Face to Face® March 2020

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Issue 61 / March 2020

Editor-in-Chief Javier González Lagunas

Assistant Editor Deepak Krishnan

Graphic Designer María Montesinos

Executive Committee 2020-2021 Board of Directors

Gabriele Millesi, President Alexis Olsson, Past President Alejandro Martinez, Vice President Sanjiv Nair, Vice President-Elect Arthur Jee, Treasurer Larry Nissen, IAOMS Foundation Chair Mitchell Dvorak, Executive Director

Members-at-Large Piero Cascone Rui Fernandes Fred Rozema

Regional Representatives

Imad Elimairi, Africa Tetsu Takahaski, Asia Nick Kalavrezos, Europe Leopoldo Victor Meneses Rivadeneira, Latin America Ian Ross, North America Jocelyn Shand, Oceania Nabil Samman, Editor-in-Chief, IJOMS

Committee Chairs G.E. Ghali, Education Alejandro Martinez, Governance and Ethics Alfred Lau, Membership and Communications Sean Edwards, Research Paul Sambrook, IBCSOMS Representative David Koppel, 25th ICOMS-2021, Glasgow Ed Dore, 26th ICOMS-2023, Vancouver FACE TO FACE Registered in U.S. Patent and Trademark Office. ©Copyright 2018. I nternational Association of Oral and Maxillofacial Surgeons. Chicago, Illinois, USA. All rights reserved under international and Pan American copyright conventions. Cover image ©mixmagic


International Association of Oral and Maxillofacial Surgeons IAOMS Foundation 200 E. Randolph St., Suite 5100 Chicago, IL 60601 USA / communications@iaoms.org

Letter from the Editor AS I SEE IT I CAN´T imagine a worst start. We planned this issue as a celebration of the decade to come. Our brilliant minds have created incredibly amazing technologies that would help us to overcome any obstacle that may arise. And then, a virus spreading across the entire world shattered it all, humbling mankind. Today I am writing this column confined to my residence by recommendation of our authorities. I don´t know when I will be able to have resume my normal life. Some of you have already gone through this experience, others will pass It in a few weeks. The nightmare is global. Now, forget about my first paragraph. Be positive. If you were Marty McFly or any other type of time traveler, what would you prefer? To visit the Roaring 20s of the Twentieth Century? Or would you head towards the mystery and uncertainty of the 2040s? The past in general has that aura of “any time in the past was better”, while for others the future is the promised land: milk and honey everywhere. Probably those working in the textile industry in Manchester during the early 20 th century will not have the same sweetened view of life that Jay Gatsby and friends had in New England. And regarding the future, there are many that sustain that the apocalyptic scenario of Blade runner is a kindergarten compared to what lies ahead. We have asked some colleagues to make an exercise on visioning the future and let their imagination free to guess how our (professional) life will be in 10 years. We have received inputs from colleagues from all over the world. How is it to work in Ecuador, what is the daily life of a trainee in Singapore, Dr Ewers, chairman of the successful Wien ICOMS talks about his life today, and we receive art from South Africa. So take advantadge of the extra free time that the virus has given us. Read us, and please, remember to share the magazine with your colleagues and national associations.


Javier González Lagunas EDITOR IN CHIEF


What will happen during the next decade?

Will it be as revolutionary and exciting as in the 20th century?

SO, YOU WANT TO WORK... 28 Ecuador.


The USA resident perspective.


A maxillofacial resident in Singapore.




WHERE ARE YOU NOW? 44 Rolf Ewers.


BEYOND THE O.R. 49 One century later.

LEARN, CONNECT AND GROW WITH IAOMS WITH a new year upon us, we are feeling refreshed and excited for what 2020 has in store. The IAOMS Chicago Headquarters, along with our Board of Directors and Executive Committee are hard at work developing and implementing new programs and opportunities for the IAOMS and OMFS Community. We are committed to our mission and eager to assist our members in growing their individual practices, as well as the specialty on a global scale. With every idea and initiative, we strive to foster a global community, advocate for the highest standards of patient care and support continuous learning and education. Together, through the power of teamwork and collaboration, we as community can learn, connect and grow. NETWORKING & EDUCATION OPPORTUNITIES


As we continue to foster a global and inclusive community, we encourage you to save the date for our upcoming networking and education opportunities. Our robust calendar of programs for the 2020 and 2021 year is developing rapidly, and we are excited to share the news!

IAOMS is on the path to digital transformation with extensive content such as Scientific Webinars, Podcasts, Online Review Courses, Virtual Conferences and more. For the surgeon on the go, we have developed the IAOMS Podcast Series. Listen to Season One “Conversations in Rio” and Season Two “Behind the Surgeon” now, available on our website and most streaming platforms. The IAOMS Education Committee is developing a comprehensive calendar of IAOMS Scientific Webinars, offered both Live and On-Demand. To access previous webinars and stay informed on future offerings, head over the Education & E-Learning portion of www.iaoms.org. Interested in more? We will be announcing details on our Second Annual Virtual Conference soon!

ICOMS Glasgow 2021: We are eager to announce the details of the upcoming 25th International Conference of Oral and Maxillofacial Surgeons. If you haven’t attended an ICOMS in the past or you are curious about our upcoming meeting in Glasgow, please head over to www.iaoms.org/icoms2021 to get familiar with our signature, biennial event. Take a moment to review the 2019 highlight video from the 24th ICOMS in beautiful Rio de Janeiro, and preview what’s to come with in Glasgow with our “Looking Ahead to 2021” promotional clip. To make the most of your trip, we’ve started gathering general information, tourism activities, details on Glasgow and more to help our members create the best experience possible. Save the Date: September 1-4, 2020 I2020 AAOMS Annual Meeting in Conjunction with IAOMS: More details to follow regarding the 2020 AAOMS Annual Meeting in Conjunction with IAOMS. We look forward to seeing you in San Antonio, Texas. Save the Date: October 5 - 10, 2020

STAY CONNECTED Year after year, IAOMS membership continues to grow on a global scale. Thank you to all 4000+ members from across the world who have joined or renewed for the 2020 year. Please note that if you have not yet renewed but would like to, our membership grace period concludes March 31, 2020. For those of you who are not yet members, please view our member benefits here and join today! We also encourage you to stay connected by following us on social media and subscribing to our email communications.


Letter from the President WELCOME Dear Colleagues, Friends & IAOMS Members, WHEN our immediate past president, Prof. Alexis B. Olsson transferred the presidential chain to me at the ALACIBU meeting in Cancun this December, it was a very emotional moment! The ceremony of transferring the chain symbolizes continuity within our association, similar to the Olympic fire taken from one continent to the other. I am aware of the honor and the big responsibility, following a long row of great presidents and great personalities. All different but with the same vision to do the best for our members, to secure best patient´s treatment and to share and bring education of the highest level to every corner in the world.

great specialty across all regions, recognizing not only academic institutions but individual surgeons. Thank you to all the oral and maxillofacial surgeons who contribute to the success of the specialty and for the great impact you have on individual lives.

February 13th, 2020 was International OMS Day, a day celebrating the efforts of Oral and Maxillofacial Surgeons on a global scale. With the various platforms of social media at our disposal, we were able to witness influx of enthusiastic posts celebrating our

Association of Oral and Maxillofacial Surgeons has developed to the global synonym for best practice, state of the art treatment and representation of the OMF specialty. This prestigious growth and recognition is due to the hard work and dedication of

I have been working for the International Association since 2003 and since then, I have seen IAOMS and the IAOMS Foundation grow and flourish. This is not only due to excellent leadership, but also a professionalized headquarters under the lead of our Executive Director, Mitch Dvorak. The International

our leadership and Chicago Headquarters. I would like to thank the IAOMS Board of Directors, our past presidents, the Executive Committee and our dedicated Foundation Chair, Larry Nissen. All these accomplishments and continued success make me extremely proud to have the chance to assist and lead our future projects and to continue the successful growth of our association. I also want to thank our members and our councilors, who are at the core of our association, for providing me with the chance to be the IAOMS President over the next two years. One of my priorities as President will be to share and provide education of the highest level to every corner in the world. This includes brining an in-person, face to face IAOMS presence to our members by attending global conferences and programs over the next two years. One of my initiatives will be to join the faculty of our Gift of Knowledge courses this upcoming year in Philippines and in Guatemala. IAOMS prides itself on the exchange of clinical and scientific expertise, and we will continue to meet our members where and when possible. With all of the exciting opportunities to get involved with IAOMS as President, I would like to share my great interest in our NextGen Community. As the NextGen liaison to the IAOMS Board and Executive Committee, I encourage you to get involved with this ever-growing community. Our NextGen Community is hard at work building an online resource for all young surgeons to connect, learn and develop their careers! Last May, we established a global NextGen Council led by Dr. Alfred Lau. To meet the 2019-2020 NextGen Council from around the world, click here. If you are a surgeon under the age of 40 and currently practicing in the OMF Specialty, we encourage you to visit www.iaoms.org/nexgen to see where we’ve been, take our monthly Scientific Quiz, connect in our community chat room and more! We are open for any suggestions and advice our members may have as every voice and every opinion counts.

“One of my priorities as President will be to share and provide education of the highest level to every cornerin the world.” At this point I originally wanted to highlight our upcoming International Symposium on Orthognathic Surgery which was scheduled in Vienna end of April. Due to the world-wide COVID-19 crisis , we had to cancel it with deep grief. The present situation will change our strategies. IAOMS, together with our Learning Studio director Debra Zabloudil, will share educational contents on our e-learning plateform and push virtual conferences until we can meet again in person, because the best part of IAOMS is you, our members. We are strong as a team in our diversity and our common goals. I will always have an open ear to your needs and expectations, and I see my duty to support you. I take honor in the opportunity to lead all IAOMS Members, our NextGen members and our female members, and hope to inspire all by being a role model. Together, we will meet our aims and live our dreams, even in corona virus times. I thank you all for your trust and support in the upcoming two years of my presidency! In the meantime I wish you strength and optimism in managing these challenging times of our global health crisis. With my warmest wishes,

Gabriele Millesi IAOMS PRESIDENT 2020-2021

What will happen during the next decade? Will it be as revolutionary and exciting as in th the 20 century?

