Wagner Oral Surgeon & Dental Implant Specialists
IS SOFT TISSUE GRAFTING (ATTACHED MUCOSAL GRAFTING) NEEDED AROUND DENTAL IMPLANTS?
Yes. This is true of any site, but especially true in compromised sites such as patients who have undergone treatments including radiation therapy or major jaw reconstruction (J Oral Maxillofac Surg 79:560-574, 2021).
Around our healthy teeth there is a band of tissue that is adherent to the bone, typically lighter in color, and firm or thick. This is called attached mucosa. The roof of your mouth is covered in it. In several ways it is a very similar tissue to the palms of your hands. These tissues can form keratin (what a callus on your hand is made of) and these tissues typically respond to stimulation (such as toothbrushing) by becoming thicker and tougher. When these tissues are missing around your teeth (or around a dental implant) there will be inflammation and often over time bone loss occurs.
We are able to graft these tissues in when needed and this usually results in an improved environment around the tooth or dental implant. Again, this is particularly an issue if the area is less healthy to start with such as an immune suppressed patient or an area that has been reconstructed.
In our practice we will try to anticipate these needs ahead of time and incorporate those procedures into a treatment sequence that makes it easiest for you as a patient and also a sequence that tries to expedite care.
If you have a growth abnormality with your jaws such as a protrusive lower jaw, and you have breathing concerns, studies have shown that having the jaw surgery could increase your risk of obstructive sleep apnea (OSA). (J Oral Maxillofac Surg 78:2061-2069, 2020). This concern and this question would mainly bring up issues if we had a patient with a high BMI, but could be a concern for any patient if other breathing issues are not addressed in the evaluation.
Oral and Maxillofacial Surgeons are expert in evaluating these concerns and relationships. Often, it is self-evident, such as if a patient already has breathing issues or risk factors for breathing problems such as a short, wide neck and/or excess pharyngeal (throat) tissues. For my patients, I will recommend that excess tissues such as with excess tonsillar tissue or excess throat tissue be addressed with tonsillectomy and palatopharyngoplasty as part of the overall plan. We also tend to recommend a combined maxillomandibular surgery for these patients as correcting cant (or angle) and width along with nasal turbinectomies can significantly improve nasal and pharyngeal airways and breathing problems.
All of these factors, along with many others, are addressed in evaluation and workup for orthognathic surgery and would be considered in establishing a “best” surgical plan. The cited article did not suggest that these issues were treated preemptively for the studied patients. If you are concerned about these issues in your surgical planning, first make sure that you are getting your information from a properly trained source such as a board certified OMS and secondly, ask questions. These procedures have been time tested and when planned properly and performed by experts can have great results.
To me, this seems like a silly question because I have had over 35 years of experience treating patients of all ages with wisdom tooth problems and absolutely the types of problems, severity of problems, and the risks of treatment increase with age – and transversely are much less in the younger patient. I have found age 15 to be the ideal age for most patients. But I would rather treat a patient at any early age rather than an older age (earlier is better with few exceptions). One of the more common statements that I hear is that “I have had my impacted teeth for years and they have never caused my any problems.” In many cases this is analogous to saying, “I have this cavity in my tooth and it has not caused me a problem yet, why should I treat it?” Well eventually, these things are likely to cause problems and the problems they cause will end up being greater than they would be with proper care and treatment. This is especially an issue with lower wisdom teeth which often put the “feeling nerve” in the lower jaw at risk.
The bottom line is – it is better to get your wisdom teeth evaluated and treated if they are at risk at any early age. Have this evaluation done by an oral surgeon who can properly assess the risks. We are the experts.
(J Oral Maxillofac Surg 78: 1892-1908, 2020)
In our practice, removal of third molar teeth (wisdom teeth) is most commonly performed under IV anesthesia. This is appropriate and I feel necessary for this treatment to be a positive experience for most patients. With intravenous anesthesia you are completely relaxed, you have no anxieties and your jaw muscles are relaxed – it makes it easy!
As we prepare you for treatment, we often have a consultation appointment where examination takes place, the treatment is discussed, x-rays are reviewed, as well as the risks and alternatives. There was a question in a recent journal article questioning the effect that presurgical information has on anxiety experience during wisdom tooth extractions. (J Oral Maxillofac Surg 77:1769.e1-1769.e7, 2019). In the consultation process, we are also building a relationship between ourselves and the patient. Our goals are to educate and inform, but also to reassure and create an environment that shows love and concern. Our wish is to reduce stress and anxiety and our techniques are generally successful.
It is my feeling that the sensitivity and delivery of the information are key to reducing and helping with the anxiety. Absolutely, use of intravenous anesthesia takes care of all fear and anxiety during the procedure and leads to best outcomes with little memory of the procedure.
