Wagner Oral Surgeon & Dental Implant Specialists

MULTIPLE TRAUMA PATIENTS WITH FACIAL FRACTURES

With the use of seatbelt restraints, airbags, and protective equipment such as helmets, we have seen a significant reduction in the number of multiple trauma incidents and facial fractures associated with traumatic brain injury. High speed automobile accidents and multiple trauma incidents such as plane or train crashes often bring in much more complicated cases, especially to our regional trauma centers. (J Oral Maxillofac Surg 65:1693-1699, 2007).

Very often we are considering care with multiple specialties, usually directed by an intensivist or general surgery team. Even with injuries that seem to be confined to the face it is a collaboration with general medical, anesthesia, and surgeon that leads to the best decision process for care.

For the most part, facial injuries can be initially stabilized and definitive treatment can be delayed, even for several weeks to allow for proper stabilization of general medical, cardiopulmonary, and neurological problems as they are prioritized. We can perform excellent repairs and treatments in a proper, sequential manner, in the best interests of a patient’s overall health needs. In many cases the best treatment is methodical and not rushed. Even though it looks grim at the time, I have seen many wonderful and successful outcomes with cooperative, collaborative care.

COMPLETE IMPLANT SUPPORTED TEETH AND JAW SURGERY TECHNIQUES

Complete implant supported teeth (All-On-Four, Teeth In A Day, Immediate Teeth, Implant Prosthetics, etc.) is wonderful treatment that we are able to provide with a high degree of success when it is done correctly. I do have concerns that every dental clinic is offering some variation of this and it is not “easy” treatment to do well. The less bone you have, the poorer the support – the greater the chances of developing problems over time. The best care is to have good bone support for your implants as a starting point.

A proper work up should be driven by the dental needs. We call this “prosthetic driven implant care”. That is; planning the initial treatment with the end in mind. This may sound intuitive, but it is not the “rule” for much of the implant care provided. There are wonderful technologies available to improve the aging jaw. The best options often take time and may take some more complex techniques, but the results can be excellent and long term.

In most cases it is straightforward and we can take advantage of the bone that is present and place implants to support teeth. Bone grafting techniques and orthognathic surgery are techniques that we are experienced in and appropriate recommendations are given where this care is needed.

 

Reference: J Oral Maxillofac Surg 65:1764-1771, 2007

DINS – DYNAMIC IMAGE NAVIGATION SYSTEM TO ASSIST IN COMPLEX MANDIBULAR THIRD MOLAR REMOVAL

To an experienced OMS the idea of complexity of surgery for any problem is a relative thought. All surgery is at the same time complex and, if prepared, trained and experienced – all is straightforward. The way we approach any surgical procedure involves planning and carrying out the plan while being prepared to deal with variables and possibilities along the way (J Oral Maxillofac Surg 75:1591-1600, 2017). The term “complex third molar extraction” usually describes a situation or case that falls outside of what we are used to as normal. We enter into any surgical case prepared to face unknowns, but you can never guarantee that all variables can be covered so we prepare with the best methods possible.

The cone beam scanner has been a quantum leap for us in evaluation and preparation for third molar extractions. This is particularly true with the cases where we see greater risks or concerns for adjacent vital structures such as the neurovascular bundle in the lower jaw.

I feel that you should get the scan for any case where the risks are accelerated by unusual positioning or development of the third molar teeth. We offer it to our patients and get the study if they agree. Planning with or without the scan takes into account the risks and concerns, and with careful planning we have a very high success rate with very few complications.

PREGNANCY AND THIRD MOLAR PROBLEMS

Many women will give a history of developing problems with their teeth and gums during pregnancy. There are certain types of problems that we see that have been studied such as progression of gum disease during pregnancy, but these are not consistent nor universal. There does appear to be a certain genetic predisposition to this but clearly, hormonal changes cause tissue fragility leading to increased risks of viral concerns (such as aphthous sores) and general periodontal inflammation (such as sore, red gums and bacterial infections). This is even noted during menses for certain individuals.

The article that I am reviewing (J Oral Maxillofac Surg 65:1739-1745, 2007) showed that there were increased periodontal problems around wisdom teeth during pregnancy. There are a combination of factors here. Wisdom teeth by themselves, especially if there is a continuity defect at the site (an opening or gap along the gum line on the adjacent tooth to the third molar area) often have an inflammatory reaction taking place. This is a normal way that teeth erupt into the mouth if there is space. The sack around the impacted tooth undergoes a reaction with increased fluid production (expansion of the sack) and then an opening of the sack to the oral cavity allowing the tooth to come through. When there is not enough space as is often the case with third molars, this exists as just an opening or tract into which germs and debris can enter into the site and cause related problems.

