Surgeon & Orthodontist at the Surgical Exposure?
Published: October 2017
Bulletin #70 October 2017
Surgeon & Orthodontist at the Surgical Exposure?
“……. do not go in (to the operating room) and bond a bracket to the canine during the (surgical) exposure”. Laurance Jerrold, 1996.1
Dr. Laurance Jerrold, an orthodontist (he is the Program Director of the Orthodontic Residency Program at NYU Langone Hospital - Brooklyn) and an attorney, is well known to the readers of the AJODO as its respected Editor for Litigation, Legislation, and Ethics and the author of series of articles published over the last 20+ years on the legal aspects of doctor-patient rights and responsibilities. The articles he writes give us all a very sound legal base within the confines of which we should be practicing. Of course, his advice is grounded in US law as it relates to medicine, in general and to dentistry and orthodontics, in particular. Nevertheless, for most countries of the Western Hemisphere, the principles he describes are largely universal and, where they do differ, they tend to be stricter in the US.
In 1996, he wrote an article in which he railed against the practice of some orthodontists who feel they must attend each of the stages of a multidisciplinary case, even when the non-orthodontic part of the plan is being carried out by the practitioner of another specialty. More specifically in the present context, he declared categorically “ ……… stay out of the operating room or operatory where another practitioner is performing their part of the treatment plan“ and “……. do not go in (to the operating room) and bond a bracket to the canine during the (surgical) exposure”. Here he was writing in his capacity as an attorney, advising that each practitioner should be responsible for his/her own sphere of activity. The point he was trying to make was to remain at “arms-length” as related to the other practitioners who may be ministering to the patient. If you maintain a degree of control or active participation in the activities of another, it increases your potential legal exposure.”1
As historically recent as the 1990’s, many impacted canines were unnecessarily sacrificed and the decision to extract was often made by the oral surgeon, rather than the orthodontist. The justification for the decision was the severity of displacement, the risk of infection and the impracticability of leaving a broad surgical site open, with or without a surgical pack, because attachment bonding to acid-etched enamel was not carried out back then – the technology was new. Thus, if spontaneous eruption was not likely to occur, the tooth would likely be considered lost.
The orthodontist was often not consulted nor invited to be present when the decision was made. At that time in most of the advanced countries, it was generally considered that direct composite bonding of attachments to erupted teeth cannot be used on surgically exposed impacted teeth for fear of contamination, spillage of etchant and bond failure. This was because of the presence of an open and bleeding surgical field where rubber dam could not be applied……. at least, for many orthodontists this was good news and a well understood but spurious argument because they really did not want to be present.
Indeed, it was as late as 1993 that Dr. Kokich published an article2 in which he illustrated the use of threaded pins set into the crowns of impacted canines, as a means of applying traction to the impacted tooth.
From the early 1970’s, we were placing preformed bands on these teeth at the surgical procedure and, as the result, we were able to re-claim many of these teeth. However, in order to place a band, the entire crown needed to be dissected free of its dental follicle and adjacent bleeding surfaces, which demanded radical surgery and efficient isolation of the tooth during the cementation process. Not every surgeon was willing to cooperate. So, for the more difficult cases, we became much more selective of the oral surgeons with whom we were prepared to work.
We adopted the use of direct bonding very soon after its introduction to clinical dentistry and, with it, the much more modest surgical requirement of exposing a small area of crown enamel only. We were able to report on its efficacy and reliability already in 19963. Many of the cases that comprised the investigated sample in that study involved impacted teeth which would earlier have been judged as intractable. Given this more user-friendly method of bonding attachments and the ability to include the surgeon in creating a suitably isolated and contamination-free area of crown enamel, we became much more expert at achieving our aims. There can be no doubt that the use of composite bonding has made our task much easier to perform and, due to the more modest scope of the surgical exposure that is now needed, the prognosis of our treated results is far superior. Many years have passed since we, like every other orthodontist, “sent” our patients to the surgeon to expose the tooth. Our protocol is to “accompany” our patient to a surgeon whose task following the initial exposure includes maintenance of hemostasis and the moisture-free area to provide us clinical operative access to the tooth. He does not go off to drink coffee while we struggle to securely place our attachment! As the result, we have become more and more adventurous and have been prepared to successfully tackle some of the most inaccessible teeth4, which makes us appreciate the blessing of CBCT imaging as a diagnostic tool5,6.
I met Dr. Jerrold for the first time after I had presented my maiden presentation at an Annual Session of the American Association of Orthodontists, in May 1998. The title of my lecture was "The Orthodontist's Presence at Surgical Exposure of Impacted Teeth - That's Quality Care!" Our meeting was very short, but I was left with the impression that our views of the overall picture were not as divergent as would seem apparent.
More recently, I was invited to write an article for an issue of Oral and Maxillofacial Surgical Clinics of North America, which appeared in August 20157. I submitted the draft manuscript (written in collaboration with Dr. Stella Chaushu) to Dr. Michael A. Kleiman, the editor of the volume under the title “Surgical Treatment of Impacted Canines: What the Orthodontist Would Like the Surgeon to Know”. The main thrust of the article was that it is in the interests of the patient, the surgeon and the orthodontist that both specialists be present and active at the surgical procedure. Initially he had concerns that “ … the realities of practice in our environment make that impossible on a steady basis” and that it was “.... just not going to happen in the US on a general basis.” I replied to Dr. Kleiman by pointing out that “... often decisions need to be made chairside which are not always foreseeable until the surgical field is opened up”. At the same time, I referred him to the website of the parent of a young patient whose experience with OMFS’s and orthodontists illustrates what she sees as the faults in the system that the real world in the US has to offer. The site is http://impactedcanine.weebly.com/ and mother describes it as a "parent-to-parent perspective". I highly recommend this incredibly well-informed mother’s website to each and every one of my readers. It is an eye-opener!
