Down Fracture- A Podcast for Talkin' Jaws

In this episode, Dr. Bobek and Dr. Wasson talk about the mandibular osteotomies that most surgeons rarely perform.

They cover where the inverted L and the vertical ramus osteotomy still have a place, how total joint replacement absorbed many of the indications that used to belong to the L, and whether the sagittal split gets reached for by default more often than it should.

Topics covered in this episode:

- Why a surgeon can finish residency without seeing an inverted L or an IVRO

- How joint replacement outcomes changed the case for the L, including what the longer-term data shows

- The indications that remain: ramus morphology, lengthening, and the multiply operated patient

- Aesthetics at the angle, and where an implant beats an osteotomy

- Where the inverted L workflow breaks down, from condyle seating to pre-drilled holes

- Why the L does not reliably avoid numbness, despite what patients are often told

- Non-unions, grafting choices, and why hardware removal is its own problem

- Whether the IVRO should be offered more often for mandibular setbacks

- Late non-unions that stay hidden behind strong fixation

- The subcondylar osteotomy for a healed fracture with a persistent malocclusion

📬 Questions or topic suggestions: [email protected]

The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.

#DownFracturePodcast #TalkingJaws #JawSurgery #OMFS #OralSurgery #OrthognathicSurgery #BSSO #IVRO #RamusOsteotomy #TMJReplacement #SurgicalTechnique #MaxillofacialTrauma #VirtualSurgicalPlanning #MedEd #residentlife

In this episode, Dr. Bobek and Dr. Wasson talk about the decision not to operate. They start from the AAOMS indications paper updated in 2025, which both find useful as a reference point and limited in practice, and spend most of the episode on the judgment it does not cover: readiness, timing, support, and the patients whose expectations will not be met by a technically successful result.

Topics covered in this episode:

- Why a list of indications does not invert into a list of contraindications

- Three kinds of patients at the first visit, and which one is hardest

- The patient who agrees with everything, and why that is a warning sign

- Clicking as a primary motivation, in orthognathic and TMJ cases

- The third molar analogy, and how the threshold changes with age

- Social reasons to wait: insurance, family circumstances, school, a new business

- BMI thresholds and age limits, and how much they actually hold up

- How to tell someone they are not ready, and why being direct often helps

📬 Questions or topic suggestions: [email protected]

The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.

In this episode, Dr. Bobek and Dr. Wasson are joined by Dr. Zubad Newaz, an orthodontist whose airway-focused practice runs across offices in New York, Vermont, and Florida, with a large share of patients treated at a distance. He completed a radiology residency before orthodontics, and has built the practice around a centralized diagnostic role so he can follow each case closely through treatment rather than splitting his time between offices.

The conversation covers how remote coordination actually functions between an orthodontist and a surgeon, where skeletal expansion fits relative to jaw surgery, and how both sides of that referral relationship see the same patient differently.

Topics covered in this episode:

- Running one treatment plan across four locations, and why a local orthodontist doing the orthodontics often works best

- Aligners, fixed appliances, and which long distance patients need a provider on the ground

- Monitoring expansion remotely with local CBCT and intraoral scans, and where the touch points fall

- Why airway-aware orthodontic practice has moved close to mainstream in the last few years

- Dr. Wasson revisiting his assumption about patients who expand with one provider and finish with another

- The three groups now offering expansion, and who is best positioned to oversee it

- Using space from expansion as currency for later segmental osteotomies

- The asymmetries that show up with expansion, including yaw from uneven pterygomaxillary release and septal base drag

- Why diagnosing what is still tethered during expansion is harder than it looks

- Device choice between FME and custom MARPE, and why the field is trending toward smaller expansions than in 2022

- Mandibular midline distraction, bone loss around the lower centrals, and mitigating it with SFOT

- Expanding the mandible during surgery instead of staging a separate distraction

- A tiered way of framing options for patients: teeth only, skeletal expansion, then jaw surgery

- How often expansion patients go on to need jaw surgery, and how often a case could be made for it

- What counts as a small, moderate, and large expansion when measured as skeletal yield rather than device activation

- Why skeletal relapse is lower than expected once expansion is held through re-ossification

- Whether to expand before MMA when a patient will have both, and why surgeons who only do single piece surgery shape that answer

- A rhinomanometry finding on where nasal airflow actually comes from, and what it might mean for mid-face expansion

📬 Questions or topic suggestions: [email protected]

The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.