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Be prepared for the NEXT DECADE By Stefaan J. Bergé Nijmegen, the Netherlands

AS WE enter a new decade, we look forward to what could be of interest for oral- and maxillofacial surgery (OMFS) in the next years. Among others, it is expected that augmented reality (AR), artificial intelligence (AI) and robot-assisted surgery (RAS) will become important building blocks in the further development of the profession. Given the important role that AR, AI and RAS will play in the future, it is important for OMF surgeons to be familiar with the principles and the scope of all three of them.

of various anatomical regions of the body, used for diagnosis, planning and surgical training. VR is meanwhile widely explored in dental implantology, orthognathic surgery, traumatology, craniofacial and reconstructive surgery. In contrast to VR, augmented reality (AR) aims to integrate virtual content in the real world. Therefore the focus of the next decade is expected to be more on augmented reality (AR).


The definition of AR refers to: “A technology that superimposes a computer-generated image on a user’s view of the real world, thus providing a composite view”(1). In the medical field, AR systems combine the real environment (e.g. the patient) with virtual images. Complex anatomy, such as the location of a tumor or the relation between an impacted molar and a nerve can be visualized directly on the patient. The ability to examine the anatomy from different angles further improves the understanding of the anatomy in the patient. Next to the visualization of complex anatomy, AR can be deployed as an extension to surgical navigation system in order to transfer a virtual planning to the patient (fig. 1).

Virtual reality (VR) describes a computergenerated 3D environment which is suitable for exploration by and interaction with a person. In medicine, VR is mostly about creating a virtual environment for the assessment

A. Principles of AR

Fig. 1. This AR example combines the real environment (the patient) with virtual images (craniofacial surgical planning). 3D Lab - OMF Department, Nijmegen, the Neherlands.

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The superimposed virtual objects are usually obtained through 3-dimensional X-rays as (CB)CT scans, which are then manipulated with commercially available software. Also MRI, angiography, stereophotogrammetry, dental scans or any other three-dimensional data set can be used in the same way. The integration or augmentation of the reality with e.g. anatomical information or a surgical plan, is actually based on the registration of fiducial markers (in OMFS mostly miniscrews, occlusal splints or QRcodes). After the fiducial markers are recognized (location, orientation and scale), the virtual image is superimposed onto the real environment, forming the “integrated image�, mostly on semi-transparent glasses. While staying focused on the surgical field, augmented reality glasses provide feedback from the planning to the surgeon. In this way, the user is not forced to switch his or her view to an external monitor where conventional navigation data is normally displayed.

At least as important as the use of AR in surgery, are the numerous AR possibilities in teaching and training(10). Ayoub and Pulijala(11) summarize AR teaching applications for local anesthesia of the inferior dental nerve, cutting and milling aspects of bone surgery, dental extractions, apicoectomies, orbital floor reconstruction and orthognathic surgery, among others.

B. Scope of AR in OMFS

The term artificial intelligence (AI) refers to a technology that allows computer systems to perform tasks that normally require human intelligence, such as visual perception, object and pattern recognition, and complex decision making(12). Although AI has not yet reached the forefront of patient care, there is an abundance of studies that show its potential(13).With its potential to improve quality and access of care as well as cost reduction, there is little doubt that AI will play a major role in shaping the future of (OMF) health care.

The most frequent application of augmented reality in OMFS is nowadays mainly in dental implantology(2) and orthognathic surgery(3). Nevertheless, other early believing authors describe also the use of AR systems in OMFS trauma-(4), TMJ(5) , craniofacial-(6,7) (video 1), ablative-(8) and reconstructive surgery(9). In the majority of this OMFS-applications, AR is used to transfer a surgical plan to the patient on one hand, and to intraoperatively check accuracy on the other hand.

C. Next decade AR is about to add a digital intelligence layer to our profession at high speed. Wearing AR-glasses during consultation time, discussing cases or performing surgery, will become routine in the next decade. In a few years from now, a generation that has been raised with an intensive daily training in AR, will enter the OMFS-specialty. At the latest then, AR will become the ruling reality in OMFS. ARTIFICIAL INTELLIGENCE

Video 1. Experimental augmentad reality in craniofacial surgery 3D Lab - OMF Department, Nijmegen, the Netherlands.

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A. Principles of AI (fig. 2(14))

B. Scope of AI in OMFS

As the word implies, in AI, the intelligence is artificial, programmed by humans to perform human activities. This AI is incorporated into computer systems to create AI systems that ultimately functions as units of “thinking machines”. The second generation, machine learning, is an application of AI that provides the AI system with the ability to automatically learn from the environment and applies this learning, to make better decisions. Deep learning models, the third generation of AI, can make their own predictions entirely independent from humans.

Although applications of AI can be found across most medical specialties, the use of AI by the OMF society is rather limited at this very moment. Nevertheless, following a recent explosion in the digitization of medical data, large sets of digital radiographic and pathologic images are now readily available, also in OMFS. As a consequence, we recently could welcome the first AI publications in OMFS-literature. Some early publications (2018-2020) deal with topics such as dento-alveolar surgery(15-18) , orthognatic surgery(19), head and neck oncology(20) and reconstructive surgery(21). C. Next decade It is expected that this starting AI scope in OMFS will increase exponentially in the next decade. Therefore, OMF surgeons should seek opportunities to collaborate with data scientists and guide them towards the relevant clinical questions using the right data. While no AI algorithm is meant to replace physicians, those physicians who use AI, might in future replace the ones who do not.

Fig. 2. when speaking of AI, it’s worthwhile to consider two different approaches: machine learning and deep learning, which both are subfields of AI. Source: https://www. deeplearning-academy.com/p/ai-wiki-machinelearning-vs-deep-learning.

The use of deep learning has been driven by the rapidly accumulating volume of medical data. Deep learning systems use artificial neural networks (ANNs). An ANN is an innovative computing model that functions in a way inspired by the neurons in the human brain network (fig. 3) by constantly adapting and train itself. Structurally, an ANN comprises input (dendrites), hidden layers (cell body), and output layers (axon). ANNs have an effective learning ability, and they can identify complex patterns and relationships within a dataset. This effective learning characteristic has made ANNs a good choice to provide support for clinical decision making (13).

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Fig. 3. An artificial neural network is an interconnected group of nodes, inspired by a simplification of neurons in a brain. Here, each circular node represents an artificial neuron and an arrow represents a connection from the output of one artificial neuron to the input of another. (https://en.wikipedia.org/wiki/Artificial_ neural_network)

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ROBOT-ASSISTED-SURGERY Medical robotics are currently transforming many aspects of medicine. They can help surgeons to perform surgeries with maximum accuracy and precision, as well as minimal invasiveness inside a human body. Medical robots also include tele-robots that can be controlled remotely, even where the surgeon or his fingers cannot be physically present. Finally, medical robots include nano-bots, a form of microscopic robots that can be swallowed like capsules or injected in a blood stream. Here, we focus on robot-assisted surgery (RAS). A. Principles of robot-assisted surgery RAS is defined as the utilization of an electromechanical machine, to enable surgeons to operate with more efficiency, accuracy and precision(22). A robotic surgical system consists of input (e.g. sensors and imagers), analysis (e.g. a surgeon) and output (e.g. manipulators and lasers). For the time being, a human is interposed between the input and output in case there are any unexpected events or aberrant anatomy during surgery(23). B. Scope of robot-assisted surgery in OMFS Within the past decade, remarkable progress has been made in robot-assisted surgery of the head and neck region. Transoral robotic surgery (TORS) was proposed and first applied clinically by McLeod and Melder(24) (2005) to excise a vallecular cyst.

The technique as well as the surgical experience has improved greatly since then. Currently, the chief indications for TORS are removal of head and neck neoplasms or cysts that can be sufficiently exposed via a robotic approach(25), obstructive sleep apnea syndrome (OSAS)(26), implantology(27), cleft palate surgery (preliminary reports)(28), and orthognathic surgery (experimental)(29). Robots can also be used for extra-oral applications, such as therapeutic or selective neck dissection(30) or craniofacial surgery (experimental)(31) (video 2). There is a tendency to believe that in specific cases, OMFS is performed with less blood loss, fewer complications, shorter hospitalization and better cosmetic results with the assistance of robotic surgical systems(32). C. Next decade From a clinical perspective, the widespread use of robotic surgical systems in head and neck surgery is an inevitable fact(33), although the development is still in its early stage. In the next decade, the current human surgeon controlled systems will probably interact or even be transformed into an active collaborative support/autonomous system. Aforementioned technologies such as artificial intelligence, augmented reality or cloud computing(34) will play an important role in that evolution. Though the development of complete autonomy remains visionary, increased competition between the commercially available RAS-systems will certainly drive the technological improvement and decrease the financial burdens in the next years. FINAL STATEMENT

Video 2. Experimental setting of a robot-assisted craniofacial planning transfer. The robot arm is indicating the planned craniotomies on the skull of the baby. 3D Lab - OMF Department, Nijmegen, the Netherlands

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As a profession, OMFS should be ready and willing to warmly adopt these new technologies, among others. If we would be able to invest in combining techniques such as augmented reality, artificial intelligence and robot-assisted surgery, we really do have the potential to improve OMFS profoundly within the next decade. Internationally well-established OMFSnetworks are mandatory to reach this goal, since big data collections are the base for all these intriguing facilities. The IAOMS could or (and) should play a facilitating role in realizing these necessary developments. ■