Pregnancy appears to enhance this process. It is likely a combination of factors (general health, nutrition, hormonal affects, stress, fragility of the tissues, as well as dental concerns) which lead to the increase in gum problems around these sites.

For me it goes back to basic dental care for wisdom teeth. Get them out at an early age before all of these problems can occur. By the way, I can treat the pregnant patient. It is safer the later in the term of pregnancy and we work with your obstetrician for the best and safest care.

 

SPREAD OF ORAL CANCER

Many of the cells in our bodies contain packets of substances that they release when given a chemical command. A good example is the release of histamines from cells in response to chemical mediators in an allergic reaction. The histamines are released from the affected cells to the surrounding tissues and into the blood stream where they themselves act as mediators or activators of other processes seen in the allergic-type reaction such as red skin, watery eyes, swelling, etc. Many cells in our bodies can be induced to produce other chemicals and hold them in “packages” in the cell where they may be released in specific circumstances when the genetic machinery of the cells (DNA) are induced or stimulated to do so.

This is a process which not only occurs in regular life processes but also occurs in many types of cancer. This is part of what makes some cancers more aggressive. Put simply, cancer can be due to a malfunctioning of the tissue cells causing them to reproduce abnormally. Along with this the cells may be able to produce “packages” of chemicals such as enzymes which tend to dissolve tissue and tissue barriers, allowing the spread of the cancer from one tissue space to another. When the spread goes into the lymphatic system or blood vessel system it more easily passes to other areas of the body. If those new areas are susceptible the cancer can start growing there (metastasis).

As researchers discover and learn more and more about these processes we get closer to finding ways to treat, counter, and even cure diseases such as cancer. Research is the key. We regularly support research activities through our organizations and other donations. Small things, like supporting a cancer run or donating to someone’s care, help to keep the fight going.

 

Reference: J Oral Maxillofac Surg 65:1725-1733, 2007.

TREATMENT OF ATYPICAL MIDFACIAL PAIN WITH A MAXILLARY SINUS LIFT PROCEDURE

I have found that atypical facial pain in the upper jaw is often related to a bone defect in the sinus wall which has healed with tissue ingrowth. This typically occurs as the result of dental trauma or a surgical defect after tooth extraction or orthognathic surgery, as examples. (J Oral Maxillofac Surg 72:2453.e1-2453.e5, 2014). Patients will have point tenderness to pressure or touch and in some cases overt pain. Organic pain can usually be differentiated from neurologic pain (brain origin-or central origin) by use of diagnostic local anesthetic blocks. Pain caused by local organic factors will typically be relieved for a short time by the local anesthetic blocking.

Historically, I have found satisfactory treatment with local bone grafting or connective tissue grafts after debridement of the areas. Guided bone regeneration (use of membranes) has also been helpful. With the advent of bone grafting techniques with alloplastic grafts such as human bone product plus LPRF/PRGF has seen good success in healing such defects and relieving these types of pain problems. Again, these would not be effective techniques to use for a condition such as trigeminal neuralgia.

SHOULD WE GET CONE BEAM SCAN (CBS) IMAGES PRIOR TO THRID MOLAR REMOVAL?

Every once in awhile I read an article in a responsible medical or dental journal that just floors me in its stupidity. The article I reference here is one of these (JADA 148(8) 575-583). This article is nothing more than an analysis of other articles written on the subject which draws a completely stupid conclusion that “clinicians should not perform CT routinely before M3M surgery because using CT images does not seem to reduce incidence or affect the patient’s prognosis of IAN injuries in comparison with using PR images.”

First, panoramic imaging (PR images) has been and still is the standard of care for evaluation of impacted third molar teeth. Second, when we recommend the cone beam scan (CT) it is to evaluate someone who may be at a greater risk for complications such as nerve injury and the reason for that study is to better visualize impacted tooth position and the relative positioning of the adjacent vital structures. This is done in order to better prepare for the procedure and therefore reduce risks. Any experienced surgeon can tell you the surgical planning and risk reduction benefits of having better imaging. I have no question that having the pre-surgical information of the exact relationship of the impacted tooth roots to the relative vital structures such as the nerve reduces the risks to the patient of having resultant injuries to these structures.

I would trust your surgeon on this one. If they are suggesting that you get a cone beam scan prior to your third molar extractions do it. It is a minor study without a lot of radiation or cost and it can possibly be the difference between having a complication like a long term nerve injury or not.

IS ORAL HEALTH THE KEY TO OVERALL HEALTH?

Here is another article which seems to suggest that tooth loss predisposes one to the development of disease – rather than the opposite. Wow! Another crazy article in what should be our nation’s premiere dental journal – the JADA. This guest editorial suggests that maintaining good oral health is the key to reducing overall health problems (JADA 148(7) July 2017:477-480).

