinical procedures easier to perform

Complications in Dental Implant Surgery

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Complications in Dental Implant Surgery

Majority of Functional Implant Failures
due to:
Lack of Oral Hygiene Maintenance

• Difficulty gaining access for proper home care

• Patient develops physical disabilities

• Disinterest of the patient (there is a reason why they

lost their teeth)

• Failure to develop adequate recall system

Complications in Dental Implant Surgery

Oral Hygiene

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Complications in Dental Implant Surgery

Oral Hygiene

Complications in Dental Implant Surgery

Lack of Oral Hygiene Home Care

and
Maintenance

Peri-implant mucositis
Peri-implantitis

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Complications in Dental Implant Surgery

Definitions
Peri-implant mucositis-inflammation in
the mucosa without loss of supporting
bone

Peri-implantitis-inflammation with loss

of supporting bone

Complications in Dental Implant Surgery

Clinical Periodontology and Implant Dentistry

By Jan Lindhe, Niklaus P. Lang, Thorkild Karring

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Complications in Dental Implant Surgery

Diagnosis
• Probing Depth
• Bleeding upon probing
• Suppuration
• Radiographic bone loss

Complications in Dental Implant Surgery

Peri-implant Mucositis:
features
• Not fundamentally different from gingivitis
• Redness/swelling of the soft tissue; bleeding
upon probing
• Reversible
• Can proceed to peri-implantitis

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Complications in Dental Implant Surgery

Peri-implant mucositis
• Reversible inflammation of the soft
tissues surrounding an implant in function
with no loss of supporting bone
• Bleeding and/or suppuration on probing
and increased probing depths (4-5mm)

Albrektsson T, Isidor F. Consensus report of session IV. In: Lang

N, Karring T, eds. Proceedings of the 1st European Workshop on
Periodontology. Switzerland: Quintessence, 1994:365.

Complications in Dental Implant Surgery

Peri-implant mucositis
• Reversible inflammation of the soft
tissues surrounding an implant in function
with no loss of supporting bone
• Bleeding and/or suppuration on probing
and increased probing depths (4-5mm)

Albrektsson T, Isidor F. Consensus report of session IV. In: Lang

N, Karring T, eds. Proceedings of the 1st European Workshop on
Periodontology. Switzerland: Quintessence, 1994:365.

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Complications in Dental Implant Surgery

Peri-implant Mucositis
Treatment
•Non surgical debridement and focused oral
hygiene
•Local Antimicrobials

Complications in Dental Implant Surgery

Peri-implant Mucositis
Treatment
•Heitz –Mayfield,L. Anti-infective treatment of peri-
implant mucositis: a randomized controlled clinical trial
Clin Oral Impl Res 2011;22:237-241
•29 patients with 1 implant with peri-implant mucositis
as diagnosed by bleeding upon probing
•Non surgical debridement/OHI/chlorhexidine
Results
•38% resolved
•78% improved

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Complications in Dental Implant Surgery

Current management:
mucositis
• Scaling or mechanical debridement with oral
hygiene instructions to disrupt biofilm (Lang,
1997)
• Antimicrobial gel- no additional benefit (Heitz-
Mayfield, 2011; Thone-Mukling, 2010)
• Generally reversible (Heitz-Mayfield, 2004)

Complications in Dental Implant Surgery

Local Antimicrobials

Arestin
Atridox

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Complications in Dental Implant Surgery

Local Antimicrobials

• Arestin (Minocycline HCL)

Complications in Dental Implant Surgery

Arestin
• Minocycline HCL
• Maintains therapeutic concentration for 14 days
• Absorbable
• Single site application
• Easy to use

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Complications in Dental Implant Surgery

Local Antimicrobials

• Atridox (Doxycycline Hyclate)

Complications in Dental Implant Surgery

Atridox
• Doxycycline Hyclate
• Controlled release of the antibiotic for 7 days
• Absorbable
• Useful for multiple sites
• Somewhat easy to use

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Complications in Dental Implant Surgery

Peri-implantitis
• Inflammatory process affecting the
tissues around an osseointegrated
implant in function resulting in loss of
supporting bone
• Deep probing depths (>5mm), bleeding
and/or suppuration on probing
• Usually circumferential defect
Albrektsson T, Isidor F. Consensus report of session IV. In: Lang N, Karring
T, eds. Proceedings of the 1st European Workshop on Periodontology.
Switzerland: Quintessence, 1994:365.

Complications in Dental Implant Surgery

Peri-implantitis
• Inflammatory process affecting the
tissues around an osseointegrated
implant in function resulting in loss of
supporting bone
• Deep probing depths (>5mm), bleeding
and/or suppuration on probing
• Usually circumferential defect
Albrektsson T, Isidor F. Consensus report of session IV. In: Lang N, Karring
T, eds. Proceedings of the 1st European Workshop on Periodontology.
Switzerland: Quintessence, 1994:365.

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Complications in Dental Implant Surgery

Peri-implantitis-features
• Deep pockets
• Bleeding upon probing
• Suppuration
• Radiographic Bone Loss

Complications in Dental Implant Surgery

Peri-Implantitis
• CLASSIFICATION*
• Early: Pocket Depth≥4mm
Bleeding upon probing and/or suppuration
Bone loss<25% of the implant length

• Moderate: Pocket Depth≥6mm

Bleeding upon probing and/or suppuration
Bone loss 25% to 50% of implant length

• Advanced: Pocket Depth≥8mm

Bleeding upon probing and/or suppuration
Bone loss>50% of the implant length
*Froum,S. and Rosen,P. A Proposed Classification for Peri-Implantitis
Int.J. Perio.and Rest.Dent. 2012;32:533-540

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Complications in Dental Implant Surgery

Peri-implantitis
Etiology
• Bacterial Plaque
• Occlusal Overload
• Cement

Complications in Dental Implant Surgery

Atieh et.al. The Frequency of Peri-Implant Diseases:

A Systematic Review and Meta-Analysis. Journal of Periodontology. 2012

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Complications in Dental Implant Surgery

Atieh et.al. The Frequency of Peri-Implant Diseases:

A Systematic Review and Meta-Analysis. Journal of Periodontology. 2012

Peri-implant
Purpose: Estimate overall frequency mucositis
of peri-implant disease in high-risk
No bone loss
groups +/- mucosal recession

Plaque
Results: 9 studies Rubor
Minimum follow up - 5 years Purulence
1497 participants BOP

6283 implants
Peri-implant mucositis – 30.7%
Peri-implantitis – 9.6% Peri-implantitis

PD ≥ 5mm
Or ≥ 3 implant threads
Bone Loss ≥ 2mm

Complications in Dental Implant Surgery

Atieh et al., 2012

• High occurrence of peri-implant disease which

may persist for years
• Long term maintenance care for high risk
groups is essential
• Smokers – 31 x more likely
• Small among participants with h/o periodontitis
• Regular maintenance care number of
participants presenting with peri-implantitis.

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Complications in Dental Implant Surgery

Peri-implantitis: Prevalence
• Variable range
• 6.4% (Albrektsson et al., 1994)
• 12-43% (Berglundh et al., 2002)
• 9.6% (Atieh et al., 2012)

Complications in Dental Implant Surgery

Classification
• Etiology bacterial, inflammatory, or
combination?
• Baseline measurements
• Stage or class I, II, III
• Mild, moderate, severe
• Time to develop disease
• Bacteria or biofilm

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Complications in Dental Implant Surgery

Bacteria around healthy vs. diseased

peri-implant tissues
• Gram-positive facultative cocci and rods
• Gram-negative anaerobic rods at sites with clinical signs of peri-implantitis
• Similar to periodontitis (Porphyromonas gingivalis, Treponema denticola,
Tannerella forsythia, Fusobacterium sp. Prevotella intermedia,
Aggregatibacter actinomycetemcomitans)
• Occasional staphylococcus aureus (deep pockets), enteric rods and
Candida albicans

Heitz-Mayfield LJ, Lang NP.

Periodontol 2000 2010;53:167-81.

Complications in Dental Implant Surgery

Confounding Variables
• Occlusal forces
• Cement or other contaminants
• Standardized radiographs
• Tools for diagnosis and maintenance
• Plaque assessment, bleeding index, suppuration
• Access for oral hygiene
• Mucosal condition
• Probing/pocket depth
• Keratinized tissue width
• Gingival fluid analysis
• Radiographs
• RFA/implant stability
• Maintenance schedule and compliance

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Complications in Dental Implant Surgery

Risk Factors
Previous Periodontal Disease
Poor Plaque Control/Inability to Clean
Residual Cement
Smoking
Genetic Factors
Diabetes
Occlusal Overload
Potential Emerging Risk Factors
Rheumatoid arthritis, increased time of loading,
and alcohol

J Periodontol 2013;84:436-43.

Complications in Dental Implant Surgery

Prevention and maintenance strategies

• Patient factors
• Smoking, periodontal disease, diabetes, genotype

• Iatrogenic factors
• Cement, prosthesis design, diagnostic tools,
implant surface, occlusal trauma, implant position

• Maintenance factors
• Biofilm, home care, regular hygiene visits

Heitz-Mayfield LJ, Lang NP.

Periodontol 2000 2010;53:167-81.

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Complications in Dental Implant Surgery

Peri-implant bone loss in cement- and screw-retained
prostheses

No evidence to support differences in marginal bone loss between cement and screw-retained restorations.
de Brandao, et al. J Clin Perio, 2013

Complications in Dental Implant Surgery

Prevention and maintenance strategies

• 61 patients maintenance program every 6 months x 2
years, then yearly x 4 years
• Chlorhexidine twice daily for 10 days (mucositis)
• Systemic and local antibiotics with surgery to
decontaminate and debride (implantitis)
• <10% mucositis and 1.4% implantitis

Corbella, S et al. Int J Dent Hygiene, 2011

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Complications in Dental Implant Surgery

Prevention and maintenance strategies

• 112 healthy and periodontally compromised

patients in supportive periodontal therapy
• Increased implantitis and implant loss in
severe periodontally compromised patients
• Lack of maintenance was associated with
higher implant loss and implantitis

Roccuzzo M, et al. Clin Oral Imp Res, 2010

Complications in Dental Implant Surgery

Prevention and maintenance strategies:

Mucositis
• Peri-implant assessment, oral hygiene,
plaque index, mechanical debridement
• One visit per year x 5 years
• Control group- 43.9% mucositis, 19.5%
implantitis
• Treatment group- 18% mucositis, 1.7%
implantitis
Costa FO, et al. J Clin Perio, 2012

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Complications in Dental Implant Surgery

Prevention and maintenance strategies

• Dental/hygiene visits every 3 months to
evaluate for mucositis or implantitis
• Probing every 6 months by dentist
• Supportive treatment
• Infection control as needed
• Radiographs, hygiene instruction, education
Algraffee H, et al. Br JOMS, 2011

Complications in Dental Implant Surgery

Patient and dentist education in supportive

care
• Consensus to treat mucositis and implantitis
• Lack of consensus on specific treatment
• Lack of consensus on disease preventive
maintenance program
• Biofilm, host immune response, etc
• Evidence of hygiene importance
• Often prostheses unaccessible for hygiene

Swierkot K, et al. J Perio, 2012

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Complications in Dental Implant Surgery

Proposed Recent Classification

Froum SJ, Rosen PS. Int J Perio

Rest Dent 2012;32(5):533-40.

Complications in Dental Implant Surgery

Classification
of
Peri-
Implantitis
based on
total number
of walls
present

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Complications in Dental Implant Surgery

Treatment Modalities:
Peri-implantitis
Key factors to
consider
Decrease bacterial
plaque
Decontaminate surface
Improve patient OH
Regenerate bone

Complications in Dental Implant Surgery

Current management:
Peri-implantitis
• Debridement and decontamination
• Non-surgical
• Mechanical (titanium, plastic, rubber), sonic,
ultrasonic, lasers, air powered abrasives
• Saline, chlorhexidine, citric acid, H2O2, lasers,
local antibiotics
• Surgical
• Debridement, pocket elimination, bone
recontouring, bone grafting +/- membranes,
implantoplasty

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Complications in Dental Implant Surgery

Treatment:
Lang et al. 2004 Consensus Statement

Cumulative Interceptive Supportive Therapy (CIST)

Complications in Dental Implant Surgery

Current management: peri-implantitis

• Cumulative interceptive supportive therapy
(CIST; Momebelli, Lang, 1998; Lang, Berglundh,
2004)
• Treatment based on disease severity;
sequential in cumulative fashion
• Success after therapy
• Measure of clinical health after treatment
• Maintenance of health

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Complications in Dental Implant Surgery

Cumulative Interceptive Supportive Therapy

• Mechanical cleansing and improved oral hygiene-
healthy or mucositis
• Antiseptic therapy with rinsing or local application of
chlorhexidine- mucositis or mild to mod implantitis
• Systemic antibiotics or local delivery- mild or mod
implantitis
• Surgical therapy- mod or severe implantitis
• Explantation- failed treatment/hopeless

Complications in Dental Implant Surgery

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Complications in Dental Implant Surgery

Complications in Dental Implant Surgery

Suarez F, et al. Implant Dent, 2013

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Complications in Dental Implant Surgery

Complications in Dental Implant Surgery

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Complications in Dental Implant Surgery

Future directions
• Prevent or eliminate initial bacterial
attachment
• Antibioadhesive or antibacterial surfaces
• Consider in high risk vs. all patients
• Preliminary studies, many in vitro
• Single or combination strategies
• New technologies
• Bioresponsive strategies
• Much more research is needed
Bumgardner J, et al. IJOMI, 2011

Complications in Dental Implant Surgery

Take home points

• Rule out non-inflammatory conditions
• Identify susceptible patients
• Appropriate implant and prosthesis design
• Reinforce maintenance and hygiene
• Prevention rather than treatment
• Large multicenter trials to evaluate important
questions in diagnosis, prevention, and treatment
• Consider removing implants if cannot maintain

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Complications in Dental Implant Surgery

Take home points

Intervene with prophylactic measures when mucositis
(bleeding) is noted
Pocket > 6 mm harbors anaerobic bacteria and
requires treatment
Baseline radiograph and follow-up at regular intervals
Do not intervene surgically without prior conservative,
antibacterial therapy
Maintain optimal oral hygiene standards after peri-
implantitis

Complications in Dental Implant Surgery

III. Esthetic Failures

Soft Tissue Failures

Failure to position implants

in proper position

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Complications in Dental Implant Surgery

Esthetic Failures due to:

• Lack of communication
• Lack of proper diagnosis
• Lack of attention to details
• Dependence on laboratory technicians

Complications in Dental Implant Surgery

Esthetic Failure

Failure to place implants into proper position

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Complications in Dental Implant Surgery

Implants have Osseointegrated but are

these examples of successful outcome?

Complications in Dental Implant Surgery

Soft Tissue Esthetics

Position of adjacent teeth and
gingival contours/health

Interproximal bone levels and

architecture

Cervical/crestal position of necks

of implants

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Complications in Dental Implant Surgery

Buccal-Palatal Inclination of Implant

Complications in Dental Implant Surgery

Failure to Correct the

Deficiency
The Implant Dentist
must make the proper
diagnosis prior to
starting any implant
procedures.
Any bone augmentation
procedure should
address and assist in
the correction of the
soft tissue defect.
Concurrent loss of soft tissue

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Complications in Dental Implant Surgery

Failure to position implants

properly

No surgical procedure will salvage this

situation. Therefore, implants must be
removed and start over!

Complications in Dental Implant Surgery

RESTORATIVE VERTICAL SOFT

CLASS PROXIMITY LIMITS
ENVIRONMENT TISSUE
1 Tooth-Tooth 1 mm 5.0 mm
2 Tooth-Pontic N/A 6.5 mm
3 Pontic-Pontic N/A 6.0 mm
4 Tooth-Implant 1.5 mm 4.5 mm
5 Implant-Pontic N/A 5.5 mm
6 Implant-Implant 3 mm 3.5 mm

Salama H, Salama M, & Garber D.

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Complications in Dental Implant Surgery

Esthetic Results with Proper Planning & Implant

Positioning
Restorative Treatment
by
Dr. Baldwin Marchack
Pasadena, CA

Complications in Dental Implant Surgery

What was this surgeon thinking?

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Complications in Dental Implant Surgery

Lack of planning
Lack of understanding patient’s expectations

Complications in Dental Implant Surgery

Defect Augmentation

424
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Complications in Dental Implant Surgery

Do you build the bridge or build the ridge?

Complications in Dental Implant Surgery

Attempt should be made at building a Ridge

425
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Complications in Dental Implant Surgery

Build the RIDGE!

Complications in Dental Implant Surgery

Ridge in a better A-P position and

Interocclusal Relationship with Alveolar Ridge
Osseous Distraction (AROD) procedure

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Complications in Dental Implant Surgery

Complications in Dental Implant Surgery

Management of Alveolar Deficiency

in
Esthetic Zone

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Complications in Dental Implant Surgery

Management of Alveolar Deficiency

in
Esthetic Zone

Complications in Dental Implant Surgery

Implant Stability Quotient to Determine

Osseointegration

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Complications in Dental Implant Surgery

Management of Patient Expectations

Complications in Dental Implant Surgery

Management of Alveolar Deficiency

in
Esthetic Zone

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Complications in Dental Implant Surgery

Management of Alveolar Deficiency

in
Esthetic Zone

Complications in Dental Implant Surgery

Meeting Patient Expectations

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Complications in Dental Implant Surgery

What I have learned Managing Complications

1. Have a clear picture of the intended treatment
results before you start treatment
2. Proper and accurate diagnosis prevents long term
complications from occurring
3. Respect surgical principles and follow evidence-based
protocols
4. Soft tissue, Soft tissue, Soft tissue then
occlusion, occlusion, occlusion!
5. Measure (plan) twice, cut once!

Complications in Dental Implant Surgery

Thank you!

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Complications in
Orthognathic Surgery
W. Bradford Williams, DMD, MD

Disclosure

Dr. W. Bradford Williams has nothing to disclose.