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Waiting for THE FUTURE to arrive By George Paul Salem. India

IT WOULD BE impossible to predict what new discovery or invention over the next ten years will change the landscape of surgery in the 2020s. However, we can hazard a guess about how existing technologies might change the way we practice oral and maxillofacial surgery (OMFS). The twenty twenties will probably herald the transition of innovative surgery from the laboratory bench to standard clinical practice. It might well be the decade of translational medicine, a term coined and promoted in the 90s. The first decade of the millennium heralded a slew of breakthrough innovations and discoveries in medicine and surgery. The human genome project launched in 1990 was officially completed by 2003 though it was anticipated to take 15 years. The sequencing

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of the human genome holds enormous potential in understanding mutations, propensity for diseases and creating a platform for devising treatment protocols. Similarly surgical aids like robotics have been in the market for a long time and used in selected institutions in the world. It’s wide spread use is imminent. According to Zachary Tomlinson in Interesting Engineering (a web portal), the next decade takes us to the “brink of sweeping changes that could mean better diagnostics, safer, less invasive surgery, shorter waiting times, reduced infection rates, and increased long-term survival rates for everyone. And that is definitely something to be excited about(1).� Artificial intelligence has revolutionised many aspects of medical care by developing algorithms and

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In fact the surgeon may become a key figure bridging technology with patient needs. The document released by the Royal College of Surgeons makes the observation that “ surgeons will, therefore, need to become ‘multi-linguists’, speaking the language of medicine, surgery, radiotherapy and bioengineering, but also possess leadership, managerial and entrepreneurial skills. In some cases, the surgeon may coordinate interventional care and act as the conductor of the surgical team, but in other instances they may play the role of the first or second violin, or perhaps may not be on stage at all”(4).

using data for diagnosis and patient management. Hashimoto et al predict that Surgeons should partner with data scientists to capture data across phases of care and to provide clinical context, for AI has the potential to revolutionize the way surgery is taught and practiced with the promise of a future optimized for the highest quality patient care.(2) AI driven machine learning , artificial neural networks and language processing has been incorporated into robotics and navigational surgery. The use of Robotics in OMFS has however been slow and tentative. For example, in 2016, cadaver trials for repair of cleft palate with the da Vinci Robot was undertaken. This was inspired by Transoral Robotic Surgery ( TORS) in supra glottic laryngectomy, radical tonsillectomy and skull based surgery. Naseer Nadjmi(2) reported excellent results in robot assisted surgery. However it still remains in the realm of clinical trials. A whole range of discoveries, inventions and innovations that incorporate pharmacogenomics, computer aided surgery, minimally invasive techniques and artificial intelligence stand on the threshold of universal clinical application in diagnosis and management- including OMFS. The question whether surgeons may in fact become unnecessary in health care is a premature one. While minimally invasive surgery may result in a shift from saws and scalpels to robots and lasers(4), the surgeon is unlikely to be displaced. Patients will still look for human touch, empathy and bedside visits.

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The next decade may also see the emergence of a new spin on science that will make some of our existing surgical experiences redundant. Some feel that emerging trends in pharmacogenomics, immunology and targeted therapy may take surgery out of the arsenal of treatment options for cancer. However, Dr Moni Abraham Kuriakose, the Director of Cochin Cancer Centre any a well known researcher and scientist in the field of Oro -pharyngeal cancers feels that while it may be true of pharyngeal and laryngeal cancers, oral cancer will continue to be managed by conventional surgery. He feels that treatment protocols and multi modality treatment may improve outcomes and improve quality of life, but alternate treatment is still distant(5). Organ preserving modalities may considerably decrease the need for post ablation reconstruction. If required, stem cells and engineered tissues could be used to reconstruct defects. Access to engineered tissue will therefore be open to more patients and more diseases. 3D bio-printing could help achieve this goal as a tool to deliver scalability, reproducibility and a reduction in cost(6).The future predictions guidebook of the Royal College of Surgeons actually believes that in twenty years, 3D printing could be used to manufacture artificial organs. And nano robotics could do surgery on individual cells.(6) If all of the above sound like flights of fancy and speculation, we must consider the unimaginable ways in which conventional surgery was eliminated in numerous situations over the last 20-30 years. Shrinking indications for open heart surgery and morbid neurosurgical interventions with relatively

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non invasive stents and endoscopic approaches are a testament to how insidiously technology takes over our traditional practices. On a more pragmatic level, the changes we can really expect to see with a degree of certainty will be in the field of guided surgery and with navigational tools. I was talking to a Maxillofacial surgeon who has practised and honed his skills as an expert implantologist over the last 25 years. He told me, a trifle blithely, that in a couple of years, computer printed guided splints will be standard procedure in implant rehabilitation and orthognathic surgery. It will help a beginner place those implants or plan orthognathic surgery with the same accuracy and precision that others have perfected over two decades. It would virtually wipe out the experience factor by a technology which is now available at an affordable price. 3D printing of splints are not new. It has become enormously cheap compared to what one could have accessed only at a significant cost some years ago. Pre fabricated splints combined with sophisticated navigational equipment will make procedures more accurate, predictable and safe. Cost of technology will in fact change the dynamics of use. Deskilling will therefore become the great equaliser. Surgical training however has not evolved spectacularly in the last several years. In the past, as in the present, one of the great challenges in training surgeons is the transition from watching and assistance to actually doing a procedure. With the advent of simulators the new trainee should advance from animal or cadaveric surgery to high fidelity mannequin surgery which provides tactile and anatomical familiarity with structures. Unfortunately simulators for standard open procedures are still low fidelity models like non organic material that mimic real tissue. New techniques to display a patient’s medical information, such as 3D images, virtual reality and augmented reality can help surgeons adapt and improve their outcomes. Procedure rehearsal incorporating novel imaging will facilitate the introduction of new procedures and enhance training(5). As of now high fidelity training is possible mostly in robotics where trainees sit at separate consoles participating in procedures in a graded and controlled fashion. They are engaged in shadow learning with the lead surgeon holding the control.


We can only speculate how the twenties will pan out for surgeons. Genetic engineering and pharmacogenomics may mean a shift in cancer management in general but conventional surgery will be the mainstay of oral cancers. There can be a paradigm shift in reconstruction due to tissue engineering and 3D bio printing but it is difficult to imagine such a scenario in the near future. Robotics have been around in several areas of surgery for a long time. The direction of travel is more likely to be one where robots and surgeons work in closer partnership, one making up for the limitations of the other. Of course we must not forget that a surgical robot is simply a tool to improve delivery of surgical therapies(7). Robotics may not have a significant role in OMFS but AI and navigational surgery might make surgery safer especially in difficult regions. Minimal invasive surgery, particularly endoscopic surgery might be used more extensively in the next decade e.g. arthroscopic surgery, sialoendoscopy and endoscopic assisted open surgeries for fracture fixations and other possibilities. Greater use of guided and navigational surgery using computer generated planning from advanced imaging is likely to be routine in the twenties. There will be newer learning techniques for trainees with low and high fidelity simulators. Large scale use of surgical mannequins is a distinct possibility at least in advanced centres. However the OMFS surgeon will remain the main stay in facial surgery and open surgery will not go out of vogue in the near future. Surgeons in general and OMFS in particular will need to train in open surgery as a safeguard against malfunctioning of machine centred surgery. In fact we must remember to keep our open surgery skills for emergencies even as we train in parallel with minimally invasive procedures. â–



The surgeon and the CONNECTED individualism By Julio Mayol Madrid. Spain

OUR SPECIES, Homo sapiens, has evolved due to its ability to collaborate with peers on a large scale. The development of this capacity gave rise to the cognitive revolution, which occurred some 70,000Â years ago(1). The most important tool has been and continues to be communication, through the use of three large narrative lines that enable individuals who do not know one another to collaborate successfully: fear, envy, and fantasy.

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Since that first cognitive revolution, there have been 4 other great revolutions that explain our present status: the agriculture, political-religious, scientific, and finally the digital revolution in which we are currently immersed. The last revolution has transformed the way we understand the relationships between human beings (in terms of hierarchies, power dynamics, and geographical, temporal and cultural boundaries) that are guided by fear, envy and fantasies. This article aims to analyze how the appearance and explosion of web 2.0 is influencing the dissemination of knowledge, in particular in the global surgical community. WHAT ARE DIGITAL SOCIAL NETWORKS? Although the internet appears in the late 1960s as a network of computers part of a project of the United States defense agency (DARPA), it is not until the early 21st century that the communication applications between devices that will soon become the key to web 2.0 are launched. LinkedIn was the first application that was launched to create a network to connect professionals. But soon after, Facebook, YouTube and Twitter emerged and were incorporated into the application ecosystem with billions of users. These applications allow the exchange of text messages, audio, images and video clips, and live streaming of video and audio, and can link files on the network. Users, even if they lack specific knowledge, are able to create and share content. They become nodes of creation and distribution of information that can influence those

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who receive the contents. This is how digital social networks (closed systems) and digital social media (open and viral systems) arise. To this profound change is added the social movement which proposes to openly share data, information and content generated in the research from public money: the open access movement. The combination of these changes has had an enormous impact that is difficult for us to see and understand. But for the first time, doctors run the risk of losing our role as agents between knowledge in any area, and the final user(2). SOCIAL NETWORKS FOR SURGEONS However, the reaction of health professionals, and more specifically of surgeons, has been to resist entering in the professional use of networks. They fear the banalization of knowledge and the risk to our individual and collective reputation(3). This lack of participation could end up being counterproductive, because social networks have become not only the new media but also channels conveying both professional and informal information between people and institutions on a matrix basis. If we are not part of the networks we will not be missed, but content (whether of better or poorer quality) will continue to be shared and others will take our place. The first uses of social networks with knowledge dissemination objectives beyond LinkedIn date back to the beginning of 2009, when the Henry Ford Hospital in Detroit and the San Carlos Clinical Hospital in Madrid transmitted surgical interventions through Twitter. Progressively since then, surgeons have been incorporated into social media either as individuals, surgery departments, hospitals, universities, professional associations of surgeons, surgical journals, etc., using multiple channels such as Twitter (individual accounts, surgery departments, professional societies, via magazines, and other interest groups), Facebook (open and closed groups of surgeons, magazine channels, patient groups), LinkedIn (groups of surgeons, professional organizations and magazines), YouTube

