Oral Surgery Sisters Podcast EP8: Karissa Burgos

Season 2 is finally here! Join us for a brand-new episode featuring Dr. Karissa Burgos, DDS, MSD on the @oralsurgerysisters channel! Don’t miss this insightful conversation on orthognathic surgery, patient education, and more! ✨ #OralSurgerySisters #OrthognathicSurgery #PatientEducation #DentalPodcast #OralSurgeryPodcast

Transcript

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We have a very special guest today. We have our dear friend Dr. Carissa Burgos. She's a practicing orthodontist here in the Las Vegas area. She went to dental school at Detroit Mercy and trained in orthodontics at the University of Colorado. So I'm so excited that you're here to join us today. Thanks for coming. Yeah, I'm so happy to be here. I was honored to be asked to come on for a multidisciplinary talk today. And uh yeah, it's just been so fun working with both of you for all of our listeners. I actually started working with Dr. Kimmy over in California. She was my orthanathic surgeon out there. We did a few cases together and then we transitioned out to the Vegas area. And she said, Oh my gosh, you know what? Like my sister lives in Vegas. You guys need to hang out. And so yeah, we went on a little blind date and it was super fun. And I know it was fun. Doing cases together. And uh it's kind of crazy that that happened because like you said, we met a few years ago in Southern California, and then just by coincidence, you moved to Las Vegas, and I was like, wait a minute. Somehow, and somehow you basically ended up working with both of us, despite the fact that we both practice in different cities in different states. Yeah. I mean, okay, I remember when you called me on the phone. We talk a lot on the phone, of course. We're at the catch-up, um, keeping up with you know, Christine Kimmy. So she told me, she was like, Oh my gosh, I met the the most fun girl and she's the sweetest. She's so kind. Her name's Carissa, and uh I had such a good time. And this was like maybe like fast forward, I don't know, a year close to a while ago. Because you at least a few years ago. And then um, and then you were like, oh hey, I think, I think my friend, I told you about her like a while ago, but she moved to Vegas, and I think you guys should all like get together and meet up. And so we truly like went out on a blind date. Like we hadn't met, and we all brought like our partners with us, and there were she's gonna like me six or seven of us, and it was we had such a good time. We have to do that again, and then we had wine after. I know, yeah. I know it was fun. It's just crazy that you guys actually work together now. Yeah, and so now her office is very close to my office out here, and so I get to ask her, like, hey, can you do this expose and bond for me? Like, what kind of chains do you use? And oh yeah, different things like that, you know. So it's uh it's really fun. I feel very lucky that I've been able to work with both the oral surgery sisters. We're lucky that we get to work with you. Yeah, yeah. But um, but there's many things that I think that we would like to talk about, maybe not all today. Um, but today we were hoping that we could chat a little bit about my favorite topic, which is orthognathic surgery. But basically just, and I think there's just a lot to talk about. There's just so many different nuances and aspects that we can talk about as an oral surgeon and orthodontist. But today, maybe just kind of scratching the surface and chatting about that dental facial deformity patient that just first walks through the door either of the office of an oral and maxillofacial surgeon like myself or an orthodontist like yourself, because there's there's a variety of those types of patients that walk through the door, whether they come in demanding some specific type of treatment, or they come in and they don't even realize that they have a problem. And so I wanted to just kind of start the conversation because it's very important for this patient population as they go through their treatment to have a solid foundation of conversation and communication between the orthodontist and the oral and maxillofacial surgeon. And so maybe if you could just start by chatting about when that patient walks through the door of an an orthodontist office like yourself and kind of what that looks like. Yeah, absolutely. This is a very important topic, and I find that many orthodontists that are newer or finishing residency, you know, recently, they maybe haven't had as much experience with orthodonathic cases. It kind of varies. Yes, there's a lot of confusion on how does the pathway start? Like how do I even have that conversation with my patient, right? Because you know, like you said, there's really two categories of patients that we see, whether they are seeing you for the first time or seeing me for the first time. I would say uh a like a minority of the patients end up being those ones that come in and they're very adamant that they are a surgical case and they understand they need that surgical correction of their jaws. Most of the patients that we see probably come in and they