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Preoperative

Intraoperative

Postoperative

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Preoperative

• Poor communication
• Orthodontic Preparation
• Inaccurate Records

Communication

Patient

Surgeon Orthodontist

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Preoperative

• Poor communication
• Orthodontic Preparation
• Inaccurate Records

Lower Incisor Inclination

435
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Inadequate Decompensation

Initial

1180

436
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Preoperative Presentation

437
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Inadequate Decompensation

130 0 0
1300 130

Dental Discrepancy ≠ Skeletal Discrepancy

Dental Decompensation Eliminated

1120

Increased Maxillary Advancement

438
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Inadequate Dental Spacing

439
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Two Years Postop

440
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Two Years Postop

Inadequate Dental Spacing

441
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Orthodontic Hardware

442
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Orthodontic Hardware

443
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Orthodontic Hardware

444
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Preoperative

• Poor communication
• Orthodontic Preparation
• Inaccurate Records

Inaccurate Presurgical Records

445
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Plan: Maxillary Impaction & Genioplasty

Centric
Occlusion
Relation

Inaccurate Model Surgery

Mn Midline to Left 3 mm

446
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Plan: Maxillary Advancement and

Asymmetric Mandibular Setback

10 Days Postop Maxillary and

Mandibular Osteotomies

447
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Incorrect Model Surgery and Splint

448
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Intraoperative

• Mandibular Surgery
• Sagittal Ramus Osteotomy
• Maxillary Surgery
• LeFort I Osteotomy

449
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Sagittal Ramus Osteotomy

technically
difficult
operation

Intraoperative

• Mandibular Surgery
• Sagittal Ramus Osteotomy
• Bad Splits
• Etiology
• Management
• Inadequate Stabilization
• Failure to Seat the Condyles
• Damage to Adjacent Structures

450
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Repair of Bad Splits in the “old days”

Key Areas to Avoid

Bad Splits

451
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Lingula

452
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Retrolingular Fovea

Inferior Border

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Resistance
STOP
STOP
STOP

Medial Cut

Inferior Border Cut

Bad Splits
Buccal plate fractures most common

455
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Buccal Plate Fractures

Remove
Replace
Regroup

Buccal Plate Fractures

Remove
Replace
Regroup

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Remove

Replace

457
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Regroup

458
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High Buccal Plate Fractures

More difficult to salvage

459
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

460
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

461
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Posterior Vertical Body Osteotomy

(PVBO): A Predictable Rescue
Procedure for Proximal Segment
Fracture During Sagittal Split Ramus
Osteotomy of the Mandible

Patterson AL, Bagby SK

J Oral Maxillofac Surg 1999; 57: 475-477

462
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

463
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

464
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

6 Weeks Postop

Bad Splits
Distal Segment Fractures

465
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Distal Segment
Fracture

Weak distal segment

466
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Proximal and Distal Segment Fracture

Inferior Nerve
Alveolar
Nerve

LingualCortex
Lingual Cortex

(Lower Part of
Distal Segment)

Condyle-coronoid segment

Most difficult
to fix

467
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Condyle-coronoid segment

Preop Mandibular Advancement

468
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

One Week Postop

6 Weeks Postop
Two Months Post-Op

469
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Unfavorable Splits

Preop panorex

470
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

One week postop

??

471
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Third Molars
Remove Before or During
Osteotomy?

Surgeon Preference
Conflicting Studies
Remove after split is
completed

472
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Distal Segment Fracture

473
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Intraoperative

• Mandibular Surgery
• Sagittal Ramus Osteotomy
• Bad Splits
• Etiology
• Management
• Inadequate Stabilization
• Failure to Seat the Condyles
• Damage to Adjacent Structures

Inadequate Stabilization

474
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Inadequate Stabilization

Preop panorex

10 days postop

475
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

6 months postop

Proximal segment rotation

476
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

477
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Hardware Failure

Preop

10 days
Postop MMA

478
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

12 weeks Postop
MMA

479
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Intraoperative

• Mandibular Surgery
• Sagittal Ramus Osteotomy
• Bad Splits
• Etiology
• Management
• Inadequate Stabilization
• Failure to Seat the Condyles
• Damage to Adjacent Structures

Failure to Seat the Condyle

480
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Stabilize Proximal Segment

1 week post SSRO

481
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Centric Occlusion

Intraoperative

• Mandibular Surgery
• Sagittal Ramus Osteotomy
• Bad Splits
• Etiology
• Management
• Inadequate Stabilization
• Failure to Seat the Condyles
• Damage to Adjacent Structures

482
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Damage to Adjacent
Structures
• Vascular
• Facial Artery/Vein
• Maxillary Artery
• Neurologic
• Trigeminal Nerve
• Lingual
• Mental
• Facial Nerve

Facial Artery at Inferior Border

483
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Maxillary Artery

6 weeks postop

Sudden onset
swelling

484
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CT Angiogram

Pseudoaneurysm of Maxillary Artery

Post Embolization

485
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Nerve Injury

• Trigeminal Nerve
• Facial Nerve

Mental Nerve

486
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Ramus cut placed too medial

487
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Nerve in the Proximal Segment

Dissect the nerve or leave it?

488
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Lingual Nerve

489
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

VII Nerve Palsy

Following Sagittal Ramus Osteotomy

490
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

491
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Intraoperative

• Maxillary Surgery
• LeFort I Osteotomy
• Bleeding
• Ophthalmic Complications
• Maxillary Position

Maxillary Surgery Complications

492
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Pterygoid Muscles at Posterior Maxilla:

Most Common Cause of Bleeding

Greater Palatine Artery

< 30 mm from piriform < 35 mm from piriform

rim in females rim in males

493
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Pterygopalatine Fossa

Pterygoid Ganglion
V2

Pterygopalatine Fossa

Pterygoid Venous Plexus

494
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Pterygomaxillary Dysjunction

YES NO

Control Pterygoid Osteotome

YES

NO

495
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Intraoperative Bleeding

496
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Intraoperative

• Maxillary Surgery
• LeFort I Osteotomy
• Bleeding
• Ophthalmic Complications
• Maxillary Position

Ophthalmic Complications
Associated with Orthognathic
Surgery

Lanigan DT, Romanchuck K, Olson CK

J Oral Maxillofac Surg 1993; 51: 480-494

497
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Ophthalmic Complications

NO!

Ophthalmic Complications

NO!

498
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Blindness After Le Fort I Osteotomy: A

Possible Complication Associated
with Pterygomaxillary Separation

Cruz AA, Santos AC

J Craniomaxillofac Surg 2006; 34: 210-216

499
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Left Lateral Rectus Palsy

Intraoperative

• Maxillary Surgery
• Bleeding
• Ophthalmic Complications
• Maxillary Position

500
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Inadequate Posterior Trimming

Adapted from: Bays, RA. “Complications in Orthognathic Surgery.” Complications in Oral and Maxillofacial Surgery. Ed. Leonard B. Kaban. Ed. M. Anthony
Pogrel. Ed. David H. Perrott. Saunders. 1997. p212

501
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Inadequate Posterior Trimming

Failure to seat the condyles

Failure to Seat the Condyle

Maxillary or mandibular
surgery

502
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

503
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Postoperative Complications

• Infection
• Nonunion
• Malocclusion/Relapse

Communication

Patient

Surgeon Orthodontist

504
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Infection

Postoperative Complications

• Infection
• Nonunion
• Malocclusion/Relapse

505
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Maxillary Nonunion

One Year Postop

506
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Maxillary Nonunion

Postoperative Complications

• Infection
• Nonunion
• Malocclusion/Relapse

507
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Malocclusion/Relapse
• Early
• Condyle Not Seated
• Relapse at the Osteotomy Sites
• Late
• Growth (Class III)
• Condylar Resorption/Remodeling

508
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Malocclusion/Relapse
• Early
• Condyle Not Seated
• Relapse at the Osteotomy Sites
• Late
• Growth (Class III)
• Condylar Resorption/Remodeling

509
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Growth

510
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Growth

Malocclusion/Relapse
• Early
• Condyle Not Seated
• Relapse at the Osteotomy Sites
• Late
• Growth (Class III)
• Condylar Resorption/Remodeling

511
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Inflammatory Arthritis

Active

512
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Burned out??

Non-Arthritis Condylar Resorption

Initial 2004 Preop 2005 Postop 2005

513
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Postop 2005

514
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

10 Years Postop

Excessive Overjet with Anterior Openbite

515
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

Preoperative

Intraoperative

Postoperative

Thank You

516
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

COMPLICATIONS AND
MANAGEMENT IN ORAL AND
MAXILLOFACIAL SURGERY

SRINIVASA RAMA CHANDRA MD BDS FDSRCS(ENG)

MAXILLOFACIAL -HEAD AND NECK ONCOLOGY| RECONSTRUCTIVE

MICROVASCULAR SURGERY

DISCLOSURE
Dr. Chandra reports no relationships with a commercial
interest.

517
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

DEFINITIONS

COMPLICATIONS WERE DEFINED AS ANY DEVIATION FROM THE NORMAL

POSTOPERATIVE COURSE

SEQUELAE IS AN “AFTER-EFFECT” OF SURGERY THAT IS INHERENT TO THE PROCEDURE

(EG, INABILITY TO WALK AFTER A AMPUTATION OF THE LEG)

FINALLY, SURGERY MAY BE WELL EXECUTED WITHOUT ANY COMPLICATIONS BUT STILL
FAIL. I F THE ORIGINAL PURPOSE OF SURGERY HAS NOT BEEN ACHIEVED, THIS IS NOT A
COMPLICATION BUT A “FAILURE TO CURE” (EG, RESIDUAL TUMOR AFTER SURGERY).

SEQUELAE AND FAILURE TO CURE SHOULD NOT BE INCLUDED IN THE CLASSIFICATION

OF COMPLICATIONS.

IMPLICATIONS OF COMPLICATIONS

• DELAY IN ADJUVANT TREATMENTS

• AUGMENT OR WORSEN LATE SEQUELAE
• AFFECT QUALITY OF LIFE
• INCREASE TREATMENT COSTS
• MAY CAUSE A PATIENT'S DEATH IF NOT DIAGNOSED AND PROMPTLY TREATED

518
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

SURGICAL COMPLICATIONS
“OPERATION WENT WELL…BUT THE PATIENT WAS NOT IN A GOOD SHAPE”

“NICE FLAP…DEAD PATIENT”

“THE ANESTHETIST…TOO MUCH FLUID”

“WAS NOT PICKED UP EARLY ON THE WARD”

“WE DID EVERYTHING CORRECTLY…”

SURGICAL COMPLICATIONS

• THE PATIENT SUFFERS…

• COST…

• MOST OF THE TIMES CAN BE AVOIDED…

519
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

SURGICAL COMPLICATIONS
“THE BREAST CANCER WARS”
BY LERNER…

…. WE LEARN FROM OTHER SPECIALTIES

SURGICAL COMPLICATIONS

“SURGICAL ERRORS AND RISKS – THE

HEAD AND NECK CANCER PATIENT”

CURRENT TOPICS IN OTORHINOLARYNGOLOGY - HEAD AND NECK SURGERY

2013, VOL. 12, ISSN 1865-1011

520
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

SURGICAL COMPLICATIONS

• 3 FACTORS

• THE PATIENT
• THE SURGICAL INSULT
• THE PERI AND POST-OPERATIVE CARE

SURGICAL COMPLICATIONS

“HOW THE MULTIDISCIPLINARY TEAM DEALS WITH THE PATIENT”

521
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

PATIENT FACTORS-

• DISEASE BURDEN
• VASCULAR ISSUES
• SMOKING
• SCARRING (POOR DESIGN AND TISSUE HANDLING ALSO CONTRIBUTE)
• NUTRITION

ANTIBIOTIC RESULTING IN HEAD AND NECK

PATIENT

522
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

SURGEON FACTORS

• POOR FLAP, INCISION AND SURGICAL PLANNING

• TISSUE HANDLING
• POOR TECHNIQUES
• MEDICATION RELATED

TRIFURCATION OF INCISIONS & FLAPS

523
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

OVER ROTATION OF THE PROXIMAL

SEGMENT

IMPROPER COMPOSITE FLAP INSET

524
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

IMPROPER COMPOSITE FLAP INSET- CERTAINLY NO

IMPLANTS AT OSTEOTOMY SITE

COMPLICATIONS CAUSED BY NECK

DISSECTION
• ACUTE COMPLICATIONS ARE WOUND INFECTIONS, HEMATOMA/
HEMORRHAGE, CHYLE LEAK, AND POSTOPERATIVE MORBIDITY SUCH AS
CARDIAC PROBLEMS AND THROMBOSIS.

• MOST COMMON LATE COMPLICATIONS ARE SHOULDER DISABILITY,

SHOULDER PAIN, REDUCED CERVICAL MOBILITY, AND LYMPHEDEMA

• A MORE UNCOMMON BUT SEVERE LATE COMPLICATION ASSOCIATED WITH

NECK DISSECTION IS CAROTID BLOW-OUT BLEEDING

Kerawala CJ, Heliotos M. Prevention of complications in neck dissection. Head Neck Oncol 2009;1:35.

525
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

WOUND INFECTIONS

• ADVANCED STAGE OF TUMOR

• TRACHEOSTOMY

• TYPE OF RECONSTRUCTION

• PREOPERATIVE RADIOTHERAPY

• NUTRITIONAL STATUS

• COMORBIDITIES

• DURATION OF SURGERY

• SMOKING AND ALCOHOL CONSUMPTION

Lee DH, Kim SY, Nam SY, Choi SH, Choi JW, Roh JL. Risk factors of surgical site infection in patients undergoing major oncological surgery for head and neck
cancer. Oral Oncol. 2011 Jun;47(6):528-31. DOI: 10.1016/j.oraloncology.2011.04.002

Robbins KTFavrot SHanna DCole R Risk of wound infection in patients with head and neck cancer. Head Neck.1990;12:143-148.

ALBUMIN AND WOUND INFECTION

• LOW LEVEL OF ALBUMIN (BELOW 3.7 G/DL) IS ASSOCIATED WITH AN

INCREASED RISK OF WOUND INFECTION. THE NUTRITIONIST THEREFORE MUST BE
AN INTEGRAL PART OF THE MULTI - DISCIPLINARY TEAM AND EXTRA EFFORT
MUST BE MADE TO MAINTAIN POST-OPERATIVE ALBUMIN LEVEL ABOVE 4 G/DL.
PRECAUTIONARY MEASURES SUCH AS MAINTENANCE OF ADEQUATE NUTRITION
AND HEMOGLOBIN LEVELS MAY PLAY A CRITICAL ROLE IN PREVENTING
WOUND COMPLICATIONS.

FACTORS AFFECTING WOUND COMPLICATIONS IN HEAD AND NECK SURGERY: A PROSPECTIVE STUDY.
D’CRUZ ET AL 2013

526
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

HAEMATOMA

1. Haemostasis

2. Check BP is
normalised before
closing neck

3. Avoid causes of post –

op hypertension:

•Starts with pre-op work

up
•Post – Op Pain
•Coughing

CHYLE LEAKS
• CHYLE DRAINS INTO THE VENOUS SYSTEM VIA THE THORACIC DUCT

• DURING LEFT NECK DISSECTION THE THORACIC DUCT IS AT RISK OF INJURY . IF

THERE ARE ANY CONCERNS IT IS GOOD PRACTICE AT THE END OF A NECK
DISSECTION TO LOWER THE HEAD AND PERFORM A VALSALVA MANOEUVRE TO
HOPEFULLY ASSESS FOR LATENT LEAKS.

• USUALLY MANIFESTS 24 TO 48HRS POST OP AFTER COMMENCING NG FEEDING.

• PATIENTS DEVELOP HYPOPROTEINAEMIA, HYPONATREMIA, HYPOCHLORAEMIA,

LYMPHOCYTOPAENIA AND AN OVERALL IMMUNOCOMPROMISED STATUS.

527
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

CHYLOMA COMPRESSING THE BRACHIAL

PLEXUS

MANAGEMENT OF CHYLE LEAKS

• NUTRITIONAL – MEDIUM CHAIN TRIGLYCERIDES

• MEDICAL
FREE VACUUM DRAINAGE AND OCTREOTIDE
• SURGICAL
AVOID IN THE FIRST PLACE!
RE EXPLORATION AND LIGATION
THORACOSCOPIC LIGATION

LOCAL MUSCULAR FLAPS

LYMPHANGIOGRAPHY – LOCALISATION OF CHYLE LEAK

528
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

SURGICAL COMPLICATIONS

“TRACHEOSTOMIES ALMOST DOUBLE THE RISK OF

OVERALL COMPLICATIONS”

DO WE NEED TO DO TRACHEOSTOMIES IN ALL OF

OUR PATIENTS?

Current Topics in Otorhinolaryngology - Head and Neck Surgery 2013, Vol. 12,
ISSN 1865-1011

CURRENT TOPICS IN OTORHINOLARYNGOLOGY - HEAD AND NECK SURGERY 2013, VOL. 12, ISSN 1865-1011

TRACHEOSTOMY RELATED
COMPLICATIONS
• BLEEDING
• LOCAL INFECTION

• EMPHYSEMA

• TRACHEITIS

• LRTI
• FISTULA FORMATION

• TRACHEAL STENOSIS

• CANNULA DISLOCATION, FALSE PASSAGE AND OBSTRUCTION

HALFPENNY W, MCGURK M. ANALYSIS OF TRACHEOSTOMY-ASSOCIATED MORBIDITY

AFTER OPERATIONS FOR HEAD AND NECK CANCER.BR J ORAL MAXILLOFAC SURG. 2000
OCT;38(5):509-12. DOI: 10.1054/BJOM.2000.0310

529
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

NERVES IN NECK DISSECTION

• SENSORY BRANCHES OF CERVICAL ROOTS- NUMBNESS AND TRAUMATIC

NEUROMAS

• GREATER AURICULAR NERVE- NUMBNESS AND TRAUMATIC NEUROMAS

• MARGINAL MANDIBULAR BRANCH OF FACIAL NERVE- WEAKNESS TO LOWER LIP (
HAYES MARTIN MANOUEVRE)
• SPINAL ACCESSORY NERVE- SHOULDER DYSFUNCTION
• LINGUAL NERVE- LOSS OF TASTE AND HYPO/PARAESTHESIA TO ANTERIOR 2/3RDS
OF IPSILATERAL TONGUE

• HYPOGLOSSAL NERVES-
• VAGUS NERVE- PROXIMAL INJURY CAUSES DYSPHONIA AND IPSILATERAL VOCAL
CORD PALSY. MORE DISTAL INJURY RESULTS IN LITTLE CLINICAL EFFECT.

• PHRENIC NERVE- ELEVATED IPSILATERAL HEMODIAPHRAGM.

NEURAL DAMAGE AFTER A SENTINEL

LYMPH NODE BIOPSY OF MELANOMA

530
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

INTERNAL JUGULAR VEIN COMPLICATIONS

• IJV THROMBOSIS OCCURS IN 15% OF PRESERVED IJV

• CAUSES:
NARROWING OF IJV – OFTEN DUE TO REPAIRING PUNCTURES, INFECTION, CENTRAL
VENOUS ACCESS, POLYCYTHEMIA, LOCAL MALIGNANCY

EFFECTS:
INCLUDE, SYSTEMIC SEPSIS, PAPILLEDEMA, AIRWAY EDEMA AND PULMONARY
EMBOLISM

Ascher E, Salles-Cunha S, Hingorani A. Morbidity and mortality associated with internal jugular vein thromboses. Vasc Endovascular Surg. Jul-Aug
2005;39(4):335-9.

BILATERAL IJV LIGATION

• VERY RARELY NEEDED

• RAISED INTRA-CRANIAL PRESSURE (ICP) OCCURS FOLLOWING BILATERAL IJV
LIGATION WITH SECONDARY SYSTEMIC HYPERTENSION (CUSHING'S REFLEX). THIS
RISE IN ICP COMMONLY REQUIRES AGGRESSIVE TREATMENT WITH
HYPERVENTILATION, FLUID RESTRICTION, STEROIDS AND MANNITOL. THE ICP
FREQUENTLY RETURNS TO NORMAL WITHIN 24 HOURS.