In this episode, Dr. Bobek and Dr. Wasson talk about what a surgeon owes a patient during a consultation. They cover the position you are put in when a patient arrives with a treatment plan you disagree with, how to say so without undermining the referring provider, and what patients can reasonably expect from an hour in a surgeon's office.

Topics covered in this episode:

- Why a consultation becomes a tightrope when the patient was referred for something you would not recommend

- Lower stakes in dentoalveolar practice: second molar implants, third molar referrals, grafting materials

- Taking the role of the bad guy so the referring provider keeps the relationship

- Why picking up the phone usually reveals a miscommunication rather than a disagreement

- How fast patients now relay your opinion back to the referring office, often before you can call

- Patients arriving with a specific request and expecting it executed, and what that asks of trust

- The cost of expansion before MMA, and the obligation to say plainly what it buys

- Asking a patient directly what their actual motivation for treatment is, and why they sometimes cannot articulate it

- Cases where bite, airway, and aesthetics align, and cases where correcting one works against another

- How much information is the right amount in a consult- Giving a contrasting opinion when the patient has already been told otherwise online

- Why disagreeing with a plan is the service being asked for- Judgment calls versus errors, and why a bad outcome from sound reasoning is not a mistake

- Research presented at the national meeting on pre-operative expectations predicting dissatisfaction

- Whether calling yourself a specialist in a condition carries an obligation to stay current on treatments you do not perform

- Conversion rates and billable chair time, and why both hosts refuse to track them

- Red flags from the patient side: absolutes, assembly line consults, and minutes with the actual surgeon

📬 Questions or topic suggestions: [email protected]

The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.

In this episode, Dr. Bobek and Dr. Wasson are joined by Dr. Shahid Aziz, an academic oral and maxillofacial surgeon in New Jersey. Dr. Aziz spent twenty years on full-time faculty at Rutgers and now leads the development of an oral surgery department and training program at Hackensack Meridian Health. He trained at Harvard and at Columbia under Dr. Steven Roser, performs over 200 orthognathic cases a year, and founded Smile Bangladesh in 2005, a nonprofit that has now run 34 cleft and orthognathic surgical missions to Bangladesh.

The conversation covers how the organization was built and funded, what it takes to make room for that work inside a surgical career, and what mission surgery has taught him about how he practices at home.

Topics covered in this episode:

- How Smile Bangladesh started, from family connections and a first mission of five people in January 2006

- What each mission costs, how it gets funded, and who keeps it running between trips

- The OMS Foundation scholarship that helps residents cover travel for global surgery

- Solving the logistics: in-country instrument storage, what still has to be carried in, and industry support for plates, screws, and virtual planning

- Why visas, not willingness, are the barrier to bringing Bangladeshi surgeons to train in the States

- Negotiating four to five weeks of global surgery into an employment contract rather than spending vacation on it- Choosing global surgery over becoming a board examiner, and how he thinks about that tradeoff now

- Going back to non-custom technique abroad: positional screws for a double jaw, bending plates, and wire

- Why he still has splints made and takes vertical measurements even on custom plate cases

- Residents who have never seen a freehand genioplasty or done model surgery

- Managing post-operative follow-up through local surgeons he has trained, with video calls and messaging

- Inside his orthognathic fellowship, and where the fellows have gone

- Why fewer residents choose orthognathic surgery, and how debt and reimbursement drive that

- Patients arriving with specific millimeter requests from social media, and airway complaints with negative sleep studies

- Reviewing every virtual surgical plan with the patient before signing off, and what he does when the trust is not there

- How the measure of a successful case shifted from function and recovery to the measurements themselves

- Getting hospital privileges and staying involved in maxillofacial trauma

- Family first, and the one thing he says he would do differently

📬 Questions or topic suggestions: [email protected]

The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.