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(video channels of either individuals or scientific organizations and surgical journals), Instagram (accounts of surgeons, professional associations and journals), and messaging systems such as WhatsApp or Telegram that are mainly used individually(3-5). Although messages shared via applications such as WhatsApp reach a large volume, the channel with the greatest professional activity due to its characteristics of social media rather than social network is, without a doubt, Twitter(6,7). It is a “microblogging� application, in which users publish entries of up to 280 characters, which can include text, photography, video clips, infographics, surveys with up to 4 options, links to websites, or live video transmissions (Figure 1). It is not one of the applications with the most active accounts (there are just over 300 million), but it has the most impact on the dissemination of knowledge and interaction between users (identified by an arroba symbol followed by a string of characters which is the username) because it creates visible and lasting links between users who have never even met in person. (Figure 2). The difference between Twitter and other platforms lies in the fact that Twitter offers the possibility of viewing the content of other users without having to follow them, which promotes the dissemination of information and knowledge in an open manner and the potential viral impact of what is shared(8,9), with poor control by the issuer. In addition, it offers the possibility of obtaining and analyzing data on the interactions between nodes, by means of graph analysis tools, transforming the analysis of what looks like a mere conversation into computational sociology(10).

Figure 1. Tweet that includes the user's account with their name and photograph, text, link to an article, mention to other users of the network and a photograph of a CT.

The initiatives on Twitter are spread across different specialties and rarely include the opinion of citizens, patients and organizations that represent them. The conversation involves both the dissemination of knowledge and the research itself while involving patients in the definition of results to include in the projects. The most active specialties on Twitter have been plastic surgery and colorectal surgery, although other specialties and subspecialties such as urology, oncological gynecology, thoracic surgery, endocrine surgery, abdominal wall, etc. have been progressively incorporated. Table I shows some of the initiatives that have been developed since the first transmission of surgery.

Your tweets got 1.2M impressions in this period of 28 days

Figure 2. Twitter analytics metrics on impressions (number of times a tweet has been viewed) and interactions (number of times a tweet has been deployed) of the @juliomayol account.

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Figure 3. Metrics of the community #SoMe4Surgery according to Twitonomy.com (more than 1000 users between February 9 and 17.

Figure 4. Users connected in a week with the hashtag #some4surgery according to analysis with Twitonomy.com in 559 locations worldwide.


surgeons, related professionals, organizations and even patients.

In order to improve the impact of surgical information shared on Twitter, virtual communities have emerged that are organized around a string of characters preceded by the # symbol (known as a hashtag). In this way, it is easy to find content using the application but, above all, the hashtag facilitates the linking and connection between users who share a common meaning(11).

As Grossman et al.(15) described in BMJ Innovations, the creation of virtual communities around surgery is based on 4 actions: 1. Connecting people to form a virtual network 2. Expanding the network by sharing interesting content to its components [members?] 3. P roviding positive feedback to members of the network to consolidate their participation 4. M easuring and making visible the quantitative results obtained via the interactions.

Initiatives of specialties or even traversals such as #plasticsurgery(12), or #colorectalsurgery(13) were very successful, even in conventional channels, especially with the #Ilooklikeasurgeon movement(14). This led in 2018 to the emergence of the #some4surgery initiative, whose mission was to create a global ecosystem of knowledge exchange between

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The conversations and activities held within the virtual community on Twitter have resulted in a large number of supranational activities and collaborations (Figure 3 and 4), ranging from the organization in 2019 of the first face-to-face summit, with the participation

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• Tweeted surgical intervention • Dissemination of conferences and conference communications (messages and live video) • Dissemination of articles (surgical journals, authors, researchers, etc.) • Journal club (organized by departments and surgery services) • Clinical sessions • Clinical cases • Static and animated infographics (posters, communications, magazine articles) • Dissemination of surgical videos • Surveys • Tweetchats (conversation through questions with experts, patients, etc.)

of surgeons and patients from countries on three continents, and even scientific publications with authors some of which have never been found. The possibility of using these ecosystems to promote and manage surgery research, even globally, is especially relevant. Obviously, participation in social networks is not without risks. The first and most significant risk is that of sharing patients’ private information publicly, either voluntarily or inadvertently. One should be extremely careful in this regard and it is advisable to follow the recommendations of guides that different surgical and medical organizations have developed regarding professional behavior in networks, such as those of the American College of Surgeons(16).

Likewise, observing certain norms reduces the risk of reputational crises that may arise as a result of disputes between professionals, between professionals and patients or as a consequence of the quality of the information disseminated. SUMMARY In summary, since the emergence of social networking applications on the Internet in the early 21st century, the number of connected people has been increasing, currently exceeding a billion. In these networks, information and informal and professional knowledge are shared, and generate more traffic of content generated by users than by any other means of communication, also feeding on the growing movement of open access to data and information (Open Access). Surgeons, as professionals dedicated to managing information to establish professional connections, and to train and help patients, cannot remain oblivious to knowledge dissemination channels. A conscious use of social networks for professional purposes, as demonstrated by the #SoMe4Surgery community, can help surgeons and other related professionals, and even patients, to establish large communities of global knowledge that improve and make for safer practice of surgery. ■ REFERENCES

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The Roaring 20’s in USA Oral and Maxillofacial Surgery development

By Hether Khosa Cincinnati. United States

THERE ARE two broad categories of pathfinders. The first kind know their end goal. Their means are end oriented. Thomas Edison for example, set out to develop a “longer lasting incandescent lamp” and along the way, his perspiration was infused with inspiration… and the fruits of his labor are now studded on our ceilings.

An interesting fact that I came across as I researched Oral Surgery in its nascence, is how the culmination of the first world war set the perfect stage for this burgeoning specialty, with –

The second kind are a bit different. They keep at it and while they are at it, their hard work and inspired creativity leads to almost serendipitous results. The reason I say serendipitous is because a body of exodontists in the early 1900s may not have envisioned the very fluid and ever-expanding boundaries of the field they founded.

✓ the post 1918 economic expansion leading to job creation

Formally, the seeds of Oral and Maxillofacial Surgery were sewn in 1918, when twenty nine exodontists signed the founding charter of the American Association of Exodontists. The National Dental Association (present day American Dental Association) recognized the specialty in 1919. Two years later, the society changed its name to the American Association of Oral Surgeons and Exodontists (ASOSE) to better represent the practitioner’s growing interest and scope of practice.

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✓ the general sense of optimism that had taken over the American populace

✓ economic expansion and job creation tie in nicely with the growth of American cities. This demographic change, the growth of urban settlements and educated and aware consumers, paved the path for “specialists” in the field of dentistry ✓ good old “supply and demand.” Post war facial injuries stressed the system to come up with solutions; this laid the groundwork for both Plastic & Reconstructive Surgery, and Oral & Maxillofacial Surgery ✓ improved anesthesia techniques ✓ the beginning of the age of antibiotics

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Dr. James E. Garretson (1825-1895) is hailed as the Father of Oral Surgery. He not only named the specialty, he also wrote what was probably our first textbook titled “Disease and Surgery of Mouth, Jaws and Associated Parts” in 1869. The text went through six impactful editions, the last of which was published in 1898. Dr. Garretson received an M.D. from the University of Pennsylvania and a D.D.S. from the then Philadelphia College of Dentistry (present day Temple University School of Dentistry). Among other things, he advocated the use of intra-oral surgical approaches for the sake of cosmesis and the use of a dental engine for bone surgeries. We are slowly inching towards the 20th century as we begin to talk about Dr. Truman Brophy (1848-1908). Through his work and his writings, he received worldwide acclaim. He organized the Chicago College of Dental Surgery. He also contributed by writing a textbook published in 1915 titled, “Oral Surgery: A Treatise on Disease, Injuries and Malformations of The Mouth and Associated Parts.”

The story of our beginnings is interesting to say the least. It was in 1840 that Dr. Chapin A. Harris and Dr. Horace Hayden founded the Baltimore College of Dental Surgery. Their motivation? The medical profession refused to accept these “physicians of the oral cavity” as some of their own. Today, one doesn’t put a lot of thought into why medicine and dentistry are two separate, almost parallel paths, under the larger umbrella of healthcare. It has been so for years… and this is why. The first of our kind - oral surgeon was Dr. Simon P. Hullihen (1810-1857). Dr. Hullihen was a physician who was awarded a “D.D.S.” as honorary recognition. Dr. Hullihen’s work had as broad a scope as one could have. In his practice, he treated infections, facial trauma, clefts and patients with trigeminal neuralgia. He is also credited with performing the first orthognathic surgery for correcting an open bite deformity. Quoting Dr. Hullihen, “He [a dentist] must claim for himself and his profession, the same respect and importance awarded to other branches of the healing arts, and that too upon the same ground-the ground of thorough scientific education.”

Dr. Chapin A. Harris

Dr. Simon-P-Hullihen. Considered by many as the Father of Oral Surgery.

