Wagner Oral Surgeon & Dental Implant Specialists

Smoking and Dry Sockets

As practicing Oral and Maxillofacial surgeons, we have known for years that a contributing factor for the development of alveolar osteitis-AO (colloquially called “dry socket”) is hormonal changes, such as the menstrual cycle. Since smoking has significantly reduced in my patient population, I have seen a significant reduction in the development of AO. The effect of proper oxygenation to the tissues is critical to proper healing. Nicotine is a vasoconstrictor (blood vessel constrictor) and can cause a decreased blood flow to the oral tissues. Carbon monoxide, a prominent component of cigarette smoke, is a potent oxygen depleter having 20 times the affinity to hemoglobin (part of your blood that carries oxygen) than oxygen-essentially depleting oxygen from the blood and tissues. So do not smoke!

Menstruation and Dry Sockets

During menstruation, the hormonal changes cause a fragility in the uterine lining allowing for these tissues to slough. Other lining tissues of the body may also be affected at the same time. Healing sites, such as extraction sockets, can show this during the menstrual cycle leading to the loss of the normal healing tissues. This results in the classic “open socket” with attendant discomfort and slow healing. The fact is, that we see this in very few patients and it is not clearly understood why it occurs in certain patients and not others. Obviously, there are other factors that contribute. I would not recommend putting off having wisdom teeth out just because of menstruation, but I would be aware of the risk especially if you have a history of tissue fragility such as oral sores during menstruation.

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For a consultation, call Wagner Oral Surgery and Dental Implant Specialists at (262) 634-4646 today! Our professional, experienced oral surgeon will take excellent care of you.

J Oral Maxillofac Surg 71:1484-1489, 2013

Introduction to Bone Grafting:

When I first came into oral and maxillofacial surgery, we were involved in a great amount of experimentation with many materials for bone grafting. Bone transfer grafts involved the use of ribs, hip bone, tibia and particulate bone grafts. We grafted blocks of ceramic (hydroxylapatite-solid and porous). We tried to get the body to induce bone healing, but only had marginal success. The problem was that our bodies are very good at absorbing bone that they feel does not belong. Also many of the areas we tried to build up have muscle pull and bite pressures that tell the body to absorb the bone.

Infection, contamination (foreign bodies), irritants (chemicals like alcohol, peroxide, menthol, etc), extremes in temperature, and mechanical displacement (to name a few) can also cause the body to reject a graft. We have been generally able to overcome these concerns with proper care and medications.

Past History of Bone Grafting:

Years ago, our initial attempts at bone grafting were largely failures. The area where the most progress was made with these bone grafting trials was in major reconstructions after accidents or cancer. The early researchers in bone grafting, were successful in transferring larger bone grafts using bone cribs (natural bones hollowed out to carry bone graft) and also vascularized grafts (major bone grafts transferred along with tissue and blood vessels to rebuild a jaw). These bone grafting surgeries are fabulous and needed, but are not practical for our day-to-day needs as it relates to the teeth and dental implants.

Synthetics in Bone Grafting:

Bone grafting took a big step with the introduction of synthetics (such as glass ionomers). These materials along with ceramics helped in providing some bridging and we were able to treat quite a few defects with these, but they were not adequate to build bone up. Generally we are able to use them in areas where there is some existing bone to widen or expand, but they do not work well to add bone thickness or adding bone onto a surface of a site.

 Your Own Bone:

We have always used native (your own) bone for bone grafting material. Early on we would take bone from the hip or long bones. There were two main problems: the donor site surgery was extensive, and also the native bone is absorbed easily. The body can recognize it and absorb it. We do still use grafts like this in major reconstructions, but it is not practical or necessary for our day-to-day procedures.

 Bone Grafting Products:

Human bone products started being introduced in the mid 1990s, but they were hard to get a hold of and these were prohibitively expensive. For us in oral surgery, the use of animal bone product (typically bovine and porcine bone) was introduced and again, expensive at first. The price did come down and it became our mainstay for grafting starting in about 2000. It was helpful with small defects, but it was only marginally helpful in larger grafts such as widening the dental ridge for implants. I used this a lot and some of you have had exceptional grafts with this and I have been successful with building up ridges and placing implants in this material and I say this in humble amazement. I was able to perform the bone grafting procedures, but it is quite a miracle of nature and frankly good genetics in some individuals who accepted this material enough to be successful.

