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How do you take off arch bars?

Discussion in 'Dental Residents and Practicing Dentists' started by The TX OMS, 05.07.06.


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  1. The TX OMS

    The TX OMS This is CardsFan's Mother

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    Local or no local? As an intern I never gave local. Now I give the patient the option and about 80% ask for local. Lately I've been removing arch bars in the OR at the end of the case instead of leaving them for the clinic monkeys (interns like fowl language and jstars).

    I tell people to pick how they want it done. If they choose local they have to stay still while I block their entire mouth. If they choose no local I tell them I will stop at anytime and numb them up, but if they refuse the shots they MUST stay still while I pull the wires. One guy kept sitting up after every wire. I got pissed and sent him home for a week after removing one quadrant of interdental wires. The guy had half an archbar flopping around his mouth when he left.
  2. scalpel2008

    scalpel2008 beep beep beep...smash

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    I like to use local. However, I've evolved into injecting just 4 times. On the maxilla, I basically insert the needle in the vestibule at the midline parallel to the occlusal plane and bury the needle all the way to the first molar and inject as i withdraw. Likewise I inject the contralateral side. Then I let them know that I won't be giving them palatal blocks because more than likely they won't need it (and they almost never do). I do a similar technique on the mandible also and find that injecting while withdrawing provides enough infiltration and it gets the mental n as well. All of this takes me about 1 minute and the patients appreciate it, especially when you yank on that one wire that has a little kink at the end of it that gets trapped on the way out...ouch.
  3. tx oms

    tx oms Welcome to Thunderdome

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    I can usually anesthetize and remove the maxillary wires no problem using the technique you mentioned, though I do anesthetize the palate to help with the wires omsres pokes through near the midline.

    I have had poor luck with mandibular infiltration. I have tried the lingual, buccal, and mental injections without a mandibular block and have been disappointed. It seems that most people who are jumpy enough to need the injections also need the mand block to account for wire rubbing over the mandible and against tooth roots.
  4. esclavo

    esclavo from frying pan into fire

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    IV sedation in the clinic supplemented with a little vestibular local in the maxilla and mandible. We use tons of Ivy loops compared to arch bars...
  5. EuroOMFS

    EuroOMFS

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    Over here, we use a topical anaethetic gel (6% lidocain if I remember correctly). I apply it in a thick layer to the gingiva both buccally and lingually and let it work for about 2 minutes. It tastes bad, but it numbs well.
  6. toofache32

    toofache32

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    You don't send them home with arch bars? How do you get them back for follow-up? We keep them on for 6-weeks even if we don't use them...that way we have a handle on the patients to get postop photos. Otherwise they have no reason to come back.....unless you wanna do more Brisemonts.
  7. north2southOMFS

    north2southOMFS Yummy.

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    IV sedation??!!!!! Wow, like our fracture clientelle (spelling?) would ever get that. Oh, and TX OMS i thought we always left them after on after surgery if we initally put them on in case there was a post op malocclusion that could be corrected with elastics later. At least that is what the big boss made us do last year.


    [Insert TX OMS's snide remark about me being 1 year under him]
  8. tx oms

    tx oms Welcome to Thunderdome

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    I'll show pictures of people who've had arch bars on for > 8 years. Keeping the bars in doesn't guarantee anything.

    As for occlussion post-op, how are arch bars going to help that? Are they going to bend the titanium plates? I've never understood that. In orthognathic surgery the jaws are in a new place that the patient's muscles are unfamiliar with; therefore, the rubber bands help establish new muscle memory. Mandible fractures go back to the original occlussion so there is no new muscle memory to establish. Am I right?
  9. OMFSCardsFan

    OMFSCardsFan Senior Member

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    FTS...I don't have time for that BS...if I think they're going to be squirrelly, I let them swish around with some Hurricaine spray for the "blankie" effect.

    I've done one Ketamine sedation to take the AB off a five year-old kid, and I've given local one time, to an eight year-old kid. Everyone else can grab the chair and hold tight...

    Once I cut the wires, which is generally close to painless, I can have them all out in thirty seconds. Five minutes for administration of local and waiting for it to take effect, I don't think so...
  10. OMFSCardsFan

    OMFSCardsFan Senior Member

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    It's a good thing, since all your ORIFs come back looking like you used the scrub nurse's hand to hold them into occlusion throughout the procedure...I'm not even sure why you put on arch bars to begin with...

    :D
  11. toofache32

    toofache32

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    We had a patient come in with arch bars that had been on for 11 years. We always call them "ugly braces" and we tell them "we're gonna put on these ugly braces to fix your jaw."