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One of Dr. Brophy’s pupils was Dr. Chalmers Lyons (1874-1935). Dr. Lyons not only established the oral surgery residency training program at University of Michigan in 1917, he also singlehandedly established the largest oral cleft practice in the country. His trainees set up the Chalmers J. Lyons Academy in 1927 and to this day, the academy sponsors the C.J. Lyons Memorial Lecture at the Annual Scientific Sessions of the AAOMS. Dr. Matthew Cryer (1840-1921) was trained by Dr. Garretson at the University of Pennsylvania in oral surgery. In 1901, he authored “Internal Anatomy of The Face.” In the same year, he founded the first complete hospital dental service in America, at Philadelphia General Hospital.

"In the field of Oral Surgery, if there’s someone who can deservedly wear the badge of a renaissance man, it’s Dr. Kurt Thoma."

Dr. Robert Ivy (1881-1974) made tall contributions to the field of orofacial traumatology and cleft surgery. He endorsed, in a big way, an interdisciplinary, coordinated team approach to cleft management. He established the Pennsylvania Cleft Palate Division of the Public Health Bureau. Dr. Theodor Blum (1883-1962), in an article published in 1925, “Oral Surgery and Its Relation to Medicine and Medical Specialties,” laid out the responsibilities of an “oral surgeon in a hospital team.” In the field of Oral Surgery, if there’s someone who can deservedly wear the badge of a renaissance man, it’s Dr. Kurt Thoma (1883-1972). Trained in architecture and dental surgery, he had keen interests in anesthesia, oral surgery, radiology and pathology. Besides being a wizard at the sciences, he also loved the finer things in life especially fast-paced automobiles! This homage to our pioneers would be incomplete without mentioning Dr. Varaztad Kazanjian. He rose to prominence in the field, against tremendous societal odds. As a 16 year old refugee and immigrant working in a wire mill, he probably had little knowledge of how seminal his contributions to this field would become. He was an oral and plastic surgeon of great repute. He pioneered the field of pediatric plastic surgery. Alongside being an educator par excellence, he also engineered maxillofacial prostheses for cleft palate patients and for those with eye, ear, nose and large soft tissue defects.

Dr. Kurt Thoma

College of Dentistry in 1877 and began practice in San Francisco the same year. Shortly thereafter, he returned to his home state of Ohio and set up his practice in Cincinnati. He continued at this practice until he passed away in 1918. He was not only a clinician but also a researcher. He was highly ranked in the Dental Department of the Cincinnati General Hospital and was the Director of Research at the Cincinnati Dental Research Club. In 1913, he started a pyramidal training program at Cincinnati General

Dr. Varaztad Kazanjian. Father of Modern Plastic Surgery

I recently graduated from residency training at the University of Maryland, Baltimore and took a full time faculty position at the University of Cincinnati’s residency program. What I didn’t know at the time was that this program came into being in the year 1913, making it the first of its kind in America. The man responsible for this program was Dr. John Ross Callahan (1852-1918). Dr. Callahan was born to Dr. Dennis Callahan, a physician and dentist in Hilsboro, Ohio. He graduated from the Philadelphia

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Hospital where the focus of training was oral surgery. A year before his passing, he was also felicitated with the Jarvie Medal for his scientific investigations. The tireless striving of these stalwarts in the early 1900s helped carve out a specialty which over the years has seamlessly integrated with dentistry and medicine. Oral and Maxillofacial Surgeons have proven their mettle at orofacial traumatology, in-

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office anesthesia, correction of dentofacial anomalies through orthognathic surgery and treatment of head and neck pathology in addition to performing dentoalveolar surgery (in all its dimensions). With our early practitioners being dual trained physiciandentists, we have left an impressive footprint in the field of cleft care and head and neck oncology. We continue to further that today with the many structured, advanced training programs/fellowships in our field. While the early 1900s were a time for laying down the framework of our specialty, the 2000s have been about the marriage of surgical art and technology: ✓ Improved diagnostic modalities. ✓ The ability to perform precise virtual surgical planning. ✓ 3D printing of hardware and stereolithographic models of craniofacial structures. ✓ Real time intra-operative navigation in the field of trauma, reconstruction and implant dentistry. ✓ Electronic medical records have helped with clinical research and audit; this has ushered in the era of quality assessment and improvement (a sort of buzz word in healthcare today). ✓ Tissue engineering which is shifting treatment paradigms in the field of reconstruction ✓ Targeted therapies and monoclonal antibodies, which are revolutionizing cancer care and management of other medical conditions.

"I guess in these times, we are only limited by our imagination. Our next generation of pathfinders will probably be some of us or some of our current dental students..." The next few years will see the development of algorithms based on big data and artificial intelligence, advances in tissue engineering (improved scaffolds, cell signaling molecules, cell preservation and handling techniques) and 3D organ printing technology. Discovery of biomarkers

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and personalized medicine will break new barriers. And while old barriers are broken, newer conundrums shall emerge. Osteoradionecrosis and medication-related osteonecrosis of jaws are two such conundrums that have come within our purview in the last few decades. These diseases bring to light the other edge of the sword - the sword called modern medicine. While radiation treatment and bisphosphonates have significantly improved outcomes in relevant contexts, they have also led to grave consequences in others. This, however, is only a prologue. With newer antiresorptives, anti-angiogenics and other biologics on the horizon, I only see the burden of this disease increasing. As practitioners of modern medicine, we have to be observant to be able to pick up early signs of what could be catastrophic side effects of novel therapies. There are a few aspects of healthcare that we should be actively working to improve. We urgently need to lessen the burden of healthcare on patients. Especially in our field where there’s a fine line between a “medically necessary” surgery and a cosmetic procedure, getting insurance companies to shoulder expenses is often a challenge. Dental/prosthetic rehabilitation in head and neck cancer survivors continues to be a financial burden for them; post treatment implants and maxillofacial prostheses are somehow not considered a medical necessity. Marching into the future, dental insurance companies should perhaps take a lesson from medical insurance companies, for whom post-mastectomy reconstructions are a non-issue. We also need to steer clear of turf wars and medical tribalism; be it oral surgery versus periodontics or oral surgery versus plastic surgery/otolaryngology, the need for healthy respect for the “other” cannot be overstated. We occupy a privileged position in the web of healthcare, operating (quite literally) within the realms of both dentistry and medicine. As a result, our access to information is tremendous and turf wars will only curb our growth as a specialty. I guess in these times, we are only limited by our imagination. Our next generation of pathfinders will probably be some of us or some of our current dental students and there may be someone (like yours truly) who, at the turn of the century, will chronicle their groundbreaking work in the field. Here’s to many more decades of roaring innovations. ■

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Prof. Wilfried Schilli (1928-2019) By R. Ewers Vienna. Austria ON SEPTEMBER 29 2019 one of the great Cranio-Maxillofacial and Oral Surgeons passed away – one of the truly great! Born on May 29 1928, Wilfried Schilli remained a “South-Badener” and loyal to his native region all his life. His professional training started immediately after the war with an apprenticeship to become a dental technician. In 1949 he went on to study Medicine and Dentistry and graduated from University in 1955. His specialty medical training in CranioMaxillofacial and Oral Surgery started in 1959 under Professor Eschler at the Freiburg University Clinic. In 1963 he spent 5 months in India working as a guest surgeon at several Universities. Back in Freiburg and under the supervision of Professor Eschler, he qualified as University Professor with the postdoctoral thesis “Die Differenzierung des Mundbodenepithels” (Differentiation of the floor of the mouth epithelium). In 1970, Professor Schilli was appointed Head of the Oral and Maxillofacial Surgery Department and he ran it until 1997. In this period he also held the offices of Medical Director of the Dental Clinic as well as of Chief Medical Director and Dean of the Freiburg Medical University Clinics. Schilli taught and trained innumerable dentists, oral surgeons and maxillofacial surgeons. It is thus indeed possible to speak of a “Freiburg School”. As one of his former students I can personally confirm the admiration we held for our teacher. He was the symbol of the threefold division of a university teacher: Physician, scientist and teacher with the patient always at the heart of his endeavours. He was

nice, jovial and conciliatory, but also a man of clear principles and limits that his students and scholars were well advised not to cross. Professor Schilli always stressed that Dentistry should be the basis and foundation of Oral and Maxillofacial Surgery. He was full of “new ideas” and although his true passion lay with Cleft Surgery, he made essential contributions in the fields of Traumatology and Implantology. He was among the first surgeons to actively join AO/ASIF (Association for the Study of Internal Fixation) where he developed new osteosynthesis procedures for mandible, maxilla and midface and co-established the AO/ASIF Consortium’s CMF-Section. In the field of Implantology, he was among the very early pioneers in the development of new implant systems, becoming one of the founding members of the International Team of Implantology (ITI). There was literally no German, European or International OMF and CMF Association he didn’t chair. From 1986 to 1989 Professor Schilli was the President of the International Association of Oral and Maxillofacial Surgeons (IAOMS). Also of great concern for him was the so called “double degree” for OMF surgeons worldwide, but particularly in the United States. Together with several colleagues he founded the Bahamas Group which convinced many colleagues in the US but also in other parts of the world of the need of “double degree” for OMF surgeons. After his retirement in 1997, Schilli devoted even more time to humanitarian tasks. In 2001 he became the founding President of the German branch of Médecins du Monde.

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For this organisation he travelled to the most remote areas all over the world to operate children with cleft lip and palate and other deformities. It was not for lack of things to do, but rather out of the notion of wanting to one more time start something really important and new, that he and his son Georg together with former colleagues and friends established the “Schilli Implantology Circle”, SIC. The scientific outcome of that group is reverted to the SIC Invent AG, a manufacturer exclusively producing and developing for SIC. It was also a great pleasure for him when in 2018 his son Georg’s firm was able to take over from Zimmer Biomet, P- I, the last Dental Implant System developed by Professor Per Ingmar Branemark, thereby uniting the philosophies of two pioneers under one roof. For him this marked the beginning of yet another new life, which now, after his death, will be carried on by colleagues, friends and family members. Professor Schilli was a man of the gentle and friendly word who would never express anything negative in writing. His confident personality, his leadership qualities and his direct unpretentious way of communicating left an impression on everyone and was equally liked by all. Those of us who were lucky to meet him very soon felt at ease around him – often helped by sharing a glass of Baden wine. We will remember him in the most positive and exemplary light and we will always hold his memory in the highest esteem. ■

So, you want to work in...