BMP:

Over a number of years, the human bone product came down in price. It was certainly accepted by the body, but we found that by itself it would tend to absorb. It was still not ideal. BMP (bone morphogenetic protein) is a growth factor or “bone induction factor” our bodies produce which helps to stimulate the body to produce bone. This substance was isolated and we started using it in bone grafts in the 1990s. It was quite expensive when it first came out, but again, as the cost came down, we could use it in our practices. This was a big step in “turning bone on” to produce more bone. Mixed with human bone product, we saw enhanced bone healing. This worked well and again, I have treated a number of you out there with this material and have received successful grafts with this over the past 15 years or so. It was a step better, but still not ideal, especially in that it caused a large tissue response with swelling. It is also still quite expensive.

PRP:

In the meantime, individuals were experimenting with the use of PRP (platelet rich plasma) which was used in surgical sites along with grafts. This technology made a lot of sense and research seemed to support its use in bone grafting procedures, but we really did not see significant improvement. Some centers really believed in it. I did not find it to give any improved results.

More recently, it was found that blood can be further fractionated (separated) into its parts through centrifugation and pipetting. These are relatively easy techniques that can be done in our office setting and without great cost.

 PRGF:

This was the advent of PRGF and this takes us up to our present technology. I have been using the PRGF technology since 2010 and I have used it on hundreds of grafting procedures. We typically use the PRGF along with human bone product as a mixture with great success. I call it a “supercharged bone graft.”

The interesting fact is that it actually works best with the human bone product (cataveric bone) rather than your own bone. When your own bone is used, your body recognizes it as your own and immediately starts to absorb it. The donated bone product is recognized by your body as “normal bone” and so you will grow bone around it. Ultimately, your body absorbs it and lays down your own bone, but it is more difficult for your body to absorb it. It actually takes months to completely absorb and during that extra time, it gives your body the chance to stabilize and mature the bone. It also gives us time to place dental and facial implants or other functional loads on the bone which stimulate it to stay and strengthen.

This is still not a perfect material in that we are still not able to easily graft large areas (areas bigger than your finger). However, that level of bone grafting is enough to be able to build up the ridges for dental implant placement or facial reconstructive surgery (orthognathic surgery).

Functional Load:

“Functional load” is a term that is used to describe a functional pressure that is placed on bone that tells it to be maintained. A tooth is an excellent example of a “functional load.” When a healthy tooth is in the jaw bone, it stimulates the bone to be present and strong in order to support the tooth – a functional load. A dental implant, once it is in place and accepted, performs the same stimulation on bone. So when we graft bone to the jaw, after a period of time without a load on it, the body will tend to absorb that bone. There are many factors that contribute, including genetic, functional and environmental.

Key Ingredients to Successful Bone Grafting:

Oxygen is one of the primary or key ingredients to the healing of any type of bone graft. In order to get bone to “take” or heal, your body has to recognize it as “acceptable” (not rejected) and then it needs to initially grow blood vessels into the graft from the surrounding bone and soft tissues. This actually takes place starting almost immediately, but can be accelerated or “induced” by properly preparing the site and with the use of natural graft enhancers such as PRGF.

Next to oxygen, there are “growth factors” which stimulate our bodies to lay down new bone and to grow blood vessels into the graft to nourish it. These growth factors are naturally present in our tissues and given off in areas of injury or where healing is going on, such as a surgical site. But we have discovered that these factors can be isolated and concentrated from our blood. What makes this even crazier is that the very part of the blood that is highest in these factors when the blood is centrifuged also contains the very cells (platelets) which produce the “stem cells” (multipotent fibroblasts) which have the ability to form into any type of tissue that they are “induced” to become. In our case, by mixing them with bone graft and placing them in a bone environment, separating them from the other tissues (barrier graft) – we are able to induce them to become bone development cells (osteoblasts) which will ultimately lay down mature bone in an area where the bone had been missing or deficient. Fantastic!

