An Alternative Airway Intervention to Preserve the Surgical Field in Oral and Maxillofacial Surgery.

Background/need. Office-based sedation has become increasingly commonplace in dental offices in recent years, allowing for practitioners to provide broader scope of care for their patients. Maintaining high standards of safety is of utmost importance when sedation is utilized in the office-based setting, especially for patients deemed at a higher-risk for intraoperative airway obstruction. This demographic includes but is not limited to individuals with a medical history significant for obstructive sleep apnea, chronic obstructive pulmonary disease, and morbid obesity. Presently, a wide variety of airway devices exist for use in the event of airway obstruction. However, in the context of oral and maxillofacial surgery, placement of these devices can encroach upon the surgical field, extending the perioperative period and putting the patient at greater long-term risk for maintaining adequate oxygenation. Methodology. The authors describe a preliminary technique trialed in our offices which utilizes a size 5.0 endotracheal tube (5OET) as an adjunct supraglottic airway to help mitigate the issue of oxygen saturation maintenance, as well as unimpeded access to the oral cavity. Implementation of the device requires identifying appropriate candidates during preoperative screening and placing the device through the nare and securing it above the glottis. Device Description. The 'tube kit' is comprised of a standard size straight 5.0 cuffed oral ETT, a 5-mL syringe for inflation of the cuff post insertion, lubricant, flex extension tubing, end tidal sampling line for capnography, tape for securement of the 5OET, and an anesthesia breathing circuit. Optional equipment pieces include an elbow connecter and a foam piece for comfort. Results/Current Status. Preliminary results have demonstrated oxygen saturations maintained above 98% when the 5OET is placed preoperatively. Continued use of the trial device will inform the development of a tube by our clinicians, and its efficacy will be studied in our offices. The next steps will be to start developing a pilot cuff that will be submitted for patent approval after its use in IRB-approved clinical studies.

Accuracy of haptic robotic guidance of dental implant surgery for completely edentulous arches.

STATEMENT OF PROBLEM: The accuracy of single implant placement is critical, as errors may cause problems with vital structures intraoperatively, as well as postoperatively with the prostheses. These issues may be exacerbated in complete-arch edentulous treatments requiring relative accuracy among multiple implants, particularly with prefabricated prosthetic structures. PURPOSE: The purpose of this clinical study was to determine the accuracy of dental implant placement by using haptic robotic guidance in completely edentulous participants. MATERIAL AND METHODS: In a prospective single-arm clinical study, 5 qualified participants elected to receive dental implants placed by using haptic robotic guidance to restore either the maxillary or mandibular arch, or both, with complete-arch implant-supported prostheses. Three dual-arch participants and 2 single-arch participants resulted in 38 endosteal dental implants being placed. A virtual preoperative restorative and surgical plan was created before surgery. This plan was matched to the surgical workspace on the day of surgery by using a bone-mounted fiducial splint fabricated from a cone beam computed tomography (CBCT) scan. Intraoperatively, the surgeons maneuvered a handpiece attached to the robotic guidance arm, osteotomies were created with a haptically constrained handpiece, and the implants were placed with 3-dimensional haptic constraints as per the virtual plan. Postoperative CBCT scans allowed the evaluation of the deviations of the actual implant placement relative to the plan. RESULTS: Twenty-three implants were placed in the mandible and 15 in the maxilla. The mean ±standard deviation global angular deviation was 2.56 ±1.48 degrees, while the crown of the placed implant showed a deviation from the plan of 1.04 ±0.70 mm and the apex of 0.95 ±0.73 mm. The signed depth deviation was 0.42 ±0.46 mm proud. No adverse events were reported. CONCLUSIONS: This clinical series for treating completely edentulous patients by using haptic robotic guidance was found to be safe and accurate. While further longer-term clinical studies are necessary to measure outcomes and to assess differences as compared with nonrobotic implementations, haptic robotic preparation appears to confer additional intraoperative advantages over other techniques for treating completely edentulous arches.

Anesthetic considerations for a patient with myasthenia gravis undergoing deep sedation in an outpatient oral surgery setting.

Myasthenia gravis (MG) is a neuromuscular autoimmune disorder which clinically presents as muscular weakness and fatigue due to autoantibody formation against acetylcholine receptors (AChR), leading to their subsequent destruction. Due to the neuromuscular implications of MG, certain considerations must be taken into account when providing anesthesia to MG patients. In the following case report, we have outlined procedural considerations for the anesthetic management of a patient with MG undergoing deep sedation for an elective oral surgery in an outpatient setting, as well as a discussion of relevant literature.

Implant therapy for a patient with osteogenesis imperfecta type I: review of literature with a case report.

Bone fragility and skeletal irregularities are the characteristic features of osteogenesis imperfecta (OI). Many patients with OI have weakened maxillary and mandibular bone, leading to poor oral hygiene and subsequent loss of teeth. Improvements in implant therapy have allowed for OI patients to achieve dental restoration. However, there is limited available literature on implant therapy for patients with OI. The greatest challenge in the restoration process for OI patients in an outpatient setting is ensuring primary stability and osseointegration. Improvements in synthetic grafts improve successful implant placement and prevent predisposing patients to unnecessary procedures. This report details the successful restoration process of an OI type I patient's maxillary arch in addition to a review of the currently available literature.

