Last week’s newsletter discussed the AOX Surgical Time-Out. This is the checklist that I perform before every single All-On-X surgery.
In similar fashion, I also utilize an “End of Surgery Checklist” that is performed after every single AOX case.
This checklist is a visual reminder that I keep taped up on the operatory wall that highlights 3 key items I need to remember to do before I de-gown, de-glove and leave the OR.
While not as robust in nature, this end of surgery routine carries just as much importance as its pre-op counterpart.
Krieger’s End of Surgery Checklist
1. Straight Abutments Torqued
For the life of me… I cannot remember to fully torque my straight abutments.
Unlike the multi-unit abutments, the Neodent straight abutments are hand tightened into place, the carrier pin is then removed, and a torque wrench with a straight abutment adapter finishes tightening these abutments to the recommended torque.
Due to a myriad of excuses, I will occasionally forget to finish tightening the straight abutments with the torque wrench – beyond the finger tightened torque. In this scenario, while the abutments are stable – they are not at an optimal torque for the prosthetic.
Because of this, I do a verbal check with my team at the end of every case, confirming that we have actually fully “torqued the straight abutments”.
2. Post-Op Local Anesthesia Given
At the close of surgery, just prior to extubation, I will often administer a small amount of additional local anesthesia. This helps provide continued post-operative pain control during the prosthetic pick-up.
I say “often” – as opposed to “always” – because this practice is patient dependent. I assess the length of the case to determine if the original local is still effective. I also assess the patient’s medical history and amount of local already administered. I then gauge appropriate local anesthetic dosing based on those factors.
Regardless, this end of case verbal check helps me remember to assess that particular patient and perform additional local anesthesia when indicated. This is much appreciated by both the patient and the prosthodontist as it helps provide a smoother and more comfortable prosthetic pick-up.
3. Throat Pack Removed
Despite the obvious nature of this surgical task – the importance of verbally articulating this action out loud and having all team members confirm that the throat pack has actually been removed – cannot be understated.
This verbal confirmation by the surgeon and team should always be done.
*Honorable Mention:
While not included in the actual written list, it should be noted that I do also try to end every case by saying thank you to both the surgical assistants and the nurse anesthetist.
Although we work together every day, cases can be stressful and intense. As a result, I always try to end by letting them know that I am thankful for their hard work and attention throughout the case.
This is easy to forget – but I think it also carries a lot of weight in the long run.
Your pre-op and post-op surgical checklists may not be exactly the same as mine. This is totally fine. The importance lies in creating and having a consistent protocol, both before and after surgery, that works for you and your team. Ultimately, this creates a safer and smoother All-On-X patient experience.
Matthew Krieger DMD
“No wise pilot, no matter how great his talent and experience, fails to use a checklist.”
Charlie Munger
Q & A with Dr. K
“Why do you favor immediate loading? Isn’t delayed loading better in some instances?” |
This is a great question.
I think that both the literature and the volume of AOX cases that have been produced in recent years, have shown that when done properly, immediate loading of an AOX prosthetic is very predictable.
I do believe that an argument can be made for delayed loading, but only in regards to some very rare surgical situations and patients. To put this in perspective, I have only treatment planned and executed one delayed load case to date out of 1,821 arches. There will be more over the coming years – but they are not common.
Your experience will also play a role in this decision. Early on in your career, you may choose to delay load more cases. And honestly, you may have better results with this technique while you are new to AOX surgery.
The second part of my response as to why I favor immediate loading, is that this is simply what patients want. This is the product that All-On-X surgeons and All-On-X practices are selling. Patients want “permanent teeth” – right away.
As mentioned above, while I have only performed one planned delayed load case – I have offered a delayed load option to a handful of patients over the years for whom I felt this was indicated. Other than the one I mentioned, the remaining patients went elsewhere or decided not to pursue surgery. Why? They wanted their teeth right away.
Whether we like it or not, this is the environment we work in and the expectations our patients have. I do not believe we should attempt to meet those expectations when not in the best interest of the patient. But, when acceptable and indicated, we should strive to provide our patients this immediate load option – as it has, in many respects, become the standard of care.