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Jury verdict for oral surgeon
LETTERS TO THE EDITOR J Oral Maxill ofac Surg 48:222-223. 1990
future of our specialty. The program at the University of Alabama is outstanding in many respects, but I find it troubling that the year of residency in the Department of Surgery includes only, at most, 4 months on the surgical services not related to oral and maxillofacial surgery. Although I do not pretend to know the details of the residency curricula of the various double-degree training programs around the country, I find this dilution of the general surgery training experience a prime weakness in dual-degree training . If this is the standard within such programs, I would then agree wholeheartedly with the editorial comment about training that is not complete. The editorial goes on to discuss Dr Walter Guralnick's original motivation for promoting the doubledegree program at Harvard University. I trained in that program and have, I believe, a good understanding of the principles that sustained me during my training. I will not speak for Dr Guralnick, but I will venture to say that much of the thrust within the Harvard program was to have a substantial experience in general surgery and its related disciplines, typically consisting of a rigorous 18months on the general surgical services, 12 months of which was in the capacity of a second-year general surgical resident with all the responsibilities attendant to that position. I believe that part of the objective of Dr Guralnick's program was to train oral and maxillofacial surgeons in basic general surgical principles, much as orthopedic surgeons and otolaryngologists are first trained in general surgery. I believe that the double-degree oral and maxillofacial surgeon has a definite place in our specialty, but I do not believe that this needs to become the standard for our profession. However, the diluted exposure to general surgery and medical training among a good number of double-degree individuals serves only to weaken our position relative to competing specialties rather than to enhance it. .
ACCURATE DIAGNOSIS OF MALIGNANT AM ELOBLASTOMA
To the Editor:-The article, "Mandibular Ameloblastom a With Metastasis to the Lungs and Lymph Nodes," by Veda et al (J Oral Maxillofac Surg 47:623, 1989) unfortunatel y confuses the issue of metastatic ameloblas toma by its own confu sion. The article , although well intended, does not amplify on the subject. The lymph node tissue cont aining tumor is not shown , the photomicrograph of the original lesion is scanty, and certainly the photomicrograph of the lesional tissue from the lung is poorly represented and may not even be an ameloblastoma. In addition, one might question the use of an ultrasonic aspirator system for removal of the tumor. : I have been generally pleased by the high caliber of our specialty's publication, but it seems that the reviewer of this article did an inadequate job. GILBERT S. SMALL, DDS Ann Arbor, Michigan
The author replies:-I am very surprised by Dr Small's comments. All of the specimens were examined by an expert pathologist who made the diagnosis of ameloblastoma in all three sites. The photomicrographs confirm this diagnosis in the primary site and the lung. I regret that a photomicrograph of the lymph node was not included , but this site also had similar findings. MINORU UEDA Nagoya, Japan GENERAL SURGERY TRAINING IN DOUBLE-DEGREE PROGRAMS
To the Editor:-I am writing to present my views about the issue of the double-degree oral and maxillofacial surgeon. In your editorial in the June 1989 issue (J Oral Maxillofac Surg 47:553, 1989), your statement that " . . . a medical degree achieved without . complete training, and a lack of educational parity with competing specialties, could lead to higher levels of frustration ..." emphasizes the problem that I see in dualdegree programs. In the same issue of the journal, Dr Charles McCallum outlines the program of training at the University of Alabama Medical Center (J Oral MaxiIIofac Surg 47:610, 1989)as part of his discussion of the
ROBERT CHUaNG, DMD, MD St Petersburg, Florida JURY VERDICT FOR ORAL SURGEON
To the Editor:-I would like to bring to your attention a jury verdict won by a member of the AAOMS in the Washington State Superior Court of Pierce County in Heidi Schneller v Gerald L. Hartman, DDS (July 1989). This verdict is particularly noteworthy because the case involved many of the complex factual and legal issues your members confront on a day-to -day basis. The former patient, a woman in her early 20s, presented to the oral surgeon in October 1984for extraction of upper and lower third molars upon referral from her general dentist. Following examination and consultation, the surgery was performed under a local anesthetic with nitrous oxide. The surgical extraction of the partial bony impactions was a routine difficult procedure, but otherwise unremarkable. During the 2 weeks after surgery, the plaintiff pre-
Letters to the Editor are considered for publication (subject to editing and abridgment), provided that they are submitted in duplicate, signed by all authors, typewritten in double spacing, and do not exceed 40 typewritten lines of manuscript text (excluding references) . Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal art icle must be received within 6 weeks of the article's publication. Receipt of Ictters is not acknowledged; correspondents will be notified when a decision is made.
