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OFFICE-BASED ANESTHESIA
Mark D. Zajkowski, DDS, MD
INTRODUCTION
for years, offering safe, convenient care for millions of patients. Recent shifts in medicine toward
this model of care have created controversies among many stakeholder groups, and our specialty
thesia, the landscape of current practice is changing as more and more parties of interest come
intertwined with dentistry and oral and maxillofacial surgery. This issue of Selected Readings in
Oral and Maxillofacial Surgery
from a “30,000 foot level”, exploring our deep history as a specialty with anesthesia, the evolution of
us can do to improve patient care and how we view ourselves as part of the larger picture of medicine
HISTORY
Surgery today without modern anes
cheap alternative to gin,5 and for its use at
thrill.
umented procedures were actually recorded
in The Edwin Smith Surgical Papyrus. These
Similarly, nitrous oxide was used for
control were attempted, from nerve compres
sion2 to hypnosis (referred to as mesmerism)3
and refrigeration, all in an attempt to alle
preparation of nitrous oxide was completed
and scientist.
to study its effects on humans in great detail,
ed with varying success, and some prominent
agents were initially overlooked.

Nitrous Oxide. Not coincidentally, Davy not
ed the “transient relief of a severe headache,
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
6
Sadly,
known for coining the term “laughing gas” to
success in his dental practice.
Later in the nineteenth century, one
for surgical pain control emerged, although
much later than it had actually occurred. On
ered ether anesthesia for removal of two neck
tion and to perform a demonstration of his
7
“The patient continued to inhale ether dur
ing the time of the operation; when informed
it was over, seemed incredulous, until the
tumor was shown to him.”7
was widely ridiculed, despite the fact that the
patient did not recall having any pain during
the tooth removal.
this clinical setting, he did not claim credit
practice in a rural environment and his lack
of opportunity for a large series of proce
Georgia, a series of events in New England
thesia as we know it.
to Morton in the delivery of nitrous oxide
for dental procedures. Morton then later
dentists, who saw this as a threat to their live
fessor of chemistry. Morton had dropped
his focus on nitrous oxide and narrowed his
efforts to using chloric ether as an anesthetic.
ether,
this new agent.
of nitrous oxide that he contacted Colton and
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
nitrous oxide, Morton provided ether anes
physician. Keep was a mentor to the young
procedure, the patient reported that while he
enrolled in medical school. Some surmise
that Keep may have introduced Morton to
ren then proclaimed the famous line, “Gen
Morton initially refused to tell his peers
it “letheon”, and attempted to patent it for
ing of Morton as the discoverer of ether. This
controversy carried on for several years, cost
ing Morton his entire wealth and personal
insane asylum, distraught over the prolonged
and understanding of ether as an anesthetic
Boston Medical Surgical Journal
es” documented the preparation, storage, and
administration of ether in his own delivery
apparatus.
tion in his role with ether anesthesia.
Eventually, all of these men were
rewarded in the annals of history. Long was
al reputation surely helped the use of ether
with annual recognition of his accomplish
as a method to remove pain from surgery.
Dentistry Moves to Nitrous Oxide
Morton, of course, is
Medical Examiner
moved on, a mixture of chloroform and ether
gotten in this history, is Dr. Nathan Cooley
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
nitrous oxide.
a Minneapolis dentist, worked extensively
on perfecting his nitrous oxide delivery
the opportunity for patients to have an
tion under nitrous oxide general anesthesia.
no fatalities.
inducing anesthesia to unconsciousness, and
effects of hypoxia on these patients.
point, the mask was removed, and the proce
record,
Oth
acceptance of nitrous oxide, including Thom
as Evans, a prominent dental surgeon in Paris,
used in inhalational anesthetics evolved. One
tile anesthetics for dentistry was halothane,
formulation and use of this method of anes
thesia has continued to evolve, with the mod
today.
sia training was offered in dental schools,
nor were there residencies for oral surgeons
to practice and train in general anesthesia.
nitrous oxide and oxygen in varying percent
ages.