    He said, "Man I've had these braces on for 11 years and my teef STILL ain't straight."
  12. omfsres

    omfsres

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    I don't necessarily agree with that. Especially with angle fractures and multiple fractures. I think the surgical access along with fracture manipulation and plate placement can give the patient enough postoperative pain that they might posture their jaw into a more comfortable position duning healing which does not necessarily jive with their pre traumatic occlusion. That in combiniation with muscle spasming and edema, in my mind, could contribute to a post op malocclusion that some guiding elastics could help alleviate. And lets face it, I don't care if I leave the AB on or not. I have two little arch bar fairies that magically remove them for me, ie interns.

    I had kid that we closed reduced and on his first week post op his mouth was a toxic waste dump. I noticed his imf was slightly loose and went to change it out. Once out of IMF a saw that the arch bars were a little loose as well. I went to tighten them down and its like the wire were all corroded and brittle and just kept breaking. I ended up replacing like half of the circumdental wires. I wish I would have checked the pH in his mouth, because it was low enough to corrode stainless steele in one week. It was either that or OMSCardsfan was the one who placed the ABs and he got another batch of the weak wires that break every time he attempt to twist them down.
  13. tx oms

    tx oms Welcome to Thunderdome

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    I'm surprised you know so much about what I do in the OR. Can you see all the way in there from the clinic?
  14. tx oms

    tx oms Welcome to Thunderdome

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    I see what you're saying. Still, taking of arch bars in clinic blows.
  15. esclavo

    esclavo from frying pan into fire

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    I don't have an indigent clinic to hid the "fringe of society" patients and I can't have them screaming in a room next to the university professor's daughter getting her thirds out... she is already whimpering with the IV. The only clinic I have is the one just like Dr. Ghali works in across the street....besides a fair amount of our fracture clients do have insurance :) As for speed, I can have the IV in and 7.5 of versed and 75 of fentanyl and a propofol bolus working in 2 minutes. With the patient cozy, I think I can take arch bars off faster than you with the patient crying and white knuckling it...
  16. gryffindor

    gryffindor

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    I tried this technique today, pretty cool! Numbed up all the gingiva without me having to stab the patient several times. Are you using a 27 gauge needle?
  17. toofache32

    toofache32

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    I hate private/insured patients. They are much more needy, question everything you do, and ask too many questions.
  18. scalpel2008

    scalpel2008 beep beep beep...smash

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    yes, 27 gauge. did you have to use any palatal blocks? i usually don't have to. it's almost like just enough of the lingual tissue/papilla gets affected by the buccal infiltration.
  19. gryffindor

    gryffindor

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    I wasn't taking off arch bars. No OMS whatsoever at this particular GP office I'm at.
  20. GatorDMD

    GatorDMD Suck ChocoSaltyBalls

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    what did you use this technique for? exo's? :confused:
  21. toofache32

    toofache32

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    Off-topic, but I'm a big fan of full V2 blocks through the greater palatine foramen. Give a regular palatal block, wait 10 seconds, then go back in and probe for the hole. It's usually more lateral than I expect. Then bury the needle slowly and unload your carpule. Works great for those anterior maxillary abscesses too close to the infraorbital nerve for infiltration to work.
  22. aphistis

    aphistis Moderator Emeritus

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    I'm dying to try a few of those, but none of the OMS guys at the school clinic like them and I'd rather not tick them off (at least not until closer to graduation).
  23. OMFSCardsFan

    OMFSCardsFan Senior Member

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    And hence the OMFS Olympics were born...
  24. OMFSCardsFan

    OMFSCardsFan Senior Member

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    Ahhh...repeat...
  25. toofache32

    toofache32

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    Then try it next time you prep #7 for a crown. :eek:
  26. esclavo

    esclavo from frying pan into fire

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    I hate them too... they are such jerks... I mean they paid $290 dollars to go to sleep to remove those arch bars! Can you believe those jerks! And the other thing is that they BATHED before they came in!!!!! They actually had the nerve to come in and smell like aftershave.... I prefer JIM BEAM!!!! And the straw that broke the camels back is that they had been brushing those arch bars... I mean, I like the slippery biofilm patients because it lubricates the wires when they travel through the embrasure!!!! I agree that those insured patients are jerks!!!!! But they do whine and a that is what I like, so I keep on treating them.....
  27. tx oms