In this episode, Dr. Bobek and Dr. Wasson are joined by Dr. Suzie Bergman, DDS, FTMJF, a general dentist in Vancouver, Washington, Adjunct Associate Professor at Pacific Northwest University School of Dental Medicine, Fellow of the TMJ Foundation, and Visiting Research Scholar in Neurological Surgery at OHSU. Dr. Bergman is also a TMD patient: a jaw injury at 19 led to two open joint procedures and, eventually, bilateral custom total joint replacement. She joins the podcast the week after speaking at the TMD IMPACT meeting, an initiative of the NIDCR and the TMJ Association.

This podcast is produced for oral and maxillofacial surgeons, orthodontists, and other clinicians. The hosts discuss clinical reasoning that depends on training and experience, applied to specific scenarios, and nothing here is a treatment recommendation. The discussion assumes a clinical background and is not a substitute for an individual evaluation with your own surgeon.

Topics covered in this episode:

- Dr. Bergman's own history: 35 years from injury to bilateral joint replacement, and what she would do differently

- Who should be the quarterback for TMD care, and why primary care and ENT do not want the job

- Whether general dentists are the practical answer or the wrong pathway entirely

- Dr. Wasson's proposed model: surgeon, physician assistant, and physical therapist, and why Dr. Bergman calls it an oversimplification

- Splints: an average of four to five per patient, and what the evidence supports

- Why the TMJ is the only joint not managed by orthopedics, and how dental billing shapes care

- Orofacial pain: 14 programs nationally and a geographic desert in the middle of the country

- Arthrocentesis for acute closed lock and the cost of delaying referral

- Physical therapy with TMD-trained PTs, and the harm from untrained ones

- The "money joint," profitable dogma, and whether colleagues are too polite to say so

- Total joint replacement outcomes today vs the proplast era, and what most dentists still believe

- TMJ Connect and Dr. Bergman's map of surgeons, orofacial pain specialists, and physical therapists

Find Dr. Bergman on Instagram at @drsuzberg.

📬 Questions or topic suggestions: [email protected]

*The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.*

In this episode, Dr. Bobek and Dr. Wasson take on a question both of them hear regularly in consultation: whether patients should undergo maxillary expansion (MARPE, MSE, DOME, EASE) before maxillomandibular advancement for obstructive sleep apnea. They cover who they think expansion is for, what is and is not established about nasal airway change compared with segmental Le Fort, and the cost, time, and surgical trade-offs of doing both. Dr. Wasson also shares a six-week post-operative MMAW case with intermolar and nasal base width measurements.

This podcast is produced for oral and maxillofacial surgeons, orthodontists, and other clinicians. The hosts discuss clinical reasoning that depends on training and experience, applied to specific scenarios, and nothing here is a treatment recommendation. The discussion assumes a clinical background and is not a substitute for an individual evaluation with your own surgeon.

Topics covered in this episode:

- Who is a clear expansion patient, who is a clear MMA patient, and why the middle group is hard

- Cost and time: roughly $10,000 to $30,000 and a year or more before jaw surgery

- Whether MARPE widens the nasal airway more than a segmental Le Fort

- Widening the nasal aperture by tilting segments in a three-piece Le Fort

- How prior expansion changes the Le Fort: scar tissue, blood supply, and resistance to advancement

- When expansion first makes sense: the anxious patient and the tongue-space complaint

- Whether expansion followed by MMA is any better than MMA alone

- Whether surgeons are going along with expansion to keep patients and referrals happy

📬 Questions or topic suggestions: [email protected]

*The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.

In this episode, Dr. Bobek and Dr. Wasson talk about how surgeons evaluate themselves when an outcome is not what they planned. They cover where critical appraisal stops being useful and starts being punishment, why both of them are harder on themselves than on other surgeons, and how surgical training builds the habit in the first place.