Magrin, J, Kowalski, L: Bilateral radical neck dissection:

Results in 193 cases. Journal of Surgical Oncology 75: 232-240, 2000

Ensari et al, Turkish Neurosurgery 2008, Vol: 18, No: 1, 56-60

531
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UPPER END JUGULAR BLEEDING

(FOGARTY’S)

CAROTID BLOW OUT

• WITHIN THE IN-PATIENT SETTING, THIS IS ASSOCIATED WITH OVER 60% MORBIDITY
AND 50% MORTALITY. NEUROLOGICAL SEQUAELAE OF EMERGENCY LIGATION
INCLUDE HEMIPLEGIA, HEMI-ANAESTHESIA, APHASIA AND DYSARTHRIA.

• IF IMPENDING BLOW OUT IS SUSPECTED (SENTINEL BLEED) ENDOVASCULAR

TECHNIQUES WITH STENT-GRAFTS MAY BE INDICATED RATHER THAN OPEN LIGATION
ALTHOUGH SHORT-TERM COMPLICATIONS STILL OCCUR.

Powitzky R, Vasan N, Krempl G, Medina J. Carotid

blowout in patients with head and neck cancer. Ann
Otol Rhinol Laryngol 2010;119:476-484.

532
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

CAROTID “BLOW-OUT”
PROTOCOL FOR MANAGEMENT
UPILE ET AL EUR ARCH ORL 2005

• SURGERY VERSUS ENDOVASCULAR STENTING!! –

• MAINTAIN PRESSURE TO CONTROL BLOOD LOSS
• MAINTAIN NORMOTENSION >60 MMHG
• MAINTAIN HAEMOGLOBIN >10G/100ML
• MAINTAIN O2 SATURATION >95%
• PROXIMAL AND DISTAL LIGATION
• DEBRIDEMENT AND WOUND IRRIGATION -- ?? MALIGNANT
• CLOSURE OF SALIVARY FISTULA
• CLOSURE OF EXPOSED ARTERIES – “NEW VIABLE TISSUE”

PNEUMOTHORAX

• THIS MAY OCCUR WHEN WORKING LOW IN THE NECK PARTICULARLY IF THE LUNG
APEX IS HIGH AS MAY OCCUR IN OVER INFLATION SECONDARY TO INADVERTENT ONE-
LUNG INTUBATION.

• ANY TEARS IN THE PLEURA SHOULD BE CLOSED AND THEIR INTEGRITY TESTED BY
HYPERINFLATING THE LUNG, PLACING THE PATIENT IN THE TRENDELENBURG POSITION
AND IRRIGATING THE AREA WITH CLEAR FLUID TO OBSERVE BUBBLES.

• ON TABLE IMAGING MAY BE NECESSARY TO DETERMINE THE NEED FOR OPEN CHEST
DRAINAGE.

• BEWARE THE PECTORALIS MAJOR HARVEST!

533
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

LARYNGEAL
NEOPLASM
BAROTRAUMA-
AUTO PEEP

PNEUMOTHORAX SECONDARY TO NECK

SURGERY

534
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

PECTORALIS WOUND DEHISCENCE

SALIVARY CUTANEOUS FISTULA

• ASPIRATION -- PNEUMONIA
• ANAEMIA
• CHRONIC LOCAL INFECTION
• INCREASED HOSPITALIZATION
• RISK OF CAROTID RUPTURE
• MORBIDITY AND DEATH

Management of salivary flow in head and neck cancer patients–a systematic review
SR Bomeli, SC Desai, JT Johnson, RR Walvekar - Oral oncology, 2008 - Elsevier

535
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

SHOULDER DYSFUNCTION

• SHOULDER DYSFUNCTION REFERS BOTH TO IMPAIRED MOBILITY IN THE SHOULDER

JOINT AND TO PAIN IN THE SHOULDER REGION AFTER NECK DISSECTION. THIS IS
INDUCED BY INJURY TO THE ACCESSORY NERVE, LEADING TO DENERVATION OF
THE TRAPEZIUS MUSCLE.

• THIS LEADS TO PROBLEMS IN DAILY ACTIVITIES AND A REDUCED QUALITY OF LIFE

• EARLY PHYSIOTHERAPY - THE TECHNIQUES THAT ARE USED ARE, FOR EXAMPLE,
PROGRESSIVE RESISTANCE EXERCISE TRAINING AND PREVENTIVE EXERCISES TO
MAINTAIN SHOULDER MOBILITY AND STRENGTH.
LAUCHLAN DT, MC CAUL JA, MC CARRON T, PATIL S, MC MANNERS J, MC GARVA J. AN EXPLORATORY
TRIAL OF PREVENTATIVE REHABILITATION ON SHOULDER DISABILITY AND QUALITY OF LIFE IN PATIENTS FOLLOWING
NECK DISSECTION SURGERY. EUR J CANCER CARE (ENGL) 2010.

LYMPHOEDEMA
• EDEMA IN THE HEAD AND NECK REGION CAUSES A DULL PAIN AND FACIAL
DISFIGUREMENT, AND IN EXTREME CASES LIPS AND EYELIDS CAN BE SO
SWOLLEN THAT VISION AND EATING IS IMPAIRED . LYMPHEDEMA THERAPY
CONSISTS OF SEQUENTIAL MANUAL LYMPHATIC DRAINAGE OF THE EDEMATOUS
REGION

• THE EFFECT OF MANUAL THERAPY FOR LYMPHEDEMA IS POORLY EVALUATED IN

HEAD AND NECK CANCER PATIENTS AND THERE IS A NEED FOR PROSPECTIVE
STUDIES AND CLEAR DEFINITIONS OF DIFFERENT LEVELS OF EDEMA

SMITH BG, LEWIN JS. LYMPHEDEMA MANAGEMENT IN HEAD AND NECK CANCER. CURR
OPIN OTOLARYNGOL HEAD NECK SURG 2010;18:153-158.

536
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

PALATAL VASCULAR LESION AND FISTULA

Exposed Hardware

537
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TRAUMATIC NEUROMA

Traumatic Neuroma after Neck Dissection: CT ...

www.ajnr.org/content/21/9/1676.ful
Br J Oral Maxillofac Surg. 2000 Oct;38(5):537-8.
Amputation neuroma of the great auricular nerve after operations on the parotid gland.
Moss CE1, Johnston CJ, Whear NM.

KELOID AFTER THYROID LOBECTOMY AND

NECK DISSECTION

538
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

TENDON EXPOSURE OF DONOR SITE ON

FIBULA AND RADIAL DONOR SITES

SURGICAL COMPLICATIONS

539
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

SURGICAL COMPLICATIONS

ANY IDEA HOW COMMON COMPLICATIONS ARE IN MAJOR H&N

SURGERY???

OVER 60%....
AND OVER 30% ARE CLAVIEN GRADE III AND ABOVE…

PERISANIDIS ET AL. BJOMS 2012

MCMAHON ET AL. BJOMS 2013

ENHANCED RECOVERY AFTER SURGERY

WHAT IS IT?

“ ERAS IS A COMBINATION OF INTERVENTIONS THAT AIM TO IMPROVE PATIENT’S OUTCOME

AFTER SURGERY”

AKA – FAST TRACK SURGERY

KEHLET – DENMARK, 1999

540
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

ENHANCED RECOVERY AFTER SURGERY

WHAT IS IT? - PATHOPHYSIOLOGY

“THE PATHOPHYSIOLOGICAL BASIS IS THE ATTENUATION OF THE SYSTEMIC INFLAMMATORY

RESPONSE SYNDROME (SIRS) THAT ACCOMPANIES ALL MAJOR SURGERY”

ENHANCED RECOVERY AFTER SURGERY

WHAT IS IT NOT?

“NOT EASY TO IMPLEMENT…”

541
 Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

ENHANCED RECOVERY AFTER SURGERY

POTENTIAL BENEFITS
FOR THE PATIENT

• RAPID RECOVERY
• EARLIER DISCHARGE – RETURN TO WORK – SOCIAL LIFE, LESS EXPOSURE TO HAI
• FEWER COMPLICATIONS – READMISSIONS
• PROCEED FASTER TO NEXT PART OF TREATMENT (I.E. ADJUVANT RTX IN H&N CANCER PATIENTS)
• PART OF THE PROCESS – “PARTNER IN HIS/HER CARE” – ACTIVE PATIENT INVOLVEMENT
• OVERALL IMPROVED SATISFACTION AND EXPERIENCE
• MORE COMPLIMENTS, LESS COMPLAINTS, REDUCED LITIGATION
• PATIENT REPORTED OUTCOME MEASUREMENTS - PROMS

ENHANCED RECOVERY AFTER SURGERY

POTENTIAL BENEFITS
FOR THE STAFF
• TEAM BUILDING OPPORTUNITIES

• MULTIDISCIPLINARY WORK
• EDUCATION – RESEARCH – TRAINING
• ACHIEVE NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (NICE) STANDARDS FOR H&N
CANCER

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ENHANCED RECOVERY AFTER SURGERY

- HAPPIER PATIENTS!

POTENTIAL BENEFITS
FOR THE HOST TRUST
• REDUCTION IN HOSPITAL STAY – HAPPIER PATIENTS AND REDUCE COST
• REDUCTION IN COMPLICATIONS – HAPPIER PATIENTS AND REDUCE COST
• REDUCTION IN BED/DAYS (INCLUDING ICU + HDU), THEATRE SLOTS (WITH REDUCTION OF CLAVIEN III
COMPLICATIONS) – HAPPIER PATIENTS AND REDUCE COST

• INCREASE CAPACITY (TREAT MORE PATIENTS WITH THE SAME RECOURSES) – INCREASE INCOME
• ATTRACT OUTSIDE INTEREST DUE TO QUALITY – INCREASE INCOME
• MIPS AND MACCRA
• IMPROVE REPUTATION, INCREASE WORKING PARTNERS AND COLLABORATION
• REDUCTION OF COMPLAINTS – REDUCE LITIGATION – REDUCE COST
• REDUCE WAITING TIMES (FOR ADVANCED H&N CANCER, TIME FROM DIAGNOSIS TO TREATMENT IS RELATED
TO OUTCOME, POORER RESULTS IF LONGER THAN 3-4 WEEKS)

ENHANCED RECOVERY AFTER SURGERY IN

OTHER SPECIALTIES

Duration of stay Duration of stay

Type WORK?
DOESofIT Operation post ERAS pre - ERAS

Lung lobectomy 1-2 days 6-7 days

Prostatectomy 1-2 days 4-5 days

Colectomy 1-3 days 7-10 days
Aortic Aneurysm 3-4 days 7-10 days

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ENHANCED RECOVERY AFTER SURGERY

DOES IT WORK?

ENHANCED RECOVERY AFTER SURGERY

DOES IT WORK?
50% REDUCTION IN COMPLICATION RATES

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ENHANCED RECOVERY AFTER SURGERY

DOES IT WORK?
COLORECTAL SURGERY META-ANALYSIS

ENHANCED RECOVERY AFTER SURGERY

DOES IT WORK?
• TO SUM UP:
• ERAS IMPLEMENTATION
• REDUCES OVERALL COMPLICATION RATES

• REDUCES HOSPITAL STAY

• REDUCES COST
• NO INCREASE IN RE-ADMISSION RATES

• LEVEL I MEDICAL EVIDENCE (MA, RCTS)

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ENHANCED RECOVERY AFTER SURGERY

DOES IT WORK?
• COLORECTAL SURGERY
• HPB SURGERY
• UPPER GI SURGERY
• ORTHOPEDICS
• OBSTETRICS – GYNECOLOGY
• CARDIO-THORACIC SURGERY
• UROLOGY

K. Lassen et al. / Clinical Nutrition 31 (2012)

817e830
Arch Orthop Trauma Surg (2013) 133:117–124
DISEASES OF THE COLON & RECTUM VOLUME 56: 5
(2013)
World J Surg (2013) 37:285–305

ENHANCED RECOVERY AFTER SURGERY

HEAD AND NECK

AT A GLANCE………

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ENHANCED RECOVERY AFTER SURGERY

AT A GLANCE

ENHANCED RECOVERY AFTER SURGERY

HEAD AND NECK
THREE PILLARS

• PREOPERATIVE PREPARATION (THE PATIENT IS IN THE BEST POSSIBLE

CONDITION FOR SURGERY)

• PERIOPERATIVE CARE (THE PATIENT HAS THE BEST POSSIBLE MANAGEMENT

DURING AND AFTER HIS/HER OPERATION)

• POSTOPERATIVE CARE (THE PATIENT EXPERIENCES THE BEST POST-

OPERATIVE REHABILITATION)

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ENHANCED RECOVERY AFTER SURGERY

HEAD AND NECK

• PREOPERATIVE PREPARATION

• ACTIVE PATIENT INVOLVEMENT – PATIENT’S DIARY

• GP – PRIMARY CARE OR FAMILY PHYSICIAN
• ANESTHETIC ASSESSMENT
• ADMISSION

ENHANCED RECOVERY AFTER SURGERY

HEAD AND NECK

• PERIOPERATIVE CARE
• DURATION OF SURGERY
• TRACHEOSTOMIES
• FLUID REPLACEMENT
• PRESSURE CARE – TEMPERATURE CONTROL
• STEROIDS
• ANTIBIOTICS
• ANALGESIA – ANTIEMETIC'S
• WOUND CARE
• THEATRE ETIQUETTE

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ENHANCED RECOVERY AFTER SURGERY

HEAD AND NECK

• POSTOPERATIVE CARE
• ENTERAL FEEDING
• MOBILIZATION
• REMOVAL CATHETER/LINES/TRACHEOSTOMIES
• ANALGESIA/DVT PROPHYLAXIS/DT
• WOUND CARE
• LABS – PATHOLOGY REPORT
• PLANNED DISCHARGE
• FOLLOW UP

REFERENCES

• KERAWALA CJ, HELIOTOS M. PREVENTION OF COMPLICATIONS IN NECK

DISSECTION. HEAD NECK ONCOL 2009;1:35.

• POWITZKY R, VASAN N, KREMPL G, MEDINA J. CAROTID BLOWOUT IN

PATIENTS WITH HEAD AND NECK CANCER. ANN OTOL RHINOL LARYNGOL
2010;119:476-484.
• PROCTOR E, ROBBINS KT, VIEIRA F, HANCHETT C, SOMMES G.
POSTOPERATIVE COMPLICATIONS AFTER CHEMORADIATION FOR ADVANCED
HEAD AND NECK CANCER. HEAD NECK 2004;26:272-277.

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Complications in the
Management of Maxillofacial
Trauma

David B. Powers, DMD, MD, FACS, FRCS (Ed)

Associate Professor of Surgery
Director, Duke Craniomaxillofacial Trauma Program
Duke University Medical Center

Disclosure

Dr. Powers has nothing to disclose

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Question
•The most common cause of
complications in the management
of mandibular fractures is:
• Patient compliance

• Injury complexity

• Operator error

• Resistant bacteria

• Hardware failure

Most Common Cause

• Surgeon/Operator

• Error in:
• Diagnosis

• Judgment

• Technique

• Recognition
• Response

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History

• Otto von Bismarck

• “Only a fool learns from his own mistakes

…. A wise man learns from the mistakes
of others”

Outline
•Common complications
• Bony

• Malunion

• Fibrous union

• Nonunion

• Delayed union

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Outline
•Common complications
• Soft tissue

• Trismus

• Ptosis

• Iatrogenic

• Fracture of dentition

• Nerve injury

Complication Terminology

•Malunion
• Successful union that is misaligned

• Malocclusion

• Deformity

•Fibrous union
• Mobility between healed segments

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Complication Terminology

•Non-Union
• Completely failed healing between
segments

• Pseudoarthrosis

•Delayed union
• Fracture has not healed in expected time
frame

Origin of Complications

•Failure to plan
• Errors in diagnosis

• Missed/misinterpreted clinical
examination findings

• Radiographic evaluation

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Origin of Complications

•Errors in application of treatment

• Improper technique

• Inadequate fixation

• Plate too small

• Plate bent incorrectly

Complications
•Brian Alpert, DDS, FACS
• Complications of injury vs. complications of
treatment

• “Treatment is supposed to overcome the

complications of injury”

• “We treat to overcome the complications

of injury, not to introduce new ones”

• “Rigid fixation is not forgiving. It will NOT

self-correct. It remains a rigidly fixed
mistake”

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Mandible Fractures and Incidence of Morbidity

Most Angle and posterior body

Mandibular body

Symphyseal region

Least Edentulous areas of the jaw

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Avoid the OIF!!

•OIF
• Open

• Internal

• Fixation

•You never got around to that whole

reduction part

How to Avoid OIFs:

•Adequate preoperative x-rays
• Spiral/Fine-cut CT scans with multiple
view/3-D reconstruction

•Visualization and wide exposure

of all fractures
•Don’t begin plating until all of
the fractures are exposed

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Maxillomandibular Fixation
•Erich Arch Bar
•Ivy Loop
•Embrasure wires
•Surgical Pins
•Composite and Light Cured
Resins

Temporary Fixation
•Bridle wire
•Gilmer Wire
•Ernst Ligature
•Risdon Wire
•Stout Wire
•External fixator
•Barton bandage

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Bone Anchored Arch Bars

•Concept designed initially by

Jeffrey Marcus, MD
• Monocortical screw fixation

• Allows for the establishment of a posterior

occlusal stop without displacement of the
condylar head

Bone Anchored Arch Bars

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Bone Anchored Arch Bars

• Knowledge of dental anatomy is still a prerequisite

for use
• Difficult to utilize and position on a
mobile/comminuted dentoalveolar table
• Recommend removal of unused surgical lugs
• Fibrous tissue overgrowth
• Uncomfortable for patient removal if this occurs
• Can loosen over the course of prolonged fixation
due to monocortical screw application

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Erich Arch Bars

•Mainstay of treatment for comminuted
and disrupted occlusal table
•Relatively inexpensive
•Time consuming
• Roughly 1 minute per tooth

• Experience level

•Risk of needle stick

Arch bars below the height of contour of the teeth have mechanical resistance to
displacement and are more likely to remain tight

Arch bars at or above height of contour of the teeth have no mechanical

resistance to masticatory forces and will loosen

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Occlusal Splints

•Use of occlusal splints without a

fixed skeletal reference can be
confusing
• Establishment of occlusion does not
correlate with facial projection

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Over-Tightening of MMF

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Surgical Pins

•Various commercial brands

• Essentially same concept

• May be used for long term fixation

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Remember average tooth lengths:

Maxillary canines - 27 mm
Maxillary molars - 19.5 mm
Mandibular central incisors - 22mm
Mandibular lateral incisors - 24 mm
Mandibular canines - 26 mm

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Intermaxillary Fixation Screws

•Complications
• Positioning of screws often negates
effective plating of maxillary fractures

• Predisposes to anterior establishment of

occlusion with distraction of the posterior
dentition

• Odontogenic trauma

Complications
•Nerve injury
• Over-reliance on nerve stimulators

• Operate by anatomic plane

• Pre-existing injury

• Iatrogenic injury

•Scar
• George Kushner, MD, DMD, FACS

• “There is no scar like no visible scar”

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Powers Corollary …..