    tx oms Welcome to Thunderdome

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    There are some great benefits to working in an indigent clinic. Roughing it in the trenches gives one more independence and exposure to a wider array of issues. In addition, the resident is usually "The Doctor", giving you the opportunity to spread your wings. Riding the coat tails of an attending through their private practice for four years is not what I want to do. Do you offer hand massages and a warm towel to your patients?
  28. omfsres

    omfsres

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    This is coming from a guy who wears a chain connected with a master lock for a necklace.
  29. toofache32

    toofache32

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    So wifey can lock him back in his cage when he gets home...
  30. toofache32

    toofache32

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    We all have our price. For some it's truly monetary, for others it's the ease of having patients who are used to the hard times they find themselves in when they sit in my chair.
  31. esclavo

    esclavo from frying pan into fire

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    No but WE get hand massages and a warm towel after each procedure....we put cucumbers on patient's eyes for protection and we operate in Hugh Heffner robes...

    You do bring up some valid points though. I have an attending in the clinic which check/reviews all of our work. The first year it is tough because the standard is so high for each procedure both in quality, speed, and outcome. It is nice to spread your wings as you call it. I like seeing almost every procedure back in the clinic to learn about outcomes-see what works and what doesn't. The nice thing about having an attending in the clinic is that the learning curve is steep (no chance to pick up bad habits). I can take out 4 full bony impactions in less than 10 minutes because I had to learn to do it quickly and efficiently. It doesn't take me a half hour and I don't hamburger up the patient while I am "learning to spread my wings". Most all my procedures are IV's (6-14 per day in the clinic). My patients aren't wide awake. I can do generals, deep sedations or regular conscious sedations in the clinic. I learn to manage the anesthetic and the procedure at the same time. I took out thousands of teeth as a dental student.... I wanted to learn to do procedures and put people to sleep at the same time....there are advantages to the program you're in, no doubt. But having a surgeon to mentor you (kick your butt for fumbling around) from the get go has its advantages. For four years I am practicing (learning to practice) exactly how I am going to practice when I graduate. My staff is top notched and the rooms are set up and ready to go. I have learned auxillary management and office flow for maximum output. Each has its advantages. Everyday during clinic time, my schedule looks like a private practice schedule: surgeries, consults, post-ops etcetera...
  32. omfsres

    omfsres

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    Those types of claims may work on dental students, but I think most of the residents here will call BS on that one.
  33. esclavo

    esclavo from frying pan into fire

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    I've got a timer on the wall in each operatory in the clinic. When I inject the patient the timer starts. When I stick gauze in the mouth and take my gloves off the timer stops. If you need witnesses or a video, I'll accomodate....I've even seen the resident under me do a case of 4 full bony-not partial bony thirds (mesial impacted on the lowers) do them in under 10 minutes. I saw a second year resident at Minnesota when I was a dental student do a set of full bony thirds in less than 10 minutes.... I'm sure I'm not the only one....
  34. scalpel2008

    scalpel2008 beep beep beep...smash

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    I don't call BS on that. I think it's very possible. We do it all the time. But we are definitely talking 17 year olds w/ mesioangular full bony impactions. No reason 10 mins isn't enough.
    1 minute to anesthetize,
    #1: 90 seconds
    #17: DB incision w/ flap 30 seconds, buccal trough and section 30 seconds, split tooth remove irrigate suture 90 seconds


    Repeat above with # 16, 17

    Total time 10 minutes...my personal record is 7 minutes for 4 full bonys. i spent the other 3 minutes pumping my fist and bagging the patient.

    14 sedations in one day is a heck of a lot...props to you esclavo for being able to do that. our clinic doesn't have the resources to handle that along with 60 patients in the regular clinic.
  35. omfsres

    omfsres

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    Whatever makes you feel good, man.

    Scalpel08, thanks for validating him, that just solidified my opinion of you.

    For all the students reading, sure there are those rare occasions you can do a quick set of thirds, but these guys want you to believe its every case. I have done a set in 15 minutes and I have done a set in 40 minutes. It all depends on the patient and the situation. I personally don't need a clock to validate my skills as a surgeon.
  36. scalpel2008

    scalpel2008 beep beep beep...smash

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    yeah, i don't recommend that technique for extractions...it OBVIOUSLY doesn't anesthetize the mandibular teeth. if you weren't removing arch bars, i don't know what you used it for.
  37. scalpel2008

