THE READERS' CORNER
This month's topics are surgical-orthodontic cases and second opinions.
1. If you are treating surgical-orthodontic cases, what percentage of your total case load are they ?
Orthognathic cases appear to be a relatively small part of the average respondent's orthodontic practice. More than 60% said that these cases made up 5% or less of their case load, while about one-fourth reported having 5-10% surgery cases . About 15% of the clinicians had 10-20% of their patients in surgical-orthodontic treatment; only two of the respondents said they had no orthognathic cases at all.
What percentage of the surgical cases are one-jaw surgeries? What percentage are two-jaw surgeries?
More than three-fourths of the readers said they used single-jaw surgery in 80-85% of their cases. The remaining one-fourth reported about 60% single-jaw surgeries and 40% double-jaw surgeries.
How is the diagnosis made in your surgical-orthodontic cases, and by whom?
Virtually all the clinicians responded that they used a mixture of criteria, including patient esthetics, cephalometric analysis, clinical impressions, and mounted models.
About 40% said the diagnosis was made principally by the orthodontist; the rest said it was carried out jointly with the oral surgeon. The most common reply was that the orthodontist makes the initial diagnosis and discusses it with the surgeon, and then the orthodontist alone or both specialists present the diagnosis to the patient.
Do you use model surgery?
More than 90% of the readers reported using model surgery. Most responses indicated that the actual cutting was done by the oral surgeon, with the orthodontist reviewing the result before the surgical splint was made.
What is your usual method of postsurgical fixation?
Rigid fixation with plates and screws was the principal method for 53% of the respondents. Wire fixation alone was used by 20%, and the remaining 26% used a combination of the two techniques.
Do you find the surgical result is predictable?
Close to 80% of the responses indicated that the clinicians were pleased with the predictability of results. About 10% replied "not always", and 10% were not happy with their results.
What problems have you encountered, and how have you resolved them?
About half of the readers said their most common problem was the relapse of mandibular advancements; another 20% reported problems associated with condylar position, resorption, or postoperative TMJ disorders. Relapse of anterior open bite was mentioned by 20%, and a few respondents listed the continuation of paresthesia, particularly in the lower lip area.
The clinicians offered few suggestions for resolving these problems; most said they simply dealt with them if and when they arose. The only solutions mentioned by any number of readers were careful planning and overcorrection, especially with mandibular advancements.
Do you think orthodontic treatment can bail out a surgical result that falls short of anticipated goals?
About 20% of the respondents said "no" , believing that a second surgery would be needed. Responses from the remaining 80% often included comments such as "sometimes" and "to a limited degree". Many felt it depended on "how far off" the teeth were, but beyond saying "maybe 2-3mm" , no one expressed a clear indication of the limits of orthodontic correction.
In what cases in which a diagnosis might indicate that surgery is the treatment of choice would you prefer to avoid the surgery and treat only with orthodontics?
The clinicians clearly felt that surgery should be avoided if the patient was medically compromised or had a poor understanding and unrealistic expectations of the surgical results. Several said that in borderline Class III cases and Class II, division 2 cases, acceptable results could often be achieved with orthodontics alone.
Specific comments included:
2. A prospective patient comes to your office for a second opinion. Do you offer a second opinion? Do you quote a fee before clinical examination? Do you quote a fee after clinical examination? Do you request diagnostic records from the first orthodontist? Do you take your own records? If the patient asks to be treated at your office, do you accept the patient? Do you communicate with the first orthodontist? Does it make a difference if the first practitioner was a general dentist?
All the respondents said they would offer a second opinion if requested to do so. Although 95% said they would not quote a fee before the clinical examination, 80% would quote at least a fee range after the examination. More than 95% would request records from the first orthodontist, but a similar number would also take their own records, particularly if the first set were incomplete or of poor quality. Nearly 95% of the readers said they would accept the patient for treatment, and more than 85% would communicate with the first orthodontist. Respondents were almost evenly divided on whether it made a difference if the first practitioner was a general dentist.
A patient under treatment at another office comes to you for a second opinion. Do you offer a second opinion? Do you quote a fee before clinical examination? Do you quote a fee after clinical examination? Do you request diagnostic records from the first orthodontist? If the patient asks to be treated at your office, do you accept the patient? Do you communicate with the first orthodontist? Does it make a difference if the first practitioner was a general dentist?