DO POSTOPERATIVE ANTIBIOTICS DECREASE THE FREQUENCY OF INFLAMMATORY COMPLICATIONS FOLLOWING THRID MOLAR REMOVAL
I was pleased to see this article in the JOMS looking at post-op antibiotic use for third molar treatment on a meaningful group of patients. (J Oral Maxillofac Surg 76:700-708, 2018) There is a big push by national and world medical authorities to try to get clinicians to prescribe less or no antibiotics for routine procedures such as the removal of third molars/wisdom teeth. The problem is that the mouth is a naturally dirty place and the gingival pockets of the teeth are particularly dirty (they contain many and varied microorganisms/germs). When we make an incision in these areas it contaminates the wound/surgical site.
Now technically, our bodies have multiple natural defenses and natural immunity which, in most cases, effectively fight off these infections and in the majority of patients you would not have a problem with infective complications. What is at issue is that even though the incidence of problems such as infection would be low with no antibiotics – there is a cost, inconvenience, and possible sequale such as pain, and need for additional treatment such as surgical drainage – which makes the antibiotic usage a reasonable “risk” after such treatment. Frankly, my patient population are generally intolerant of complications and expect me to do everything reasonably possible to give them the best, least complicated, experience.
Because of this, I use postoperative antibiotic treatment for most of my procedures. The last point would be “how much is enough?”. I have found that a minimal dose of 4 days of penicillin 500 mg qid is effective. We will often use a one week course of Amoxicillin 875 mg bid in cases where we feel the risk may be greater. Appropriate substitutes are used for allergies and of course more broad spectrum antibiotics are considered when there is a more serious infection suspected or diagnosed.
DOES THE CONE BEAM SCAN (CONE BEAM COMPUTED TOMOGRAPHY) CHANGE THE TREATMENT DECISION TO REMOVE IMPACTED THIRD MOLAR TEETH?
The main reasons why I recommend a cone beam scan (CBCT) for third molar extractions is when there is significant risk to the nerve in the lower jaw (inferior alveolar nerve) or when there are significant lesions (typically cysts or tumors) associated with the jaw and/or teeth. For me, the cone beam scan has never affected my decision as to whether or not to remove the tooth. (J Oral Maxillofac Surg 78: 1061-1066, 2020). Rather, it has acted as an aid – again to assess the position, anatomy, and risks.
The noted article comes from Hungary. Europeans have often embraced the idea of coronectomy for treatment of third molar teeth. I strongly disagree with this technique as being an appropriate alternative to careful removal. I have yet to see the case that would change my mind.
As it relates to that thought process though, I can see how the view from a panoramic x-ray may cause a great deal of fear and the CBCT can completely relieve that fear by showing the tooth and risks in 3D and helping to guide the surgery and reduce those risks. For me, having the CBCT reduces the risks by empowering me with the information of actual anatomy – such as whether the nerve is on one side or the other of the tooth root, separated or intimate with the root, free of the tooth or surrounded by the tooth. Again, in our hands we rarely have problems with the nerves because of thorough diagnosis, x-ray examination, and a careful surgical technique.
First off, as I have blogged before, get wisdom teeth out at an early age – about 15 years old – and you avoid 99% of the problems that tend to occur including the problems talked about in this article. But assuming that you are older and still have your wisdom teeth, as a rule, the earlier you have them out the better.
I am addressing an article that proposes grafting of bone defects on the back of second molar teeth associated with impacted third molar teeth. (Compendium February 2020, Volume 41, Number 2, Pgs. 76-82).
For most patients, it is best to perform as non-traumatic an extraction as possible, allow for natural healing, and then address periodontal defects as a secondary surgery. Typically, the problems necessitating removal of the third molars – such as infection and/or inflammation – adversely affect the outcomes of any grafting procedures that may be done. As a rule, we have good healing after our third molar removal procedures. We use careful techniques, we debride, clean and irrigate the surgical site, and suture the tissues for best outcomes. This results in nice healing contours and good periodontal health for most patients. If there is existing disease such as infection or periodontal bone loss, we address those types of concerns at the time of surgery as we can. If there are healing problems such as a bone defect, we would address that once we have a clear, healed site with good tissue coverage. The main exception for me is when we are dealing with a large lesion defect in which case bone grafting is often considered.
First off, I will advise you before you start reading that this is an opinion piece and I am just giving you my experience, although in our practice we have extensive experience in the use of both titanium and ceramic implants. The “reintroduction” of ceramic implants in our practice is what brought on this blog post.
