When we perform bone regenerative procedures such as grafting of extraction sockets or osteotomies to build up the bone for treatments such as dental implants, we use various materials to aid in guiding the body to grow more bone. The use of synthetic barrier grafts and PRGF are relatively painless methods that have resulted in quantum leaps in our ability to grow new bone to enhance treatments such as dental implants, bone grafting, and orthognathic surgery.

An Exciting Research Area

This area of research is very exciting and in many ways it is still at its infancy. As we learn to genetically engineer tissues, we will see even more growth.

The referenced article shows the use of marrow stromal cell sheets to “grow” periosteum (the tissue layer right on the surface of bone that helps guide and stimulate bone development). Again, we are already using synthetic barrier grafts to help guide bone regeneration. And we are using natural tissue derivatives such as BMP (bone morphogenetic protein) and PRGF (platelets rich in growth factors, plasma rich in growth factors) to enhance bone development. The developments of new and better natural materials for these procedures give us promise for even better outcomes in the future.

If you are interested in dental implants and have been told that your bone is “not good enough” make sure to look into these options. In most cases, we are able to treat these concerns with easy office based out-patient procedures.

Call (262) 634-4646  to schedule a consultation for dental implants.

Ref: J Oral Maxillofac Surg 72:1078-1083, 2014

As an oral and maxillofacial surgeon, I am often asked by referring doctors what the protocol is for dealing with patients who are taking bisphosphonates and related medications. These drugs are associated with what has been termed medically-related osteonecrosis of the jaw (MRONJ), previously referred to as bisphosphonate osteonecrosis (BRONJ).

Define the Problem

Bisphosphonates, as a category of drug, started in wide use for bone density problems such as osteoporosis in the mid 1990s. The intravenous forms started being used along with other cancer chemotherapeutic agents and became more widely used in the early 2000s. I saw my first case of BRONJ at the beginning of 2003 and I assumed at that time that it was just some type of a bone disorder caused by trauma. Dr. Robert Marx wrote a letter to the editor in our journal that I happened to read at about the same time that I saw additional cases coming into my office. He and other researchers defined the problem. We saw many more cases between 2003 and 2008 as there was some resistance to recognizing the cause and effect. It was also found that the dosage amount, frequency, and duration had a significant effect on the development of the disorder. As the prescribing doctors realized the relationship, they started titrating the dosage better and this has resulted in a significant decrease in the number and severity of cases that we see. Some of the new intravenous forms for osteoporosis appear to again present a greater concern.

At this writing, the drugs implicated in the pathogenesis of MRONJ include bisphosphonate drugs both oral (such as Fosamax, Boniva, and Actonel) and intravenous forms (such as Zometa, Aredia, and Reclast), monoclonal antibodies Demosumab and Bevacizumab; and the multikinase inhibitor Sunitinib. These drugs are being commonly used in medicine, orthopedic and oncology for the treatment of osteoporosis, osteopenia, Paget disease, multiple myeloma and other metastatic malignancies. They have proven effective in preventing or at least minimizing fractures of the musculoskeletal system as well as controlling bone pain. This provides a better quality of life for these patients; however patients do require routine dental care and possibly emergency oral surgical treatment while taking these medications.

CTX Blood Test

CTX (c-terminal telopeptide) is a blood test that measures one of the breakdown products of type I collagen, which occurs during bone resorption. Thus, the serum levels of CTX can be used as an indicator of bone breakdown/resorption. I do not feel that this blood test is necessarily a reliable predictor for the development of osteonecrosis, but it certainly can provide a guide both to assess the risk of developing osteonecrosis, but more importantly can be a guide to physicians for adjusting dosage of the drug that they are giving. A serum level less than 100 pg/mL represent a high risk of ONJ; 100-150

Having gone through a residency training program which was strong in trauma, orthognathic, tempromandibular joint, dentoalveolar, and implant surgery I came into practice well versed and confident with these treatments. Over the years, we have progressed with the technologies. Adult orthodontics has become more and more popular which has brought some of these patients in for jaw reconstructive surgery/orthognathic surgery to correct growth problems such as jaws that are too long or short or narrow. Most of these surgeries are performed for functional reasons, although there are some that have cosmetic motives.

In my hands, I have found that patients of all ages tolerate the procedures well. As you might expect, the younger patient’s lives are simpler and it is less of an intrusion.

Patient Coaching

No matter what your age, I coach my patients to make sure they really understand the ins and outs to make a proper surgical decision. Our techniques, materials, and methods such as use of absorbable fixation have resulted in improved outcomes and a better overall experience for even older patients.

Ref: J Oral Maxillofac Surg 72:1995-2004, 2014

I was recently introduced to two tissue analysis methods that are on the cutting edge and give us a glimpse of the future of oral and maxillofacial surgery and medicine.