Oral and Maxillofacial Surgical Clinics of North America is a respected publication not normally seen by orthodontists in general and I recommend that our article should be read in its original form by both surgeons and orthodontists alike. Since it is crucial in support of my present argument, I offer here a short list of a few of the practical issues discussed in it which often arise during the surgery. These need answers to orthodontically-oriented dilemmas which can only be resolved by the orthodontist and which the surgeon may be ill-equipped to answer.
There are many ways to expose a tooth and the surgeon or periodontist could choose and successfully perform any one of them in most of the cases that he/she sees. However, it is the orthodontist who can predict which method will produce the healthiest and most esthetic soft tissue architecture that will be present after the tooth is brought into alignment in the treated case. The cost of a lack of on-the-spot input may be counted in terms of a poorer periodontal prognosis of the treated result. The fact that the patient or surgeon or orthodontist live too far from one another might mean that the orthodontist cannot be present, but we think that it must be recognized that this is not an ideal situation. The presence of the orthodontist at the surgical episode serves the patient's best interests. We also find that it speeds the procedure, reduces discomfort and eliminates misunderstandings and mistakes. From my own anecdotal experience over many years, the presence of the orthodontist is highly appreciated by the patient/parent and goes a long way to encourage confidence and trust.
Bonding of an attachment at the time of surgical exposure is not something which a surgeon is adept at performing, because it involves simultaneous and lengthy flap and tissue retraction, establishing and maintaining a completely dry, clean and blood-free surface of enamel while etching, rinsing, drying, painting with resin, light-curing, loading composite on the attachment, placing and curing. This is a highly technique-sensitive string of events which the surgeon does not perform on a routine basis. Orthodontists successfully bond hundreds of attachments every month!
The bonding location of the attachment is strictly the orthodontist’s realm and it is not always possible to determine this before surgery. Furthermore, a decision may have been made when the exposed tooth comes into view which may dictate the need to draw the tooth in a direction not previously considered suitable and this may require a change in a more usual or predetermined bonding site.
Immediate application of extrusive force from a customized spring mechanism is of considerable value if it is performed by the orthodontist under cover of the pervading anesthetic, at surgery.
Extreme displacement of an impacted tooth usually dictates its extraction, often due solely to the difficulty in attachment bonding or the inadvisability of performing an open surgical exposure. There can be no doubt that the teamwork that combines the superb skill of the surgeon in controlling bleeding and the parallel skill of the orthodontist in bonding attachments offers a superior assurance against bond failure.
In relation to my opening quotation from Dr. Jerrold’s article, I would submit that, because of the multitude of avoidable problems and unnecessary complications that may occur when the surgeon exposes a canine without direct participation and cooperation of the orthodontist in the operating theater, the likelihood of legal recourse on the part of the patient is high and may still involve the orthodontist as a co-defendant.
I forwarded the rough draft of this bulletin to Dr. Jerrold a few days ago, for his comment. He responded that he did not agree with the last part of that sentence and noted as follows:-
“……Assuming the referral was correct, and the exact procedure to be performed was not specified or directed by the orthodontist (an example of a higher degree of participation or control) the orthodontist has LESS exposure if he does not participate in the surgical procedure. If the orthodontist is actively participating in the procedure, it is that fact that increases his exposure.”
My response is as follows: “… that same fact of orthodontist participation significantly REDUCES the chances of failure, thereby reducing the risk of being sued.
Clearly then, you are damned if you do and you are damned if you don’t !
So, where do we go from here? Ethically, we should put the patient’s well-being first – after all, we are doctors, not lawyers! So, inform the patient, earn his trust, elicit his/her consent for you to do what you know to be is in his/her best interest. Then do it.
We must not lose sight of the fact that it is the orthodontist who must see the patient through the remaining lengthy period of treatment. Failure to deliver the desired result will often sour the patient-doctor relationship and that, more than anything else, can lead to a disgruntled patient and to legal recourse.
References:
1. Jerrold L. It’s not my job! American Journal of Orthodontics and Dental Orthopedics, 1996, 110: 454-455.
2. Kokich VG, Mathews DP. Surgical and orthodontic management of impacted Teeth. Dental Clinics of North America 1993; 37:181-214
3. Becker A, Shpack N, Shteyer A. Attachment bonding to impacted teeth at the time of surgical exposure. European Journal of Orthodontics 1996; 18:457-463.
4. Becker A. Extreme tooth impaction and its resolution. Seminars in Orthodontics 2010; 16:222–33.
5. Chaushu S, Chaushu G, Becker A. The role of digital volume tomography in the imaging of impacted teeth. World Journal of Orthodontics 2004; 5:120–32.
6. Becker A, Chaushu S, Casap-Caspi N. Cone-beam computed tomography and the orthosurgical management of impacted teeth. Journal of the American Dental Association 2010;141(Suppl 3):14S–8S.
7. Becker A, Chaushu S. Surgical Treatment of Impacted Canines: what the orthodontist would like the surgeon to know. Oral & Maxillofacial Surgical Clinics of North America 2015; 27:449–458