222
LEITERS TO THE EDITOR
sented on several occasions with alveolar osteitis at the site of tooth No. 32. Several topical anesthetics were used to treat the dry socket successfully. Thereafter, the patient did not present to the oral surgeon until February of the following year, 1985. At that time, bilateral etisplacement of the meniscus was observed. The patient was not seen again by the oral surgeon. However, without his knowledge, the patient presented to numerous local practitioners, including general dentists, general dentists who claimed to specialize in tempormandibular joint (TMJ) dysfunction diagnosis and treatment, oral surgeons, and physicians. She claimed that over a period of time, her condition had become much worse, eventually reaching the point where the condyle would subluxate completely out of the fossa and beyond the eminence. The case came to trial almost 5 years after the surgery. Although the patient had not consulted a dentist or physician for treatment in almost 3 years prior to the trial, she claimed to have suffered excruciating pain and severe disability since the date of the surgery. At trial, the plaintiff established a prima facia case for substandard care and treatment through the testimony of a Denver, CO general dentist, Roger Druckman, DDS, and through the patient's father, Tacoma pediatrician James L. Schneller, MD (who claimed to have developed, on his own, an expertise in TMJ diagnosis). The plaintiffs witnesses testified that even though the surgeon used a bite block, lower jaw support by an additional operative assistant, and sectioned and elevated (without forceps) the lower right third molar, the surgeon used excessive force and therefore fell below the standard of care. These witnesses, Drs Druckman and Schneller, further testified that TMJ dysfunction should always be an aspect of the informed consent/consultation process; further, that the extraction of the lower right third molar caused the injury claimed at the time of trial. The defense witnesses included, in addition to Dr Hartman, Robert V. Walker, DDS, of Dallas, TX; Dale S. Bloomquist, DDS, of Seattle, WA; and Robert E. Dunley, DDS, of Tacoma, WA. In addition, Thomas Jost, DDS, of Vail, CO, testified with regard to the plaintiffs experts' qualifications in oral surgeryspecifically, Dr Jost, as the Director of Oral Surgery at Fitzsimmons Army Medical Center in the 1970s, attested to Dr Druckman's nontraining. The trial lasted over 2 weeks, and was very technical and emotional. At the conclusion of the case, a jury of 12 was instructed to decide the issue of malpractice, but was not allowed to consider the lack of informed consent claim (this being dismissed by the judge as lacking sufficient evidence). The jury deliberated for approximately 6 hours and, at the conclusion, found that the defendant oral surgeon was not negligent, thus returning a verdict in his favor. This case was a prime example of how difficult and uncertain it can be to take an oral surgeryffMJ case through trial. It is also a reaffirmation that the jury sys-
223 tem works, and that even the most sympathetic case can be decided on the merits, as opposed to sympathy for another human being. All the participants on behalf of the defense of the oral surgeon are to be commended for their integrity and their candor in testifying before the jury-not because their testimony was favorable to the defendant doctor, but because their testimony was submitted objectively and in an effort to present credible information to the judicial system. The defendant doctor, Gerald L. Hartman, DDS, is also to be commended for his courage and his perserverence in defending against these claims. Many doctors under the same or similar circumstances would have taken the safe, easy, and less expensive route by settling out of court. The Schneller v Hartman verdict should send a message both to the professional and the lay community that frivolous claims against dental specialists should not be tolerated and should be defended vigorously. I hope your members will take pride not only in the results, but in the way in which the various specialists who worked on either side of this case conducted themselves as participants in the judicial system. ROBERT W. SARGEANT ales, Morrison & Rinker Seattle, Washington
POTENTIAL PROBLEMS WITH ORTHODONTICS AND RIGID FIXATION
To the Editor:-It has been my impression over the last 3 to 4 years that I have seen many more impacted second molars-especially in patients undergoing early orthodontic therapy. In addition, I have seen more impacted third molars that are displaced either buccally or lingually. It is my impression that orthodontists are able to achieve distalization of first molars during orthodontic therapy now, and this is causing impaction of second molars in some cases and greater displacement of third molars. Secondly, most of the articles I have reviewed regarding rigid fixation cite its increased stability and the earlier function for the patient. However no one seems to discuss infections involving rigid fixation, reoperation of rigid fixation cases because the condyle has been displaced or because the occlusion is not correct after surgery, and the inability sometimes to achieve the proper midline relationship of the mandible in asymmetrical cases. I have seen instances of all these problems, and yet no one seems to discuss them in relation to rigid fixation. I think these are considerations that need to be addressed so rigid fixation can be viewed more objectively in orthognathic cases. I would appreciate anybody who has information regarding either of these issues to please contact me. JOEL M. SALON, DDS, MD Lyndhurst, Ohio