say, Hey, I've never really liked my smile, but I really want to see what I can do to improve it. But uh sometimes they a lot of patients don't necessarily want surgery. I mean, that's most people don't want surgery. There's very much a patient education component of it. Uh, but sometimes patients will come in and their mandible will walk through the door for the rest of them, right? And they come in and like, oh, can you do this with a good whip line doc? And I'm like, ah, you know, so let me just tell you what I see. That's where I always start. If this is their first experience with an orthodontist, they've never gotten this information before. So I give them their scans and I say, hey, you know, this is where your jaw is, this is why it looks like this, like there's just too much growth in one versus the other. That's why you're you see your smile or your profile, and it seems like it's not balanced. I usually kind of and just for listeners who because I think we have a variety of listeners, listeners, even people who are applying to dental school, when you say scans, what's the like the full workup entail for you as an orthodontist? Yeah, and so for me at least, I I was in a practice in California that did the CBCT pretty routinely on every patient. The 3D image is always the best. You know, that's a great way to see you know how things fit, and you can kind of dissect and show the patient a little bit more. They can visualize it. Yes, but some offices don't have that capability, so for uh the bare minimum, as far as an orthodontic screening appointment or a consultation, we like to have a lateral Ceph and a panoramic x-ray. And then we take a couple intraoral photos, and all of those things really help us to educate the patient and kind of give them their diagnosis. Um, but yeah, and so that's kind of where we start the conversation. And like you said, some of them come in and they don't even know that surgery is an option. And if it looks to me like they are definitely a candidate for surgery, then we have to decide does the patient actually want the surgery, right? Because sometimes they'll come in and they say, Yeah, like what's it gonna take? They just think like maybe a few braces or a couple of aligners are gonna get that result that they're looking for. And I have to be the one to inform them, like, oh, this is what we can achieve, and this is probably what we can't. Yeah. So we want to get this correction. I'll show them maybe a before and an after of a surgical case. Oh, and then I'm like a previous yeah, it's like a you know, just an anonymous kind of like before and after sample. It's like, if this is what you're hoping for, like a nice traumatic finish with a really good result, your profile will change. Uh, you'll be able to chew food like you've never chewed before. Uh and so if we want to really accomplish that, you have to be considering a surgical plan. And so if they seem open to it, then we kind of start that conversation. I'll tell them what it might be like to go through that process. Uh to very simply put it, uh, we tell them there's uh maybe six months of prep for your surgical treatment. Then we send you over to the oral surgeon, they do their magic, and then you'll probably be drinking out of a straw, you know, for all of your meals for a couple of weeks. But then after that, it's a pretty easy recovery. Um, they're gonna tell you everything that you need to know about the specifics of your surgery and any other uh complications or risks, benefits, all of those things. I kind of leave most of that explanation up to you guys at your consultation. And then they have maybe a few more months of treatment afterwards uh with me to kind of get that bite in the perfect spot, really focus on those like micro aesthetics, is what we call them in our I'm gonna use that word micro. Yeah, so we've got like the macro aesthetics, the micro and the mini. So got a lot of different um different topics to kind of. I told them fine-tuning, but I like micros though. Microesthetics because they kind of see, oh, that sounds really scientific, but it really is at the end of the day. It's like half a millimeter of movement in my world makes a dramatic difference. Like people can see that visually, like in smiling photos or on Instagram, of course. Yeah, definitely on Instagram. Yeah, yeah. So that's kind of what my experience has been doing uh that initial consultation. But you said that you have a lot of patients that come in to see you first without seeing the orthodontist. Does that I mean I wouldn't say a lot, but it really depends. I think also it's because of I'm not in the traditional maybe what you think of in, I'm not in a private practice setting. I'm in a hospital-based setting under medical insurance, basically. But there are definitely a chunk of patients that come through my clinic, let's say, where they don't have any orthodontic appliances on. They've I say, Oh, who's your orthodontist? They say, Oh, I haven't seen an orthodontist. I want jaw surgery, which is I mean, I feel it's it's a little bit out of the norm. Traditionally, I think ortho gnathic patients as an oral surgeon