•“I didn’t make it, but I’m going to take it”

Panfacial Fractures
•Complex and contiguous fractures of the
mandible, midface, and/or the cranial vault
•Mechanisms
• Usually high energy

• High speed motor vehicle collisions

• Gunshot wounds

• Blast injuries

• Falls from great height

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Panfacial Fractures

•No single recipe for successful

treatment
•Principles of management

Remember the Predator Effect …..

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The Predator Effect

Panfacial Fractures
•Anatomic considerations
• Cranium

• Frontal sinus

• Midface

• Orbits

• Zygoma

• Maxilla

• Nose

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Panfacial Fractures

•Anatomic considerations
• Mandible

•Remember high association with

other injuries

Panfacial Fracture
•Face is a 3-D structure projecting
from the cranial base
•Functions:
• Protective (“Bumpers”)

• Eyes

• Brain

• Cranial base/spine

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Panfacial Fracture
•Functions:
• Masticatory

• Airway

•Skeletal structure lends support to

external soft tissue drape
•Skeletal support organized in
horizontal and vertical buttresses

Surgical Anatomy

•Width
•Height
•A-P Projection

Markowitz BL, Manson PN. Panfacial fractures: Organization of treatment. Clin Plast Surg 1989;16:105-114.

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Biomechanics
•Upper third: NOSE

•Middle third: CHEEKS

•Lower third: CHIN

Biomechanics

•Two Craniofacial Buttresses

• Horizontal & Anterior-Posterior

• Vertical

Phillips et al.: Le Fort Fractures. In J. Prein (Ed.) AO Manual of internal fixation in the craniofacial skeleton. New York: Springer-Verlag, 1998; 108-126.

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Biomechanics
•Horizontal
•Anterior-Posterior
• Temporal arch

• Frontal bar

• Orbital rims

• Malar prominence

• Horizontal ramus of mandible

Phillips et al.: Le Fort Fractures. In J. Prein (Ed.) AO Manual of internal fixation in the craniofacial skeleton. New York: Springer-Verlag, 1998; 108-126.

Biomechanics
•Vertical
• From dental plane to skull base

• Frontal-Naso-Maxillary (Medial)

• Zygomatic-Maxillary (Lateral)

• Pterygo-Maxillary (Posterior)

• Mandibular Ramus and Condyle

Phillips et al.: Le Fort Fractures. In J. Prein (Ed.) AO Manual of internal fixation in the craniofacial skeleton. New York: Springer-Verlag, 1998; 108-126.

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Biomechanics
•Facial Units
• Upper Face

• Cranial unit

• Midface unit

• Lower Face

• Occlusal unit

• Mandibular unit

Phillips et al.: Le Fort Fractures. In J. Prein (Ed.) AO Manual of internal fixation in the craniofacial skeleton. New York: Springer-Verlag, 1998; 108-126.

Panfacial Fractures

•Classic fracture patterns across the

midface
•Isolated LeFort fractures are rare

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Panfacial Fractures
•Buttresses disrupted in panfacial
fractures
•Comminution
•Masticatory forces cause migration
of fragments to assume a less
angular shape
•Characteristic spherical/round
facial shape

Panfacial Fractures
•Aesthetic goals:
• Restore facial angularity and shape

• Restore vertical height

• Restore horizontal width

• Restore anterior projection

•Knowledge of the predictable

anatomy of skeletal buttresses
• Roadmap to success

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Panfacial Fractures
•ABC’s
•C-spine evaluation and stabilization
•Physical exam:
• GCS/CNS exam

• Dentition

• Occlusion

• Visual acuity/Ocular exam

• Enophthalmos and/or Vertical dystopia

• Facial height, width, projection

Panfacial Fractures
•CT Scan
• Entire maxillofacial region

• Axial and coronal

• Thin cuts through orbit and midface

• Spiral

• 3-D reconstruction

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Panfacial Fractures
•Plain films
• Mandible

• Orthopanogram

• May be unattainable

•Cervical spine series

• CT vs. conventional

Do not compromise your analysis

of the fractures, and your plans
for fixation, by accepting suboptimal
radiographs!

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Panfacial Fractures
•Considerations:
• Timing of definitive treatment

• Documentation of pre-existing injuries

• Paresthesia/Anesthesia

• Visual Acuity

• Epiphora

• Anosmia

Panfacial Fractures
•Considerations:
• Surgical exposure

• Reduction

• Sequence of Fixation

• Primary bone grafting

• Soft-tissue re-suspension

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Panfacial Fractures
•Early definitive treatment (24 to 72 hours) optimal
• Stabilize patient

• Acute neurosurgical and ophthalmologic issues take priority

• Stable head injury patients can tolerate prolonged anesthesia

as long as ICP maintained below 25 mm Hg

• Less soft tissue contracture

• Critical for soft tissue correction of NOE fractures with

telecanthus

•Other intra-operative pearls

• Controlled hypotension

Panfacial Fractures
•Subunit principle
•Repair subunits as a priority –
“simplifies” the fractures
• Cranial-orbital subunit is repaired independent to
the lower face

• Maxillo-mandibular subunit is repaired

independent to the upper face

• Complex patterns simplified to the LeFort I level

• Minor discrepancies in reduction unavoidable –

camouflage these at this LeFort I level

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Where do we begin?

Maxillo-Mandibular unit

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Panfacial Fractures
•Start with whichever arch is least
disrupted to establish your
foundation
• Historically the mandible due to larger
segments

• If the patient has an injury that completely

disrupts the mandible with minimal injury to
the mid face - perform mid facial
reconstruction first

Maxillo-Mandibular unit

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The mandible is key in re-establishing

the height of the face

Consider being more aggressive about

addressing a subcondylar fracture

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Consider being more aggressive with addressing subcondylar fractures

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Panfacial Fractures

•Cranio-orbital subunit repair

• Inside – Out approach (Paul Manson, MD) for the
cranio-orbital subunit
• Priority is the naso-orbito-ethmoid complex restoration and
correction of telecanthus

• Work laterally toward orbital rims and zygomas

Panfacial Fractures
•Cranio-orbital subunit repair
•Outside – In approach (Joe Gruss, MD) for
the cranio-orbital subunit

• Lateral orbital rim and zygomatic arch first

• Work centrally to the nasal root

• Accurate Zygomatic-sphenoid reduction

facilitates repair

• Zygomatic arch reduction facilitates accurate

restoration of facial width and projection

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Reduce the fracture between the Zygoma

and the Greater Wing of the Sphenoid

Do you need to expose the zygomatic arches

through the coronal incision?

Medial Columns

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Lateral Columns

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Forced Duction

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NOE
•“Bow-StringTest”
(medial canthal tendon integrity)
• Place the thumb or index finger over the
medial canthus/nasal root and apply lateral
tension to the upper and/or lower lid

• A lax MCT is diagnostic of a NOE complex

fracture

NOE Reduction
•Key to reduction is Central Fragment
and medial canthal tendon
•Challenging reduction
• Most common error is being too anterior with
transnasal wiring

•Technically difficult fixation

•Tendency for recurrent telecanthus
•Persistent midfacial or nasal retrusion
can be common post-operatively

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NOE fracture repair

•Closed reduction and transnasal
wiring
•ORIF via limited open approach
using Lynch incision, horizontal
nasal or “gullwing” incision
•ORIF via existing wounds
•ORIF via bicoronal, sublabial,
midfacial degloving or other hidden
incision technique

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Type III
Management

Technological Advances

•Medical modeling
•Titanium barb on wire
•Radiology
•Pre-formed plates

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Canthal Detachment
•Technically challenging
procedure in experienced hands
•Product development leads to
increased efficiency
• Resident training

• Frequency of surgical provider exposure

to trauma

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O-Arm

Cere-Tom®

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Soft Tissue Management

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Tissues become ptotic without anatomic support

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Fat Repositioning

Lessons Learned
•It is a critical error to rush the
patient immediately to the
operating room without a
comprehensive pre-operative
evaluation
• 3-D Radiographs

• Stereolithography models

• Surgical access

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Lessons Learned
•A logical, sequential treatment
plan is more important than a
dogmatic approach
•Anatomical changes
• Blast effect

• Tissue viability

•Necessary medical/dental
consultations

Steps of Treatment
• Use the uninjured cranial base as the • Maxillo-Mandibular subunit is repaired
foundation upon which to rebuild the facial independent of the upper face
skeleton
• Repair the least disrupted dental archform
• Apply the “sub-unit” principle of repair first

• Cranio-Orbital subunit is repaired • Becomes template for reconstruction

independent of the lower face
• Convert a complex panfacial fracture pattern
• Lateral wall of the orbit is valuable site to into simplified LeFort I
evaluate malar component
• Consolidate and camouflage malreduction at
• Arch is the key for facial width and projection the LeFort I level

• Mostly straight along its length with • Place fixation hardware at sites of bony
slight curvature near buttress
zygomaticomaxillary suture
• Resuspension of soft tissue envelope

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Conclusions
•All surgeons make errors
• If you claim none ….

• You have not done enough cases

• You do not see your post-ops

•Most common error in management of complications

• Trying to do the least invasive treatment

•Aggressive, yet clinically appropriate, management

of complications reduces overall morbidity
•Be honest with yourself and acknowledge your errors
and take corrective action both now and in the future

Summary
• Infection, Delayed Healing, Non-Union

• Larger plate

• Bone graft

• Malunion, Malocclusion

• Dentofacial deformity

• Trismus

• Gain and maintain function

• Iatrogenic injuries

• Attention to detail

• To paraphrase von Bismarck…..

• “Be wise”

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Complications in TMJ Surgery

Pushkar Mehra, DMD, MS, FACS

Eber Stevao, DDS, PhD

Disclosure
Dr. Mehra and Stevao reports no
relationships with a commercial interest.

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Temporomandibular Joint Disorders

(TMD)

Symptoms associated with pain related to head and

neck musculature and Temporomandibular Joints
(TMJ)

Role of occlusion, parafunction, dentofacial

deformities, and psychosocial factors

Common TMD Presentation

• Pain (intra-articular)
• Myofascial pain and spasms
• Decreased joint mobility
* Open and Closed Locks
• Clicking and Popping
• Crepitus

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Other factors affecting TMD

• Gender
• Age
• Medical history
* autoimmune/connective tissue diseases
• Wilkes staging

Spectrum of TMJ Surgery TT

Minimally Invasive
Arthrocentesis (lavage)
Arthroscopy

Open Joint Procedures

Arthroplasties
Disc-related surgery
Total Joint replacement

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Prevention of Complications

Appropriate (scientific) knowledge

Adequate skills (surgical)
“Experience”

Wrong Diagnosis - Incorrect Surgery

Large Condyle
Osteochondroma
Bulbous, pedunculated or sessile mass
Slow growing
Can continue to grow into middle to late age

Condylar Hyperplasia
Usually teenage females
Long and elongated condyles
Likely to burn out - teenage or early second decade

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Surgical Options

• High Condylectomy
• Condylar Hyperplasia

• Low condylectomy

• Complete condylectomy
• Osteochondroma

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Wrong Diagnosis - Incorrect Surgery

Small Condyle
Congenital and developmental conditions
Condyle vs. Condyle-Ramus unit
Associated facial asymmetry
Variable joint function
e.g.: Hemifacial macrosomia
Degenerative joint disease (Arthritides)
Flattening, joint space narrowing, osteophytes, etc.
Condylar Resorption

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Wrong Diagnosis - Incorrect Surgery

Decreased mouth opening

Closed-lock type clinical picture
TMJ intra-articular conditions
Ankylosis
Fibrous or Bony
Extra-articular conditions
Muscle disorders
Coronoid hyperplasia
Zygomatic arch impingement

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Wrong Diagnosis-Incorrect Surgery

Increased mouth opening

Chronic dislocation
Condyle out of fossa on CT scan
> normal mouth opening
Needs professional reduction

Open lock
Condyle within fossa
< or normal mouth opening
Self-reducing

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External Auditory Canal Puncture

•Auricle
•Tympanic membrane (TM)

Note : TM separates EAC from the Middle Ear

Possible consequences
• Canal laceration and bleeding
• Cholesteatoma
• TM perforation
• Otitis media
• Otorrhea
• Ossicle disruption
• Conductive hearing loss
• Vertigo

Management of EAC Complications

Minor bleeding
• warm saline irrigation and packing

Severe bleeding
• Oxymetazoline drops during the procedure, followed by Ofloxacin drops
(5 drops, twice daily for 5 days)

• Optional: Steroid (Dexamethasone) (4 drops, twice daily for 5 days)

Note: TMJ surgery can usually be completed in same setting

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EAC Laceration

Simple puncture
•Primary or no repair of laceration

•Packing
• Xeroform gauze, Gelfoam or Ear wick packing to
minimize hematoma formation with antibiotic
(+/- steroid) eardrops
Note: Remove packing after 2-3 days and re-examine

Most heal uneventfully but infection, granuloma formation, epithelial

inclusion cyst formation can occur

Tympanic Membrane Perforation

* 80% heal spontaneously in 4-6 weeks with antibiotics and water

precautions
• Size (>50%, age, infection) can adversely affect healing

• If ossicles are disrupted:

• Temporal bone CT scan may be needed
• Surgical repair is required

Note: untreated injuries can result in permanent fibrous fixation of the ossicles and
conductive hearing loss

Recommendation: Intraoperative ENT consultation

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Acute Otitis Media

• Systemic antibiotics- Sulfa or Amoxicillin for respiratory flora

• Pseudomonas and Staph coverage may be needed

• Water precautions

• Audiometry for quantitative evaluation hearing loss

Usually none to mild; if severe loss encountered, ossicle injury should
be suspected

• Refractory infections and large perforations may need

surgical repair

Consider Tympanoplasty vs. Hearing aid device

Middle Fossa Perforation

• Bleeding from meningeal vessels, dural tear with CSF leak, and
damage to the temporal lobe itself can result

• Intraoperative neurosurgical consultation mandated

• CSF leaks may be easier to see in open joint surgery as compared

to arthroscopy due to continuous fluid irrigation

• Intracranial bleeding is the main concern which can cause

increased ICP leading to brain compression

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Middle Fossa Perforation

•Glenoid fossa bone perforation alone

• Establish a neurosurgical monitoring protocol
- ICU admission
- CT scan baseline to rule out intracranial bleeding
- Repeat CT scan every 6 hours (if neurological deficits noted)
- Postoperative antibiotics not needed if no dural tears

•Bleeding
• Extradural/Subdural Hematoma formation depending on
whether the dura is intact or not
- Neurosurgery consult and follow-up
- ICU admission

Dural Tear / CSF Leak

Neurosurgical monitoring and baseline CT scan are

required to rule out intracranial bleeding

- Intraventricular catheter may be needed

- Lumbar drain may be required
- Antibiotics are usually prescribed

- Small tear
- Can seal with fibrin glue and local hemostatic agents

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Hemorrhage

• Vessels encountered during TMJ procedures

• Facial artery, internal maxillary artery, temporal
artery, temporal vein, facial vein,
retromandibular vein, and external jugular vein

• Hemorrhage can happen either

intraoperatively (more common) or
postoperatively

• Expanding hematomas can lead to airway

compromise and potentially make
reintubation difficult

Strategies for Prevention of

Hemorrhage

• Comprehensive screening for congenital and/or

acquired coagulopathies in high-risk patients

• Hypotensive anesthesia

• Angiography
• CT angiogram is beneficial in ankylosis cases and multiply
operated patients

• Intraoperative Navigation

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Management of Acute Hemorrhage

• If vessel is identifiable, ligation controls proximal and
distal bleeding

• If not visible, pack the wound with local hemostatic

agents (e.g.: Surgicel, Avitene, Topical thrombin and
gauze)

• Bimanual digital pressure is very useful for internal

maxillary artery

• Secure airway

• Baseline hematological investigations

Management of Acute Hemorrhage

• Consider need for blood (derivatives, products)

transfusion

• Electrocautery is useful only for very small vessels

• Possible External Carotid Artery (ECA) ligation

• For stable patients, embolization under angiography is

the gold standard

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Effect of External Carotid Ligation

• Ligation above the:

lingual artery 40% of blood flow

facial artery 73% of blood flow

posterior auricular artery 99% of blood flow

* 24% mean blood flow comes from collateral distal segment

Rosenberg I. et al. The effect of experimental ligation of the external carotid artery and its major branches
on hemorrhage from the maxillary artery. Int J Oral Surg. 1982;11:251.