future of our specialty. The program at the University of Alabama is outstanding in many respects, but I find it troubling that the year of residency in the Department of Surgery includes only, at most, 4 months on the surgical services not related to oral and maxillofacial surgery. Although I do not pretend to know the details of the residency curricula of the various double-degree training programs around the country, I find this dilution of the general surgery training experience a prime weakness in dual-degree training . If this is the standard within such programs, I would then agree wholeheartedly with the editorial comment about training that is not complete. The editorial goes on to discuss Dr Walter Guralnick's original motivation for promoting the doubledegree program at Harvard University. I trained in that program and have, I believe, a good understanding of the principles that sustained me during my training. I will not speak for Dr Guralnick, but I will venture to say that much of the thrust within the Harvard program was to have a substantial experience in general surgery and its related disciplines, typically consisting of a rigorous 18months on the general surgical services, 12 months of which was in the capacity of a second-year general surgical resident with all the responsibilities attendant to that position. I believe that part of the objective of Dr Guralnick's program was to train oral and maxillofacial surgeons in basic general surgical principles, much as orthopedic surgeons and otolaryngologists are first trained in general surgery. I believe that the double-degree oral and maxillofacial surgeon has a definite place in our specialty, but I do not believe that this needs to become the standard for our profession. However, the diluted exposure to general surgery and medical training among a good number of double-degree individuals serves only to weaken our position relative to competing specialties rather than to enhance it. .
ACCURATE DIAGNOSIS OF MALIGNANT AM ELOBLASTOMA
To the Editor:-The article, "Mandibular Ameloblastom a With Metastasis to the Lungs and Lymph Nodes," by Veda et al (J Oral Maxillofac Surg 47:623, 1989) unfortunatel y confuses the issue of metastatic ameloblas toma by its own confu sion. The article , although well intended, does not amplify on the subject. The lymph node tissue cont aining tumor is not shown , the photomicrograph of the original lesion is scanty, and certainly the photomicrograph of the lesional tissue from the lung is poorly represented and may not even be an ameloblastoma. In addition, one might question the use of an ultrasonic aspirator system for removal of the tumor. : I have been generally pleased by the high caliber of our specialty's publication, but it seems that the reviewer of this article did an inadequate job. GILBERT S. SMALL, DDS Ann Arbor, Michigan
The author replies:-I am very surprised by Dr Small's comments. All of the specimens were examined by an expert pathologist who made the diagnosis of ameloblastoma in all three sites. The photomicrographs confirm this diagnosis in the primary site and the lung. I regret that a photomicrograph of the lymph node was not included , but this site also had similar findings. MINORU UEDA Nagoya, Japan GENERAL SURGERY TRAINING IN DOUBLE-DEGREE PROGRAMS
To the Editor:-I am writing to present my views about the issue of the double-degree oral and maxillofacial surgeon. In your editorial in the June 1989 issue (J Oral Maxillofac Surg 47:553, 1989), your statement that " . . . a medical degree achieved without . complete training, and a lack of educational parity with competing specialties, could lead to higher levels of frustration ..." emphasizes the problem that I see in dualdegree programs. In the same issue of the journal, Dr Charles McCallum outlines the program of training at the University of Alabama Medical Center (J Oral MaxiIIofac Surg 47:610, 1989)as part of his discussion of the
ROBERT CHUaNG, DMD, MD St Petersburg, Florida JURY VERDICT FOR ORAL SURGEON
To the Editor:-I would like to bring to your attention a jury verdict won by a member of the AAOMS in the Washington State Superior Court of Pierce County in Heidi Schneller v Gerald L. Hartman, DDS (July 1989). This verdict is particularly noteworthy because the case involved many of the complex factual and legal issues your members confront on a day-to -day basis. The former patient, a woman in her early 20s, presented to the oral surgeon in October 1984for extraction of upper and lower third molars upon referral from her general dentist. Following examination and consultation, the surgery was performed under a local anesthetic with nitrous oxide. The surgical extraction of the partial bony impactions was a routine difficult procedure, but otherwise unremarkable. During the 2 weeks after surgery, the plaintiff pre-
Letters to the Editor are considered for publication (subject to editing and abridgment), provided that they are submitted in duplicate, signed by all authors, typewritten in double spacing, and do not exceed 40 typewritten lines of manuscript text (excluding references) . Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal art icle must be received within 6 weeks of the article's publication. Receipt of Ictters is not acknowledged; correspondents will be notified when a decision is made.