are always referred by the orthodontist. So they've had all of those conversations up front. They come to me already with this expectation that they need surgery or they want surgery. So you as the orthodontists have done a lot of the that work in conversation already for me. Um, of course, there's kind of a smaller subset of patients that are not the traditional orthopnathic patients. Let's say they're a cleft patient and they're referred by the cleft craniofacial team or a plastic surgeon or something, or a patient with sleep obstructive sleep apnea and they're referred from the ENT surgeon or the sleep sleep clinic or the sleep doctor. So of course there's a little outliers, but traditionally they are referred from the orthodontist. But I was having this conversation with one of my mentors recently where with social media becoming so having so much more of an influence on patients, not just in dental or oral surgery or orthodontics, but also just in healthcare in general, and for younger and younger group populations like millennials, Gen Z, then I think a lot more people and patients are seeing that on, let's say, Instagram or TikTok, and they're like, oh, I want that surgeon, let's say. And so they just end up in the surgeon's office, but they haven't established care with an orthodontist or even a dentist. Like I've had patients come and I'm like, yeah, I'm like, oh, two's who's your orthodontist? Oh, I don't have one. Oh, well, do you have a dentist? Uh yeah, I have I don't know. I don't know. I haven't seen them in a couple years. Yeah. Yeah. So I think it maybe it is changing a little bit, which is, and we kind of talked about this where maybe m putting more of a challenge on the oral and maxillofacial surgeon, of course, to one inform them of finding a dentist and orthodontist, but then they're the first point of contact. And so as an oral surgeon, I have to be able to have that conversation of, oh yeah, yes or no, I do think you're a surgical candidate versus not. Let's have you see an orthodontist first and have a conversation, at least, even if they're clearly a surgical case, at least, of what they can do orthodontically if if they're on the fence about surgery. So I think maybe the landscape is changing a little bit. Definitely. At least compared to patients are much more encouraged to take it upon themselves to go out and find you know a provider these days. There's so much more availability and exposure online for different dental offices. And so, but there is a lot of misinformation as well, right? You know, like we were saying before, there are some offices that do a great job of promoting themselves on social media, but maybe they don't do orthodathic cases or you know, they're kind of spinning their wheels. The patient is trying to find that um uh team that's gonna get them through a surgical case, and then they get a little bit frustrated or burnt out from the process because they're you know running around before they have all of the information. And so I would say for our listeners and viewers that are dental providers, uh, that's kind of be the biggest takeaway is really just informing the patient and making sure they understand why they're going to this consultation. Because what I don't like is that they get to the oral surgeon and they're like, Well, I don't know if I really want surgery, or I try to only send patients that know that they want it and they have this expectation of what surgery entails. They shouldn't be coming to you asking, right, should I be getting surgery or not? You know, it's like they do actually a lot. Yeah, but I think that's and I probably every orthodontist is different because I definitely have gotten patients um referred by orthodontists where they've had a conversation with them about maybe let's say they're a borderline case or maybe orthodontic camouflage is possible where we're avoiding surgery and just correcting things as much as possible orthodontically. Um, but they have come to see me referred from the orthodontist and they say, Oh, my orthodontist wanted your opinion about whether or not to pursue surgery. And so it's kind of, I think, again, a challenge a little bit, because ideally they come to me and they're like, Yeah, I'm I'm ready for surgery. But I never want to push surgery on somebody. It's a big decision to proceed into. Yeah. Well, and I think some of it is also they want me to have the conversation first about risks and potential complications. See information I can't give them, like, usually what it will entail. Because then some I mean, definitely after I've had that conversation, then they're like, oh wow, I didn't know that I would be out of work that long or be on an altered diet for that long, or or this or that. And so then they they really need so I mean I think it's good to have the all the information. Kimiko, do you have just in your personal experience, not evidence-based, just an estimate of a percent of patients where they actually do hear the standard risk, benefits, alternatives, and they actually decide they don't want to go through with the surgery. After I've talked to them. After you've talked to