Topics covered in this episode:

- Whether you are harder on yourself or on the surgeons whose revisions you inherit

- The duality of doing the work well and accepting that it could be better

- Why complications are difficult to discuss openly, with colleagues and with patients

- Evaluating a case where the occlusion, airway, and midlines are all correct but numbness persists on one side

- Dr. Wasson's rule: do not beat yourself up unless you can name something to do differently next time

- MMA at roughly 86 percent surgical success, and what the other 14 percent means for the surgeon

- The distinction between a failed outcome and a failed surgeon

- A case that checks every box, full sensory recovery and good occlusion and aesthetics, with an AHI of 7 down from 40

- How the healthcare system defaults to assigning blame to an individual

- Going from panoramic films and cephalograms to cone beam imaging, and how more visibility invites more self-criticism

- How rarely attendings comment on a good outcome, and what that trains into residents

- Doing the wrong thing and getting the right answer, and the reverse

- Where the real complications get discussed, and the role shame plays in keeping them quiet

- The opposite failure mode: rose-colored glasses, and the surgeon who has never had a non-union

- Wisdom from retired surgeons, including why SARPE asymmetry may not be worth agonizing over

In this episode, Dr. Bobek and Dr. Wasson are joined by Dr. Gary Bouloux, chair of oral and maxillofacial surgery at Emory University. Dr. Bouloux chaired the AAOMS special committee that produced the 2024 TMJ management guidelines, and he represented the specialty at the FDA and National Academies meetings on temporomandibular disorders that preceded them. He performs roughly 300 arthroscopies a year and is currently on the committee revising those guidelines.

The discussion covers where the treatment algorithm has moved, why the guidelines skew toward total joint replacement after failed minimally invasive surgery, and the manufacturing bottleneck that has left Australia and New Zealand without a viable custom device.

Topics covered in this episode:

- The FDA meeting with patient advocacy groups and why it was a difficult starting point

- How the National Academies report and its recommendations led to the AAOMS guidelines

- What is being updated in the current revision, and what has not changed

- Biologics: why steroids underperform, and the case for hyaluronic acid combined with injectable PRF

- The practical side of making IPRF in an office, and the reimbursement problem

- Why the guidelines move from arthrocentesis or arthroscopy toward total joint rather than open arthroplasty

- New data suggesting a single prior arthroplasty is the covariable most associated with worse total joint outcomes

- Arthroscopy at roughly 70 percent success, and what to do with the 30 percent who fail

- The pediatric exception, and how weak the disc plication literature actually is

- Where the term IPD came from and why disc position moved out of the center of the diagnosis

- Unilateral versus bilateral surgery, and whether the contralateral joint should be replaced at the same time

- Coronoidectomy, fat grafts, and heterotopic bone in joint replacement

- Two manufacturers, a 23-week turnaround, and what happened to the Australian market

- Whether KLS Martin and 3D printed devices can bring real competition

- How many joints a year it takes to stay competent, and what the orthopedic literature says

📬 Questions or topic suggestions: [email protected]

The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.

#DownFracturePodcast #TalkingJaws #JawSurgery #OMFS #OralSurgery #TMJ #TMJSurgery #TMJReplacement #Arthroscopy #Arthrocentesis #TMD #OrofacialPain #MaxillofacialSurgery #PRF #TotalJointReplacement

In this episode, Dr. Bobek and Dr. Wasson discuss infection in orthognathic surgery, including how to define it, how often it actually occurs, and how they each approach antibiotic use around the time of surgery.

Topics covered in this episode:

- How to define surgical site infection in orthognathic surgery and why the criteria matter for tracking outcomes

- Reported infection rates in the literature and what clean contaminated surgery benchmarks look like

- The debate around post-operative antibiotic prescribing: who uses them, who does not, and why- How the mandible differs from the maxilla in terms of surgical site infection frequency

- When drainage after surgery signals infection vs normal healing

- Hardware as a driver of persistent infection and the role of plate and screw fixation vs positional screws

- When to remove hardware and how timing affects recovery- True osteomyelitis after jaw surgery: how rare it actually is, how to diagnose it, and how it differs from non-union

- Why non-union is more likely than osteomyelitis in the setting of a persistent post-op problem

- Antibiotic selection, dosing schedules, and compliance considerations

- How patient expectations and clinical reality both shape antibiotic prescribing decisions in practice

📬 Questions or topic suggestions: [email protected]

The Down Fracture Podcast is for informational and entertainment purposes only and does not constitute medical advice. All opinions expressed are solely those of the hosts and their guests.