training in hospitals that eventually led to
separate anesthesia departments dedicated to
the education of future practitioners, dentists
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
dentists to provide anesthesia. Over the years,
making shoes.
in hospital residencies for dentists interested
in anesthesiology.
dentists and oral surgeons were not allowed
to participate in training at many of the other
departments of anesthesia at the Mayo Clin
ment of oral surgery training programs in the
with their medical colleagues, and the rapid
During that time, outpatients rarely if ever
received general anesthesia.
vinced of the ideal properties of the drug
for outpatient dental extraction. Lundy con
year residency in anesthesiology, and served
administer anesthesia to any patient who was
not admitted to the hospital overnight.
dency and returned home to Southern Cali
School as its Chair and also served as a pro
fessor at the School of Medicine.
demonstrating the superior anesthetic tech
gery residents who had completed training in
other hospitals.
the teaching of anesthesia to dentists and oral
surgeons, and served as one of the founders
mixture of nitrous oxide and oxygen. One
deliver the pentothal, which eliminated the
need for multiple thiopental syringes and
the increasing power of medical anesthesi
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
sively, omitting oxygen, nitrous oxide, local
anesthesia, or monitors of any kind (other
focus on the teaching of standards in pain and
anxiety control was necessary for our profes
sion to advance.
courses on the delivery of thiopental anesthe
sia all over the country. This sparked the gen
eration of intravenous anesthetics delivered
nationwide, with varying updates and addi
ences on pain and anxiety control. This led
to the “Guidelines for Teaching the Compre
rate thiopental for outpatient general anes
thesia in oral surgery, a dentist teaching at
and anxiety control among dental students,
accreditation of dental anesthesia programs
of sedation. This generally consisted of
tal specialty.
period of sedation.
pharmacologic methods for procedural seda
the risk of general anesthesia in the dental
ment.
Despite these advances and relatively
good outcomes, the typical preoperative
workup for patients was seldom more than
oral surgeons only delivered pentothal exclu

alleviate anxiety for many patients without
the inherent risk of a general anesthetic.
titioners shifted the focus of their practice to
a conscious sedation anesthesia, with excep
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
ushered in a new era of oversight and regula
deep sedation was more effective than mod
A NEW ERA OF PUBLIC AWARENESS
AND OVERSIGHT
priate monitoring.
ifornia Society of Oral Surgeons developed
conference. The participants at the confer
ence pointed out the critical need for greater
research in dental anesthesia with regards to
pharmacologic approaches, environmental
risk assessment, new drugs, and the need for
resources to conduct this research. The con
clusion of the conference was,
“The use of all effective drugs carries some degree of risk, however small.
Available evidence suggests that use
of sedative and anesthetic drugs in the
of safety. However, even this record can
anesthesia and emergency management for
facial Surgeons adopted this program, and
made it mandatory for all state component
Several studies of the safety of anes
thesia gave credence to oral and maxillofa
Lytle and Stamper reported a mortality rate of
vey of Southern California oral and maxillo
20
ate guidelines governing requirements
patients, in a survey of Massachusetts oral
One of the most recent prospective
cohort studies of anesthesia in an oral surgery
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
22
Encompassing
the entire spectrum of anesthesia, they found
to pursue his passion for outcomes and per
formance measurements that he so strongly
work, detailing 337 patient admissions and
with all complications deemed minor and
.
Particularly with anesthesia safety, med
icine has come full circle in the pursuit of
in testing its one page of minimum standards
23
in
The list of standards, now known as the Man, had grown
This was a radical concept, and not
each of his patients with meticulous detail
with his “end result cards” that contained
patient demographics, diagnosis, treatment,
similar conditions. This also meant that treat
patients. Most shockingly to his colleagues,
he pushed to make the failures in treatment
25
ity conferences to openly discuss treatment
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The “drift” of our specialty towards this
tional facilities to its accreditation standards
services, including psychiatric facilities,
spotlight of an unforgiving press.27
more interested in how safe outpatient anes
Board of Governors.
Committee on Patient Safety and Risk Man
premiums for anesthesiologists.
of accredited facilities came a refocusing
disciplines with an interest in patient safety
performance processes. Currently, the focus
of the accreditation process is the review of
structured around functions central to patient
care delivered to the patient,26 including
Of particular importance to the oral
and maxillofacial surgery community is the
goal of conducting safety research and edu
cation, providing patient safety programs and
campaigns, and promoting the national and
international exchange of information and
patient safety, and continues to fund a num
specialties have mandated accreditation or
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
Standards, and the Statement on the Safe Use
.
)
based Anesthesia
administration of and facility for providing
the anesthetic, with recommendations on
the facility. The document reviews clinical
care guidelines that include patient and pro
cedure selection, perioperative care, moni
transfer procedures. These are in agreement
can argue that the fundamental change is well
underway, as you will read later in this review.
anesthesia for medicine and dentistry are
who practices within the standard of care in
the adoption of the ASA Standards on Basic
Monitoring
Over the years, the
produced many guidelines for anesthesiolo
sources. Technologic advances in monitoring
have also allowed for a greater safety margin.
are continually updated.
to review the
good suggestions to improve clinical care
ered. Some of the more relevant guidelines
Guidelines for
, The Anesthesia Care
Team, Guidelines for Ambulatory Anesthesia
and Surgery, Basic Anesthetic Monitoring