them. And they've decided, like, oh wait, I didn't know that I'd have to get this or this surgery was this because we always say with this surgery, I would say it's big surgery, big risk. You know, and it's elective. It's elective, it's not, it's not a life-saving surgery. Yeah. Which I fe I think, which that's that's a different conversation about the term elective, but um but sometimes I've told I tell if I use that word with patients, then they freak out because they're like, oh no, is this not covered? Right because it's not medically necessary. But I can totally see that because it because it is a surgery that will bring a patient improved quality of life and functioning, aesthetics, the s the psychology behind your appearance. So yeah, you're right. It's you don't want to say elective, but but you're it's not gonna tell them it's not a life or death surgery. Yeah, I tell them it's not the same as if you come to me and you have appendicitis and you need your appendix removed. Non-emergent. Yes, yes. Yeah, there you go. All the good phrases. Okay. But um verbiage is very important to our patients, as we know. They've got to find keywords that they'll take away and kind of have a better idea of what they're expecting. But yeah. Well, you asked me a question about. Oh, you said what percentage is. Yeah, do you have like do you in your uh experience, what small percentage be say, oh, uh actually wait, I don't want to do this anymore? I would say it's quite small, but mostly for that reason where you say by the time they get to me, they have they're at least open to the idea. And they've and and now there's just so much online, like we said. So they've looked a lot up already. And so most of the I would say it's very rare, like less than one percent. Okay. Because most of them have kind of filtered out already. I'm that like I'm sure the percentage for you is a lot higher. Right, right. For me, it is higher. I would say after visiting with an oral surgeon, there is a small percentage that come back and say, Hey, I decided not to go forward with that. Most of the time it's honestly because of the insurance coverage or the cost. They weren't seeing as much of an out-of-pocket, or maybe it wasn't a covered benefit with whatever insurance they have. And unfortunately, that does play a big part in how uh they make their decisions as patients. Like, we get it, like cost is important. And so it helps us to decide which pathway we're going down, knowing that you know, I kind of kind of make the make sure the patient understands the expectation as well. Like, if we can't do the surgery for whatever reason, then these are the limitations of what we can do. And so that's the big uh responsibility that I take on in my consultations or starting a treatment plan, making sure they understand what they're getting out of this whole experience, whether it's a surgical case or not, really. So, how often would you say that happens where they decide not to pursue surgery in the in the middle of treatment? Oh, because those movements are different, obviously. Yes, that is a great question. This has happened before, where they um we, you know, they we decide for our listeners, for example, the the pathway you go down is almost completely opposite, whether you're doing surgery or not. And so it sometimes we start saying, like, hey, yeah, we're gonna do this surgical correction, and so we're not gonna wear any elastics because we don't, we're not gonna get that correction from your rubber bands, we're gonna get it with the surgery. We have to decompensate the way their teeth lean. You know, there's uh a lot of patients that the teeth kind of compensate for themselves if you have mismatching jaws, things like that. And so we actually make it look worse in order to get a better surgical correction. Like I always try to warn my patients, it gets worse before it gets better. So I trust the process. Yeah, but then I have had it happen. It's probably it's a very low percentage, less than 10%. But there is a percentage that say, hey, you know, like I I don't I can't be out of work that long. I didn't realize it was gonna take this much time to do all that, and then we have to change gears. And so I I let them know again, it's all about patient education, just letting them know what their options are with that new decision. And so I tell them, hey, you know, this is how it's gonna, I can align your teeth. I I can leave it like this, where you smile from the front and people can't tell as much, like the teeth look straight. We can give you some better smile arc here, but I can't correct this bite relationship. And sometimes they're not even great candidates for like a camouflage extraction plan. I'll let them know if they fall into that category, but it does add some treatment time as far as the orthodontic component goes. We uh kind of have to go backwards a little bit in order to do that camouflage or just the alignment because we're going in a whole different direction there. But it would be fun to show maybe some cases in another segment where we can kind of describe for our listeners like what that actually means. That's true. It's