    scalpel2008 beep beep beep...smash

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    quick on the opinions aren't we? i clearly prefaced my validation by specifying 17 year old with mesioangular impactions. and if i made it seem the norm to take out a set of 4 impactions in <10 minutes, that wasn't my intent. i'm sure the average time is more like 15-20 minutes because of those cases that do take 25-30 mins. but a fair # of young patients can have their FBIs out in about 10 mins. you know you've had those cases when everything goes well. including having 2 blade handles with new blades, good sedation, soft bone, sharp burs, and a occasionally, as much as we hate to admit it, that four leaf clover in your mailbox. :luck:
  38. omfsres

    omfsres

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    You're right. I just got fired up. I don't know where you are at in your training, but I know esclavo is in 3 of 4 and damn near a chief. The only people I know of that brag about how fast they can shuck thirds are general dentists and oral surgery interns. If you(esclavo) want to impress me, show a video of you doing a radical neck with no faculty in the room. But somehow I bet its more like connect the dots and bovie between my hemostats. Not saying you won't get there someday, chief.
  39. scalpel2008

    scalpel2008 beep beep beep...smash

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    4 of 6. here's a great idea that we've done several times and it ends up being fun and also motivating. I encourage you all to try it if you aren't already doing so. occasionally, if the manpower in clinic permits, 2 residents will go in on the same sedation and one will do the right and the other the left side. basically, we just have fun and trash talk and it really motivates you to do things well and quick; at the same time you get to see a slightly different technique. as much as attendings motivate you, there's something about shucking impacted wizzies with a peer assisting that makes you want to do it well. and it often ends up being more beneficial than holding sticks in the OR for the lower levels.
  40. Fowl_Language

    Fowl_Language Member

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    nobody cares how fast a couple of exodontists can plow a field by dragging their big man-balls through the dirt.
  41. tx oms

    tx oms Welcome to Thunderdome

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    Your hyperbolies are so eliquent, and funny as sh!t.
  42. Ankylosed

    Ankylosed Member

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    Somewhat off topic but, I was scrubbed in with and talking to Dr. Joseph (from recent md vs. omfs article) the other day about plastics issues. He was expressing to me that an orthognathic case (which we were doing Lefort I) and sometimes a set of FBI's can be much more challenging than a simple rhytidectomy (which he does in office). When I told him I was "skinning" complete organ donors into Large Area Grafts in about 45 minutes, he said he would let me come to his office and start performing these procedures :laugh: Of course he was joking, but the point is these plastics guys were talking all this smack when we know who has the real surgical skills. He also mentioned he would take an experienced scrub nurse like me over a worthless, smack talking intern like CardsFan.
    P.s. If I hear anymore talk about Louisiana residents I will send some of my big coonass buddies from the G surg unit to split your grill like the rednecks you treat.
  43. scalpel2008

    scalpel2008 beep beep beep...smash

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    like ellis says...thirds can be the most difficult procedure we do. i agree with him. i think its because you expect it to be easy and so the difficult ones can be tremendously frustrating.
  44. gryffindor

    gryffindor

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    There are other non-OMFS procedures in dentistry where anesthesia of the buccal gingiva makes the patient more comfortable. For example: doing a series of class V restorations that go slightly subgingival, packing retraction cord for multi-unit veneer impressions, SRP, or even a prophy for the skittish patient who always asks for gobs of topical prior to you touching a scaler to the enamel.
  45. scalpel2008

    scalpel2008 beep beep beep...smash

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    i think it would work well for those procedures. glad you found a good use for it. :thumbup:
  46. OMFSCardsFan

    OMFSCardsFan Senior Member

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    I'm the smack-talker?

    Not sure what I did to get your panties all in a bunch. Care to expand on that? You've spiked my curiousity.

    As for the GSurg guys, we work pretty closely with them when they're on the trauma service, and I think any one of them will tell you that they'd rather work with my service than ENT's any day. I hardly have the reputation for being a smack-talking prick...
  47. north2southOMFS

    north2southOMFS Yummy.

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    On the other hand you do have the reputation for having the largest bitch tits in the hospital. :horns:

    (see avatar to the upper left.)
  48. Periogod

    Periogod Senior Member

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    Now this is some good stuff; a little OMFS resident infighting. CardsFan told me that Ankylosed holds his scalpel with a limp wrist.
  49. Ankylosed

    Ankylosed Member

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    That's right, six inches limp...
  50. esclavo

    esclavo from frying pan into fire

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    The only thing I've ever heard a general dentist brag about is how early he gets out of the office, how fast he sends a patient to the emergency room or how small his handicap is at the golf course.... as for interns taking out teeth, for me it is like watching a constipated dog at the park akwardly humping over to take a dump but can't.... very painful to observe....

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