tice. These new standards applied irrespec
tive of whether the anesthetic was general,
regional, or monitored anesthesia care. The
recorded at least every 5 minutes
the case
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assess ventilation, the participants depending
more on either a precordial stethoscope or
nect monitor with alarm
Many surgeons had resisted this moni
low concentration alarm
with oral surgery patients and a lack of con
ment
2
grew, pulse oximetery and end tidal CO2
mandate the use of capnography. The guide
30
when either a pulse oximeter or capnograph
was used.
Medicine has continued in updating
and general anesthesia the adequacy of
ventilation shall be evaluated by continual observation of qualitative clinical
ed or invalidated by the nature of the
initially used in operating rooms to prevent
intraoperative awareness, these monitors
facility.32 Nevertheless, these monitors have
not yet reached universal acceptance and
standard of care.
the monitoring advances as well, rapidly
incorporating state of the art technologies to
Despite the long and consistent safety
record of anesthesia in oral and maxillofacisl
method persist. This is somewhat due to
outpatient anesthesia, capnography had not

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
found on the package inserts in propofol con
THE CULTURAL SHIFT TO
OFFICE-BASED SURGERY
The advancements mentioned previous
tion of general anesthesia and not involved
in the conduct of the surgical/diagnostic pro
cedure.”
thesiologists asserted that the insert was cor
rect, offered its own statement on the safe use
ditional settings, particularly among medical
to have procedures performed in an outpatient
setting has increased, so too has the increase
procedures, resulting in the need for deeper
sedation, analgesia, and general anesthesia.33
tists. The statement read,
sedation/anesthesia, it should be adminadministration of general anesthesia,
who are not simultaneously involved in
insert, and failure to follow these rec-
west of health care”.
events occurred, they were reported in the
Wall Street Journal article highlighted the
“crackdown” on doctors performing unreg
35
The data gath
36
showed
The controversy has waxed and waned,
nurse anesthetists to provide itinerant anes
thesia services independent of anesthesiolo
most common respiratory events were air
events were due to incorrect dosing or drug,
allergic reaction, or malignant hyperther
mia.33
surgery practitioners.

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
ulations with a wide spectrum, from a limited
ments for the administration of anesthesia to
nent neurologic damage or death occurred
to hospitals.37
Study
ASA Closed Claims
ment or monitoring. Of particular note in
this study was that the provider was often an
oral surgeon, periodontist or nurse anesthe
of this paper was that providers should have
airway management training as well as the
gists guidelines and the reporting of adverse
events.
put regulations in place or were considering
doing so, with some granting exceptions to
accredited facilities or mandating accredita
Currently in the oral and maxillofacial sur
or regulations) dental practitioners to undergo
limiting.22 Despite this report and continu
ing ongoing efforts of our specialty to edu
Oral and maxillofacial surgery has
anesthesia training, experience, and consis
tent positive outcomes assessment, the tide
in 2007, with the passage of legislation that
cialty practices and more towards third party
maxillofacial surgeons to have their practices
serving the oral and maxillofacial sur
gery community well for decades, is likely
encroaching tide of state regulations on our
in outpatient settings.
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
oral and maxillofacial surgeons, as long as
they practice within the scope of their dental
license.
Because the waiver took over two years
York undertook the accreditation process,
for and against outside regulation of oral and
Journal of Oral and Maxillofacial Surgery.
nario for the oral and maxillofacial surgeons
three different experiences undergoing this
Journal of Oral and Maxillofacial Surgery
article.
Nevada surgeons also were caught in
the crosshairs of state regulations with the
sive control of anxiety and pain control, the
the AAOMS Parameters of Care as reasons
The following year, he acknowledged
the rapid trend of regulation of medical
maxillofacial surgeons in practice to ensure
facial surgeons were not directly involved in
menting voluntary accreditation, we now
future.
with mandated
reporting of complications, and stiff penalties
for those not in compliance.
gery societies and associations.
These experiences should serve as a
move out of the “cottage industry” and more
into the current mainstream of transparent,