Maybe that is a little complicated, but suffice it to say: the ease of use of PRGF and human bone product has been a quantum leap for the reconstruction for the dental ridge in order to replace or secure the teeth. We can even use this technology along with block grafts (sections of bone that are taken from your own jaw structure) and build up or widen larger areas.

Soft Tissue Bone Grafting:

Soft tissue bone grafting is another separate subject, but worth mentioning here. When we rebuild up deficient areas of the jaw such as for dental implant treatment, we usually need to improve the tissue bed. Tissue along the dental ridge and along the teeth and implants needs to be thick, strong tissue. We call this tissue “attached gum tissue” and it is the tissue which naturally occurs around the necks of your teeth. It has the characteristic of producing and containing keratin which makes it tough (much the same way the keratin in the skin on the palm of your hand forms a callus). The tissue naturally occurs on the roof of the mouth (palate) and we are able to take tissue from the palate and transplant it to other areas to make them more healthy, such as bone grafted areas of the dental ridge. There are synthetic tissue graft materials which can help in this. The PRGF technology can also be used to enhance this kind of tissue grafting as well.

Success!

I am very excited about where our office is at with these procedures. We have stayed at the forefront of bone grafting technology and I continue my education on a regular basis. I look forward to new and even better technologies that will help my patients achieve a high quality of life. These are easy office procedures. If you would like to know how this bone grafting technology can help you, just call (262) 634-4646 and come in for a consult.

When tissues are starved for oxygen (ischemia) there is increased pain. When tissues don’t receive oxygen, they die. Angiogenesis is a term that describes the formation of blood vessels. We use the term a lot when talking about healing after bone grafting. When we place a graft, such as a bone graft or a soft tissue graft into a living environment, such as the jaw, almost immediately the body begins to start to grow new, tiny, vascular channels (blood channels). As these extend into the graft, they provide the starting point for the development of blood vessels (angiogenesis). It is this process that gives life to the graft. The use of bone grafting enhancers, such as BMP and PRGF induce and promote this process. That is why we have increased success with grafting when we use these additives. It is the oxygen-carrying capacity of blood and the flow of oxygen and nutrients to the new forming tissues that is the key to success with bone grafting.

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Irritants and chemicals, such as nicotine and carbon monoxide, can block this process and so we try to eliminate these types of irritants when grafting. On a very basic level, it is all about getting oxygen to newly forming tissues to help them live and grow. (Ref: J Oral Maxillofac Surg 71:2048-2057, 2013)

If you are ready to talk to our team about our innovative bone grafting techniques, call our Racine, WI, office at (262) 634-4646.

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We have been using PRGF as an adjunct to bone grafting for about three years. This has been a great leap in the success of bone grafting during oral surgery. Bisphosphonates and related drugs are used in the treatment of post menopausal osteoporosis and some related bone diseases. They are also used intravenously as part of treatment for certain types of cancers.

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When we perform oral surgery, including extractions on patients who are on these drugs, we see a certain percentage complicated with slow or poor healing which can include a type of bone breakdown that we call DRONJ (drug related osteonecrosis of the jaw). A recent study (J Oral Maxillofac Surg 71:994-999, 2013) showed significant healing improvement when PRGF was used in extraction sockets on patients who are on these drug regimens. There are many variables that can lead to poor healing, but adding PRGF to the treatment protocol for these patients is relatively easy and inexpensive. The inconvenience and the expense of treatment in cases where we have poor healing or bone break down can be significant. 

If you are ready to talk to our team about our expert oral surgery services firsthand, call our Racine, WI, office at (262) 634-4646.

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We use PRP (platelet rich plasma) as an oral surgery tool. It works as a graft extender and as an architecture for bone and tissue healing. (J Maxoillofac Surg 70:2191-2197, 2012) We started using this technology years ago, and it was certainly helpful in surgical sites. The article shows improved blood vessel in growth with its use after oral surgery.