Facial Nerve Injury

Occurrence

*12-32% with most resolving in 2-6 months

Prevention

1. Proper surgical incisions and approach

2. Facial nerve monitoring

*Active or Passive

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Management of Facial Nerve Injury

Step 1:

Evaluate facial nerve dysfunction

Grade Description Characteristics

I Normal Normal facial function

At rest: Normal symmetry and tone
II Mild Forehead motion: Moderate to good
Eye motion: Complete closure with minimum effort
Mouth motion: Slight asymmetry

At rest: Normal symmetry and tone

III Moderate Forehead motion: Slight moderate
Eye motion: Complete closure with effort
Mouth motion: Slightly weak with maximum effort

At rest: Normal symmetry and tone

IV Moderately severe Forehead motion: None
Eye motion: Incomplete closure
Mouth motion: Asymmetric with maximum effort

At rest: Asymmetry
V Severe Forehead motion: None
Eye motion: Incomplete closure
Mouth motion: Asymmetric with maximum effort

No movement
VI Total paralysis

Electrodiagnostic Testing (EDT)

NET (Nerve excitability threshold): face observed for lowest DC current

which produces a twitch

MST (Maximum stimulation test): similar to NET but differentiates for

strength and amount of contraction

ENoG (Electroneurography): adds ability to record facial muscle action

potential

EMG (Electromyography): measures muscle action potential generated

by spontaneous and voluntary action.
Note: 80% accuracy in predicting poor outcomes 10-14 days after injury

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Indications for
Surgical Exploration and/or Repair
No set guidelines
Affected by factors such as age, medical co-morbidities, and patient
motivation

Denervation is likely when electrical activity is increased and spontaneous

fibrillation potentials develop - this may prompt surgical exploration

Sunderland classification (5 classes of injury) is another helpful tool which

when used with EDT may help guide decision-making

Class I – No axonal discontinuity

* no voluntary movement but twitching elicited by
testing distal to site of injury
* no benefit from surgery

Non-Surgical Management

• Cornea protection
• artificial tears 5-10 times/day with ophthalmic ointment
at night
• Use of moisture chamber and patch taping

• Physical Therapy
• massage, electrical nerve stimulation, surface
electromyography (mirror biofeedback), repetition of
common facial expressions

• Botulinum toxin
• treat orbicularis oculi spasms, inject into contralateral
frontalis muscle to mask ipsilateral frontalis weakness,
improve ipsilateral lacrimation by injecting into gland

• Facial makeup to mask facial imbalance

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Surgical Management

Zygomatic, buccal and marginal mandibular branches

• Primary nerve repair
• Cross-face grafting
• Cable grafting
• Regional muscle transposition
• Free muscle flaps
• Hypoglossal-facial nerve transfer

Temporal branch
• Supplemental static facial procedures
• Upper lid gold weight
• Browlift (unilateral for younger and bilateral for elderly pts)
• Blepharoplasty,
• Eyelid spring, Silastic loop
• Lower lid shortening and repositioning procedures

Auriculotemporal (Frey) Syndrome

Affected patients have sweating and flushing of the skin along the
distribution of the injured Auriculotemporal Nerve (ATN) during
mastication

Most common after parotid surgery

Management:
• Mapping of the affected area

• Minor Starch-Iodine test- qualitative test to evaluate sudomotor

function (gustatory sweating)
Note:

1. Some studies have shown that the use of an endaural incision for TMJ surgery effectively avoids
Frey Syndrome

2. Preauricular approach leads to temporary AT paresthesia in 14% of cases

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Management of
Auriculotemporal Syndrome

Patients who are not concerned

* No treatment required

Patients desiring conservative treatment

* Antiperspirant deodorants
* Topical anticholinergics (e.g.: scopolamine)
* Botolinum toxin type A – 0.5 to 2.5 units delivered at the level
of the superficial dermis within 5 mm radius
* Botolinum toxin type B – for patients who develop resistance to type A

Patients desiring surgical treatment

* Flaps (e.g.: SMAS, sternomastoid, temporoparietal fascia) which act as a
physical barrier to prevent sympathetic and parasympathetic fibers
connection
* Acellular implant placement (e.g.: Alloderm)

Postoperative Malocclusion

Minor Occlusal discrepancies

Orthodontic or Prosthodontic evaluation and treatment
should be considered

Major Occlusal discrepancies

Repeat TMJ or orthognathic surgery may be indicated. In
patients who received total joint alloplastic replacement,
revision of the prosthesis is often required

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Continued Pain after Surgery

• Persistent pain (lasting greater than 6 months)

• May be caused by neural injury during TMJ
surgery
• 35% pts with peripheral trigeminal nerve injury
will develop chronic pain
• 23-45% seeking treatment due to trigeminal
nerve injury will develop painful dysesthesia

Continued Pain after Surgery

• Diagnostic approach
• Patient complains
* Anesthesia
* Hypoesthesia
* Dysesthesia – spontaneous or provoked
• Time course and inciting injury
• Neurosensory test – Magnetic Resonance neurography

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Continued Pain after Surgery

Post-operative pain Subacute pain Chronic pain
(< 1 month) (1-3 months) (> 3 months)

Comprehensive H&P Comprehensive H&P Refer to pain

specialist
Limit opioids where possible Screen patients
(NSAIDS, neuromodulating drugs
Screen patients needing opioids Opioid trial
after 2 weeks
Opioid naive < 50 mg MED Opioid naive < 50 mg MED

D/C opioid if functional Opioid contract

recovery complete
Opioid naive Random drug screening
D/C with no taper

Management of
Heterotopic Bone/Ankylosis

•Excess bone formation around joints

•Causes pain and interferes with jaw function,

mastication, speech, oral hygiene, growth/development,
breathing, and normal life activities

•Patients predisposed to this condition include those with

history of TMJ trauma, reactive arthritis, osteoarthritis,
connective tissue/autoimmune disease,
endocrine/metabolic disorders, multiple operated joints,
foreign-body giant-cell reaction, repeated TMJ steroid
injections, unsuccessful previous TMJ autogenous grafts
and alloplastic implants

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Treatment options for non-TJR

Re-Ankylosis and Postsurgical
Hypomobility Patients

• Conservative Management
• Physical Therapy
• Brisement procedure
• Low dose radiation
• Medications (e.g.: Indomethacin, Etidronate)

• Surgical Management
• Open TMJ surgery
- Bone debridement and interpositional grafting with
muscle, fascia, fat
- Coronoidectomy (unilateral or bilateral)

Infection after TMJ Surgery

Prevention of Infection

Preoperative considerations
Nutrition, Systemic disease control, Smoking, Pre-existing
remote site infection

Perioperative considerations
Skin preparation, Antibiotic Prophylaxis, Contamination from
various sites

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Infection

Microbiology found in TMJ prostheses infections

• Coagulase-negative Staphylococcus
• Propionibacterium acnes
• MRSA
• Serratia sp.
• Peptostreptococcus sp.

Microbiology found in infections after TMJ procedures

other than TJR
* Klebsiella pneumonae
* Pseudomonas aeruginosa

Note: Negative cultures do not always preclude joint infection

Treatment of Postsurgical Infection

• After non-TJR Surgery

• Follow standard guidelines for postsurgical infections
• Removal of cause
• Empiric or culture-directed antibiotic therapy
• Incision and drainage, if required

•After TJR Surgery

• Treatment as above
• If refractory, then usually require exploration and prosthetic
joint removal with or without replacement

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Recommended Protocol for Refractory and

Severe Postsurgical TJR infections

Obtain CT scan with contrast

Open procedure with removal of prosthesis and culture
specimen procurement
Treatment options
Immediate replacement of prosthesis
Scrub prosthesis with sterile brush and Iodine solution (Wolford et al)
Delayed replacement with new or same (sterilized) prosthesis
Place irrigation catheters
Penrose drains
Intravenous antibiotic therapy for 4-6 weeks followed by
possible oral antibiotics

Management of Heterotopic
Bone/Ankylosis in TJR patients

Single-stage surgery
Ankylosis release, joint reconstruction with new prosthesis
Two-stage surgery
1st procedure:
Ankylosis release and placement of an alloplastic spacer
Postsurgical maxillomandibular fixation
2nd procedure:
Alloplastic joint reconstruction
* For patient-fitted joint replacements, a CT scan is obtained after
the first procedure. A stereolithographic model is created and the
custom total joint prosthesis manufactured
Note: Autogenous fat graft packing and low-dose radiation postoperatively should
be considered for these cases

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Complications specifically related to

Alloplastic Total Joint Prostheses

Fragmentation, screw loosening and foreign-

body reaction
Hypersensitivity/Allergy
Prosthesis dislocation
Infection

Metal Hypersensitivity and/or Allergy

Hypersensitivity (allergic reaction) to metals and cellular

reactions to the metals of the joint prosthesis.

Metals of interest include nickel, cobalt, chromium,

molybdenum, titanium, vanadium and aluminum.

The hypersensitivity reaction can start at any age and is

more common in women

Potential hazards are cell toxicity, carcinogenicity, and

hypersensitivity.

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Preoperative Testing (Controversial)

In-vivo testing such as patch testing, and in-vitro

methods such as lymphocyte transferase test (LTT),
leukocyte migration inhibition factor test (LMIFT),
lymphocyte activation test (LAT)

TMJ Concepts prostheses have an articulation of metal against

HUMWPE. Theoretically, this produces a less intense response since
the amount of Cr-Co-Mo alloy present on the condylar head is
comparatively smaller and the wear particles are insignificant

Treatment

Patients with hypersensitivity reactions to metals

in total joint replacement need elimination of exposure
to metal ions by removing the prosthesis.
Another alternative is to use a titanium-only
customized prosthesis

Note: Some researchers have claimed that autogenous fat grafts placed
around the prosthesis may help decrease the exposure to allergens and
metals

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Prosthetic Joint Dislocation

May be related to technical surgical error or design flaws

TMJ Prostheses have different designs
TMJ Concepts: longer posterior stop
Biomet: longer anterior stop

Risk factor:
Patients undergoing concomitant coronoidectomy

Treatment Considerations:
1. Short-term MMF with guiding elastics
2. Revision surgery (with same or different prosthesis)

Thank You!!!!

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Complications in Craniofacial
Surgery
Jennifer E. Woerner, DMD, MD, FACS
LSUHSC-Shreveport
Department of Oral and Maxillofacial
Surgery

Objectives
• 1) To familiarize the learner with craniofacial
surgical procedures.
• 2) Educate on the most serious intraoperative
complications to occur during a transcranial
approach to include: venous air embolism,
hemorrhage, dural tears, and death.
• 3) Describe the most common early and late
postoperative complications encountered
during craniofacial surgery.

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Disclosure
• “I have no relationship(s) with industry to
disclose relevant to content of this CME
activity”

Craniofacial Surgery
• Reconstruction of either congenital or acquired
deformities of the skull, face, neck, and/or jaws
• Birth of the term began with Paul Tessier in the
1960’s following his description of a transcranial
approach to correct orbital hypertelorism
– At the time, craniofacial surgery and maxillofacial
surgery were considered separate specialties
• craniofacial surgery - superior to the orbits requiring a
transcranial approach
• maxillofacial surgery - inferior to the orbits, mainly affecting
the midface and jaws

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Craniofacial Surgery
• Many children born with craniofacial
conditions not only have deformities requiring
transcranial approaches, but defects affecting
the skull base
– Impacts growth and position of both midface and
mandible
– often requires maxillofacial surgery for correction

Craniofacial Team
• A multidisciplinary team best serves patients with
craniofacial conditions
– Parameters of care by the American Cleft Palate and
Craniofacial Association (ACPA)
– Essential members of team:
• audiologist, craniomaxillofacial surgeon, geneticist, nurse
coordinator, nutritionist, orthodontist, otolaryngologist,
pediatrician, pediatric anesthesiologist, pediatric dentist,
pediatric neurosurgeon, pediatric ophthalmologist,
prosthodontist, psychologist, social worker, and a speech
language pathologist

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Common Transcranial Procedures

• Craniosynostosis Repair
• Hypertelorism Correction
• Le Fort III Advancement

Craniosynostosis
• Premature fusion of one or more cranial sutures
– Most commonly an in utero event
– Virchow 1851
• restriction of growth perpendicular to the fused suture,
compensatory growth at patent sutures
– Characteristically abnormal head shape

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Craniosynostosis
Non-Syndromic (85%) Syndromic (15%)
• 1:2,000 live births • 1:20,000 live births
• 90% random occurences • Common gene mutations
– fibroblast growth factor
receptors (FGFR-1, FGFR-2, or
FGFR-3)
• Most common syndromes
– Apert, Crouzon, Pfeiffer,
Muenke, and Saethre-
Chotzen

Common Comorbidities
• Intracranial Hypertension and Restricted Skull Growth
– Single suture synostosis:
• 13-14% incidence of intracranial hypertension
– Multi-suture synostosis:
• 42% incidence
– Associated with lower developmental (DQ) and
intelligence quotients (IQ)
– Indicators:
• Symptoms- headaches, irritability, nausea and vomiting, difficulty
sleeping, and possible developmental delay
• Exam findings- tense, widely patent uneffected cranial sutures,
bulging fontanelles or engorged scalp veins
• Radiographic- cortical thinning or a lückenschädel (hammered-
metal) appearance of inner cortex

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Common Comorbidities
• Hydrocephalus
– Uncommon with single suture synostosis
– ~12% of syndromic cases
– Apert and Crouzon: Jugular foramen stenosis
– Can blossom intraoperatively
• Can ultrasound intraoperatively to check ventricle size

Common Comorbidities
• Visual Acuity and Ocular Motility
– Atrophy of the optic nerve, strabismus, ocular motility
disorders, or direct trauma to globe
– Visual acuity s/p cranial vault surgery dependent on
preoperative insult and deficit
– Abnormal ocular movements
• 67% of patients with metopic synostosis
• Vertical strabismus very common in unilateral coronal
synostosis (37-50%)
• Recession of supraorbital rims at risk for direct trauma to
globe

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Common Comorbidities
• Neuropsychiatric Disorders
– Recent data trending toward cognitive and/or
behavioral disorders in children with single suture
craniosynostosis has found that these deficits may
not be evident early on, but often develop over
early childhood
– mental and psychomotor development delays

Craniosynostosis Repair

Left: Preoperative Frontal View

Center: Preoperative Superior View
Right: Intraoperative Superior View of Metopic Synostosis

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Craniosynostosis Repair

Left: Exposure Following Removal of Frontal Bone and Orbital Bandeau

Center: Removed Bone with Synostotic Suture
Right: Reconstructed Orbital Bandeau

Craniosynostosis Repair
Top Left: Frontal View of
Orbital Bandeau in Place
Bottom Left: Superior
View of Orbital Bandeau
in Place
Top Right: Lateral View
of Orbital Bandeau and
Frontal Bones Replaced
Bottom Right: Lateral
View of Orbital Bandeau
and Frontal Bones
Replaced

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COMMON
COMPLICATIONS (10%)
Intraoperative Early Postoperative Late Postoperative
Subdural hematoma Bleeding Incisional alopecia

Dural tears/Cerebrospinal fluid Hematoma Hypertrophic scarring

loss
Anesthetic complications Corneal abrasion Skull and orbital irregularities

Periorbital injury Stitch abscess Diplopia, strabismus

Hemorrhage Cerebrospinal fluid leak Sterile abscess secondary to plate

hydrolysis
Venous Air Embolism Volume and electrolyte disturbances
(SIADH/CSW syndromes)
Death Infection / meningitis

Loss of vision

Airway obstruction

Death

Intraoperative Complications
• Subdural hematoma • Dural Tears/CSF Loss
– 5-6-% of cases
– ~1-2% of cases – More common in syndromic
cases
– Most minor and do not
– Difficult dissections
require intervention – Often easily repaired
– Can become large if primarily
• Large tears may need patch or
patient coagulopathic sealant
– Avoid aggressive – If occurs over sagittal sinus
can result in significant blood
retraction on brain or loss
trauma during dissection – If concerned about continued
CSF loss:
• Consider lumbar drain
temporarily

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Intraoperative Complications
• Anesthetic • Periorbital Injury
Complications – ophthalmic ointment
– Loss of airway most and tarsorrhaphies with
common silk sutures
– Padding around eye for
prone positioning
– Prevent Mayfield from
putting pressure on
globes

Intraoperative Complications
• Hemorrhage • Venous Air Embolism
– One of top 2 complications – Exposed diploic channels during
– Average loss = 21-65% of EBV osteotomy, air enters venous
– Begins with scalp incision circulation and into right atrium
(RA)
– Increases during osteotomies – If patent foramen ovale
– Prevention and continuous pulmonary hypertension and
monitoring most important increasd RA pressure Right to
– Management: left shunt
• local anesthetic – If air passes into coronary or
• reverse Trendelenberg cerebral circulation
• warming protocols cardiovascular collapse
• cauterize bleeding areas – Management:
• bone wax on emissary veins • Lower head of the bed below the
• local measures to prevent bleeding heart
from the dura • Apply bone wax
• reduce surgical time • Irrigate surgical site
• Adjuncts-erythropoietin, cell salvage, • 100% O2
tranexamic acid
• Stop surgery until s/s resolved

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Intraoperative Complications
• Loss of • Death
Airway/Respiratory – Nguyen and colleagues
Failure
utilized the Agency for
– One of top 2 complications
Healthcare Research and
– Craniofacial syndromes
with severe midface Quality (AHRQ)
hypoplasia Healthcare Cost and
• mask ventilation, Utilization Project
intubation, or extubation (HCUP) Kids Inpatient
challenging
Database (KID) for 1997,
– Consider armor reinforced
tube, sutured to chin 2000, 2003, and 2006
– Recheck position prior to – Of 3426 cases, mortality
prep rate < 1% nationwide

Early Postoperative
• Bleeding
• Hematoma
• Corneal Abrasion
• Stitch Abscess
• Infection/Meningitis
• Cerebrospinal Fluid Loss
• SIADH/CSW Syndromes
• Loss of Vision
• Airway Obstruction
• Death

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Early Postoperative
• Bleeding • Corneal Abrasion
– Bleeding should be – Completely preventable
controlled – No-No’s while sedated
intraoperatively, but can – Lubricant to eyes till
occur in the post- edema resolves
operative period if
coagulopathy ensues
– Not uncommon for H&H
to drop due to
equilibration
– Transfuse if symptomatic

Early Postoperative
• Stitch Abscess • Infection/Meningitis
– Fairly common – Subgaleal abscess rare
– Usually due to deep and meningitis
vicryl exceedingly rare
– Warm compress, may – Timely drain removal
consider po antibiotics – Sterile technique
– Perioperative antibiotics

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Early Postoperative
• Hyponatremia • Loss of Vision
– ~30% will have some – Exceedingly rare
form – Can be due to fronto-
– Secretion of orbital advancement and
Inappropriate Anti- retraction on
Diuretic Hormone globe/optical nerve or
(SIADH) impingement of bony
– Cerebral Salt Wasting segments on globe
(CSW) Syndromes – Must protect globe
during surgery

Late Postoperative
• Incisional Alopecia • Hypertrophic Scarring
– Fairly common – More common in keloid
– Temporal region formers
– Scar revision upon – Amenable to revision,
completion of head steroid injections, and
growth laser resurfacing

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Late Postoperative
• Skull and Orbital • Diploplia/Strabismus
Abnormalities – New onset strabismus
– Some deformities effect • 17-46% of patients s/p
skull base and it is not fronto-orbital
uncommon to have advancement
continued assymetric • resolved when present
gowth preoperatively in 3.4%
• Unilateral coronal
• Syndromic forms
– Can have temporal
wasting in children with
multiple procedures

Late Postoperative
• Sterile Abscess
– Dependent on type of
resorbable hardware
– Some children more
prone due to foreign
body reaction
– Presents at 6-12 months
post-op during
resorption of plates and
screws

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Hypertelorism Correction
• Same complications that are associated with cranial vault
reshaping, plus:
– Ocular complications
• Strabismus, loss of stereopsis, superior orbital fissure syndrome,
canthal malposition, extraocular muscle entrapment, blepharoptosis
– Possible infection
• Must remove ethmoid and sphenoid sinuses in order to translocate
orbits
– Attempt to prevent infection from sinus into brain
– Often seal off sinus cavities with TISSEEL and/or pericranial flap
– Anosmia or CSF rhinorrhea
• Due to proximity to cribiform plate
– Need for secondary surgery
• Rhinoplasty
• Orbital translocation

LeFort III or Monobloc Advancement

• Same complications that are associated with cranial
vault reshaping, plus:
– Ocular complications
– Possible infection
• Cut through ethmoid and sphenoid sinuses in order to mobilize
midface
– Attempt to prevent infection from sinus into brain
– Often seal off sinus cavities with TISSEEL and/or pericranial flap
– Higher infection rate for monobloc
– Anosmia or CSF rhinorrhea
• Due to proximity to cribiform plate
– Need for secondary surgery
• Possible need for formal orthognathic in future

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LeFort III or Monobloc Advancement

• Other rare, but serious complications:
• Meningitis
• Meningoencephalocele
• Encephalocele
• Prevention of rare injuries:
– Use of virtual surgical planning and study of
stereolithic model
– Consider use intraoperative guidance system
– May consider piezoelectric saw over traditional
– Careful dysjunction and advancement

References
• Nguyen C, Hernandez-Boussard T, Khosla RK, Curtin CM. A National Study on Craniosynostosis
Surgical Repair. The Cleft Palate-Craniofacial Journal. 2012;50(5):555-560.
• Zakhary GM, Montes DM, Woerner JE, Notarianni C, Ghali GE. Surgical correction of
craniosynostosis. A review of 100 cases. (1878-4119 (Electronic)).
• McCarthy JG EF, Sadove M, et al. Early surgery for craniofacial synostosis: an 8-year experience.
Plastic and reconstructive surgery. 1989;73:521-533.
• Cohen SR, Holmes RE, Meltzer HS, Nakaji P. Immediate cranial vault reconstruction with
bioresorbable plates following endoscopically assisted sagittal synostectomy. The Journal of
craniofacial surgery. 2002;13(4):578-582; discussion 583-574.
• Pietrzak WS, Kumar M, Eppley BL. The influence of temperature on the degradation rate of
LactoSorb copolymer. The Journal of craniofacial surgery. 2003;14(2):176-183.
• Ahmad N, Lyles J, Panchal J, Deschamps-Braly J. Outcomes and complications based on experience
with resorbable plates in pediatric craniosynostosis patients. The Journal of craniofacial surgery.
2008;19(3):855-860.
• Greensmith AL, Meara JG, Holmes AD, Lo P. Complications related to cranial vault surgery. Oral and
maxillofacial surgery clinics of North America. 2004;16(4):465-473.