hard to visualize like what what those two pathways look like and how you set it up. But I imagine that's really challenging because I I imagine you would you try to have uh identified a certain like if they decide to pursue surgery, identify a surgeon before you start the orthodontic treatment to make sure because if you are going to decompensate and make their bite look worse, you want to make sure that they're set up with a surgeon first. And I usually will do that as part of my consultation. I say, hey, like let me take a um itero scan, or you know, so that we can start planning out your movements, and then whenever you have met with the surgeon, I will touch base with them about what I reasonably might need in order to make sure it fits nicely and looks good, and they can give me their expertise on whether it's a double jaw, single jaw, you know, all the different parts that go with it, and then we can communicate together. But generally we don't start until they have confirmed that who they want to be their surgeon and uh that they know what it's gonna take to get all of it done. Yeah, see that makes sense, but I have just gotten so many patients that come through the door, they're in braces, haven't talked to a surgeon yet, and they're like, Oh, I'm ready for surgery. Yeah. Which happens a lot, but then I'm like, how do they know? Because you're making the bite worse. Right, right. And so they're actually gonna get their surgery. Yeah. Unfortunately, that does happen quite a bit. And I've had it with Where the patient changes their mind, the other right. It's like where we we tell them, hey, you know, the bites pretty off, you know, especially with very um mandibular, like retronathic patients that just have a really long overjet. They their front teeth on the top are like miles away from the bottom. And there's I tell them, like, I can try my best, but there's um there's a limitation to what we can do with just elastics or just with an extraction. And I usually will recommend that surgery from the beginning, and they say, Oh no, I don't want to do that. And then we get to work, right? I say, okay, we know we're um, you know, going for a compromise here. Yeah. And about a year in, they say, Well, hey, like it looks really, really not good. And I'm like, Well, we told you that this is all we're gonna be able to get. Like, you're still gonna have quite a bit of overlap here. And then they say, Well, I like now that I know what the result is, like uh in my mind, I was still picturing that surgical outcome, but I thought it was gonna look better than this. And I say, Well, then our next step is surgery, and so sometimes they're like, Okay, fine, I'll go do it. And that is what convinces them that they got the minimal correction from the braces or the alignment, and then they still weren't fully satisfied with their treatment. And then I just tell them, you know, this is an option we talked about from the start. We weren't very into that at the beginning, and then it's more encouraging for them to go meet with the surgeon at that point. But once again, it adds time to the treatment plan. I haven't seen that happen though, and I think I think that's it's just hard because even though you explain that to them and have that conversation, like you said, it's hard for them to visualize. Although I imagine that you can show them kind of simulations and whatnot, yeah, but it's of their just their done their occlusion, and they're not it's hard for them to imagine that in their smile. Yeah. And so they end up not being happy. But then usually when they come to me, they're s they're like, oh, it didn't work, and I'm like, I'm sure they explain that, but you know, you don't know. Yeah, it seems like we have to continue to reinforce uh these topics and ideas to the patient that, hey, remember, remember I told you this, like this is the compromise, we had recommended surgery. Because even though we definitely review these things with our patients at the consult, it's kind of like what we heard at the CE event that we had on Thursday. Uh, that whether it be anxiety or too much time passed by, but they do forget these like vital key pieces of information. Because I had so many patients in residency where they all were like, I don't get like my pain is worth like my did not have pain in my bite before. Like, why is it like this? I'm like, remember, your your teeth, we're we're setting the teeth up like almost like they're two different arches, because I'm the one that's gonna be putting them together. If you didn't want surgery, then your orthodontists would be trying to get your teeth to come together. But remember, you're you're gonna get surgery. So you when it's and they're just like, oh, oh yeah. Some of them are like, oh yeah. Yeah, some of them are like, I I this, yeah, this is new to me. And I'm like, um, I know it's not new to me. Yeah, isn't it in the chart? Because people say, Well, I didn't know that. And so we have to remind them. But I think it's also it it, I mean, if you reflect on how long we've been doing it and how much training we had to go through, it is very complex, complicated, nuanced