Wagner Oral Surgeon & Dental Implant Specialists

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.

Our Philosophy Regarding Wisdom Teeth

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.

Who is the best oral surgeon in Wisconsin? Richard M. Wagner DDS.

Who is the best oral and maxillofacial surgeon in Wisconsin? Richard M. Wagner DDS.

Who is the best oral surgeon in the Milwaukee area? Richard M Wagner DDS.

Who is the best oral and maxillofacial surgeon in the Milwaukee area? Richard M Wagner DDS.

Dr. Richard M. Wagner is an Oral and Maxillofacial surgeon who has practices in Racine and Kenosha, Wisconsin. His consistency in excellence and care make him the best.

Skills and experience: Dr. Wagner has been performing oral and maxillofacial surgery procedures and anesthesia for over 30 years. He is excellent. He knows his art, he has a great set of artists hands and a great surgical mind. He is kind, gentle, caring, and skilled. What else could you want? Well he is also a very balanced person which rounds it all out.

Techniques: Dr. Wagner has pioneered many procedures and techniques in Wisconsin. He stays on the cutting edge of his specialty. He has embraced advancements in surgical techniques, dental implants, grafting materials and methods over time. He continues to train and learn continually.

Extensive training and experience. Dr. Wagner went through residencies in both surgery and anesthesia. He regularly attends continuing education. He has been trained by and with many of the greatest oral and maxillofacial surgeons in the country and the world.  Dr Wagner is board certified through the American Board of OMS.

Character: Dr. Wagner is a man of character and integrity. He is a man of faith. He lives his Christian faith. His stated goal is to be a servant-leader putting others’ needs above his own. He personalizes his practice, meaning that he recommends and performs treatments for his patients consistent with how he would take care of his own family and friends. On a personal level, he is married to his childhood sweetheart. He has four children and nine grandchildren.  He loves them, and they all love him!

Fun: Dr Wagner does not have a big head. He also does not take himself too seriously. He is very comfortable and confident in himself to the point that it will make you feel the same!  He has fun in his work and he wants you to enjoy the experience, even though he recognizes the stresses and concerns.  He wants you to be comfortable and relaxed.

Staff:  Dr. Wagner‘s team is experienced, caring, and attentive.  The office is well staffed. Our staff are diverse as individuals but they are all-in on our practice philosophy of high-quality comprehensive care with attention to patient comfort details.

The bottom line is that Dr Richard M. Wagner is “the complete package”.  He will be the first to tell you that he is fallible, but he has been consistent and true to his patients, practice, staff, family and community.  The Best!

Ok, if you are reading this blog entry you are certainly a one percenter. Maybe you are even a part of the problem or part of the solution. At any rate andragogies also called “medical pimping” has been a part of medical and surgical training forever (at least my forever). (J Oral Maxillofac Surg 77:1101-1102, 2019) This is particularly close to my heart in that I feel that much of my skill and surgical/medical demeanor (which I feel has been proven over time to reflect excellence and stability) was shaped significantly by this process.

“Andragogy” and “medical pimping” can take many forms. In our case it was the constant challenging through questioning under stressful situations which was provided by so many of my teachers and mentors. If you receive these challenges as an affront or an insult, you are looking at it like a child who feels that discipline from a parent is mean or a form of punishment or torture. The truth is that challenging training and especially extreme challenging training under duress is what differentiates a basic soldier from an elite warrior such as a ranger or a Navy Seal. It is also what differentiates a basic surgeon from an elite or excellent surgeon. It is the ability to handle a situation calmly, with great skill and ability, and with a continually recalibrating proactive approach. This is part of your preparation and this is part of your application during surgery.

There is a big push in today’s training to try to reduce stress, reduce challenges, and provide an “easier path” for surgical training. The goal is to create a more homogenous result.

I am so grateful to the many men and women who were involved in my training who challenged me, “pimped me,” stressed me, and often frustrated me. I recognized it then and I really recognize it now…they loved me enough to want to make me into the best surgeon possible – who wanted my training to exceed the greatest challenges I might experience in the real world.

If you have read my blogs on the subject you know that I am almost completely opposed to the procedure of coronectomy as a treatment for impacted third molar teeth. I base this on a number of factors including – we rarely have problems with complete removal in the first place; the procedure leaves “the problem” in place; our experience is that we end up having to care for these patients in the future with removal of the tooth; it is my belief that the reason this procedure was introduced was to create the need for a second surgical procedure and additional billing in light of socialized dental care and manage care situations. (J Oral Maxillofac Surg 77:1108-1115, 2019)

The stated article claims that the reoperation rate for the coronectomy procedure is about 5%. In the conclusion, they recommend that a follow up study for more than 6 months is recommended! I’d say! We are starting to see these cases come through where some practitioner (usually not an oral surgeon) performs the coronectomy and then, when it becomes a problem, they refer it to us to solve and treat. In many cases the risks with the procedure, such as to the feeling nerve, adjacent teeth, or sinus, end up being much greater than they would have been had we done the complete procedure in the first place. We also see many more collateral problems such as infection or bone loss on the adjacent teeth in these situations.

There is no question, based on my experience, that proper care with early complete removal of third molar impactions is the correct treatment. There are very few exceptions and we will consider the coronectomy procedure when it is appropriate.

We do not use the STOP-BANG questionnaire per-se to screen patients who are planned for intravenous anesthesia. (J Oral Maxillofac Surg 77:1135-1142, 2019) STOP – BANG is an acronym for questions you would ask someone you suspect might have sleep apnea.  Snoring – Tired – Observed – Pressure – BMI – Age – Neck – Gender. (see: stopbang.com) The fact of the matter is, whether you have OSA or not and whether or not you have had it diagnosed, we approach all patients with the same cautions and concerns as we go into oral surgical procedures. We use a titrated dose anesthetic technique which is by-design a safer way to provide the care. We are also constantly monitoring for airway, breathing, PO2, and PCO2. We support breathing as needed as we provide anesthesia and care using appropriate adjuncts.

The fact of the matter is that our surgical site is the mouth, so we are immediately aware of changes in breathing and breathing character as we proceed with care. And we are able to modify our techniques as needed to support proper breathing.

Of course we go through a presurgical screening and questionnaire including an evaluation of existing medical problems such as OSA.

There are systems available for computer guided techniques to approach difficult-to-visualize structures such as dental implant sites, the temporomandibular joint (TMJ), and impacted teeth such as supernumerary teeth. (J Oral Maxillofac Surg 77:1130-1134, 2019)  I have had the opportunity to train in and try these techniques and use this equipment. In most cases, as it relates to oral and maxillofacial surgery, it is a technique looking for an application. What I mean by this is that, in my opinion, having this technology is really neat, but unnecessary.

We use cone beam imaging to view and treatment plan our difficult procedures such as approaching impacted supernumerary teeth. With this technology we are able to “do the surgery virtually” and then approach the actual patient with a high degree of accuracy and certainty. Adding on the guided technique has three concerns. First it is very expensive and adds a level of cost to the procedure. Second the technology as it exists today is not exacting and to me I trust my own skill, artistry, and experience more in the operating situation as opposed to a technology with tolerances that are questionable. Third is that we perform hundreds of these procedures and, although challenging, we do not have problems.

I will continue to monitor the developments with all of the related technologies. Surgeons love new devices and techniques. But, especially when providing the best care for your patients, and trying to provide it at a reasonable expense, you need to use the procedures and instruments consistent with that outcome. That is the best outcome.