There is no question that maintaining good oral health, oral care, and oral hygiene are good for you, and an important part of your overall health care. But to suggest that getting it all correct with your mouth is going to reduce your rheumatoid arthritis or diabetes is very convoluted. The idea that patients with autoimmune disease such as rheumatoid arthritis tend to have poor oral care is more likely a reverse relationship. The autoimmune condition more likely predisposes one to having infective problems such as periodontitis or tooth decay. Similarly with the diabetic patient, a reduced immune status will contribute to dental disease. Because of this it is especially important for individuals with these concerns to get regular dental care.

We also must look at the social and environmental issues that may face individuals who are more prone to these conditions, especially nutrition deficiencies or balanced nutrition problems such as obesity and their contribution to a reduced immune status/connective tissue disease-conditions. Social issues such as access to care or proper home care would also be significant contributing factors. Although oral/dental disease can lead to systemic medical concerns; I feel the poor oral health issue is more commonly a symptom of other health/social factors rather than being the cause of them.

Dental Implants: Aftercare

Dental-Implants-Aftercare
Are you considering dental implants but are worried about the recovery time?
Don’t worry, we’re here to give you the facts!

The recovery time following dental implant surgery tends to vary but is usually based on the amount of teeth being implanted, whether or not a bone graft was needed and how well the individual manages his or her recovery. The science and technology behind dental implants have improved drastically over the last few years, improving post-surgery pain and comfort for patients.

Recovery Time
Typically, you will have the fastest recovery time if you had a standard, single dental implant placed with no bone grafting. With a simple procedure like this one, there is very little discomfort or pain after the surgery. Mild bruising and soreness can occur, but this can typically be managed with over the counter pain relievers. In more severe implant cases, such as those where multiple teeth are implanted or severe bone grafts are needed in order to accomplish the implant, the recovery time tends to be longer and the discomfort can be more intense.

Post-Op
It is important to keep your mouth clean after surgery, which can be done by rinsing your mouth gently with saltwater beginning the day after surgery. You may begin brushing your teeth the night after the surgery, but make sure to be extremely gentle around the surgery area as to not disrupt the healing process. Remember that in the week following your surgery, there should be no smoking and no sucking through a straw, as this can seriously inhibit your healing process. Stick to a diet primarily consisting of soft foods for the first 7-10 days following your surgery before beginning to return to your normal diet.

As you can see, the recovery process after receiving a dental implant is fairly predictable and comfortable. It is important to follow the instructions that we give you, and always remember that if you have any questions or concerns regarding a procedure or following your surgery, you can always give us a call.

WHY DO WOMEN SUFFER FROM TMJ PROBLEMS MORE THAN MEN?  

The quick answer is that women, on average, have smaller anatomy than men and their smaller anatomy does not handle the stresses on the joint system placed by other variations in anatomy and physiology as well as it does for men. (2019 American Association of Oral and Maxillofacial Surgeons 0278-2391/19/30453-7)  The most common main cause of TMD (temporomandibular dysfunction – a term used to group a wide variety of primarily muscular disorders of the jaw apparatus) is an imbalance in the way the jaws guide past each other in various movements such as side to side and front to back. This is primarily affected by abnormal tooth positons. The most typical of these is a jaw growth variation where the molar teeth are providing the guidance in the side to side jaw movements – what we call “balancing guidance.” The typical patient has a “reverse curve” to their bite. These problems can usually be addressed by orthodontic treatment alone, or in conjunction with jaw surgery (orthognathic surgery).

The truth is there are so many variables that come together from the joint anatomy, to the joint and capsule anatomy, to the jaw and facial anatomy, to the tissue receptors, to the chemistry of the joint structures, to psychological influences, to etc., etc. It is almost amazing that our jaw joints, in fact our bodies, function normally at all. Fortunately, our bodies have considerable ability to accommodate and compensate for abnormalities, injury, and disease processes.

When we consider internal joint diseases such as arthritis and autoimmune conditions we enter into another very wide realm of conditions and disorders that may have a significant effect on joint pain and joint problems. All of these things need to be fleshed out as we analyze joint conditions. On a very basic level my approach is to first make sure that the medical concerns are being dealt with and then deal with the physical problems addressing the obvious “big” problems first and keeping our eyes open to the other significant variables as we move forward.

If you have jaw joint problems discuss them with your dentist. Seek out consultations with a board certified orthodontist and oral surgeon. Get as much information as you can and watch out for “TMJ specialists.” Many of them do a good job, but there are way too many who are providing unnecessary therapies and treatment regimens without the likely chance of a solution.