information. And so I can imagine it is overwhelming. I mean, even when I I and I ha with the education that I've had, go see a different type of specialist just for my own health. It is, you know, there's a lot of nuances and things, and I can research as much as I can, but even there's a lot of information that I don't know or remember after I leave those appointments. So I can see how it's a little confusing. That kind of information, like we heard at that course, that it's very overwhelming, right? The the information that you get that you need jaw surgery, that you may have to take off time from work, that it is gonna impact your life in some way. Those are big things to digest as a patient. So, you know, sometimes they're hearing it for the first time, and that's a lot, and it's very uh anxiety provoking. And so then all of a sudden, the good information that you share after telling them that fact then kind of goes out the window. Yeah, goes in one ear, out the other. Um, and that's just the the challenge of of that initial meeting, right? And so for any for any type of procedure or treatment. But I I usually tell my patients, at least for orthocnathic surgery, the first time I meet them, I give them a lot of information. And then at the end, I tell them, I know it's a lot of information, don't worry. We're gonna have different multiple appointments over the course of your treatment, including one long pre-op appointment before, right before your surgery, where we go over everything in detail. I'll give you information to go home with that you can read over, and you kind of have to take it in steps and in in like take everything in little bites, and then you go home, do your own research, chat with your family, because you it like for especially if it's a teenager, let's say, chat with your family and then write down questions that you have and then bring them to me the next time you come. Also, you'll have multiple appointments with your orthodontists, so you can ask them questions as well, just so that by the time you get through the next, you know, year, a couple of, it's not like it's a long treatment process, so they'll have time to go through and hopefully by the time they have their surgery they're well informed and understand the risks fully. But it is a I I get that it's a lot for them to take on. It's a big ask too to be able to have everyone giving the same information and a bunch of different specialties, and then the patient understanding and interpreting it correctly. But yeah, that's kind of the the beauty in communicating like through different specialties, right? Just mean having that open line of communication with your oral surgeon. Yes. I didn't know like when I was going through my training and everything that I was gonna get to work alongside some of my closest friends, and it was like very easy to touch base on certain cases, and um, yeah, it it seemed like they're like they would have been much more out of reach to be able to have that line of communication with your surgeon or with your specialist. And so it You mean like in residency? Well, yeah, just coming out of school. It seemed like, oh, you know, like how am I gonna build these relationships with the the people in my community that are gonna be doing these services for my patients? But I didn't realize they're all gonna be my age and they're gonna be super fun to hang out with. And so yeah, it's kind of cool the just the how how it evolves as you get farther into your specialty. So that's true. So we've talked a lot about the orthognathic surgery patient, and and like we said, there's so much more that we could talk about, which hopefully we will get into in the future. We will. But but we will. But basically, what we've talked about is that it really just is incredibly important to have strong communication between the orthodontist and the oral and maxillofacial surgeon so that we can set these orthognathic surgery patients up for success because there's just so many different steps, and it is a little confusing for the patient because I think it's easy when let's say it's like, oh, I just I need my wisdom teeth out, I'm gonna see the oral surgeon, and then that's it. But this is something that I I have to explain to my patients. This is not just you're seeing your orthodontist because you're getting braces, and then you're seeing your surgeon so that they can move your jaws in a better position. No, this is we need the orthodontist so that we can set your upper and lower jaw up, level and align the teeth, and set you up for a good bite that we're gonna achieve during the surgery, but then afterward, you need to go back to your orthodontist. You're not done there. You need to go back to your orthodontist to fine-tune the bite for the micro aesthetics of the smile, give you the best smile. And so we're working, we're really working hand in hand. And sometimes I think they don't understand that initially. It's much more longitudinal than normal dental procedures, right? It's like you go in for a crown or for a single tooth extraction, it's all done in a very short amount of time. But for orthanathic cases, there's