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References
• Phillips RJ, Mulliken JB. Venous air embolism during a craniofacial procedure. Plastic and
reconstructive surgery. 1988;82:155-159.
• Meyer P, Renier D Fau - Arnaud E, Arnaud E Fau - Jarreau MM, et al. Blood loss during repair of
craniosynostosis. Br J Anaesth 1993;71:854-857.
• Poole MD. Complications in craniofacial surgery. Br J Plast Surg. 1988;41:608-613.
• David Dj Fau - Cooter RD, Cooter RD. Craniofacial infection in 10 years of transcranial surgery. Plastic
and reconstructive surgery. 1987;80(0032-1052 (Print)):213-223.
• Munro Ir Fau - Sabatier RE, Sabatier RE. An analysis of 12 years of craniomaxillofacial surgery in
Toronto. Plastic and reconstructive surgery. 1985;76:29.
• Marchac D RD. Complications. In: Marchac D RD, ed. Craniofacial surgery for craniosy-nostosis.
Boston: Little, Brown and Company; 1982.
• Marchac D, Renier D. Fibrin glue in craniofacial surgery. (1049-2275 (Print)).
• Ruiz RL, Ritter AM, Turvey TA, Costello BJ, Ricalde P. Nonsyndromic craniosynostosis: diagnosis and
contemporary surgical management. Oral and maxillofacial surgery clinics of North America.
2004;16(4):447-463.
• Ghali GE, Sinn DP, Tantipasawasin S. Management of nonsyndromic craniosynostosis. Atlas of the
oral and maxillofacial surgery clinics of North America.10(1):1-41.
• Caccamese J, Costello BJ, Ruiz RL, Ritter AM. Positional plagiocephaly: evaluation and management.
Oral and Maxillofacial Surgery Clinics.16(4):439-446.

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Complications of Minimally Invasive

Facial Cosmetic Surgery
E. M. Ferneini, MD, DMD, MHS, MBA, FACS
Editor in Chief, American Journal of Cosmetic Surgery
Private Practice, Greater Waterbury OMS
Medical Director, Beau Visage Medical Spa
Assistant Clinical Professor, Department of Craniofacial
Sciences, Division of OMFS
University of Connecticut

August 23, 2017

Disclosures
Dr. Ferneini reports no relationships with a commercial
interest.

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Cosmetic Procedures ISAPS 2015

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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–Global aesthetic medical and surgery market by region 2012-2018

–Value of global aesthetic medical and surgical market

from 2012 to 2018, by region (in billion euros)

United States European Union Asia-Pacific

7000
Latin America Worldwide 6,566

6000

4,910
5000
4,579
Market value in billion euros

4,266

4000

3,179

3000
2,424
2,266
2,088
2000

1,381
1,188
1,020 1,051
926 860
1000 765 818
721
530 528 576

0
2012 2013 2014* 2018*

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Source: IMCAS

–Countries with the highest number of cosmetic procedures 2016

–Countries with the highest total number of

cosmetic procedures in 2016*
Number of procedures
0 500000 1000000 1500000 2000000 2500000 3000000 3500000 4000000 4500000

United States 4,217,862

Brazil 2,524,115

South Korea (2015) 1,156,234

Japan 1,137,976

Italy 957,814

Mexico 923,243

Russia 896,629

India 878,180

Turkey 789,564

Germany 730,437

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

–Source: ISAPS

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–Top nonsurgical cosmetic procedures worldwide 2016

–Top nonsurgical cosmetic procedures

worldwide in 2016
Number of procedures
0 1000000 2000000 3000000 4000000 5000000 6000000

Botulinum toxin 4,931,577

Hyaluronic acid 3,372,445

Hair removal 1,146,523

Photo rejuvenation 623,243

Chemical peel 585,614

Nonsurgical skin tightening 511,481

Nonsurgical fat reduction 433,351

Microdermabrasion 361,070

Cellulite treatment 247,696

Full Field Ablative 210,844

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

–Source: ISAPS

Layers of the Skin

– REALTIVE SKIN DEPTHS

1. Epidermis 125¹ - 250²

2. Papillary Dermis 125 - 400³
3. Upper Reticular Dermis 400 - 600
4. Middle Lower Reticular Dermis 600
- 1000
5. Subcutaneous Tissues 1000 – 2000

– (1) Lips – Lids –Neck

– (2) Forehead – Cheeks – Nose
– (3) Dermis 1000, except lids Neck 150-
250

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Epidermis

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Initial Evaluation
Patient selection is key
Unrealistic
Psychiatric history
multiple physician visits

PMH:
Immunodeficiency/Immunosupression
Uncontrolled DM
Acne
Smoking

Education
Consistent/Reliable Results

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Assessment by Facial Zones

• One option is to assess
each patient’s face in
thirds or facial zones
Upper face
Middle face
Lower face
• Also compare 2 sides for
symmetry

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Assessment Scales
● Many scales available to facilitate approach to assessment
and treatment

Available Scales

Brow position1 Global face6

Forehead lines2 Upper face7

Lip fullness3 Mid face8

Marionette lines4 Lower face9

Crow’s feet5 Neck volume10

–1. Carruthers A et al. Dermatol Surg. 2008;34:S150-S154. 2. Carruthers A et al. Dermatol Surg. 2008;34:S155-S160. 3. Carruthers A et al.
Dermatol Surg. 2008;34:S161-S166. 4. Carruthers A et al. Dermatol Surg. 2008;34:S167-S172. 5. Carruthers A et al. Dermatol Surg.
2008;34:S173-S178. 6. Rzany B et al. Dermatol Surg. 2012;38:294-308. 7. Flynn TC et al. Dermatol Surg. 2012;38:309-319. 8. Carruthers J et al.
Dermatol Surg. 2012;38:320-332. 9. Narins RS et al. Dermatol Surg. 2012;38:333-342. 10. Sattler G et al. Dermatol Surg. 2012;38:343-350.

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Goal

• patient and surgeon

satisfaction

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

PATIENT EXPECTATIONS/RESULTS!
Unhappy patient=WORST COMPLICATION!!!

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Facial Skin Types

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

WOUND HEALING

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Treatment Modalities
1. Dermabrasion/Micro
15.5 million minimally
2. Laser Resurfacing invasive cosmetic
3. Chemical Peels procedures performed in
2016
4. Facial Fillers

5. Neuromodulators

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Complications

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Complications of Dermabrasion/Laser
Resurfacing
Infection
Bacterial infection rates 4 to 12%
Fungal infection rates around 2%

Hypo/Hyperpigmentation
Dark Skinned Patients
Prevention with UV blocking lotions for 2-3 months

Scarring Risk
13-cis-retinoic acid (Accutane)

Herpes Simplex Risk

Roberts et al 1997
907 patients with CO2 laser treatment
HSV infection of 3% was reduced to 1% with acyclovir prophylaxis
Acyclovir 5 days prior and 10 days post procedure
E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Hyperpigmentation
Treatment:
Usually transient
Treated with skin reconditioning
regimens
Hydroquinone bleaching creams
Retinoids
Avoiding sun exposure during the
first postoperative 3-4 weeks is
beneficial
Sunscreens

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Herpes Prophylaxis
Acyclovir 400mg tid – start 24hrs prior to procedure;
Continue for total of 7-10 days

Valcyclovir ( 1000mg/day X 14 days)

Famciclovir – better absorption, less frequent dosing

Prophylaxis regardless of history of cold sores

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Complications of
Dermabrasion/Laser Resurfacing

Milia
Common with laser
resurfacing
Overuse of
obstructive
ointments
Post-op cleansing
Needle-assisted
enucleation for
persistent lesions

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Acne
Mild post-op complication
Interruption of follicular subunits
Mild: topical clindamycin
Moderate to severe: tetracycline PO
Prophylactic Abx should be considered for high-
risk patients

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Post-Operative Erythema

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Prolonged Erythema
Uncommon for
longer than 2-3
weeks:
consider contact
dermatitis or early
scarring
Tx: Mild topical
steroid

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Herpes Infection after laser

resurfacing

Pozner el al: Laser Resurfacing: Full Field and Fractional, Clin Plastic Surg 43:515-525, 2016.

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Laser Protection
Cornea & Retina
accessible of danger from UV and most lasers

Eye protection:
Eyewear (goggles) is the most common laser protective
measure. It should provide all around shielding and
adequate visible light transmission.

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Fire Hazards & Prevention

Drapes, clothing, dry hair, Place Laser in STANDBY mode when
plastic materials, including ET not actually treating a patient.
tubes can be ignited, especially
when oxygen is in use. Moisten any hair near the treatment
field.

Remove mascara and eye makeup

when working around eyelids.

Alcohol or any other cleansing agent

must be allowed to completely dry
before laser use.

Reduce intraoperative oxygen

concentration to <40%.

A fire extinguisher and water should

be readily available.
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Cutaneous Burns
Prevention:
Cutaneous burns can occur
Knowledge and careful
with any laser.
observation of specific
clinical endpoint responses
for each treatment
Primarily due to improper modality:
device, dosimetry, and/or Elimination of the
treatment technique photodamage, rhytids,
wrinkles or lesion being
treated

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Complications of Chemical Peels

Infection
Hyperpigmentation
Post-procedural care
Bacterial
Post op Abx Darker skin, OCP’s &
Fungal pregnancy
Herpetic Prophylaxis with
Acyclovir hydroquinone
Prophylaxis UV avoidance
Cx any non-healing
wounds

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Other Complications
Hypopigmentation
After deep peel
More common in very light or very dark skin

Scarring
Infection (post-treatment)
Accutane
Recently operated skin
Recently radiated skin
keloids

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Infection

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Cardiovascular complications
Landau (2007)
181 patients with full face peels
6.6% arrythmias
Increased with DM, HTN, depression

Prevention
IV sedation
IV Hydration
EKG prior to therapy
Monitoring with close follow-up
Landau M. Cardiac Complications in Deep Chemical Peels. Dermatologic Surgery 33(2): 190-193, 2007.

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

FROSTING/Chemical Peel

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Smoking and Skin Necrosis

Increases risk of skin slough
Negative effect on wound healing and flap vascularity
Rees TD, Liverett DM, Guy CL: The effect of cigarette smoking on skin-flap
survival in the face lift patient. Plast Reconstr Surg 73:911-5, 1984.
12 times greater risk for skin slough in smokers
Webster RC, Kazda G, Hamden US: Cigarette smoking and face lift:
conservative versus wide undermining. Plast Reconstr Surg 77:596-604,
1986.
Conservative technique
S-lift
Stop smoking 4-6 weeks pre-op
Avoid ALL nicotine containing substitutes
E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Soft Tissue Fillers

Adverse Events

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Complications associated with Facial

Soft Tissue Fillers

Ferneini EM, et al

Am J Cosmet Surg, 31(4):238-242, 2014.

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Facial Filler Complications

Missed Expectations

Product-Related Complications
Hypersensitivity Reaction
Nodule Formation

Technique-Related Complications
Infection
Lumps/Bumps
Over/Under Correction
Skin Necrosis
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Know Your product!

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Potential Sequelae & Complications

Immediate-onset Immediate-onset Delayed onset
(0-2 d) (3-14 d) (>14 d)
Erythema* Angioedema Persistent erythema
Swelling* Nodules (inflammatory Nodules (inflammatory or
Edema* or noninflammatory) noninflammatory)
Injection site tenderness* Infection
Ecchymosis* Granulomas
Under- or overcorrection Acneiform eruption
Implant visibility (Tyndall Delayed immune-mediated
effect, white bumps) hypersensitivity
Vascular compromise Telangiectasias

*Often fade quickly.

Sclafani AP et al. Dermatol Surg. 2009;35:1672-1680. E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Most Common Side Effects

Significant Tyndall
persistent effect
swelling from
(particularly the overly
lips) superficial
placement

Overcorrection
with lumpiness

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Avoiding Complications
Appropriate Antisepsis

Handwashing

Prep Skin: Alcohol, Chlorhexidine

Avoid injecting large amounts of Product

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Necrosis

Impending Necrosis Treatment:

Warm-water gauze compress
Massage
Nitropaste
Hyaluronidase
LMWH
ASA

Glaich AS, et al. Derm Surg., 2006;32:276-281

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Venous Compression Syndrome

Purple (not deep blue) mottling of area not
injected
Swelling but NO pain
Management
Warm compresses
Ultrasound/e-stim facial
These patients do well
No need for nitropaste (no hypoxia)

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Managing Venous Occlusion

(presentation: delayed, dull pain, discoloration)

Massage, warm compresses, 2% nitroglycerine

paste (based on patient’s medical condition).
If caused by HA, inject hyaluronidase

If impending massive In cases of skin breakdown,

skin necrosis, start antibiotic therapy
consider hyperbaric O2 (topical, parenteral, or both)

Conservative debridement

Frequent follow up

Sclafani AP et al. Dermatol Surg. 2009;35:1672-1680. E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Managing Arterial Occlusion

(presentation: immediate or early, blanching, severe pain)

Stop injecting, attempt aspiration

Massage, warm compresses, 2% nitroglycerine

paste (based on patient’s medical condition).
If caused by HA, inject hyaluronidase

In cases of skin breakdown, start antibiotic

therapy (topical, parenteral, or both) .

Conservative debridement

Frequent follow up

Sclafani AP et al. Dermatol Surg. 2009;35:1672-1680. E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Sudden Bilateral Vision Loss and Brain

Infarction Following Cosmetic Hyaluronic
Acid Injection

Shan He, MD; Min-Muh Sheu, MD; Zei-Lun Huang, MD;

Chen-Hsin Tsai, MD; Rong-Kung Tsai, MD, PhD
JAMA Ophthalmol. 2013;131(9):1234-1235

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Glabellar region

Eye pain, Headache, & Vision loss

central retinal artery occlusion (R eye)

MRI: acute infarction in the right frontal, occipital, and parietal lobes

Clinical features: brain infarction and central retinal artery occlusion in

the right eye due to an HA injection

The patient was treated with topical timolol maleate, oral

acetazolamide (500 mg), and aspirin (100 mg) daily
E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Dorsal nasal artery

Ophthalmic artery

Embolus enters ocular circulation and the internal carotid

artery through retrograde arterial flow after the inadvertent
injection of hyaluronic acid into the dorsal nasal artery

Minimizing risk
Intradermal injection for augmentation of the glabellar region
should be given superficially and medially, and aspiration is
also recommended.

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Urgent Treatment of Retinal

Embolus
Lower ocular pressure
Ocular massage
Topical glaucoma medications (β-blocker, iopidine)
Acetazolamide (Diamox 500 mg)
Anterior chamber paracentesis

Induce vasodilation
Breathe in paper bag (increase CO2)

Aspirin

Beer K et al. J Clin Aesthet Dermatol. 2012;5(5):44-47. Weinberg MJ, Solish N. Facial Plast Surg. 2009;25(5):324-328.
Slide courtesy of Nancy Swartz, MD, and Marc Cohen, MD.

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An Overview of Vascular Adverse Events

Associated With Facial Soft Tissue Fillers:
Recognition, Prevention, and Treatment

Ferneini EM, Ferneini AM

J Oral Maxillofac Surg 74:1630-1636, 2016

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Vascular Anatomy
No valves in Face

All Arteries/Veins lead to vital organs

Thrombotic necrosis from intravascular injection

Blindness

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Filler Danger Zones

Glabella: Supratrochlear artery

Lip: Labial artery

NLF: Angular artery

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Fillers: Blindness & Prevention of

Complications
Study 1: Avoiding and Treating Blindness From Fillers: A
Review of the World Literature.
Beleznay K, Carruthers JD, Humphrey S, Jones D.
Dermatol Surg. 2015 Oct;41(10):1097-117.

Study 2. Blood Aspiration Test for Cosmetic Fillers to

Prevent Accidental Intravascular Injection in the Face.
Casabona G.
Dermatol Surg. 2015 Jul;41(7):841-7.

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Visual Risks (Study 1)

Review of literature of visual complications (up to January 2015)

98 cases were identified

Affected areas were: glabella (38.8%), nasal region (25.5%),

nasolabial fold (13.3%), and forehead (12.2%)

Most likely filler to cause visual complications is autologous

fat (half of reported cases), followed by HAs (one quarter of
cases)

Patients experienced sudden visual loss (Blindness) and pain.

Most cases did NOT recover and the CNS was involved in a
quarter of the cases

No treatment to treat blindness was effective

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Location of Injection for each case of

blindness

Avoiding and Treating Blindness From Fillers: A Review of the World Literature.Beleznay K, Carruthers JD,
Humphrey S, Jones D. Dermatol Surg. 2015 Oct;41(10):1097-117. E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Prevention (Study 2)
Aspiration: Only reliable when the needle diameter is sufficient

In this study from Brazil, the authors tried to aspirate red ink from a cup
using the syringe of 16 filler products.

Positive aspiration was defined by the presence of the ink in the syringe
less than 10 sec after the product was aspirated.

In 7 fillers, the aspiration test was initially negative: Juvederm ultra XC,
Juvederm Ultra Plus XC, Perlane, Emervel Classic, Emervel Lips, Radiesse
1.5 mL (mixed with 0.25 mL lidocaine), Radiesse 1.5 mL (mixed with 0.5
mL lidocaine). After adjusting for a larger needle diameter, the aspiration
test became positive.

In 9 fillers, the aspiration test was initially positive: Voluma 1 mL and

2mL, Volift, Volbella, Restylane, Restylane Vital, Esthelis/Belotero,
Rennova Lift, Sculptra (mixed with 10 mL saline and 2 mL lidocaine—final
solution, 12 mL). When reducing needle size for Esthelis (27), Emervel
lips (27), Emervel Classic (27), Radiesse (23), Juvederm Ultra XC (25),
Juvederm Ultra Plus XC (25), the aspiration test remained positive.

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Prevention

These differences can be explained by

the size of the needle: as smaller needles
minimize pain and adverse events.