like everything we do, is framed within our
practice guidelines. Contemporary practices
AAOMS Parameters of Care
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permit or license to provide this care, and the
practice within the anesthesia team model.
Care, with material on emergency protocols
and monitoring standards.
The
l is predi
cated on a surgeon with at least two assis
ties other than to monitor the patient during
systemic diseases and evaluation of patients,
and monitoring, and emergency manage
WHAT AND WHY DO WE NEED TO
sistants, oral and maxillofacial surgery will
other specialties to emulate, as well as to gain
some political capital in defending our treat
ment model.
AAOMS
Parameters of Care
So, you may ask, if the oral and maxil
an exemplary record of safety over the years,
has committed to maintaining standards that
technology and science improve, what or
why do we need to change?
standards with regard to anesthesia contain
anesthesia, general standards, criteria and
considerations for anesthesia in outpatient
facilities, special considerations for medi
cally compromised patients, and outcomes
assessment indices for deep sedation and
general anesthesia. This document generally
sia, with the exception of propofol delivery
a companion to the AAOMS Parameters of

maxillofacial surgery procedures are within
regulations continue to increase, so too will
seen all too often in the past, a reluctance to
those outside of the specialty to set it for us.
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maxillofacial surgery stays complacent, with
tion for accreditation.
the New York and Nevada experiences, and
facility include a clear demonstration to your
patients that you offer the highest level of
patient safety and care, a competitive edge
in marketing your practice, attainment of a
foolish arguments that will doom our spe
cialty to the loss of autonomy that we have
worked so hard to preserve.
ensure safe and appropriate care is delivered.
Currently, accreditation for an oral and
es, with a premium added to payments due
solely to the accredited status of our facility.
ited facilities, and offer patient resources for
the patient to partner with you in their care.
care, and monitoring of outcomes. There are
certain advantages and disadvantages within
licity kit to promote the accredited status of
downloaded for your media campaigns.
_____________________________________________________________________________
TABLE 1: AREAS FOR WHICH THE JOINT COMMISSION OFFICE-BASED
SURGERY PROGRAM SETS STANDARDS-BASED PERFORMANCE
Environment of Care
Emergency Management
National Patient Safety Goals
Provision of Care, Treatment & Services
Records of Care, Treatment & Services
Leadership
Life Safety
Medication Management

Transplant Safety
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______________________________________________________________________________
TABLE 2: SERVICES AND REPORTS AVAILABLE FROM CONSULTANT WEBSITES
Audits
Benchmark Studies
sea and vomiting)
Essential Internal Studies (cost of care/medical supplies, patient satisfaction, patient waiting
times)
High Risk Process Analysis
(e.g., recovery room audit)
policies and procedures
tialing, policy and procedure review.
perioperative checklists, links to specialty guidelines, emergency management drills, human
resources forms, etc.
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process focuses on operational systems criti
The survey process evaluates actual care pro
tion to the patient tracer activity, the surveyor
also reviews key operational systems that
directly impact patient care. These surveyors
are health care professionals who practice in
experience in similar settings. Often, the sur
veyor during site visits is a fellow oral and
maxillofacial surgeon or dentist.
time to make corrections if needed. Once
creditation decision is made; maintenance of
accreditation is fairly straightforward.
Calendar.
____________________________________
varies among the agencies, the current direct
Many accredited facilities retain a con
cies and procedures updated, and keep prac
tices informed of changing standards. One
fees for multiple locations. There are also
annual fees to remain accredited, currently
offers
monthly email that reports scores for your
practice and reminders to keep records, stud
hire a consultant for the initial evaluation, or
for ongoing maintenance of your accredited
consulting companies as well as among the