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We now use PRGF (platelets rich in growth factors) to enhance surgical sites and bone grafts. The literature has lagged a little in the reporting the results with PRGF, but from a surgeon’s hands-on experience PRGF has been a quantum leap in improved healing and “take” of bone grafts. I have no question that our use of this material on our grafts has improved not only the quantity and quality of our graft results, but has significantly decreased the time it takes to get bone healing.

We process the blood right in our office (using centrifugation and fractionation). In this process we isolate the PRGF. PRP is also a byproduct of this process (fractions 1 and 2). In many cases, such as a simple bone graft we just use the PRGF. In larger grafts, I will still use the PRP either to act as a coating over the graft or in the donor site when we are using a host bone graft.

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I expect that in the future these growth factors will be synthesized and we will not have to separate them from the blood (such as with BMP). For the types of grafting that we do it is still an efficient and cost effective way of providing this care. The best part is that we have excellent results and we are now able to rebuild structure and place dental implants in places that were previously impossible or at least much more difficult.

If you are ready to learn more our quality oral surgery services firsthand, call our Racine, WI, office at (262) 634-4646.

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Do you play football, basketball, soccer, tennis or volleyball? Do you like to ride your bike or skateboard? Maybe you do gymnastics or play in a softball league.

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Regardless of what sports you participate in, there’s always risk of injury. Safety gear like a properly fitted mouth guard can help prevent broken teeth and injuries to the lips, tongue, face or jaw.

Mouth guards can be purchased at almost any sporting goods store, but a custom-fitted mouth guard from your general dentist offers superior fit and protection because it closely adapts to your teeth. It will stay in place and makes it easy for you to talk and breathe.

Prevent Dental Injury this Spring

As an oral surgeon, I know that dental injuries are among the most common sports-related injuries. Victims whose teeth are knocked out and don’t have them properly preserved or replanted may eventually pay thousands of dollars per tooth, spend hours in the oral surgeon’s chair and possibly develop other dental problems such as periodontal disease.

The American Dental Association estimates mouth guards prevent approximately 200,000 injuries each year in high school and collegiate football alone.  Dr. Wagner recommends that everyone involved in athletic activities use a mouth guard to protect their teeth.

Taken from: The American Dental Association

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For a consultation, call Wagner Oral Surgery and Dental Implant Specialists at (262) 634-4646 today! Our professional, experienced oral surgeon will take excellent care of you.

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We have been using the PRGF (plasma rich in growth factors) technology for about three years. This has been a quantum leap in bone grafting. I just read an article which showed that use with implant placement improved stability significantly at 12 weeks (J Oral Maxillofac Surg 70:2761-2767). I see it regularly for immediate implants but the cost and time factors have kept me from using it routinely. I certainly consider it especially in more “difficult” areas. I do offer it to patients who would like the best.

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For a consultation, call Wagner Oral Surgery and Dental Implant Specialists at (262) 634-4646 today! Our professional, experienced oral surgeon will take excellent care of you.

One of the great challenges with implant care is having excellent gingival esthetics around the site. Implants at this time are flat, in a biologically contoured area. Attempts have been made to make contoured implants. I do picture a time where we will take a scan of the extraction socket and mill a custom dental implant for that socket right at the time of extraction and it will have matching contours. For the time being, we do have to compensate for this.

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Papilla forms are dependent upon bony projections extending above the CEJ to support the tissue position and health. This is a special problem when we are dealing with multiple implants next to each other. We can mask this by trying to make the gingiva thicker and this can be done by grafting dense or thickened mucosa in these areas.

In the esthetic zone, we tend to submerge implants slightly so that we get a minimum of 3 mm of gingival height facially. In the posterior regions, the tissues are often thin and firm and so we will often have 2 mm tissue heights on the facial aspect of a dental implant site. This is great for cleansing, but makes esthetic restoration challenging.