222
LEITERS TO THE EDITOR
sented on several occasions with alveolar osteitis at the site of tooth No. 32. Several topical anesthetics were used to treat the dry socket successfully. Thereafter, the patient did not present to the oral surgeon until February of the following year, 1985. At that time, bilateral etisplacement of the meniscus was observed. The patient was not seen again by the oral surgeon. However, without his knowledge, the patient presented to numerous local practitioners, including general dentists, general dentists who claimed to specialize in tempormandibular joint (TMJ) dysfunction diagnosis and treatment, oral surgeons, and physicians. She claimed that over a period of time, her condition had become much worse, eventually reaching the point where the condyle would subluxate completely out of the fossa and beyond the eminence. The case came to trial almost 5 years after the surgery. Although the patient had not consulted a dentist or physician for treatment in almost 3 years prior to the trial, she claimed to have suffered excruciating pain and severe disability since the date of the surgery. At trial, the plaintiff established a prima facia case for substandard care and treatment through the testimony of a Denver, CO general dentist, Roger Druckman, DDS, and through the patient's father, Tacoma pediatrician James L. Schneller, MD (who claimed to have developed, on his own, an expertise in TMJ diagnosis). The plaintiffs witnesses testified that even though the surgeon used a bite block, lower jaw support by an additional operative assistant, and sectioned and elevated (without forceps) the lower right third molar, the surgeon used excessive force and therefore fell below the standard of care. These witnesses, Drs Druckman and Schneller, further testified that TMJ dysfunction should always be an aspect of the informed consent/consultation process; further, that the extraction of the lower right third molar caused the injury claimed at the time of trial. The defense witnesses included, in addition to Dr Hartman, Robert V. Walker, DDS, of Dallas, TX; Dale S. Bloomquist, DDS, of Seattle, WA; and Robert E. Dunley, DDS, of Tacoma, WA. In addition, Thomas Jost, DDS, of Vail, CO, testified with regard to the plaintiffs experts' qualifications in oral surgeryspecifically, Dr Jost, as the Director of Oral Surgery at Fitzsimmons Army Medical Center in the 1970s, attested to Dr Druckman's nontraining. The trial lasted over 2 weeks, and was very technical and emotional. At the conclusion of the case, a jury of 12 was instructed to decide the issue of malpractice, but was not allowed to consider the lack of informed consent claim (this being dismissed by the judge as lacking sufficient evidence). The jury deliberated for approximately 6 hours and, at the conclusion, found that the defendant oral surgeon was not negligent, thus returning a verdict in his favor. This case was a prime example of how difficult and uncertain it can be to take an oral surgeryffMJ case through trial. It is also a reaffirmation that the jury sys-
223 tem works, and that even the most sympathetic case can be decided on the merits, as opposed to sympathy for another human being. All the participants on behalf of the defense of the oral surgeon are to be commended for their integrity and their candor in testifying before the jury-not because their testimony was favorable to the defendant doctor, but because their testimony was submitted objectively and in an effort to present credible information to the judicial system. The defendant doctor, Gerald L. Hartman, DDS, is also to be commended for his courage and his perserverence in defending against these claims. Many doctors under the same or similar circumstances would have taken the safe, easy, and less expensive route by settling out of court. The Schneller v Hartman verdict should send a message both to the professional and the lay community that frivolous claims against dental specialists should not be tolerated and should be defended vigorously. I hope your members will take pride not only in the results, but in the way in which the various specialists who worked on either side of this case conducted themselves as participants in the judicial system. ROBERT W. SARGEANT ales, Morrison & Rinker Seattle, Washington
POTENTIAL PROBLEMS WITH ORTHODONTICS AND RIGID FIXATION
To the Editor:-It has been my impression over the last 3 to 4 years that I have seen many more impacted second molars-especially in patients undergoing early orthodontic therapy. In addition, I have seen more impacted third molars that are displaced either buccally or lingually. It is my impression that orthodontists are able to achieve distalization of first molars during orthodontic therapy now, and this is causing impaction of second molars in some cases and greater displacement of third molars. Secondly, most of the articles I have reviewed regarding rigid fixation cite its increased stability and the earlier function for the patient. However no one seems to discuss infections involving rigid fixation, reoperation of rigid fixation cases because the condyle has been displaced or because the occlusion is not correct after surgery, and the inability sometimes to achieve the proper midline relationship of the mandible in asymmetrical cases. I have seen instances of all these problems, and yet no one seems to discuss them in relation to rigid fixation. I think these are considerations that need to be addressed so rigid fixation can be viewed more objectively in orthognathic cases. I would appreciate anybody who has information regarding either of these issues to please contact me. JOEL M. SALON, DDS, MD Lyndhurst, Ohio