Optical Coherence Tomography

OCT uses an optical signal to process three-dimensional images that can be taken from biological tissues. The light is from the infrared region of the electromagnetic spectrum, and this long wavelength helps to non-invasively produce images of tissue morphology. It is currently used in ophthalmology to assess the retina and progression of glaucoma and in cardiology to assess plaque development in coronary arteries. Its applicability in OMS could be even more versatile than what is seen in other medical specialties.

Current OCT technology allows for penetration of approximately 1 to 2 mm, which is appropriate for analyzing superficial lesions which might occur on the tissues in the mouth. The present screening technology that we have involves using stains and light refraction to just analyze tissue thickening. Images from the OCT system have been shown to effectively diagnose and identify indicators for oral cancer and pre-cancer such as dysfunction of the epithelial layer. This does not eliminate the need for a biopsy, but it appears to be a more effective screening method.

Raman Spectroscopy

Raman spectroscopy is a noninvasive technique that uses vibrational energy to assess scattered light from biological molecules and ions. The wavelength of the difference between the incoming and reflected lights corresponds to the molecular vibrations and leads to characteristic patterns of specific bonds. This can be important in identifying bonds not only in hard tissue, but also in soft tissue. Although many forms of spectroscopy exist, Raman spectroscopy has the advantage of its applications to fresh tissue and a better resolution, providing information regarding molecular structure and osseous structure, including protein structure and mineral crystallinity.

Again, although these methods can provide vital information, they do not describe the detailed molecular and metabolic activities of bone. This method might be extended to evaluate osseous pathologies, because molecular changes occur before the morphologic alterations in hard tissue abnormalities. Thus, Raman spectroscopy might identify bone diseases before the pathology reaches devastating proportions.

I know I have said it before, but I feel very fortunate to be practicing in the present time. New diagnostic and treatment methods during my career such as improved scans/cone beam scans, materials such as titanium dental implants, and improved anesthetic drugs and techniques make it easy and exciting for me to get up and come to my clinic in the morning. I love what I do!

Ref: J Oral Maxillofac Surg 72:1876-1879, 2014

During the late 80s and during the 90s we were introduced to various ceramic coated dental implants. I embraced this technology because it made sense. We placed many of these and many of you have been functioning on them for years. In fact, I have been placing dental implants for over 30 years and failure of these implants, as with all implants, has been rare. As technological advances progressed, it was discovered that a roughened surface on titanium improved the bond-interface between the implant and the bone. At that time, I switched over to the all titanium implant-because it made sense. And it did!

The Return of an Old Standby

Over the years, we rarely see failures and with the titanium surface, different from the ceramic implants, we have actually found that the maintenance of the bone height and tissue interface remains more stable on the roughened surface implants. Based on the history I do not believe that the ceramic implants do this as well. We are now seeing a return of the ceramic coated implants and I welcome this renew ed application of an “older” technology.

Solid Implants Despite Imperfections

Recently, I had to remove two implants from a patient’s lower jaw. These had been placed by another surgeon and the angulation was poor. It was encouraging to find how completely solid and bonded in the bone they were, even with bone loss and inflammation. And there were original machined surface implants which were the first type of implants that we used in the 1980s. The importance of this is that even though these implants were placed poorly, they were very solid and stable in the bone. I see dental implants as a permanent, very strong, and biologically very compatible replacement for teeth as well as an effective attachment for devices such as dentures and facial prostheses.

Ref: J Oral Maxillofac Surg 72:1928-1936, 2014-10-16

Dr. Anna Marie Williams came to the University of Wisconsin – Parkside right at the point where they were transitioning from their local campus to the new campus where it exists today, on their beautiful grounds in Kenosha County. Dr. Williams worked tirelessly to pursue excellence from the students and faculty in developing an exceptional Pre-Med Program, which, under the careful hands of her successors, continues even today with Dr. Brian Lewis guiding the program. I had the good fortune of meeting up with her almost immediately upon entering the university as I had declared the pre-med track as my plan.

A Relentless Pursuit of Excellence

As with so many other students thorough the years, she took the initiative to seek me out and provided intense guidance from day one. She was no-nonsense. She never minced words. She was tireless in her efforts to push us toward excellence and ultimately toward our goals. To say that she was dedicated is such an understatement. There was rarely a time day or night that you would not find her at the university and she would always encourage us and behind the scenes be advocating for us. To have her as a guidance counselor in this process was absolutely valuable and I feel that I can say without a doubt hat she is one of the people along side of my parents and my wife without whom I would have never made it through.

Trail of Legacy

Once I was finished with professional school and residency, we came back to this area and I had the pleasure of working with her on a number of different projects including her scholarship fund and the DOC’s program. Over the years I would speak to her regularly and she always wanted updates on my family and my practice life. She continued to be deeply involved in many activities including the Anna Marie Williams Nature Trail at the University of Wisconsin – Parkside. In fact, her obituary mentions her endowed scholarship as a place for donations. When I met with her shortly before her death, the nature trail was something that was strong on her mind. Her desire to keep that going and developing was a wish that she had. The trail is still a developing project and if you are a lover of nature, this would be a great legacy to support.