By Jorge Barona Quito, Ecuador

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OUR COUNTRY, a founding member of the Latin American Association of Oral and Maxillofacial Surgery and Traumatology, has seen constant positive changes over the past few decades, starting with our accreditation as specialists in the field. The basic requirement for accreditation is to hold a Dentistry degree and a specialization in an accredited university or hospital center recognized by the National Secretary of Higher Studies.


The governing body of our specialty, the Ecuadorian Association of Oral and Maxillofacial Surgery (AECOMF), currently has 75 members who are either oral surgeons or maxillofacial surgeons. This association is registered and has legal status in the country’s Ministry of Public Health. Applicants must be reviewed and their certification approved by the scientific committee before they can qualify as a member of the AECOMF. Degrees that are not in accordance with the international curriculum of dentistry are not accepted until The National Secretary of Higher Studies reviews and approves the degrees undertaken via distance education. Not all public and private hospital centers provide oral and maxillofacial surgery services; this is especially true in older hospitals due to the archaic conception that dentists should not participate in hospital activities. We have consistently been gaining surgical and academic participation in these sites. In the capital (Quito), there are three full-time specialization programs, each with a duration of 4-years. Residents in these programs perform various rotations in national surgical services, and in other countries as part of academic partnerships.

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Department of Oral and Maxillofacial Surgery I.E.S.S. Hospital (Quito).

Areas of surgical competency: Oral Surgery, Implantology, Oral and Maxillofacial Pathology, Facial Trauma, Orthognathic Surgery, Cleft Lip and Palate, Temporomandibular Joint, Salivary Gland Pathology, Reconstruction, Facial Aesthetic Surgery, Facial Harmonization, Obstructive Sleep Apnea, Distraction osteogenesis surgery. Multidisciplinary areas: Microvascular Reconstruction, Craniofacial reconstructive surgery, oncology. We annually host a national event, where guests recognized internationally in their field participate in choosing the topics that will be discussed at the conference. This year, for example, the event will be held in the city of Guayaquil from September 15 to 17. The topics that will be covered include Facial Aesthetic Surgery, Facial Harmonization, Dental Implants, Orthognathic Surgery, Virtual Trauma Planning, and Facial Reconstruction (in conjunction with the AO Foundation). ■

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Gainesville, Florida. United States

first 3 years of our career, with the biggest challenge being a general surgery internship year between junior and chief years of OMS. This varies from program to program but the discontinuity in training is a constant.

THE DEVELOPMENT of the dual-degree OMS program took place in the 1970s at University of Nebraska in response to a need for a broader residency training and for the integration of dentistry and medicine. The direction our specialty was taking, and higher standards for better patient care, shaped this change in training. Today approximately 52% of the graduating residents are single degree and 48% are double degree. The challenges faced in our field during integrated training have raised objections which have persisted over the years. These are not only limited to debt accumulation as a result of an additional 2-3 years of medical school tuition, but also a less than ideal transition into medical school and fears of surgical training being truncated. Lack of integration between dental and medical school curricula prolongs medical training, often compromising OMS training time. The continuity of our residency education is also affected as we intermittently return to OMS service in the

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We have learned to adapt to these challenges by taking on a more active role during the first two years of residency: maintaining a focus on the aspects of medical school training that will ultimately improve our ability to be better surgeons for our patients; focusing on gaining as much OMS knowledge as possible while on service and away, reading oral surgery texts and publications for our monthly journal club meetings; immersing ourselves in research projects which we can complete while on medical school rotations. It is during this time that our mentors play a key role as their support, as well as their recognition of the importance of a strong medical education, greatly influences our focus and stamina. Fortunately, the support for dual-degree trained residents extends across program directors and faculty. As our training continues, the hope is for our medical background to strengthen our surgical training and influence future career choices in advanced fellowships or academics. The dual-degree concept has itself influenced the development of fellowship programs within OMS and contributed to our acceptance within the medical community. The biggest challenge we face is protecting our OMS surgical training time while complying with medical school and medical licensing requirements. It is our responsibility as NextGen OMS surgeons to advocate for improvements in our training, loan debt reform and maintenance of a broader educational perspective.

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Average Cost of Education and Training in OMS College: $24,472 Dental School: $261,305 Medical School: $173,960 Total: $459,737 2018-2019 OMS Program and Resident Stats Accredited OMS programs: 101 Single degree programs: 55 Dual degree programs: 46 Residents in training: 1165 Residents in Single-degree programs: 674 (58 %) Residents in Dual-degree programs: 491 (42 %) Structure of the six-year OMS residency/M.D. program First year: OMS: 2 months Medical school, second year level: 10 months Second year: Medical school rotations, third year level: 12 months Third year: Medical school rotations, fourth year level: 2 months Anesthesia, resident level: 6 months OMS: 4 months Fourth year: OMS junior level: 12 months

Fifth year: General surgery internship: 10 months OMS: 2 months Sixth year: OMS chief: 12 months

First year: OMS: 12 months

Second year: OMS: 1 month Medical school, second year level: 11 months Third year: Medical school rotations, third year level: 12 months

Fourth year: Medical school rotations, fourth year level: 2 months Anesthesia, resident level: 6 months OMS: 4 months Fifth year: General surgery internship: 4 months OMS: 8 months Six year: OMS chief: 12 months

Dual-degree Oral and Maxillofacial Surgery Training in the United States: “Back to the Future” Kaban, Leonard B. et al. Journal of Oral and Maxillofacial Surgery, Volume 78, Issue 1, 18 - 28. “2018-2019 OMS Program, Resident and Faculty Summary Report.” American Association of Oral and Maxillofacial Surgeons, 2019, www.aaoms.org/docs/ education_research/edu_training/aaoms_faculty_resident_summary.pdf.

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A DAY IN THE LIFE OF A MAXILLOFACIAL RESIDENT IN By Yong Chee Weng National University of Singapore

I RECEIVED my BDS from the National University of Singapore in 2015. After two years of rotations as a junior dental officer, I started my journey as an Oral and Maxillofacial Surgery (OMFS) trainee in 2017. There are two stages of OMFS specialist training in Singapore - Basic Surgical Training and Advanced Surgical Training. Basic Surgical Training (BST) lasts for 3 years and is conducted as a nation-wide training

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programme. During this phase, all trainees will not only rotate in OMFS departments across various hospitals in Singapore, but also in other medical departments such as General Surgery, Otolaryngology, Plastic Surgery and Anaesthesia. Trainees are also required to be involved in research and submit a thesis. The Advanced Surgical Training (AST) phase typically lasts 2-3 years and is held within the trainee’s sponsoring

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Hours 15:00 h institute. At the end of the AST, the trainee undergoes a final national examination before they receive their specialist accreditation. Each day’s activities are different, depending on whether there are any didactics or meetings, and whether the trainee is rostered for outpatient clinics or the operating theatre. Regardless, let me recount a typical day in my life as an OMFS BST trainee in Singapore!

07:30 h

The day starts with ward rounds with the consultants. Other than checking on our patients and making necessary changes to our plans, consultants also teach the trainees how to manage patients in the ward. As usual, I present findings and overnight events to the consultants.

I have a quick lunch break before attending the outpatient clinics. In the clinics, we see patients for consultation, reviews and minor surgical procedures (like dentoalveolar surgeries, implant surgeries, biopsies, arthrocentesis or minor orofacial trauma). These procedures are done under local anaesthesia with or without sedation. For today, I have arranged to see only two patients, for a wisdom tooth surgery consultation and a review of a medication-related osteonecrosis of the jaw.

08:00 h

I make my way to the operating theatre where we will be conducting an orthognathic surgery and an odontogenic cyst enucleation. The first case is a patient with a skeletal class III facial profile due to a retrognathic maxilla and a prognathic mandible, planned for Le Fort 1 Osteotomy Advancement and Bilateral Sagittal Split Osteotomy (BSSO) Setback. Under the supervision of my consultant, I perform the BSSO on the left side. Even though it is not my first time doing it, I value all the feedback I get - every case provides different challenges and fresh perspectives.

13:00 h

The second case involves the enucleation of a dentigerous cyst associated with an impacted lower molar. For this case, I will be assisting a senior, a registrar, as there seems to be a significant risk of damaging the inferior dental nerve. One year spent in the operating theatre on this case!

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Hours 17:30 h

21:00 h

I am off for my exit rounds. We are going to review all the patients in the ward, including the patient who just completed her orthognathic surgery. We also have a new admission today for a right submandibular abscess due to an infected extraction socket. The patient is listed under the emergency operating theatre list – I hope we get to do the incision and drainage before midnight as I am on call tonight!

Our patient with the submandibular abscess is getting transferred to the operating theatre now. Better make my way to the operating theatre and quickly refresh my surgical anatomy.

19:00 h Everything is quiet for now. Time for dinner! Will never know when I get a call.

01:30 h Just as I thought that I would finally get to rest. Another call from the Children’s Emergency – another boy who had a fall, this time a 4-year-old who has intruded both his upper teeth. Thankfully, the intrusion is minor and he has no other injuries.

05:30 h Peaceful for the rest of the night! Time to have a quick coffee and check on patients before the ward rounds. Glad to see that the patient who had orthognathic surgery is already awake and drinking water with a syringe.