correlates with your chance of success should
you encounter an unannounced survey. Links
to some of the various services and reports
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
align your practice with current accreditation
standards, a calendar of studies is posted,
our facilities review “near misses” that could
have resulted in harm to a patient in a logical,
progressive manner to ensure it never hap
of data.
oral and maxillofacial surgery practices give
an accurate infection rate for their facilities
medication errors in facilities if there is no
formal medication management plan?
an accredited facility has far more failsafe
mechanisms in place to avoid adverse events
Journal of Oral and Maxillofacial
Surgery
process improvements that an accredited
ation may refresh a practicing oral and maxil
lofacial surgeon in emergency drills every six
years, it offers little in those areas of accredi
Patient Safety Goals into practice. Surely,
if modeling our practices along the practic
to practice for so many years has room for
the improvement that accreditation can offer.
and risk prevention.
and the potential role for accreditation in oral
cialty to do the right thing and move in the
of the accrediting agencies to tailor a program
______________________________________________________________________________
TABLE 3: APPLICABLE GOALS FOR A WELL-RUN OMS PRACTICE
decision making
Knowledge and skills management
Development of effective teams
Coordination of care across patient conditions, services and settings over time
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research found “a health care system that fre
knowledge into practice, and to apply new
technology safely and appropriately.” One of
the most salient points in the report was that
medicine is using outdated systems to deliver
care we will need to have “redesigned sys
tems of care, including the use of information
technology to support clinical and adminis
trative processes”.52
largely aimed at chronic conditions in medi
____________________________________
thesia Evaluation as a central component, or
run oral and maxillofacial surgery practice
typically already incorporates, and others
for the typical oral and maxillofacial surgery
practice, with the goal of making the process
addressed safety and human error.53
HOW DOES OMS FIT IN WITH THE
NEW CULTURE OF SAFETY AND
50
was a
landmark in a national reckoning to improve
in their care, and hundreds of thousands suffer
prevent. Medication errors alone, occurring
either in or out of the hospital, are estimated
to account for over 7,000 deaths annually.
52

“Crossing the
approaches. The
(which
is all too common in medicine) focuses on
attention, forgetfulness or moral weakness.
The
focuses more on the
conditions that individuals work under, and
or lessen their effects. This approach under
that “error is not the monopoly of an unfor
mishaps tend to occur in recurrent patterns,
hence the need for the system approach. Rea
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TABLE 4: FIVE KEY PRINCIPLES SHARED BY HROS
does not allow a process to rely on a single person without redundancy.
______________________________________________________________________________
tem accidents shows how a series of weak
result in an untoward event.
tions and facing great potential for error and
positive results.
improvement (as in auto manufacturing with
ing extracted, for example, a series of errors
in the system could leave this potential error
undetected until the adverse event happened.
improvement to reduce the rate of defects).
dency, stemming from our training in the sci
55
Two overriding principles
Reason surmises that almost all adverse
active failures and latent (system) conditions.
surement tools to eliminate inappropriate
variation (known in medicine as the “art”
rationale) and to document the continuous
improvement (via outcomes).56
57
(constant vigilance
cognitive function, dynamic tasks, chang
ing technologies, and time pressures while
line) and
(immediate actions
taken to reduce further damage when an error
industrial areas like this (such as an aircraft
carrier, a nuclear power plant or air traf
ciples.
great effectiveness that are exceedingly reli
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out where the weakness in the system resides
tion, and act as powerful reminders of system
60
care system. This method of continual assess
ment and improvement makes systems (such
“Effective leadership of
in the process of care to achieve maximum
patient safety and satisfaction, delivered with
Barach notes that several complex,
approach for data collection, analysis and
improvement.
standard protocols for anesthesia delivery
was for health care to adopt
modeled on the crew resource
management used in the aviation industry,
lofacial surgery team can enhance the safety
training.
lature seeking to “do something”. This pro
resource management are to produce positive
Crew resource management incorporates
team training sessions, simulation, group
perfects this concept, they can potentially
is exactly what has happened in aviation, and
the parallels in anesthesia are easy to see.
team can truly work together for the common
goal of safe, effective care.
Oral and maxillofacial surgeons have
clearly heeded the call to improve skill sets
and participate in team training. This is seen
grams for residents and practitioners alike.
cial surgeons have participated in some type
referred to as a “failure mode analysis”
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
______________________________________________________________________________
on the input of the user, and now are the
tinues to improve to the point that teams can
train around surgical events and simulate the
effects of an anesthetic.
a wooden model of a soldier.62 Medical simu
central venous and pulmonary artery pressure
as well as allowing management of the air
62
simulation models have incorporated model
internet.63
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
______________________________________________________________________________
and were revised for training for responses
and explosive incidents.
The advantages
of multiple users in remote locations and
sive” experience show unlimited potential for
training of health care and industrial profes
sionals worldwide.
convert to electronic medical records. These
records, coupled with improvements in mon
itoring systems can help us incorporate the
to ensure a high level of care, and can help us
mentioned previously.
PUTTING IT ALL TOGETHER…
Below, are some sample screen shots
electronic medical record) to tie some con
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
______________________________________________________________________________
system approach to error reduction and the
to ensure a completion of informed consent.
lofacial surgeon.
This anesthesia record is divided into
different segments, following a logical se
case (all images courtesy of Carestream Den
incorporation of the team in the care process,
and the provision of another opportunity for
signed.
The documentation of these key ele
review of medical conditions and allergies, a
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
_____________________________________________________________________________
ing for the surgical “time out”, assurance of
the correct patient and procedure, and mark
ing of the operative site (performed on the
of importing monitored data at the onset of
the patient visit. This segment documents the
cally imported from the monitors, and allows
the preoperative evaluation, as well as the
documentation of extremity positioning to