In addition, a slow injection speed may

decrease the risk of vessel occlusion or
obstruction of peripheral flow.

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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External carotid system—A, external carotid; B, temporal artery; C, facial artery; D, inferior labial artery;
E, superior labial artery; F, angular artery; G, alar branches of angular artery; H, infraorbital artery; I,
zygomatic artery; J, transverse artery of the face; K, orbital artery; L, frontal branch of temporal artery
internal carotid system; M, supraorbital artery; N, supratroclear artery; O, dorsal nasal artery.

Blood Aspiration Test for Cosmetic Fillers to Prevent Accidental Intravascular Injection in the Face.
Casabona G.Dermatol Surg. 2015 Jul;41(7):841-7. E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Complications: 0-2 days

Overcorrection
Know the properties of the product you use!!!

Implant visibility
HA can produce bluish nodule
Others cause white nodule
Massage
Hyaluronidase
mechanical deroofing of nodule

Vascular compromise
Arterial: Immediate skin blanching with necrosis (glabella)
Aspiration, massage, warm compress, 2% nitropaste
+/- hyperbaric oxygen for impending necrosis
Venous: violaceous discoloration
Nitropaste and warm compresses

**Skin breakdown treated with Abx and debridement

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Complications: 3-14 days

Noninflammatory Nodules
Observation
Massage
Reassurance

Early Inflammatory Nodules

Abx
I&D plus culture (if fluctuance)
Close f/u visit at 48 hours
If no response, obtain cx

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Complications: >14 days

Hypersensitivity
Bovine collagen 3-4% + skin test
HA <1%

Nodules
massage

Inflammatory nodules
Evaluate for infection
No infection but no response at 7-10 days intralesional steroid
Still no response biopsy and culture

Granulomas (1%)
Massage
Intralesional steroids

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An Overview of Infections Associated

With Soft Tissue Facial Fillers:
Identification, Prevention, and
Treatment

Ferneini EM, et al

J Oral Maxillofac Surg 75:160-166, 2017

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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SPECTRUM OF ACTIVITY FOR ORAL ANTIBIOTICS

AGAINST GRAM-POSITIVE ORGANISMS

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Hypersensitivity Reaction
Ferneini EM, et. al

Hypersensitivity Reaction to Facial Augmentation with a

Hyaluronic Acid Filler: case report and review of
literature.

Am J. Cosmet Surg, 30(4):231-234, 2013

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E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Hyaluronidase
Plast. Reconstr. Surg. 133: 127e-
131e, 2014
Major advantage of HA fillers
Corrects unwanted results
Removes all/some of the filler
247 reactions reported to FDA
Wydase: bovine (no longer available)
Amphidase: bovine (150U)
Vitrase: bovine (200U)
Hylenex: human recombinant (150U)
Animal reactions
E. M. Ferneini, MD, DMD, MHS, MBA, FACS

“An Ounce of Prevention is Worth

a Pound of Cure” Benjamin Franklin

Inject slowly:
Low pressure injections
Use extreme caution in region of large
vessels
– Angular artery
– Supratrochlear artery
– Supraorbital notch / foramen
– Infraorbital foramen

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Avoiding AEs
Exclude patients with contraindications
Understand facial anatomy; inject at proper level1-3
Don’t inject if soft tissue infection or irritation present3
● Perform skin testing if using Artefill3
● Prepare skin with antiseptic agent (avoid chlorhexidine near
eyes)2,3
Use proper dilution, storage, and injection techniques
Take sterile precautions during reconstitution3
Use smallest needle that still allows accurate injection3
Avoid rapid injection, rapid flow rates, higher volumes4
Minimize injection sites
Make sure patients understand follow-up instructions
1. Sykes JM. Available at: www.medscape.org/viewarticle/729421_print. Accessed February 5, 2013. 2. Cohen JL. Dermatol Surg.
2008;34:S92-99. 3. Bailey SH et al. Aesthet Surg J. 2011;31(1):110-121. 4. Glogau RG, Kane MA. Dermatol Surg.
2008;34(suppl1):S105-S109.

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Optimizing Results With Fillers

Patient preparation strategies1-3
Limit use of anticoagulants (eg, aspirin, NSAIDS, fish oil, vitamin
E) in week prior to treatment (if medically able) as these may
increase bruising, bleeding at injection site
Avoid smoking around time of the procedure
Select the “right” filler
Product depends on type, size, depth of defect
Be knowledgeable about the filler you choose
Use the appropriate injection technique
Slow flow rate may minimize acute adverse events
Don’t overfill or overtreat
Touch-up possible at follow up

1. Zeichner JA et al. J Drugs Dermatol. 2010;9:1059-1060. 2. Cohen Jl. Dermatol Surg. 2008;34:S92-S99.
3. Collins SC et al. Dermatol Surg 2002;28:447-452.
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Neuromodulators

Minimizing AEs, Increasing

Satisfaction

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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E. M. Ferneini, MD, DMD, MHS, MBA, FACS

BoNT-A Preparation & Use

–On-label –Off-label*
BOTOX BOTOX
DYSPORT2 XEOMIN3 DYSPORT XEOMIN
Cosmetic1 Cosmetic
(300 U vial) (100 U vial) (300 U vial) (100 U vial)
(100 U vial) (100 U vial)
Preservative- Preservative- Preservative- Preserved Preserved Preserved
free saline free saline free saline saline saline saline
2.5 mL or 0.5 mL – 1.0 mL – 1.0 mL – 1.0 mL –
2.5 mL
1.5 mL 8.0 mL 4.0 mL 3.0 mL 4.0 mL
diluent
diluent diluent diluent diluent diluent
volume
volume volume volume volume volume
Use within Use within Use within Use within Use within Use within
24 h 4h 24 h 7–10 d 7–10 d 7–10 d
Single Single Single More than More than More than
patient use patient use patient use 1 patient 1 patient 1 patient
vial vial vial per vial per vial per vial
–*With appropriate storage and safety measures.
– 1. BOTOX Cosmetic [package insert]. Irvine, CA: Allergan, Inc.; 2013. 2. DYSPORT Cosmetic [package insert]. Scottsdale, AZ:
Medicis Aesthetics Inc.; 2010. 3. XEOMIN [package insert]. Greensboro, NC. Merz Pharmaceuticals, LLC; 2011.
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Pertinent Medical History

● Current infections
● Neuromuscular, autoimmune disease
● History of HSV infection
● Allergies
● Pregnancy or breast feeding
● Bleeding issues or tendencies
● Current medications
● Immunosuppressants
● Blood thinners (eg, aspirin, NSAIDs, Vitamin E, warfarin,
clopidogrel, fish/flaxseed oil, herbal supplements)

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

More Common AEs

Depend mostly on injection location,
technique
Periocular, perioral, eyelid margins Both Upper and Lower
Face
most prone
• Ecchymosis
Tips to minimize these AEs
Use small (30–32G) needle, light
• Swelling
injection pressure • Pain at injection site
• Asymmetry
Have patients avoid nonessential anticoagulants 7-10 d before
procedure
Pinch skin just before injection, inject slowly
Use topical anesthetic or ice for anxious patients
Apply direct pressure, cold compresses, or both after
injection
Reconstitute with preserved saline

–Emer J et al. Clin Dermatol. 2011;29:678-690. E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Less Common AEs

Lower Face
Upper Face • Flu-like symptoms
• Ptosis (brow, eyelid) • Increase or loss of mandibular
• Unmasking of mild existing dental show on smiling
eyelid ptosis (forehead) • Oral motor insufficiency
• Headache • Inability to raise/lower the
• Flu-like symptoms lip or
• Interference with eyelid irregular movement of lower
function lip
or eye physiology (crow’s • Unintended placement of
feet) toxin in
• Lower lid retraction, scleral depressor labii inferioris
show • Difficulty swallowing
(crow’s feet) • Neck weakness
• Effect on upper lip • Dry mouth
musculature/lip drop (nose)
E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Adverse Effects
Generalized reactions:
Nausea

Fatigue

Malaise

Flulike symptoms

Rash

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Adverse Effects
Sequelae that can occur at any site due to percutaneous
injection of neurotoxin:
Pain
Edema
Erythema
Ecchymosis
Headache

A 2012 single-center, double-blind, randomized study

demonstrated a statistically significant reduction in
subject-reported procedural pain in participants
pretreated with lidocaine 4%

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Adverse Effects
Ice applied immediately after injection will further reduce
the pain as well as the edema and erythema associated with
an IM injection

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Adverse Effects
Ecchymosis can be minimized by avoiding aspirin, aspirin-
containing products, and NSAIDs for 7 to 10 days before
injection

Bruising occurs most frequently in older patients taking

aspirin and in middle-aged persons taking vitamin E

Limiting the number of injections and applying post-injection

digital pressure without manipulation will also assist in
reducing bruising

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Glabellar Complex
Ptosis

Diffusion of the toxin

through the orbital
septum
Levator palpebrae muscle

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Avoiding Ptosis
Injections should not cross the midpupillary
line, & should be 1 cm above the eyebrow
Digital pressure at the border of the
supraorbital ridge while injecting the corrugator
reduces the potential for extravasation

Patients should remain in an upright position for

3-4 hours following injection
Avoid manual manipulation of the area

Active contraction of the muscles may increase

the uptake of toxin & decrease its diffusion

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Ptosis Treatment
Apraclonidine 0.5% eyedrops
Alpha2-adrenergic agonist that causes contraction of Müller muscles
Contraindicated in patients with documented hypersensitivity

Phenylephrine (Neo-Synephrine) 2.5% can be used

when apraclonidine is not available
Contraindicated in patients with narrow-angle glaucoma and in
patients with aneurysms

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Frontalis
Brow ptosis

Injections in the forehead should always be above

the lowest fold produced when the pt is asked to
elevate their forehead

If the patient has a low eyebrow, treatment of the

forehead lines should be avoided, or limited to that
portion of the forehead 4.0 cm or more above the
brow

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Crow’s Feet
Bruising, diplopia, ectropion and an asymmetric smile
(zygomaticus major)

Inject at least 1 cm outside the bony orbit or 1.5 cm lateral to

the lateral canthus

Violating these boundaries can result in diplopia due to medial

migration of toxin
paralysis of the lateral rectus muscle
E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Optimizing Results With BoNT-As

Use of the lowest effective dose in the lower face reduces
risk for asymmetry, muscle dysfunction, and temporary
oral paralysis1
Start low, titrate up, touch-up at follow-up visit if needed

Superficial injection of many BoNT-A microdroplets may

create more natural-looking brow lift than more aggressive
treatment of central frontalis and nearby depressor
muscles2

Threading may yield more uniform results than depot

technique3
Injections made at angle along length of muscle; toxin dispensed
while withdrawing
–1. McNamara D. Skin Allergy News. 2012. Available at:
www.skinandallergynews.com/index.php?id=372&cHash=071010&tx_ttnews[tt_news]=
94269. 2. Evans J. Skin Allergy News. 2007. Available at:
www.skinandallergynews.com/index.php?id=372&cHash=071010&tx_ttnews[tt_news]=
3165. 3. Worcester S. Skin Allergy News. 2012. Available
at:www.skinandallergynews.com/index.php?id=372&cHash=071010&tx_ttnews
[tt_news]=138471. All accessed February 4, 2013. E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Safety Information:
FDA requirements for all approved
neuromodulators, issued April 30, 2009

Boxed Warning: Distant Spread of Toxin Effect

Effects of BoNTs may spread from area of injection
Symptoms hours to weeks after injection
Life-threatening swallowing and breathing difficulties, also
reports of death
Risk likely greatest in children treated for spasticity
Symptoms can also occur in adults, particularly in predisposed
patients

No serious AEs have been reported related to distant

spread of toxin effect with aesthetic use at labeled
dose
E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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Conclusion

Proper knowledge of the product

and/or procedure is necessary to
avoid complications
Patient expectations, informed
consent, & proper patient selection

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

Thank you!
[email protected]

E. M. Ferneini, MD, DMD, MHS, MBA, FACS

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ORAL & MAXILLOFACIAL SURGERY REVIEW

A Comprehensive & Contemporary Update

COMPLICATIONS OF COSMETIC SURGERY

MO BANKI MD DMD FACS

Clinical Faculty, Department of Surgery, Warren Alpert
Medical School of Brown University
Clinical Faculty, Department of Craniofacial Sciences,
University of Connecticut

No Relationships to Disclose

• References Used:

– Neligan, Peter C., et al. Core

Procedures in Plastic Surgery,
Elsevier 2014.
– Aston Et Al: Aesthetic Plastic Surgery,
Elsevier, 2009.
– Dutton: Atlas of Clinical and Surgical
Orbital Anatomy, 2nd Edition,
Saunders, 2011.
– Guyron: Aesthetic Plastic Surgery
Video Atlas, Saunders, 2011.
Dutton: Atlas of Clinical and Surgical Orbital Anatomy, 2nd Edition
– Warren: Plastic Surgery Volume 2:
Aesthetic Surgery, 3rd Edition,
Saunders, 2013.

M. BANKI MD DMD FACS

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PATIENT SELECTION

• EXPECTATIONS
• MEDICAL HISTORY
• SURGICAL HISTORY
• MEDICATIONS
• SMOKING
• DOCUMENTATION AND PHOTOGRAPHY

M. BANKI MD DMD FACS

RHYTIDECTOMY

MO BANKI MD DMD FACS

Clinical Faculty, Department of Surgery, Warren Alpert
Medical School of Brown University
Clinical Faculty, Department of Craniofacial Sciences,
University of Connecticut

713
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

YOUTH & BEAUTY

• BALANCE
• HARMONY
• PROPORTIONALITY
• SYMMETRY

STIGMATA OF AGING FACE

Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014.

M. BANKI MD DMD FACS

714
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AGING FACE

MUSCLES OF FACIAL SKELETON

Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

715
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

ANATOMY- S.C.A.L.P
Bagheri, Bell, Khan, Current Therapy in Oral & Neligan, PC., et al, Core Procedures in Plastic
Maxillofacial Surgery, W B Saunders, 2012. Surgery Elsevier 2014.

M. BANKI MD DMD FACS

FACIAL NERVE
Aston, et al, Aesthetic Plastic Surgery, Elsevier, 2009.

M. BANKI MD DMD FACS

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

FACIAL NERVE
Neligan PC, et al, Plastic Surgery, Volume Two, Aesthetic, Elsevier, 2013.

M. BANKI MD DMD FACS

RHTIDECTOMY INCISIONS
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

In the Temporal Hairline Along Temporal Hairline

M. BANKI MD DMD FACS

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RHTIDECTOMY INCISIONS
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

RHTIDECTOMY INCISIONS
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

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LIPOCUTANEOUS FLAP
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

SMAS PLICATION
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

• Loop Suture
• Plication of SMAS =>
– Effacement of Nasolabial
Folds
– Reduction of Jowls

M. BANKI MD DMD FACS

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SKIN REDRAPING
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

• Tension-free skin redraping

and closure.
• Vector of pull is oblique and
less vertical than that used to
manage deeper tissue.

M. BANKI MD DMD FACS

LATERAL SMASECTOMY
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

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EXTENDED SMAS TECHNIQUE

Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

COMPLICATIONS

• INFECTION
• HEMATOMA
• FACIAL NERVE INJURIES
• SKIN FLAP NECROSIS
• HAIR LOSS
• HYPERTROPHIC SCARS
• PAROTID FISTULA

M. BANKI MD DMD FACS

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HEMATOMA

• Expanding hematoma should be immediately addressed

to avoid flap necrosis.
-Coaguopathy
-Anticoagulants
-Hypertension
-Compressive dressing, drains, smooth emergence
from anesthesia, head elevation, icepack.

M. BANKI MD DMD FACS

INFECTION

Rare occurrence
-Staph aureus, MRSA
-Pseudomonas aeruginosa
-Atypical mycobacterium
-Principles of infection management: I&D, C&S,
broad spectrum antibiotics, adjust based on
speciation and susceptibility.

M. BANKI MD DMD FACS

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FACIAL NERVE INJURIES

Mild transient facial paresis Ellis, Zide, Surgical Approaches

to Facial Skeleton, William &
common up to 12 hours after Willkins 1995.
surgery due to local anesthetics.
-Temporal/ Frontal branch
of facial nerve
-Marginal mandibular
branch

M. BANKI MD DMD FACS

FACIAL NERVE INJURY

Neligan PC, et al, Plastic Surgery, Volume Two, Bagheri, Bell, Khan, Current Therapy in Oral &
Aesthetic, Elsevier, 2013. Maxillofacial Surgery, W B Saunders, 2012.

M. BANKI MD DMD FACS

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PAROTID FISTULA

• Iatrogenic injury to the parotid gland is rare.

– Edema, serous drainage, erythema, pain.
– Early drainage and observation.
– Botox if symptoms persists.
– Amylase.

M. BANKI MD DMD FACS

BLEPHAROPLASTY

MO BANKI MD DMD FACS

Clinical Faculty, Department of Surgery, Warren Alpert
Medical School of Brown University
Clinical Faculty, Department of Craniofacial Sciences,
University of Connecticut

724
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ANATOMY- OSTEOLOGY
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

ANATOMY
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

725
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

ANATOMY- FAT PADS & NASOLACRIMAL SYSTEM

Blepharoplasty in Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial Surgery (2nd Edition), BC Decker Inc,
2004.

M. BANKI MD DMD FACS

ANATOMY
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

726
Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

ANATOMY
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

ANATOMY
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

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UPPER EYE LID BLEPHAROPLASTY

Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

UPPER EYE LID BLEPHAROPLASTY

Blepharoplasty in Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial Surgery (2nd Edition), BC Decker Inc,
2004.

M. BANKI MD DMD FACS

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TRANCONJUNCTIVAL LOWER BLEPHAROPLASTY

Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

TRANCONJUNCTIVAL LOWER BLEPHAROPLASTY

Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

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TRANSCUTANEOUS LOWER BLEPHAROPLASTY

Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

TRANSCUTANEOUS LOWER BLEPHAROPLASTY

Blepharoplasty in Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial Surgery (2nd Edition), BC Decker Inc,
2004.

M. BANKI MD DMD FACS

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CANTHOPEXY
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014

M. BANKI MD DMD FACS

BLEPAROPLASTY COMPLICATIONS- ANATOMIC CLASSIFICATION

• Eye:
– Chemosis
– Dry Eye Syndrome
– Corneal Abrasion
– Retrobulbar Hematoma
– Globe Perforation
• Skin (Eyelids): Over- / Under-resection
– Lagophthalmos
– Blepharoptosis
– Lid Malposition (Entropion, Ectropion)
• Muscle:
– Inferior Oblique Injury
• Fat:
– Excessive Removal: Hollowing
– Inadequate Removal: Suboptimal Results

M. BANKI MD DMD FACS

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M. BANKI MD DMD FACS

RETROBULBAR HEMATOMA

Aston: Aesthetic Plastic Surgery,Elsevier,2009.