Nearly 90% of the respondents said they still would offer a second opinion to a patient already under treatment, although several said they would do so "carefully" . Ninety-five percent still would not quote a fee before clinical examination, and only 60% (compared to the 80% in the previous set of questions) would quote a fee after clinical examination. More than 80% would still request diagnostic records from the first orthodontist and take their own if necessary. However, only 60% would accept the patient for treatment, and many of these said they would only do so with the "consent" of the first orthodontist. All the clinicians said they would communicate with the first practitioner. Again, respondents were evenly divided on whether it made a difference if the first practitioner was a general dentist.
Comments included:
A patient under treatment at another office comes to you for a second opinion and expresses a wish to sue the other practitioner. You believe there may be a basis for a suit. What do you tell the patient? Does it make a difference if the other practitioner is an orthodontic specialist?
This question generated numerous detailed responses. In general, virtually all the respondents emphasized that they would attempt to be conciliatory and non-judgmental. They would strongly recommend that the patient return to the first practitioner and try to clear up the matter. They would attempt to communicate with both the patient and the practitioner for as long as possible, and only as a last resort might they refer the case to a peer review group such as the local dental society. More than three-fourths of the respondents felt it made no difference whether the other practitioner was an orthodontic specialist.
Specific comments included:
JCO wishes to thank the following contributors to this month's column:
Dr. Kenneth Albinder, Virginia Beach, VA
Dr. Richard Alston, Tarboro, NC
Drs. David Asatani and Kent Payne, Covina, CA
Dr. Alex Axelrode, Pinole, CA
Drs. Donald H. Baxter and William A. Raineri, Fayetteville, NY
Dr. Stephen Bosonac, Clark, NJ
Dr. Terry Burke, Middleton, WI
Dr. G.R. Casey, Fort Benning, GA
Drs. Edward Cook and Arnold Cook, Bethlehem, PA
Dr. James Davis, Glendale, AZ
Dr. Robert DeShields, Strongsville, OH
Dr. Olwyn Diamond, Baltimore, MD
Dr. James Felli, Corning, NY
Dr. James Greenlees, Clawson, MI
Dr. Mark Hablinski, Houston, TX
Dr. Waldo Harshberger, Frederick, MD
Dr. R.D. Jackson, Alexandria, LA
Dr. Douglas Jolstad, Minnetonka, MN
Dr. Donald C. Jordan, Tacoma, WA
Dr. M.C. Kastrop, Billings, MT
Drs. Jack King, Melvin Mayerson, and Theodore Pope, Dayton, OH
Dr. Lester Kuperman, Fort Worth, TX
Dr. Samuel Lake, Bellevue, WA
Dr. Thomas C. Lovlien, Ashland, WI
Drs. Steven Misencik and Mark Misencik, Strongsville, OH
Dr. Edward Morin, Worcester, MA
Dr. Robert Morrison, Hutchinson, KS
Dr. David Musich, Schaumburg, IL
Dr. Scott Nash, Mount Vernon, WA
Dr. George V. Newman, West Orange, NJ
Dr. Lee Pargot, Somerset, NJ
Dr. William Parker, Paducah, KY
Dr. Charles Patton, New Castle, PA
Dr. Edwin Polk, Stillwater, OK
Drs. Morgan C. Powell and J. Robert Fleming, Urbana, IL
Dr. Fred Salvatoriello, Hanover, NH
Dr. Russell Schwindt, Manitowoc, WI
Dr. Richard Snyder, Columbus, OH
Dr. Jeffrey Staples, Mission Viejo, CA
Dr. Paul Styrt, San Diego, CA
Dr. Calvin Upshaw, Smyrna, GA
Dr. Frank Verde, Cockeysville, MD
Dr. Andrew Weiss, Chicago, IL
Dr. Edwin Wentz, Lubbock, TX
Dr. Jim Williams, Fort Wayne, IN
Drs. Alex Willis, Richard Vanek, and Raymond Ball, Jacksonville, NC
Dr. Warren Youngquist, Colorado Springs, CO
Dr. Steven Zeh, Louisville, KY