lots of preparing, there's maybe up to two years of braces that uh we have to kind of be touching based on different kinds of that um, I have a question. So, or uh if you could give us information so other oral surgeons can be successful, I know that uh the oral surgeons out there, they most of the oral surgeons out there don't do as much orthomathic surgery as you for them. What would be the standard pieces of communication between the orthodontists and what would you appreciate to ensure that the um lines of information are getting to each other? So is there a correspondence letter that you send to the oral surgeon first? And then after, do you send a standard letter and what is in that letter and how many visits do you expect from the oral surgeon? Like, is there anything standard that maybe uh oral surgeons and orthodontists out there can follow so that they can be successful with their communication? I think for the most part, the orthognathic surgeons that I know, it's pretty similar, but like we said, traditionally the orthodontist will refer to the oral surgeon, these patients that perhaps need surgery. And so usually I am getting a referral letter from the orthodontist with basically this is this is my exam, these are my findings, my recommendation is for a combined orthodontic and surgical approach. Sometimes the orthodontist will be more specific in terms of, oh, I think this patient needs double jaw surgery, like a LaFort 1, a BSSO. Um, sometimes it'll be more general, like I'm referring this patient for orthocnathic surgery. And then I will see the patient for consultation, and sometimes they'll send over photos, radiographs. Is that standard to have that or that you do you expect that to be centered? I expect it. Or do you take your own imaging and then you will send what you obtained to your orthodontist? I don't know if it's it's I'm because I've been hospital-based, it's a little different. Like the um position that I'm in is I don't have access to, let's say, a lateral ceph, or always a panorex, or always an intraoral scan. So sometimes I w will request those from the orthodontist if they have it, but I think a traditional um standard oral maxillofacial surgeon in private practice, they'll have their own cone beam CT and be able to take a like an Iteroscan and so and picture so they won't need those things from um, they'll take their own new records, which some of which I will. Um and I think I think that's pretty standard for private practice setting. And then after I see the patient for consultation, then I'll draft my own letter typically with my own findings and my tentative surgical plan. So for example, like Lafort 1, BSSO, possible geneoplasty or or even like. At that point too, do you give an estimate if you think it's gonna be a segmental for a student? Sometimes, yes. Sometimes it's a little bit tough to tell initially, but um yes, I'll say possible segmental if needed. Um, do you recommend any premolar extractions or not? Yeah, premolar extractions. Third molars if they need to come out or not. Yes. I think most oral surgeons will recommend third molar extraction beforehand. Yeah. You do it during the surgery. Yeah, I'm comfortable taking them out during the BSSO or during the orthognathic surgery if needed. But some of them are. That would be important for the orthodontists to know because they don't know what your techniques are. True. And some some orthodontists um I think prefer the wisdom teeth out to help move the teeth. Um, and so they want those extracted before, which that's fine. Um, as long as we because sometimes, like I said, sometimes they'll get referred to me in the middle of treatment, and they're if they're gonna be ready for and they need a BSSO in like six months, then I wouldn't want them to extract the wisdom teeth just to uh because there won't be enough time for healing. So I'll I'll basically go through all of that and put it in my letter addressing all of those different things and then send it back to the orthodontist. So usually I mean, I think everyone's different. I'll usually call the the orthodontist's office or try to find some way to communicate with them, whether that's an email, a direct phone number, and then send them the letter and or just open up that communication line of communication. And then the last thing I'll ask is what is your estimated time for surgery? When do you anticipate being done with the pre-surgical orthodontic movements? And then ask the orthodontist if there's any anything that they're concerned about or anything else that they want to talk about. Um, usually if it's if it's straightforward, like yeah, patient will be ready in a year and there's no need for extractions and they're just decompensating and leveling and lining, then for the most part, I won't really need to see the patient or communicate too much with the orthodontist until they're a few months away from being ready for surgery. And then most of the time they'll have the patient or s reach back out to me or reach back out to me directly a few months before to check progress and make sure that things are coming together. Take we can take