Wagner Oral Surgeon & Dental Implant Specialists

THE REMOVAL OF HORIZONALLY IMPACTED MANDIBULAR THRID MOLARS

Difficult wisdom teeth are the regular practice for an oral and maxillofacial surgeon (OMS). We are expert in removing third molar teeth (wisdom teeth) and we know how to evaluate and treat all of  them – even when they are associated with difficult anatomy and/or pathology such as cysts and tumors. (J Oral Maxillofac Surg 79:748-755, 2021).

An experienced OMS knows the advanced techniques and has the diagnostic methods and instrumentation to perform these procedures with excellence. Please note that as much as we can handle the very difficult impactions – we are also the experts for removing the easy ones! And remember, we have the skills and facilities to provide your care with the added comfort of anesthesia. We will take great care of you!

New techniques and instrumentation are coming up all of the time. New ways of imaging also help with the surgical techniques. Even with all of these new materials and methods. Surgeries have risks and these have to be reviewed with your surgeon along with treatment alternatives and options. Horizonal impactions look nasty on the x-ray and frankly they do have a number of increased concerns compared to a tooth that might be just tipped a little bit or vertical in position. I keep repeating this in my blogs, but it is true that the earlier the tooth is removed typically the risks will be lower. If you have gotten past that and are now facing a difficult horizontal impaction, just make sure that your surgeon has the experience, skills, materials, and methods to handle the procedure.

 

 

 

DOES LEUKOCYTE AND PLATELET-RICH FIBRIN WORK?

There is a big difference between leukocyte and platelet-rich fibrin (LPRF) and platelets rich in growth factors (PRGF) in results and efficacy. LPRF came out as an alternative to PRGF because the technique for collecting and processing the material was easier and took less time. A recent article came out showing that LPRF was no more effective than blood clot in the healing of jawbone defects. (J Oral Maxillofac Surg 79:575-584, 2021).

I have been using PRGF for over 10 years. PRGF showed a quantum leap in the healing of jaw defects as a part of bone grafting techniques. There are surprisingly still relatively few surgeons taking advantage of this process. The main reasons are cost and time. If you want excellence – go with PRGF.

These other techniques such as PRF or LPRF result in a “mixing of cells” and lack the specific concentration of growth factors which gives us so much better results in our bone grafting and implant procedures. I am happy to answer questions regarding these techniques. Our goals are to provide the best care, in a cost effective way, without sacrificing results. We have a great track record with PRGF and I am proud of it. Do your research. Be aware that these processes have similar names and very often offices are advertising the use of these materials without using the proper techniques.

CAN DENTAL INFECTION SPREAD TO THE HEAD OR BRAIN?

The anatomy of the head and facial blood vessels allows for blood to flow in either direction as there are no valves in these vessels. This design helps to keep the brain alive in case of head/face trauma and/or head/face vessel blockage (such as a blood clot or a lesion). The point is, that the blood flow can reverse if needed to keep the brain nourished and oxygenated. It is a fabulous design! A concern is that this same system that can be a life-saver in the case of a blockage, can be a liability in the case of a severe facial infection such as an abscessed tooth (odontogenic infection). (J Oral Maxillofac Surg 79:389-397, 2021)

Infection along with swelling, inflammation, and possible vascular blockage – can result in germs traveling in the reverse direction from the face, mouth, or neck areas and ending up infecting the brain with possible intracranial infection and even death. We see case reports of this rarely, but it does occur.

The bottom line is that we should never take these infections lightly. Proper early open incision and drainage along with antibiotic therapy can be a life-saver. Do not be satisfied with “going on an antibiotic and seeing how it goes”. We are here for you!

DOES ORTHOGNATHIC SURGERY AFFECT BREATHING?

The technical question would be “does orthognathic surgery affect the upper airways?” There is a favorable effect of orthognathic surgery in the upper airways regardless of the surgical approach. Bimaxillary (upper and lower jaws together) advancement and counterclockwise rotation of the mandibular occlusal plane are the most significant contributors. (J Oral Maxillofac Surg 79:450-462, 2021). From the time that I (Dr. Wagner) trained in the 1980s, I have found that orthognathic surgery essentially always results in improved airways and breathing. Many times, this is a significant improvement. A big part of this is that the design of the procedures and workup toward surgery is logically oriented toward returning the individual to as normal an anatomy as possible. Putting “things” in correct place is usually in line with improved mechanics. In places where it is not, a skilled surgeon recognizes this in the treatment planning stages and modifies the procedures to give the best results.

I often talk about the “art of surgery” and this is certainly true of this type of treatment planning. The art of it is being able to see the result of it in your minds eye ahead of time. This is a big part of the “fun”, “joy” and satisfaction of providing life-changing care such as this.

There are also adjunctive procedures that can be done at the same time as orthognathic surgery such as improvement of nasal mechanics (turbinates, septoplasty, etc.) which we build into our procedures where possible – which contribute significantly to improved breathing as well.

IS SOFT TISSUE GRAFTING (ATTACHED MUCOSAL GRAFTING) NEEDED AROUND DENTAL IMPLANTS?

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.

CAN JAW SURGERY INCREASE THE RISK OF OBSTRUCTIVE SLEEP APNEA (OSA)?

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.

DOES RETAINING THIRD MOLARS RESULT IN THE DEVELOPMENT OF PATHOLOGY OVER TIME?

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)

ANXIETY DURING THIRD MOLAR EXTRACTION

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. An image of various 3D view angles generated CBCT scans.