It has been a distinct honor and privilege to know Anna Marie. I have always held her in high regard and respect as a mentor, teacher, and adviser. I also considered her my friend. I will truly miss her.

Dr. Richard M. Wagner

I have seen and treated many cases of drug-induced osteonecrosis of the jaw or DIONJ. This was formerly called bisphosphonate related osteonecrosis of the jaws (BRONJ) but now other drugs have been shown to cause it as well. In this disorder there is bone exposure, bone death, and pain. It typically occurs in the areas of the jaws where there are teeth. It may not occur until after a dental procedure such as tooth extraction or oral surgery.

Difficult Surgical Challenges to Overcome

A recent study in the Journal of Oral and Maxillofacial Surgery (J Oral maxillofac Surg 70:2501-2507, 2012), looked at a review of cases where surgical treatment was used. These are difficult surgical challenges. My criterion for treatment is related to clinical signs and symptoms.

Drug Removal Is Not an Option Sometiems

In many cases, removal of the drug is not an option as the patient often needs the drug as part of their chemotherapy for proper bone maintenance. Surgical debridement of the dead bone and antibiotic therapy remains the best treatment option in many cases.

Call (262) 634-4646  to schedule a consultation if you are experiencing jaw breakdown due to medicine.

I have seen and treated many cases of drug-induced osteonecrosis of the jaw or DIONJ. This was formerly called bisphosphonate related osteonecrosis of the jaws (BRONJ) but now other drugs have been shown to cause it as well. In this disorder there is bone exposure, bone death, and pain. It typically occurs in the areas of the jaws where there are teeth. It may not occur until after a dental procedure such as tooth extraction or oral surgery.

Difficult Surgical Challenges to Overcome

A recent study in the Journal of Oral and Maxillofacial Surgery (J Oral maxillofac Surg 70:2501-2507, 2012), looked at a review of cases where surgical treatment was used. These are difficult surgical challenges. My criterion for treatment is related to clinical signs and symptoms.

Drug Removal Is Not an Option Sometiems

In many cases, removal of the drug is not an option as the patient often needs the drug as part of their chemotherapy for proper bone maintenance. Surgical debridement of the dead bone and antibiotic therapy remains the best treatment option in many cases.

Call (262) 634-4646  to schedule a consultation if you are experiencing jaw breakdown due to medicine.

So many people and agencies use the term “oral surgeon” or “dental surgeon” to label oral and maxillofacial surgeons. I have resisted the reference when I can, but I admit that it is hard to say, “Maxillofacial” [/makˌsilōˈfāSHəl/]. If you know how to say it, it rolls off the tongue nicely but most people certainly at first attempt have a hard time so they fall back on “oral surgeon.”

The Mouth Is at the Heart of Training

Historically, an oral surgeon was a dentist who removed teeth and performed gum surgery. The specialty of oral and maxillofacial surgery came out of the key need for a facial surgeon to understand and coordinate care with the oral and dental structures. Our doctorates are in dentistry, which is a medically trained doctoral program with the mouth and oral structure care at the heart of the clinical training.

Post-Doctoral Training

Oral and maxillofacial surgery is the most extensive post-doctoral training specialty coming off of dentistry. Many oral and maxillofacial surgeons will also complete the two years of medical clinicals and then also carry their MD degree.

If you look at my personal profile, I completed 13 years of higher education prior to starting my practice. Of course, I regularly attend continuing education programs and classes to update and upgrade my education.

Call (262) 634-4646 to schedule an appointmet with a skilled maxillofacial surgeon.

In a way, we have “earned” the title of oral and maxillofacial surgeon, but I am happy for you call me an oral surgeon if you like.

Oral Infections Should Not Be Ignored

Patients with significant oral, dental, or facial infections typically present to their dentist early on in the process. They get antibiotics, and are treated or referred to an oral and maxillofacial surgeon for care, which may include drainage of the infection and sometimes definitive care such as removal of an associated abscessed tooth. This staging of care is appropriate and cost effective. In my years of practice I have never seen a case that we treated that required hospitalization. Conversely, we do see quite a few patients who report to the hospital emergency room after allowing an oral or facial infection to become advanced.

Family History of Negligence

They typically have a history of having been on an antibiotic off and on several times and not following through with care. They are typically admitted and then we care for them at the hospital facility. The most common scenario I see is when it is perceived by the patient that the hospital will “treat them for free” or that “insurance will cover it better” at the hospital. Neither idea is true and the fact of the matter is, that the cost for this care is not just in dollars.

Severe Infection Can Be Prevented

Very often when infections get more serious, they can spread and cause damage to adjacent tissues. We do even see cases where people die because of the spread of the infection to the brain or to the chest.

When an oral problem spreads to become a facial infection, appropriate surgical drainage and treatment should be provided to avoid more serious problems and conditions.

If you suspect oral infection, call (262) 634-4646 to schedule an appointment.

J Oral Maxillofac Surg 71:656-658, 2013