M. BANKI MD DMD FACS

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RETROBULBAR HEMATOMA

• Pain:
– Rapid Onset
– Out of Proportion for
Blepharoplasty
– Usually Unilateral
• Tense Proptotic Globe: Resistant
to Retropulsion.
• Anterior displacement of the globe
is limited by its anchoring system
(Medial and Lateral Canthal
Tendons).
• Marcus Gunn Pupil

Aston: Aesthetic Plastic Surgery,

Elsevier, 2009.
M. BANKI MD DMD FACS

Dutton: Atlas of Clinical and

Surgical Orbital Anatomy, 2nd
Edition

M. BANKI MD DMD FACS

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RETROBULBAR HEMATOMA

• Retrobulbar Area:
– Orbital Apex:
• Optic Canal:
– Optic Nerve (CN II)
– Ophthalmic Artery
(Branch of Internal
Carotid Artery)
– Superior Orbital Fissure:
• Superior Ophthalmic Vein
• CN III
• CN IV
• CN V1
• CN VI
Dutton: Atlas of Clinical and Surgical Orbital Anatomy, 2nd Edition.
– Anopsia and Ophthalmoplegia

M. BANKI MD DMD FACS

RETROBULBAR HEMATOMA

• Marcus Gunn Pupil:

– “Swinging Flashlight Test”
– Relative Afferent Pupillary
Defect (RAPD)
– Normal Eye: Intact Direct
and Consentual Pupillary
Constriction upon shining
the light => Both pupils
constrict when illuminated.
– Marcus Gunn Pupil:
Paradoxical Response =>
Both pupils dilate when
defective eye is illuminated.

M. BANKI MD DMD FACS

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RETROBULBAR HEMATOMA
• Treatment:
– Medical Emergency
– Ischemic Optic Neuropathy leads to
permanent loss of vision.
– Compartment Syndrome
Phenomenon: Intraorbital Pressure
exceeds perfusion pressure of the
optic nerve circulation and retinal
arteries.
– Decompression:
• ICP => Craniotomy
• Lower Extremities => Four
Quadrant Fasciotomy
• RBH IOP> 40mmHg
(Tenometry) => Lateral
Canthotomy/ Cantholysis to
allow the orbital contents to
expand beyond the orbit.
M. BANKI MD DMD FACS

RETROBULBAR HEMATOMA

• Lateral Canthotomy and

Cantholysis (LCC): a vision-
saving procedure.
• Open all incisions
• Mannitol (1-2mg/Kg)
• Diamox (500mg)
• Corticosteroids
• Ophthalmology Consult

M. BANKI MD DMD FACS

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RETROBULBAR HEMATOMA
• Rare:
– 1 in 2,000 risk of significant hemorrhage.
– 1 in 10,000 risk of permanent visual loss.
• How to Avoid Them:
– Detailed Preoperative Evaluation:
• Hypertension, Coagulopathy, Anticoagulation Meds
– Past Ocular History: to rule out pre-existing visual dysfunction blamed on
operation
– Clonidine 0.2 mg
– Intraoperative close attention to hemostasis
– Postoperative:
• Head elevation to lower intravascular pressure
• Avoid Valsalva Maneuver: anti-emetic, cough suppressants
• Finger counting in recovery room. Sudden loss of light perception is cause
for concern.
• Apply ice compresses
M. BANKI MD DMD FACS

CORNEAL ABRASION
• Noted immediately postoperatively.
• Pain, foreign body sensation, light
sensitivity.
• Fluorescein/ cobalt blue light to
establish the diagnosis.
• If significant pain: slit lamp to rule out
globe perforation.
• Antibiotic and anesthetic ophthalmic
drops.
• Resolves within 24 hours.
• Caused by: abrasion from tape placed
by anesthesiologist or surface
desiccation. Aston: Aesthetic Plastic Surgery, Elsevier, 2009.

• Prevent by placement of globe shields

and postoperative ophthalmic
lubricant.
M. BANKI MD DMD FACS

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DRY EYE

• Corneal irritation (less severe than abrasion).

• Foreign body sensation, dryness, irritation, blurry vision,
photosensitivity and redness.
• Exposure keratopathy from poor eyelid closure.
• Establish diagnosis with fluorescein/ slit lamp: punctate corneal
staining.
• Treat with lubricant ophthalmic drops.

M. BANKI MD DMD FACS

DRY EYE SYNDROME

• Late diagnosis compared to the early

ocular sicca symptoms.
• Widening of palebral fissure after
blepharoplasty may not be tolerated by
patients with border line tear
production (Sjogren’s, history of dry
eye syndrome)
• Schirmer's Test: Assesses basal tear
secretion
– Placement of filter paper in the
conjunctival sac for 5 minutes.
– Less than 10 mm of moisture is
considered abnormal.
• Post-blepharoplasty vision loss in
patients with keratoconjunctivitis sicca
has been reported.

M. BANKI MD DMD FACS

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CHEMOSIS

• Conjunctival edema secondary to:

– Allergies
– Sinusitis
– Surgery
– Incomplete eyelid closure
• May lead to corneal drying:
hindrance to lacrimal film
dispersion => FB sensation
• Treat with preservative-free
artificial tears and ointments.
• Topical steroidal eye drops in
consultation with ophthalmologist
to rule out elevated IOP and
infective keratitis.

M. BANKI MD DMD FACS

UPPER EYELID PTOSIS

• During preoperative assessment

rule out pre-existing aponeurotic
ptosis secondary to a subtle and
undiagnosed levator palpebrae
superioris attenuation or
dehiscence.
– Measure Margin Reflex
Distance (MRD)
– Patients with ptosis and
dermatochalasis often
compensate with involuntary
frontalis reruitment. Aston: Aesthetic Plastic Surgery,Elsevier, 2009.

• Postoperative mechanical ptosis

secondary to edema resolves
spontaneously.

M. BANKI MD DMD FACS

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UPPER EYELID PTOSIS

• Ptosis is defined as an upper lid

margin lower than two millimeters
below the upper limbus (border of
cornea and sclera).
• Margin-Reflex Distance (MRD):
– Measure from light reflection
point on the cornea to the
upper eyelid margin: about 4-5
mm.
• Horner’s Syndrome, Myasthenia
Gravis

Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011.

M. BANKI MD DMD FACS

LAGOPHTHALMOS

• Causes of postoperative
lagopthalmos:
– Excessive skin resection.
– Surgical trauma to the orbicularis oculi
muscle.
– Incomplete eyelid closure secondary
to pain.
• Leads to exposure keratopathy.
• Preoperative Evaluation:
– Establish adequacy of Bell’s Reflex or
Phenomenon: cephalic rotation of the
globe upon forced opening of the
eyelid and is protective.
– Rule out dry eye disease: ocular sicca
symptoms (FB sensation, tearing,
photophobia).
Guyron: Aesthetic Plastic
M. BANKI MD DMD FACS Surgery Video Atlas,
Saunders , 2011.

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LAGOPHTHALMOS

• Preoperative Markings:
– Pinch Test
Young

Middle-
age

Older

M. BANKI MD DMD FACS

LOWER EYELID MALPOSITION

• Predisposing Factors:
Globe protosis and malar
eminence hypoplasia:
-Positive Vector
-Negative Vector: the
position of the cornea is anterior
to the infraorbital rim =>
Increased risk of lower lid
retraction and ectropion after
lower eyelid blepharoplasty.
• Thyroid Ophthalmopathy

M. BANKI MD DMD FACS

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LOWER EYELID MALPOSITION

• Preoperative Assessment:
– Evaluate Horizontal Eyelid
Laxity:
• Snap-Back Test: the lid
should spring back against
the globe immediately.
• Distraction Test: > 6-7 mm
is abnormal
• If lower eyelid laxity is found, an
appropriate tightening technique
(i.e. lateral canthopexy) should be
performed at the time of
blepharoplasty.

M. BANKI MD DMD FACS

STRABISMUS

– Diplopia is rare and maybe

due to: ophthalmic ointment ,
edema, or transient paresis of
extra-ocular muscles.
• Intermittent
• Clears with blinking
• Self-limiting
– Persistent binocular diplopia
can be due to iatrogenic
strabismus secondary to injury
to inferior oblique muscle.
• lies between the nasal and central
fat pockets.
– Usually due to aggressive use
of cautery.
Dutton: Atlas of Clinical and Surgical Orbital Anatomy, 2nd Edition

M. BANKI MD DMD FACS

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SUMMARY

• Perform a thorough preoperative exam

of the entire periorbita and identify:
• Pre-existing ocular disease
(visual dysfunction, strabismus,
dry eye syndrome)
• Ptosis
• Lower lid laxity or negative
vector
• Asymmetries (and D/W patient)
• Mark the patient in the upright position.
• Control the blood pressure.
• Achieve excellent hemostasis.
• Perform canthopexy if lower lid laxity
exists and skin resection is planned.
• Evaluate vision post-operativaly and
have high index of suspicion for sudden
and atypical pain onset.
M. BANKI MD DMD FACS

PRIMARY RHINOPLASTY-
AN INTRODUCTION BASIC PRINCIPLES

MO BANKI MD DMD FACS

Clinical Faculty, Department of Surgery, Warren Alpert
Medical School of Brown University
Clinical Faculty, Department of Craniofacial Sciences,
University of Connecticut

742
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ANATOMIC LANDMARKS

(1)

(2)
(1) Zimbler, Marc Ham, Jongwook. Aesthetic Facial Analysis, Cummings: Otolaryngology: Head and Neck Surgery, 4th ed 2010
(2) Blepharoplasty in Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial Surgery (2nd Edition), BC Decker Inc, 2004.
M. BANKI MD DMD FACS

RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

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RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

Four tip-defining points of the

nose:
1.Supratip break
2. columellar-lobular
Angle
3. Tip-defining points of each
intermediate crus of the lower
lateral cartilages.

M. BANKI MD DMD FACS

RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

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RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

-A vertical line through the most

projected part of the upper lip
should divide the nose into two
equal parts.
-If the nasal tip comprises more
60%, then the nose may be
overprojected.

M. BANKI MD DMD FACS

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Copyright © Oakstone Publishing, LLC, 2017. All Rights Reserved.

RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

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NASO-FACIAL ANGLE
ANGLE OF NASAL DORSUM AND FACIAL PLANE

Zimbler M, et al. Aesthetic Facial Analysis, Cummings: Otolaryngology: Head and Neck Surgery, 4th ed.

RHINOPLASTY- EVALUATION
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

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ANATOMY- MUSCLES
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

The paired depressor septi

nasi muscles can result in
drooping of the nasal tip
during smiling. This added
tension on the nasal tip must
be recognized pre-operatively
and corrected by resection in
order to achieve a cosmetic
result.

M. BANKI MD DMD FACS

ANATOMY- BLOOD SUPPLY

Rhinoplasty in Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial Surgery (2nd Edition), BC Decker Inc,
2004.

The arterial supply of the nose arises from the branches of the
external (dark blue) and internal (light blue) carotid arteries.

M. BANKI MD DMD FACS

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ANATOMY- CARTILAGENOUS FRAMEWORK

Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

ANATOMY- CARTILAGENOUS FRAMEWORK

Rhinoplasty in Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial Surgery (2nd Edition), BC Decker Inc,
2004.

M. BANKI MD DMD FACS

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ANATOMY- SEPTUM
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

ANATOMY- TURBINATES
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

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RHINOPLASTY
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

Internal nasal valve a structure formed by articulation of the

anterior ridge of the upper lateral cartilage with the anterior
septal edge.

M. BANKI MD DMD FACS

INTERNAL VALVE
Core Procedures in Plastic Surgery. Neligan, Peter C., et al. Elsevier 2014.

M. BANKI MD DMD FACS

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RHINOPLASTY- SPREADER GRAFTS

Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

TIP SUPPORT MECHANISM

Rhinoplasty in Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial Surgery (2nd Edition), BC Decker Inc,
2004.

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RHINOPLASTY- CEPHALIC TRIM

Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

RHINOPLASTY- SUTURE TECHNIQUES

Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

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RHINOPLASTY- SUTURE TECHNIQUES

Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

RHINOPLASTY- GRAFTS
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

Rohrich, Rod J; Hoxworth, Ronald E. Published January 1, 2012. Pages 137-166. © 2012.

M. BANKI MD DMD FACS

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RHINOPLASTY- GRAFTS
Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

Harvest of cartilage from nasal septum for grafting

procedures or for removal of grossly deviated septum.
It is important to maintain 1 cm dorsally and caudally
for nasal support.
Miloro, M et al, Peterson’s Principles of Oral and Maxillofacial
Surgery (2nd Edition), BC Decker Inc, 2004.

M. BANKI MD DMD FACS

RHINOPLASTY- WEIR’S EXCISION

Guyron: Aesthetic Plastic Surgery Video Atlas, Saunders, 2011

M. BANKI MD DMD FACS

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SUMMARY
Guyron: Aesthetic Plastic Surgery Video
Atlas, Saunders, 2011.

Systematic approach to patient

evaluation and selection:
-Medical history
-Patient’s expectations
-Facial & Nasal Analysis:
-Skin and cartilage quality
-Alar width
-Tip definiton
-Nasal base
-Upper, middle, and lower 1/3’s
-Dorsum
-Columella
-Tip projection
-Tip rotation
-Septum
-Nasal valves
-Sound surgical planning and
execution

M. BANKI MD DMD FACS

COMPLICATIONS

• Excessive Bleeding
• Septal Hematoma
• Infections
• L-Strut Fracture
• CSF Leak
• Septal Perforation
• Internal Nasal Valve Collapse
• Aesthetic Complications

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BLEEDING/ EPISTAXIS

• Intraoperative Bleeding or Postoperative Epistaxis

– Coagulopathy
– Anticoagulants
– Hypertension
– Local anesthetic with epinephrine
– Afrin (Oxymetazolin)
– Postoperative icing
– Anterior or Posterior Packing
• Antibiotics
• Remove in 24-48 hours
• STSS
• Interventional Radiologist: Angiography/ Emobolization

M. BANKI MD DMD FACS

SEPTAL HEMATOMA

• Bleed within the confines of the potential space between elevated

mucoperichondrial flaps
– Trans-septal Whip Sutures
– Inferiorly based drainage incisions
– Silastic removable intranasal splints
• Presentation: Nasal obstruction, pain, rhinorrhea, fever.
• Diagnosis: By inspection and visualization of the ecchymotic septal
mass.
• Treatment: Early recognition and prompt evacuation of the
hematoma.

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INFECTIONS

• Post-rhinoplasty infections are very rare.

– Requires immediate incision and drainage as well as coverage
with a broad spectrum antibiotics.
– Risk of toxic shock syndrome: Staph aureus exotoxin release =>
nausea, vomiting, rash, fever, hypotension, tachycardia.
– Cavernous sinus thrombosis.

M. BANKI MD DMD FACS

L-STRUT FRACTURE

• Preserving 1 cm wide septal L-strut that remains

attached to the perpendicular plate of ethmoid and nasal
spine- maxillary crest area is recommended.
• Intraoperative fracture of dorsal portion of the septal “L
Strut” due:
– over-resection of the septum
– Excessive septal manipulation
– Misguided medial osteotomies
• Failure to repair leads to significant dorsal support
saddle-nose deformity.

M. BANKI MD DMD FACS

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CEREBROSPINAL FLUID LEAK

• Rare and occurs as a result of the fracture of the

cribriform plate: anosmia, potential intracranial injury
• CSF rhinorrhea, positional headache.
• Beta-2 transferrin test.
• Treat with strict bedrest.
• If no resolution endoscopic repair is required.
• Treat for any signs of meningitis.

M. BANKI MD DMD FACS

SEPTAL PERFORATION

• Iatrogenic trauma during septoplasty.

• Septal abscess or necrosis.
• Managed by prolonged splinting.
• Symptoms: crusting, epistaxis, whistling, nasal valve
distortion.
• Large perforations can lead to saddle nose deformity
due loss of support.

M. BANKI MD DMD FACS

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INTERNAL NASAL VALVE COLLAPSE

• Formed by the caudal margin of upper lateral cartilage, nasal

septum, and floor of the nose (and occasionally a large inferior
turbinate).
• Commonly occurs due to excessive removal of the nasal roof
including the upper lateral cartilages or over-resection of cephalic
portion of the lower lateral cartilages.
• Also a poorly executed lateral nasal osteotomy can compromise the
valve by moving the nasal bones too medially.
• Treat with the use of spreader grafts to lateralize upper lateral
cartilages thereby increasing the width of the middle nasal valve.

M. BANKI MD DMD FACS

AESTHETIC COMPLICATIONS OF BONY PYRAMID

• Open Roof Deformity:
– Occurs following dorsal hump removal and causes the cross-
section of the nose to have a trapezoidal shape as opposed to
the aesthetically pleasing triangular form.
• Rocker Deformity:
– This can occur if the lateral nasal osteotomies are carried too far
superiorly onto the frontal bone.
– When medial digital pressure is applied to the lateral nasal
bones, the superior portion f the osteotomy will move laterally
causing asymmetry.
• Stair-Step Deformity:
– If the placemat of the lateral osteotomies is anterior to the
ascending process of the maxilla, there will be a palpable step-
off that could also be visible.

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AESTHETIC COMPLICATIONS OF THE MIDDLE THIRD

• Pollybeak Deformity:
– Supratip fullness when lower third of the dorsum projects more than the tip leading
to a convex appearance of the nasal dorsum.
• Under-resection in the middle third and anterior septal angle.
• Over-resection of the bony pyramid.
• Over-resection of the supratip structures leading to dead space and
subsequent scarring.
• Post-operative loss of tip projection leading to tip ptosis.

• Saddle Nose deformity:

– Caused by over-reduction of the cartilaginous vault and the quadrangular cartilage
without enough dorsal strut remaining.
– L-shaped strut of 1 cm is needed caudally and dorsally to prevent a saddle nose.

• Inverted-V Deformity:
– Occurs after dorsal hump reduction if there is inadequate support of upper lateral
cartilage leading to its collapse where it articulates with the nasal bone.

M. BANKI MD DMD FACS

COMPLICATIONS OF NASAL ALA/ TIP

• Alar Retraction and Pinched Tip Appearance:
– Caused by aggressive cephalic resection of the of lateral crura.
– Can also lead to excessive colummellar show.
– Treated with strut grafts and lateral crural repositiong.
• Columellar Retraction:
– Caused by over-resection of caudal septum and medial crura.
• Hanging Columella:
– Caused by placement of a large strut graft, septal extension or
tip graft.
• Persistent Tip Bulbosity:
– Caused by widening of the interdomal distance, inadequate
lower lateral cartilage resection, or thick and inelastic skin.

M. BANKI MD DMD FACS

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SUMMARY

• BALANCE
• HARMONY
• PROPORTIONALITY
• SYMMETRY

• PATIENT EXPECTATIONS
• PATIENT SELECTION
• PROPER PLANNING

ORAL & MAXILLOFACIAL SURGERY

REVIEW
A Comprehensive & Contemporary Update

MO BANKI MD DMD FACS

Clinical Faculty, Department of Surgery, Warren Alpert
Medical School of Brown University
Clinical Faculty, Department of Craniofacial Sciences,
University of Connecticut

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