catheter. These steps are critical to involve
the entire surgical team, much like in the re
view of crew resource management discussed
earlier.
The chronologic time details are
automatically entered from the monitor at
the completion of the case. Many of these
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_____________________________________________________________________________
elements incorporate the National Patient
the incorporation of a graphical user inter
are easily and seamlessly incorporated into
the patient record, and include the culture of
safety in an oral and maxillofacial surgery
facility.
of the procedure and stored within the anes
thetic record for review should the monitor
show changes, allowing a comparison to the
The times are either manually entered
one of the most exciting portions of the elec
medications are provided during the case,
ing a “real time” recording of events. Typical
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
______________________________________________________________________________
lection of data is later scanned into the an
esthetic record after completion, and is used
on the following day. This allows the patient
another opportunity to review postoperative
notations on any complications or anesthetic
recovering as expected.
later entered in the recovery room, as well as
documentation of the escort and instructions
provided for postoperative care.
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
CONCLUSIONS
is a graduate of
Oral and maxillofacial surgeons have
ways to the progress in anesthesia for well
proud of our long track record of safety in our
illofacial surgery at Massachusetts General
doctor practice in South Portland, Maine that
practices the full scope of the specialty, and
pioned to improve patient care. Times, how
ever, are changing, and with the increased
having served on numerous committees and
task forces.
on how we provide care.
the opportunity to again lead the way in this
exploring the coast of Maine with the love of
his life Michele and their two children. This
issue of SROMS is dedicated to them.
and safety of the care delivered, the devel
our systems of care, and the modeling of our
forward and preserve the autonomy that we
have worked so hard to gain.
should seriously consider the accreditation of
for the right patients all of the time. To offer
anything less to our patients undermines not
of the pioneers in oral and maxillofacial sur


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REFERENCES
mitigating human suffering in surgical
operations and acute diseases. Boston
anesthetic in surgical operation. South

and Oral surgery. Philadelphia, Lea &
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
thesia Survey of the Southern California
Society of Oral and Maxillofacial Sur
prevention in anesthesia and surgery.
2006.
experience among Massachusetts oral
Standards for patient monitoring during
outcomes of clinical practice of oral and
The End Result of a Life in Medicine.
index monitoring allows faster emer
gence and improved recovery from
propofol, alfentanil, and nitrous oxide
dation of patient safety. Perioperative
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accrediting agencies and suggestions
for changes in private practice oral and
maxillofacial surgery facility evalua
states crack down on doctors who per
lessons learned from the closed claims
Deja vu
mission of accreditation of healthcare
maxillofacial surgery. Oral Maxillofac
2000.
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Crew resource management and team
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oral and maxillofacial surgery resi
dents in general anesthesia and airway
and Sutton R (eds) Research in Organizational Behavior,
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RELATED ARTICLES IN SELECTED
READINGS IN ORAL AND MAXILLOFACIAL SURGERY
Risk Prevention for Oral and Maxillofacial
Selected Readings in Oral and Maxillofacial Surgery .
Sedation. Vasiliki Karlis, DMD, MD,
Selected Readings
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man, DMD, Selected Readings in Oral
and Maxillofacial Surgery
son, DMD. Selected Readings in Oral
and Maxillofacial Surgery .
Outpatient Orthognathic Surgery Performed
and Douglas P. Sinn, DDS. Selected
Readings in Oral and Maxillofacial Surgery .
DMD, MD. Selected Readings in Oral
and Maxillofacial Surgery .
Selected Readings
in Oral and Maxillofacial Surgery . Vol.
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