19:30 h Thank goodness I always finish my meals fast. Got a call from the Children’s Emergency – a 12-year-old boy has had a fall, broken his front teeth and sustained an upper lip laceration.

07:30 h The cycle repeats itself. Back to morning ward rounds again!

NETWORKING, social media and associations. How does an experienced educator find ways to further his knowledge within the specialty? Learn the story behind Dr. Faisal Quereshy and how he continues to access new information utilizing the OMF community. Listen to the last episode of “The IAOMS Podcast Series: Behind the Surgeon” today. All episodes of Season 1 and Season 2 are now available to stream. Be the first to hear about the upcoming Season 3 of our podcast series and additional educational programming by subscribing to our emails and following us on social media. ■

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ICOMS Glasgow 1-4 September 2021

AAOMS San Antonio (Texas) 5-10 October 2020

ACOMS Singapore 23-25 October 2020 EACMFS Paris, 15-18 September 2020

EACMFS Paris 15-18 September 2020

CIALACIBU Cartagena de Indias (Colombia) 14-17 March 2021

AAOMS San Antonio (Texas) 5-10 October 2020 CIALACIBU Cartagena de Indias (Colombia), 14-17 March 2021 ANZAOMS Tasmania. 26-28 November 2020 PanAfCOMS

2021, Dates to be determined

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1 2 0 2 0 2 0



ACOMS Singapore 23-25 October 2020

ANZAOMS Tasmania 26-28 November 2020

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From Proust to Pivot


John Zuniga Professor in the Department of Surgery at UT Southwestern Medical Center. Dallas, Texas

o AAOMS meeting in 2018.

Bike ride with OMS friends at Chicag

What is your favorite word? Wonderful! - You can ask my residents, when they do well, when it goes well, when the outcome is achieved I will say Wonderful (in different languages). What is your least favorite word? Oops - likewise, indicates less than what I wanted to achieve.

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What is your favorite drug? Vitamin B complex – until nerve growth factor becomes available. What sound or noise do you love? Seagulls – there is ocean nearby. What sound or noise do you hate? Car horn blaring – when no emergency exists.

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My wife and me with our 4 children,

What is your favorite curse word? Shit – Says it all when something negative is occurring or just did. Who would you like to see on a new banknote? Barack Obama – best president US ever had. What profession other than your own would you not like to attempt? Law. If you were reincarnated as some other plant or animal, what would it be? Otter – loves to frolic and always seems happy. If Heaven exists, what would you like to hear God say when you arrive at the Pearly Gates? Let’s go for a ride (bicylce of course).

What do you consider the most overrated virtue? temperance. On what occasion do you lie? Forgetting simple tasks at home What do you most dislike about your appearance? Belly excess during winter Which living person do you most despise? Donald Trump What is the quality you most like in a man? Humility What is the quality you most like in a woman? Passion

What is your idea of perfect happiness? Happy marriage with best friend. What is your greatest fear? Losing love ones. What is the trait you most deplore in yourself? Critical and calculating approach. What is the trait you most deplore in others? Lying. Which living person do you most admire? My father. What is your greatest extravagance? My bicycle and all the toys it goes with. What is your current state of mind? Awareness and planning.

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ents, 2019.

a couple of grandchildren and my par

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Which words or phrases do you most overuse? What’s up.

What is your most marked characteristic? Goal oriented and confident.

What or who is the greatest love of your life? Who- my wife and children. What - cycling.

What do you most value in your friends? Humility.

When and where were you happiest? Current. Which talent would you most like to have? Fast twitch muscle strength with long endurance capacity. If you could change one thing about yourself, what would it be? Explore options and conditions sooner than later.

Who are your favorite writers? John Irving, Steven King. Who is your hero of fiction? Indiana Jones. Which historical figure do you most identify with? Abraham Lincoln. Who are your heroes in real life? My father, Rolf Ewers, RV Walker, Bejan Iranpour.

Our entire team January 2020.

What do you consider your greatest achievement? Having 4 great children.

What are your favorite names? Alex, Gabrielle, Amanda, Daniel.

Where would you most like to live? On the ocean front.

What is it that you most dislike? Fakes and liers.

What is your most treasured possession? My Racing bicycle.

What is your greatest regret? Not doing a post-doc.

What do you regard as the lowest depth of misery? Hurting people you love.

How would you like to die? At home or on the bicylce.

What is your favorite occupation? Oral and Maxillofacial Surgery – none better!

What is your motto Do and be seen doing. ■

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ART AND SURGERY IN SOUTH AFRICA By Kurt Bütow Pretoria, South Africa

Cleft Lip Bilateral (60-2017).

KURT BÜTOW, Professor/Chief Specialist emeritus and former Head of the Department of Maxillo-facial and Oral Surgery, University of Pretoria [currently in his own private surgical practice] and an IAOMS distinguished international fellow, has been sketching and painting, which ranks secondary to his passion for primary and secondary cleft surgery, for more than 40 years. He has produced over 800 line drawings in surgical papers and books and some of his more than 110 paintings have also been published. The most recent version of the book, “Cleft – Ultimate Treatment” includes 150 of his line drawings and 2 of his paintings. During the period of Kurt’s maximal surgical and academic activity, the line drawings (and a few paintings) were mostly produced for lectures, journal-publications and academic books. A sketch is a very powerful 3D visualization tool and is an excellent method of guiding a surgeon in procedures where he or she does not have any, or insufficient, experience. It must be accurate. About 8 of the more than 110 paintings by Kurt are directly or indirectly related to cleft surgery. The rest of Kurt’s paintings stretch over a wide variety of topics, which include desert landscapes (influenced by his country of birth, Namibia), wildlife, landscapes, indigenous flowers, the magic of sunrises and sunsets of Southern Africa, and many more. Kurt also specifically created graphic designs for the front covers of his first two academic books. He is a Director of the IBCSOMS Senate and designed the Hood of the IBCSOMS graduation gown and the Lapel Pin for this members of this international board. Most of Kurt’s paintings belong to the family. ■

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Mid-Facial Distration (64-2017).

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“The at work around the world” IAOMS FOUNDATION FELLOWSHIP PROGRAM

Thank you to our long-time supporter, KLS Martin, and the Osteo Science Foundation for their generous commitments to the Fellowship Program. We are pleased to introduce the 2020-2021 Fellowship recipients.

CLAUDIO HUENTEQUEO MOLINA (Chile) Osteo Science Foundation Oncology and Microvascular Reconstructive Surgery Fellowship The Ninth People's Hospital in Shanghai, China

HUSSEIN ALI ABDULNABI (Iraq) KLS Martin Oncologic and Microvascular Reconstructive Surgery Fellowship Peking University School & Hospital of Stomatology in Beijing, China

ENKH-ORCHLON BATBAYAR (Mongolia) KLS Martin Cleft Lip and Palate and Craniofacial Surgery Fellowship GSR Institute of Craniomaxillofacial and Facial Plastic Surgery in Hyderabad, India & Bhagwan Mahaveer Jain Hospital in Bangalore, India


Collaboration with the Osteo Science Foundation helped to grow the Visiting Scholars Program by more than 300% this year. Congratulations the 2019-2020 Osteo Science Foundation Visiting Scholars.

MICHA CYRUS SONGWA (Kenya) Visiting: U niversity of Texas Health Science Center. San Antonio, TX, USA

KONSTANTINOS KATOUMAS (Greece) Visiting: U niversity of Florida, College of Medicine. Jacksonville, FL, USA

LIYANA ARACHCHIGE JAYASINGHE (Sri Lanka) MIHAI RADULESCU (USA) Visiting: Q ueen Elizabeth University Hospital Visiting: H ospital para el niño Toluca Estado Glasgow, Scotland de México. Toluca, Mexico

ANUJ JAIN (India) Visiting: U niversity of Texas Health Science Center. San Antonio, TX, USA

MAIDAH HANIF (Pakistan) Visiting: H ospital Universitario Ramón y Cajal. Madrid, Spain

EACH YEAR, we are able to award opportunities to trainees and surgeons who are passionate about their profession and eager to acquire new skills. What they learn through the IAOMS Foundation’s programs enables them to become better surgeons, but the knowledge they acquire empowers them to become teachers and stewards of the OMS specialty. This is a powerful combination, as they can then act as an extension of our organization, sharing the gift of knowledge by teaching and mentoring their colleagues at home.

Dr. Larry W. Nissen IAOMS Foundation Chair

In order to continue to expand these programs, we need your help. Not only in the form of financial support, but also through participation and positive advocacy for our organization and its activities. On behalf of the IAOMS Foundation, thank you to our members, affiliated associations, foundations, and corporations who continue to support our mission and programs. And, thank you to all of the individuals who apply for these opportunities. Your pursuit of excellence and desire2019 to betteriaoms.org serve the needs March 43 of patients everywhere is inspirational. ■

Where are you now?


Dr. Rolf Ewers

By Deepak Krishnan Cincinnati. Ohio


ear Dr. Ewers

How do you spend your time these days? Since more than 7 years I am retired from the chair of the University Hospital for Cranio-Maxillofacial & Oral Surgery in Vienna. Fortunately, I am still chair of the CMF Implant Institute Vienna and enjoy working three day in the week there. I found a new hobby by performing studies on very, very atrophic maxillae and mandibles treating them with ultrashort Bicon implants. Our results are very promising as they are much more successful as we expected and to publish these results and give lectures about it worldwide keep me very busy. What do you read in OMS literature these days that fascinate you? Actual the whole scope of our fascinating field: Especially the fast development of our started computerized medicine, tissue engineering in boneand soft tissue replacement and the personalized medicine in Tumor-Surgery.

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What do you consider the single most meaningful contribution you made to the specialty of Oral Maxillofacial surgery? 1. Participating in the early development of stable and mini Osteosynthesis methods. 2. Developing the Horseshoe Le Fort I osteotomy together with Prof. Haerle.

