Poster Session
the need for increased exposure to the coding and bill-
ing practices of third party carriers within the curricu-
lum of oral and maxillofacial surgery residency.
Materials and Methods: This study involved 12 oral
and maxillofacial surgery residents at Howard University
Hospital. 600 clinical charts completed over the preced-
ing 11 months were reviewed over a 1-week period.
Radiographs and clinical documentation were re-evalu-
ated by a dental committee comprised of one PGY-4
resident and 2 attendings and compared to the coded
dental procedure that was ultimately billed out.
The Inclusion criteria were as follows:
● Extraction completed By OMFS resident
● Complete clinic chart examination and radiographs
for interpretation
● Clinic patients Only
● Procedure(s) involving permanent dentition
o D7140 simple extraction:
– erupted tooth or exposed root
● D7210 Surgical Extraction:
– erupted tooth requiring elevation of mucoperiosteal
flap and removal of bone and/or section of tooth
● D7220 Soft Tissue Extraction
– Surgical extraction of impacted tooth that is at least
partially unerupted and whose position makes it unlikely
to wholly erupt. Soft tissue covers the tooth’s occlusal
surface.
● D7230 Partial Bony Extraction:
– Surgical extraction of an impacted tooth that is at
least partially unerupted and whose position makes it
unlikely to wholly erupt. Bone covers part of the crown.
● D7240 Complete Bony Extraction:
– The surgical extraction of an impacted tooth, a tooth
that is at least partially unerupted and whose position
makes it unlikely to wholly erupt. Bone covers most or
the entire crown.
● D7250 Retained Root Extraction:
– Mucoperiosteal flap elevation and bone removal are
needed for surgical removal of residual tooth roots (cut-
ting procedure)
Exclusion Criteria:
– Primary tooth extraction
– Extraction by non-OMFS resident
– Non-extraction procedure
– Non-clinic patients
– Incomplete charts
Resident levels of training were defined by the follow-
ing criteria:
● PGY-1
– ⬍12 months of OMFS training
● PGY-2
– ⬍24 months of OMFS training
● PGY-3
– ⬍36 months of OMFS training
● PGY-4
– ⬍48 months of OMFS training
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Methods of data analysis:
● Kappa-test
– Cohen’s Kappa coefficient is a method for assessing
the degree of agreement between two raters. (ie. PGY
assessment versus Procedure)
Results: Preliminary findings
– P⬍ .0005 for PGY 1-4
● Residents will benefit from more educational expo-
sure to billing and coding courses Starting PGY-1
Conclusion: Results underscore the potential of mod-
ules and courses to increase the accuracy of billing and
coding procedures
It is important to have a foundation of knowledge; this
can be provided by a well-designed curriculum designed
to introduce the basics of coding and billing. Research is
important to validate the efficacy of a selected curricu-
lum.
References:
1991 Ridky et al: survey of 8 surgical residencies 100% faculty had no
formal training 70% past residents felt inadequately prepared for en-
tering practice 78% faculty thought a formal training program should
be offered to residents
2004 Fakhry et al: survey of 5 surgical residency programs 82%
attendings and 92% residents thought topic important for clinical
practice 85% residents ranked themselves as novices with regard to
knowledge of subject 33% residents received no training; 32% reported
having a lecture on subject
POSTER 18
Cervicofacial Subcutaneous Emphysema
After Surgical Extraction: Report of
Four Cases and Review of Literature
J. Miller: University of Connecticut, S. E. Lieblich
Statement of the Problem: Subcutaneous air emphy-
sema from using a high speed front exhausting hand-
piece for surgical extractions is a rare but well known
complication. Due to its infrequency as compared to
other complications, cases can be misdiagnosed and
mistreated. The aim of this study is to aid the oral and
maxillofacial surgeon in the diagnosis and management
of subcutaneous emphysema due to the inappropriate
use of front exhausting handpieces in surgical extrac-
tions by dental practitioners.
Materials and Methods: We present a retrospective
case series of 4 patients diagnosed with cervicofacial
subcutaneous emphysema resulting from the use of front
exhausting air driven handpieces during dental extrac-
tions that presented to the Hartford Hospital emergency
room.
Method of Data Analysis: A case series and subjec-
tive review of the literature.