Office-Based Anesthetic and Oral Surgical Management of a Child With Hereditary Sensory Autonomic Neuropathy Type IV: A Case Report.

Hereditary sensory and autonomic neuropathy type IV (HSAN IV), or congenital insensitivity to pain with anhidrosis, is an exceptionally rare genetic disorder that results in the complete loss of pain and temperature sensation as well as anhidrosis. Anesthetic management of these patients can be difficult because of significantly increased risks during general anesthesia. Literature on perioperative anesthetic management is typically written in the context of a hospital setting. As such, our case presents a unique report on the anesthetic management of a HSAN IV patient who presented for extraction of 2 teeth in an office-based setting. In determining how to safely manage the procedure, we decided against general anesthesia as we lacked the facilities and equipment to safely handle previously reported complications. We were successful in providing sedation with nitrous oxide in oxygen and applying 20% benzocaine topical ointment on the surgical site in lieu of administering general anesthesia. We had an anesthesiologist present and obtained intravenous access prior to the surgery to help manage any complications. This report provides support that simple dental extractions can be accomplished safely in the HSAN IV patient in the office-based setting, thereby avoiding unnecessary risk.

Review: An overview and analysis of novel oral anticoagulants and their dental implications.

BACKGROUND: Dabigatran, rivaroxaban, apixaban and edoxaban are approved novel oral anticoagulants (NOACs) as alternatives to Vitamin K antagonists (VKA). Physicians are prescribing an ever-increasing amount these drugs to their patients due to various advantages over existing medications. AIMS: The objective of this review is to provide the dental professional with current literature surrounding the emergence of NOACs, as well as various case studies on the subject, in an effort to guide clinical decision making regarding these medications. The pharmacological profiles of these NOACs and idarucizumab, a reversal agent for dabigatran, will be detailed in this review. MATERIALS AND METHODS: A review of the literature on NOACs was undertaken and the Pubmed, Medline, and Embase databases were used to identify articles published in the English language. Additionally, major dental medicine journals were hand searched, followed by a review of the ClinicalTrials.gov database. RESULTS: Due to minimal research regarding dental treatment of patients on NOACs and minimal clinical experience of practitioners treating these patients, there is currently insufficient data to establish an evidence-based NOAC management protocol in a dental setting. DISCUSSION: In this review, the most significant advantages of NOACs over VKAs was found to be limited interactions with other drugs as well as rapid onset and offset of action. CONCLUSION: Despite these benefits, as well as various others, NOACs still lack specific management parameters as well as antidotes or reversal agents. Therefore, dental professionals must use caution when treating patients currently taking these specific anticoagulants.

Congenital granular cell lesion of the tongue: a report of two cases and review of the literature.

The congenital granular cell lesion most commonly occurs on the maxillary or mandibular alveolus of neonates. Extra-alveolar congenital granular cell lesion is exceptionally rare, with only 10 cases reported. Two additional cases occurring on the tongue are presented with a description of the clinical, histopathologic, and immunohistochemical features. The differential diagnosis is discussed, and the literature reviewed.

Referral patterns of general dental practitioners for oral surgical procedures.

PURPOSE: The health maintenance organizations (HMOs) in the United States continue to be a powerful force in the field of medicine. Their infiltration into dentistry has placed an emphasis on having the primary care provider (general practitioner [GP]) function as the central orchestrator from which patient care cascades. The purpose of this study is to determine the self-perceived threshold and referral tendencies for the GP to a specialist for oral surgical needs. MATERIALS AND METHODS: Six hundred dentists were randomly selected to receive a questionnaire containing 16 clinical cases. These randomly arranged cases consisted of a brief case history and appropriate radiographs. Each case differed in complexity and was grouped according to surgical difficulty as follows: group I--simple dentoalveolar surgery, group II--complex dentoalveolar surgery (including any third molar case), group III--cases requiring placement of an implant, group IV--simple surgery for a medically compromised patient, and group V--complex surgery for a medically compromised patient. RESULTS: Differences in the referral patterns of cases were noted comparing age, gender, and years of practice of the GP. A higher referral rate to the specialist was also observed in patients with remarkable medical conditions. Most general dentists referred the complex dentoalveolar surgery cases. There exists a gender difference in the referral patterns of female dentists compared to their male counter parts in similar age groups and years of clinical practice. Most dentists referred the implants procedures to oral and maxillofacial surgeons or periodontists. Referrals for simple and complex surgical procedures were most often made because of inadequate surgical experience. CONCLUSIONS: When designing dental health policy with regard to exodontia, dentoalveolar surgery and management of the medically compromised patient, insurance companies and public health administrators should consider the existing competencies and level of comfort of the GP.