We can help this through building up these tissues either at the time of extraction and bone grafting or subsequently as an interpositional mucosal graft. Again, the desire would be to get 3 or 4 mm of thickened tissue especially to the facial aspect which gives some cosmetic coverage to the abutment and the base of the crown. The tissues can be simultaneously thickened interproximally to improve the papilla forms. 

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The trade off is that this leaves some increased pocketing. The good news is that the newer implant designs do have a roughened titanium surface at the level of the biologic width and it has been found that the gingival fibers like to cinch down and “attach” around this area when the tissues are healthy.

My challenge at the time of implant treatment is to effectively teach patients the benefits of thickened tissue contours and get them to accept the possibility of additional cost and treatment. The tissue grafting procedures can always be done down the line after they have the teeth, but they are certainly best done prior to restoration.

As a team, our goal is to be looking at these tissue contours and expected tissue height, and to anticipate these cosmetic challenges. This will allow us to encourage patients toward appropriate care.

For a consultation, call Wagner Oral Surgery and Dental Implant Specialists at (262) 634-4646 today! Our professional, experienced oral surgeon will take excellent care of you.

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Cleaning around implant teeth is as important as cleaning around our natural teeth. There are some concerns as it relates to the materials we use around them and the possible injury to the implants. In an ideal implant situation, the top of the implant between the crown and the bone actually attracts attachment of the gingival fibrous tissue similar to the way that the titanium surface in the bone attracts bone growth and maturation. This is an intimate bond, not a biological bond.

When cleaning around implants, it is important not to be stripping that tight tissue attachment from around the implant. The newer implants that oral surgeons use which take advantage of biologic-width should be maintaining a healthy level in the bone and also should maintain this healthy tissue attachment. Obviously, when there is periodontal bone loss on an implant then hygiene will need to be addressing those areas. The use of instruments made for implants such as the Hu-Friedy Implant Care II scalers, Color-Vue probes, and Perioprobes are good ideas. We use titanium surgical instrumentation whenever we are working around implants. This avoids the metallic contamination which can adversely effect integration.

As an oral surgeon, we want to continue to communicate about dental implant care, we ensure the best outcomes for our patients. 

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For a consultation, call Wagner Oral Surgery and Dental Implant Specialists at (262) 634-4646 today! Our professional, experienced oral surgeon will take excellent care of you.

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Exostoses or tori, are benign outgrowths of bone. They commonly occur on the jaws. Right now, feel with your tongue on the inside surface of your lower jawbone all around and on the roof of your mouth. In the normal lower jaw, the bone is smooth and extends essentially straight down from the lower teeth. In the roof of the mouth, the palate normally forms a high arch. If you feel bumps of bone in these areas, you have been blessed with exostoses or tori. They occur in about 15% of the population. In some cases, they may be all around on the gums and jaws. Sometimes they cause problems, especially when they get large. They can interfere with the retention of dentures and they can cause periodontal issues on the adjacent teeth. They often get injured and cause pain. It is a common surgical procedure for us to remove them.

Torus vs. Exostoses

When I went through school to be an oral surgeon, the term torus or tori (plural), referred to having these bone growths present at birth. The term exostosis or exostoses, referred to these as developmental bone growths slowly growing through life which is the most common finding. In fact, I am not sure that I have ever seen a case, during my time as an oral surgeon, of having them present at birth. Because of this, I have spent a good part of my career as an oral surgeon trying to put forth the correct usage of the word exostosis in reference to these. I believe I am the only oral surgeon, with maybe the exception of the teacher I had in residency, that imprinted the original thought on me, who has had this ambition.

Recently I was reading an article (J Oral Maxillofac Surg 70:1286-1291, 2012), where, as usual, they are using the terms interchangeably. In reality, I realize that it just does not matter. As an oral surgeon, I like using proper terminology, but the term “tori” is just cute. I might picture “Tori” as cute little cartoon characters from another planet. It is a much easier word to remember than exostosis, so I give up. Let’s just call them tori!

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For a consultation, call Wagner Oral Surgery and Dental Implant Specialists at (262) 634-4646 today! Our professional, experienced oral surgeon will take excellent care of you.