Results of Investigation: Common presenting signs
of subcutaneous emphysema include voice changes,
sore throat, neck and chest pain, dysphagia, dyspnea,
AAOMS • 2012

dysphonia, and wheezing. Exam findings include face
and neck swelling, crepitus, erythema, trismus, and re-
spiratory distress. Mediastinal involvement may present
as a friction rub on cardiac auscultation, EKG changes,
and pneumothorax on imaging. Of our 4 patients, all had
surgical extraction of a lower molar with the use of a
front exhausting handpiece between 3 hours and 2 days
prior to presentation. Immediate unilateral swelling was
noted in one patient, although all presented to us with
significant facial swelling. 2/4 patients had noticeable
voice changes. Crepitus was present in 2/4. Leukocyto-
sis was present in 3 of 4. In all patients, CT scan was
performed, with findings of significant cervicofacial sub-
cutaneous emphysema. One patient had mediastinal in-
volvement, managed conservatively by inpatient obser-
vation. Two patients required emergent airway stabiliza-
tion, surgical exploration and drainage, with ICU level of
care. The last patient was discharged from the emer-
gency room after an observation period. Hospitalization
ranged from 12 hours to 5 days. All patients were ad-
ministered intravenous antibiotics while in house.
Conclusion: Subcutaneous emphysema is a well
known complication, which can arise anytime forceful
air is distributed through the soft tissues. The first case
was reported in 1900 and has been associated with air
generating dental instruments such as high speed hand
drills, compressed air syringes and penetrating trauma.
The roots of lower molars can directly communicate
with several potential spaces. Spread to the retropharyn-
geal space is the main route of communication from the
mouth to the mediastinum. Any of the above clinical
findings after use of a high speed front exhausting hand-
piece should prompt immediate suspicion and further
investigation. Even though there are limited published
cases in the literature, the frequency of occurrence of
this complication is much higher than what is reported
due to the high use of front exhausting handpieces by
dental practitioners for oral surgery procedures. Our
case series presents the spectrum of possible outcomes
and is a reminder as to how easily a common, yet flawed
dental practice can result in potentially life threatening
complication. Due to risk of airway compromise, close
observation is mandatory. CT scan is valuable for evalu-
ation of extent. As spaces have been opened up, the
prophylactic use of an antibiotic is strongly recom-
mended. It is the responsibility of all specialties of den-
tistry to avoid, be able to recognize and treat this condi-
tion appropriately for the safety of the patient. The use
of a high speed front exhausting handpiece for the
surgical extraction of teeth is contraindicated.
References:
McKenzie WS, Rosenberg M. Iatrogenic subcutaneous emphysema
of dental and surgical origin: a literature review. J Oral Maxillofac Surg
67:1265-1268, 2009.
AAOMS • 2012
Poster Session
Patel N, Lazow SK et al. Cervicofacial subcutaneous emphysema:
case report and review of literature. J Oral Maxillofac Surg 68:1976-
1982, 2010.
POSTER 19
Application of Beta-Tricalcium
Phosphate/Collagen Composites to
Extraction Socket Preservation: An
Experimental Study in Canine Maxilla
E. Marukawa, T. Yukinobu, I. Hatakeyama, K. Omura:
Tokyo Medical and Dental University Graduate School
Bone resorption after teeth extraction complicates
dental implant treatments and results in aesthetic prob-
lems or denture instability. In patients exhibiting resorp-
tion of the buccal plate, preservation of alveolar bone
after extraction is particularly difficult. Recently, animal
studies and clinical studies on socket preservation by
means of various bone graft materials have been re-
ported. A few studies on the application of beta-trical-
cium phosphate (␤-TCP) for socket preservation have
been published1,2. While the successful preservation of
the alveolar ridge achieved with ␤-TCP has been re-
ported1, more reduced new bone formation and im-
paired healing compared to Bovine Bone Mineral in the
early stage after extraction have also been indicated2.
Recently, some composite materials with collagen have
been developed and reported to decrease the resorption
rate as the application of the single bone graft material
leads to the prolonged healing of extraction sockets and
their residual growth. In this study, the bone defect
model simulating the extraction socket involving the
buccal dehiscence was designed to investigate the use-
fulness of ␤-TCP/collagen composites (TCP/Col), for
socket preservation.
Following the extraction of the second and third pre-
molars of the maxilla of thirteen beagle dogs, the bone
defect with buccal dehiscence (5 ⫻ 3 ⫻ 7 mm) was
prepared. The defects were filled with either TCP/Col,
␤-TCP or collagen, or left intact and evaluated at 4 and 8
weeks after surgery. A total of 3 micro CT images were
selected and measured the area size occupied by the
newly formed bone and residual TCP. The area size
occupied by the newly formed bone, residual TCP, and
osteoid in the bone defect site of the specimens were
also measured and evaluated. The endpoint differences
between the groups were analyzed using Mann-Whitney
U test (p ⬍ 0.05).
No evidence of postoperative infection was found in
all cases. At 4 weeks after surgery, the TCP granule was
retained in the bone defects and the active bone forma-
tion was observed in the TCP/Col group and the ␤-TCP
group whereas in the collagen and the non-graft groups,
connective tissue grew into the defect. The medians of
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