Ceramic implants were developed to meet increasing patient desire to achieve natural-looking esthetics. The “new” ceramic implants are milled from zirconia (atz). We use the NobelPearl Implant. It is a 100% metal free white ceramic implant that gives a natural soft tissue appearance upon placement because of its color. There is a study from 2014 that shows that the soft tissue around zirconia implants presents a better color match to the soft tissue of natural teeth when compared with titanium which may give a darker color to the tissue, especially if there is bone loss or tissue recession over time. Zirconia implants are especially beneficial to patients with a thin gingival biotype or thinness to the gums around the teeth. In fact, the tissues around the zirconia implants have been shown to be comparable to those around natural teeth in esthetics. These implants are designed for a low inflammatory response. Zirconia has also demonstrated a low plaque affinity as well.
We have been placing dental implants for over 30 years. In our practice we have used ceramic coated implants in the past, but with the use of zirconia, because of its strength, we are now able to use an implant completely made out of ceramic rather than the previously used ceramic fused to metal. For the sake of discussion, the previous technology worked well and we have hundreds of these implants placed that are still functioning well. We feel the new technology is even better, again with a metal-free alternative when making your implant choices.
The advantages of the all-ceramic implant are that it has a homogenous color, the studies have shown that the gum response around these implants is favorable, the tendency is to have a better height of the gum point between the teeth (interdental papilla), and a reduced inflammation in the gingival sulcus or the gums around the implant crown. Each of these points are based on studies and in our practice we have not had these implants in use for a long enough period of time to make this as a long term judgement. The plain truth is that patients are now seeking treatment with metal-free restoration options. It is my personal opinion that there is no problem with titanium and the use of titanium metal implants and in our practice we have never seen a problem with a patient having an adverse reaction to the material. However, with the superior esthetics that are offered with this new implant, and if it meets the patients’ desires for a nonmetal restoration, we are happy to provide this as an alternative.
One of the unique features of the NobelPearl Implant is that it has an innovative retention screw for the restoration which is made out of a carbon fiber reinforced polymer which gives a strong ceramic to ceramic connection. The ceramic material absorbs compressive forces and the screw withstands tensile forces due to the way they have designed the carbon fiber reinforced polymer.
These implants can be used for a broad range of applications including single tooth restorations and multiple unit restorations. It can also be used in guided surgery applications. We are excited to be offering these as an implant alternative in our practice and we continue to look forward to progress and advancements for the benefit of our implant patients.
The above posting is based off of the article Metal-Free Implant Solutions for Optimal Integration and Esthetics: NobelPearl Implants, Author: Nader K. Salib, DDS© Nobel Biocare USA, LLC.
As an oral and maxillofacial surgeon and one who is experienced and expert in the treatment of and removal of third molar teeth, I read with great interest the article titled “Management of Third Molars” in the Dental Academy of CE.com’s magazine. I will first reference you to our article on the subject which is based off of the white paper from the AAOMS on the subject along with our practice experience.
The Dental Academy article goes through a number of areas of assessment as to the “necessity” of removal of third molar teeth. It is my strong opinion, if our goal is to have a healthy mouth, that third molar teeth should be removed at an early age (I suggest age 15 as an ideal age in many cases) or at as early an age as possible. The exception to this is if there is a healthy arch length to support the eruption of the teeth – this is rare – and this can be assessed at an early age.
The article references early age as being better for most all parameters, but the article incorrectly uses the clinical picture rather than the risks of treatment as the driving thought in the decision. I see this many times in general dental practice and I feel that it leads to much worse problems for patients who may put off treatment.
Having decades of experience in this, I can tell you without hesitation, that it is best to have third molar teeth evaluated and removed if needed at an early age. Age 15 is felt to be ideal and younger is generally better no matter your age. We would be happy to assess the position, condition of your wisdom teeth, and need for removal. We will give you an honest, competent opinion.
I apologize up front if you are drawn to this blog to seek a solution to a crooked face. We do perform orthognathic surgery in our practice which can address this; however this blog is directed at an article comparing observers-variations in how facial asymmetry is seen. (J Oral Maxillofac Surg 73:1606-1614, 2015). Our training and the training of various cosmetic facial surgeons tends to heighten our awareness of facial abnormalities, imperfections, and asymmetries. For this reason, oral and maxillofacial surgeons and other facial surgeons have the highest observation awareness of these variations when this is studied. To me it might be that I notice and wonder if my treatment of this patient would enhance their life. Most of us are aware of the various asymmetries, abnormalities, and “quirks” in our appearances because we ultimately unwittingly examine our own faces each day in the mirror.
Not surprisingly, women are more perceptive than men to others’ facial abnormalities and asymmetries. I am fairly certain that this is cultural in that women are much more in tune with cosmetics and cosmetic related issues.
The fact remains that beauty is skin deep. I am always heartened when I meet individuals who have “abnormal” facial appearances as a result of trauma, disease, or defect and also have a “glowing,” positive, happy personality. I will take the positive attitude to good looks any day.