progress models to see how things are setting up, and then from there decide what the timeline for surgery, which is pretty soon after that. Um and then usually I'll try to update the orthodontist during that perioperative time. For example, this this is the day of surgery, and then around that time there's communication about surgical hooks and certain things like the specific surgical wire and what the orthodontist prefers in terms of seeing the patient after surgery. Because I've had some orthodontists where they don't see the patient until maybe eight or ten weeks afterward. Whereas other orthodontists they want to see the patient a couple weeks after the surgery just to eyeball things and see if there's any broken brackets or loose wires, things like that, which I think either either is fine. But then I'll tr I'll just try to update them. Oh, surgery went well, maybe send pictures of the occlusion, um, and then update them through the six or eight weeks after surgery before they go back to the orthodontist. Is there anything else that you wish, oh, I wish my oral surgeon would update me on this, or besides what's in that letter, anything else that you're like, oh, it it we could be more successful if we did this better? Yeah, no, that's uh one reason why I enjoyed working with Dr. Kimmy on our cases because that I got so many updates on how they're doing, if they're ready, because um, in my experience with other providers and other oral surgeons, they're expecting me to tell them when we're ready. Like they're just waiting on the orthodontist to do their thing so that it's set up nicely for the case. And so I would tell other providers for that are orthodontists that it's really good to take regular uh either scans or alginate oppressions if we're still doing that, uh, just to get your own study models at different checkpoints throughout your orthodontic uh treatment plan. And then that's gonna help guide you to knowing how long it's gonna take and when they're ready for that surgical correction, because then shortly after that, they need to see you, and then we put on the surgical hooks and all of that. So, yes, the study models are very important, and then we've actually saved the patient some time maybe by doing the um the virtual uh meetings, like we did like that surgical simulation, and you confirmed with me that like this is what we're planning to do with the movements. What do you think? Like, how do you anticipate correcting this component because they have like missing teeth or they have you know smaller laterals, and we can't actually, you know, get them a full class one or whatever it might be. That's true. So having that pre-surgical meeting, I think, is very important in some capacity. And then I love knowing how it went and seeing um how uh if there were any complications or if they weren't able to do the amount of correction that they had planned, something like that. And then I'm sure you guys don't really probably get much of the before and after, like after you've uh kind of gotten them through the surgery component. Like how often do you actually see them once their braces are off and when they're all done? So I usually after I see them re after they've recovered and then I send them back to the orthodontists, I always tell them, let me know when the braces come off, come back, we'll do a final check. So I can I mean, not all of them do come back. I mean, I could probably hunt them down, but but um I I tell them we're we're I usually call it call it a final check. We'll do a final check, make sure everything is still healing well, and then take a look once the braces are off. Um, but more for you know, I like to see it too. It's part of it. Yeah, and that it is that is true. Some of them like they come in bet in the middle of braces. I'm always like, oh, I wish I had photos of when you first started this process. Um, but that is true. You bring up good a good point about the digital surgical planning session um where usually I won't have the orthodontist hop on unless they're they I always invite them to if they would like to, but it is kind of hard to coordinate times and and whatnot with schedules. But if they want to, or if there's something, something like you say, calm more a little bit more complicated about it. But if not, I'll always um try to send a photo of the case report or at least the occlusion setup to the orthodontist to confirm that that's that's gonna be okay for them to finish if we achieve that result surgically. Yeah. So yeah. But um anything else? I feel like we we hit a lot of good points. Yeah um, but at the same time, we didn't even get into a lot of details. Yes. It would be awesome in our next session to go through a full orthodnethic case for our listeners from start to finish so that they're more encouraged to take on those types of cases because we really can make a big impact on people's lives if we're all kind of more comfortable with those uh pathways, I guess. Definitely. Well, thank you so much for joining us today and having starting this discussion. But hopefully we'll have many more discussions to come. Many more. Thank you. Thank you guys.