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3. Initiating resorbable osteosynthesis methods. 4. D eveloping bone forming material out of natural marine algae transformed in Hydroxyapatite called Algipore and combined as TCP and HA called SYMBIOS. 5. E xperimental proof on adult Cercopithecus Aethiops monkey that adult TMJ structure can react to compression and decompression according to Wolff’s law. 6. D eveloping Stereolithography models out of CT and MRI data. 7. P ioneering computerized medicine with navigation surgery, augment<ed reality and virtual reality and telemedicine. 8. P ioneering precision surgery by using CAD/ CAM produced templates for implantology and orthognathic surgery. 9. D eveloping the Camlog Guide system. 10. Developing the one step vertical pedicled sandwich plastic (PSP) with interpositioning of marine derived bone forming material Algipore.

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11. P erfectionating the two-step horizontal pedicled sandwich plastic (PSP) with interpositioning of marine derived bone forming material Algipore. 12. Developing the lateral Sinus lift with augmenting marine derived bone forming material Algipore. 13. O rchestrating the world first cadaver tongue transplant in our hospital. 14. P erforming studies with ultrashort Bicon implants and metal free CAD/CAM produced resin full arch prosthesis called TRINIA® on class V and VI atrophied maxilla and mandibles (according to Cawood and Howell - 1988). What is your perception of how the specialty has changed from when you started to now? The OMS surgery became minimal invasive, more precise and gets now personalized as precision medicine with more predictable outcomes and much better results. What do you not miss about your academic work? It depends what you mean with “academic” work.

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Do you keep in touch with former colleagues? Yeas, very much. I follow what they are achieving like getting new positions or celebrating new achievements. I follow their resent research work and sometimes they even participate me in their publications as senior author. In the moment I am very proud that Gabi Millesi just was installed as new President of the IAOMS Association! What would you change about your career path if you could go back and do so? To be honest: nothing I belong to the lucky ones as I had with Professor Schilli in Freiburg/Germany a fantastic teacher and mentor in an excellent CMF Department with many good attending- and assistant Professors and Residents. Later, one of the attending Professors took me to Kiel/Germany as deputy chief for nine years. Professor Haerle’s CMF Department also was an exceptional good training and patient care center. Having spent six years study time for Dentistry and Medicine and nine years CMF training in Freiburg and nine years’ experience as deputy chief of a University CMF Department I was well prepared to take the position as chief of the CMF Department in Vienna/ Austria which is one of Europe largest and renown’s University Hospital for Cranio-Maxillofacial & Oral Surgery. Which technological advance in the specialty would have made a difference in your surgical activity? I always tried to work according to the “motto” -reading prevents from inventing-! And I always was afraid not to be up-to date. Nevertheless, we missed some developments and did not get it immediately firsthand. As example I would name the Bisphosphonate induced Osteonecrosis of the jaws, the use of short

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implants which had been in the marked already 25 years before I started using them and many more examples. What advice do you have for the OMS trainee starting training in 2020? The future will me more precise surgery by getting even more minimal due to computerized surgery but probably it will get replaced by more personalized Medicine due to all the Gentechnologies. The future also of Surgery will be in the dimensions of genes and cells which will change our whole field and will support the individual medicine and parallel to this the AI will participate and accompany this development. How do you reflect on your involvement in the IAOMS? How important was the association in your career? As my mentor Professor Schilli and one of the other mentor Professor Fries had been Presidents of the IAOMS I was raised with the idea to go and be international. As my vita also shows my interest in being international it always was my goal to take activity in this organization and be part of an international colleague team. What are the qualities you most value in a career academic surgeon? I enjoyed being trained in a very academic University and CMF Department, and then working in such institutions to be able to treat many patients, to research in excellent facilities with access to experimental lab- and animal lab facilities and to teach Students and Residents. What are you currently reading? First, I still try to be up-to date with the national and International CMF and Computer technology literature. I just finished “Becoming” by Michelle Obama and now I am reading ”Brief Answers to the Big Questions” by Stephen Hawking. ■

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HOW CAN I GET STARTED WITH RESEARCH? By Sean Edwards Ann Arbor, Michigan. United States

THIS IS a question I get posed fairly often from students and residents in our institution. Too many think that this is a rigid process with too many barriers to get started. Many of our residents think the ideas must come from faculty. Many think you need a grant or significant source of funding to undertake a research project. Fortunately, none of this is true. In fact, all you need is a question to get started. Too often we think that all research must come in the form of a prospective multi-centre clinical trial. While it is true, that the clinical trial is the pinnacle of research and, when well conducted, allows us to draw the most meaningful conclusions about causality this is not the only form of useful research. In fact, the very design of a randomized clinical trial is dependent upon observational data that informs us about the incidence of events relevant to the question of interest. Furthermore, there are many questions in surgery that do not lend themselves to randomized trials or where they may even be unethical.

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Questions come from our observations. As surgeons we tend to think that this must be limited to clinical problems. This too is not the case. We are not just surgeons. We are also educators. Our teaching methods should be studied. We are mentors. The happiness and success of our trainees should be studied. We are leaders. The impact of our role in organized medicine and dentistry should be investigated. My point here is that we are surrounded by opportunities to make observations and ask questions. So where should you start? First, it should be of interest to you. If the topic is not attractive to you, then you won’t devote the time and effort to do it well. Second, look to your resources and I don’t mean just patients. Are you in a large university? This will make some projects easier since you can look for collaborators. You may have colleagues interested in educational outcomes and learning styles. You may have colleagues interested in the use of simulation.

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These are all important areas for the development of our specialty. Are you in a clinic that treats a lot of patients with a particular condition? Look to this patient population. If you are in a busy trauma unit, what is unique about the injuries you see? It could be the ages of the patients or the mechanism of injury. What are the most vexing problems you see on a daily basis? Do you treat your patients according to a different protocol than a colleague? These are all good starting points to formulate a question to investigate.

“The best part of the any research project is analyzing the data you collect and drawing conclusions.”

Have you heard of patient reported outcomes (PROs) research? This is a very promising area of research that is just beginning to make way in Oral and Maxillofacial Surgery. When a patient asks you how long it takes to recover from a mandible fracture repair what do you answer? I know what I tell my patients, but is this really the case? How about when a patient will feel comfortable jogging after a fibula flap? Do we really know when our patients

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resume these types of activities? PROs can also reflect the impact of an intervention or disease on a patient emotionally and economically. Once you have your question, you need to decide how to investigate the answer and whether the data exists or can be collected. A retrospective chart review is often a good start if the data is well collected. Electronic medical records (EMRs) are searchable and can help you identify patients. They can also be used to standardize data gathering for prospective projects. What used to take days searching charts by hand can often be done in a matter of hours.

The best part of the any research project is analyzing the data you collect and drawing conclusions. Working in groups make this more interesting and can spur some great discussions. Finally, write your paper and present your work. We all want to hear what you learned and we want your knowledge added to our specialty. I hope I have given you some simple examples of how to get started in research in Oral and Maxillofacial Surgery. I hope you take away that this is simpler than you might imagine. All you need to do is start. So, what are you waiting for? Ask a question and get started! ■

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Beyond O.R.

One century later By Javier González Lagunas (follow me on


“It was the best of times, It was the worst of times, it was the age of wisdom, it was the age of foolishness…” CHARLES DICKENS described the decade of the 1920s 60 years ahead of time when writing “A Tale of Two Cities”

It is the women’s suffrage movement. The birth of the New Woman. Gandhi starting his nonviolent movement. It is penicillin and sulfamide. It is about insulin and the discovery of vitamins. Vaccines and antitoxins for measles and tuberculosis. Phenobarbital to treat epilepsy.

It was the birth of a new world, a sense of freedom with endless optimism Maybe we are fantasizing about the epic names for the decade: The Roaring 20s, the Golden 20s, the Swinging 20s…

The electroencephalograph and the iron lung. Cushing developing revolutionary neurosurgical techniques.

Just read some facts. Electricity everywhere, the first radio station, the television, the telephone, the Ford automobile. It was the beginning of the modern life: the jukebox, the electric razor, frozen food… Lindbergh crossing the Atlantic for the first time in the Spirit of St Louis. It was the music, the cabarets in Berlin, a new era after WWI. Paris was a party and also a magnet for artists and culture. Coco Chanel. C’est la belle epoque! The 20s are about the Magic Mountain, The Great Gatsby, Ulysses and In Search of Lost Time. The generation of 27. The advent of jazz, Billie Holiday and Louis Armstrong. Ravel´s Bolero, Stravinski, Bartok and Schoenberg. It is The Bauhaus and the Dada movement. Dali´s Girl at a window. Picasso and Olga Khokhlova. André Breton and surrealism. Weimar´s Republic and Bertold Brecht. Nosferatu and Metropolis.

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Archibald McIndoe and Harold Gillies. Ivy and Kazanjian. Aufricht and Fomon. But there was also darkness in this decade. It was the time of the prohibition of alcohol in US and the rise of the mobsters. Black Friday and the start of the Great Depression. The peak of the Ku Klux Klan. Sacco and Vanzetti. The rise of communism, Stalin assuming Soviet Union leadership. The emergence of fascist and Nazi movements in Europe. The Chinese Civil War. Every now and then a milestone event marks a before and after in the history of a generation. Today, with the COVID-19 crisis, we are facing one of those landmarks that will leave a global print. Healthcare, economics and lifestyle will be drastically affected in the short term. Are we any close to the spirit of the 1920s? They also faced the Spanish Flu pandemic of 1918. Now we know that all our technological advances have not been able to stop the infection spread. An unexpected blow to our boundless optimism. We will succeed, defintely. But, what will we be able to show in 2030? Stay at home, stay healthy. ■

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