Wagner Oral Surgeon & Dental Implant Specialists

Surgically assisted palatal expansion, also called rapid palatal expansion, is a common orthognathic procedure that can be done on individuals of any age. (J Oral Maxillofac Surg 72:2278-2288, 2014). In the younger patient it involves just a loosening of the structures. In the teen and older patient I typically do a complete osteotomy as it is not a particularly invasive procedure, our patients do well with a quick recovery (usually outpatient), and with low risk.

There are 2 basic techniques or patterns that we follow and these depending upon the bite. The first of these is a midline osteotomy which means separating the upper jaw down the center of the palate to widen it. The other is called a paramedian separation which is usually right behind the lateral incisor teeth or eye teeth and then separation down the palate. All of this is done through the mouth and just through a small incision under the upper lip and gums. This is a procedure that is done in concert with the orthodontist who manages the dental movements during the healing process using the palatal appliance as shown. Basically, we are making small cuts in what are thin bones and then very slowly (orthopedically) moving the bone, teeth, and tissue during the bone healing process. This improves the jaw position and actually adds your own bone and tissue to the jaw in the process. This is a procedure we have done for over thirty years with good results.

There was an article in our journal in August 2019, from a Chinese source studying the use of orthodontic traction to help erupt wisdom teeth that have a high risk of nerve injury. (J Oral Maxillofac Surg 77:1575.e1-1575.e6, 2019)

There are certain cases where I feel this could be used and I would be happy to provide this care and coordinate this care. Having said that, there are three important points to consider; 1.) In our practice we take care of many patients with a high risk for nerve injury. We rarely have problems with this as we use advanced imaging to localize the risk ahead of time, and we are careful and gentile in our technique. 2.) The cost of treatment will be significant using the orthodontic technique as there will necessarily be at least two surgical procedures (one to locate and attach the appliance and one to ultimately remove the tooth as it is erupted) and there will be orthodontic fees. 3.) There are no guarantees that the procedure will work. As with any orthodontic eruption procedure – there are a number of variables that we do not control that can interfere with success.

If you are interested in pursuing this care for impacted wisdom teeth we would be happy to discuss it at your consult.

In our practice we have never seen a case of Gardner Syndrome – at least any that we have been aware of (J Oral Maxillofac Surg 77:1617-1627, 2019)  Gardner Syndrome is characterized by uncountable adenomas throughout the colon and rectum, with a high risk of developing colorectal cancer (CRC). If left untreated it has almost 100% penetrance. The syndrome also is characterized by extraintestinal manifestations, such as osteomas, odontomas, supernumerary teeth, impacted teeth, and a multitude of soft tissue tumors, including lipomas, fibromas, epidermoid cysts, and desmoids. A simple dominant mechanism of inheritance has been implicated. It is caused by a mutation in the adenomatous polyposis coli (APC) gene, located on chromosome 5q21. Mutations of the APC gene result in a protein product that loses the ability to degrade beta-catenin, which in turn promotes fibroblastic proliferation. What this means is that the body can produce various abnormally excessive tissues which include benign growths – such as we see in the mouth with multiple bony projections on the jaws (exostosis or “tori”) – typically small, round, raised, tissue covered “bumps.”

Exostoses appear normally in the general population. About 15% of all groups have these in varying amounts. Some people have a few small ones, some have many and/or large ones.

What I have observed over time is what I believe to be a partial penetrance of the gene expression. We have seen a number of patients who show the multiple osteomas/exostoses who also show a family history of colon cancer. The truth is that this may just be a coincidence as they may fall into the normal 15% of the overall population. But anecdotally, I have observed that those patients where we have seen the two things together – colorectal cancer and a history of multiple exostoses – the exostoses are more significant in size, number, and location.

For me, in my practice, I just observe and report when I see multiple exostoses. I will ask about family history for colorectal cancer and I will advise the patient about the possible relationship. This is informational, is presented in a non-alarming way, and could help to make an early diagnosis of a potentially serious condition.

This question is posed in an article in JOMS August 2019. (J Oral Maxillofac Surg 77:1557-1565, 2019) As long as patients understand the concerns and risks associated with treatment with or without antibiotic coverage I am happy to provide care either way. We have a great deal of experience in providing care under both scenarios. My experience is that the risk of not using prophylactic antibiotics far outweighs the risks of taking the drugs or the concerns associated with the cost of taking the drugs. There are certainly exceptions and of course every case has its own set of variables that may affect the decision and these should be evaluated and discussed with your surgeon. In our practice we do this. I am aware of the many opinions put out on the internet, especially the warnings against the overuse of antibiotics.

As a routine I would recommend prophylactic antibiotic coverage after oral surgery procedures. There has also been quite a bit of study about taking a premed antibiotic before oral surgery procedures and this has been shown to be helpful in reducing infection risks. The oral environment naturally harbors many microorganisms and viruses. Surgical procedures, however sterile, still trap these organisms in surgical sites and introduce them into deeper tissue layers.

If you are an otherwise healthy patient the likelihood that you will tolerate the drugs well is good. For my family, I would recommend taking the antibiotics. If you are immune compromised or are at greater risk because of age or medical conditions – for my family I would recommend taking the antibiotics and even a premedication. For those who have problems or sensitivities with antibiotics, it is reasonable to avoid them as is possible. Certainly there are specific circumstances that might skew the decision one way or the other and we should discuss these.

Outpatient anesthesia delivered by Oral and Maxillofacial Surgeons (OMFS’S) in the office continues to be an extremely safe procedure.  (J Oral Maxillofac Surg 77:1602-1610, 2019)  We see regular and consistent attacks on the practice of surgery and anesthesia provided in the office setting by OMFS’S from many fronts. The plain truth is that this is all driven by financial factors. We provide a safe treatment at a significantly reduced fee compared to other outpatient surgery centers and we make a good living at it. There are other centers and practitioners who would like a piece of that pie so we get pressed and attacked trying to push this care into other locations such as surgicenters or hospitals.

The plain truth is that OMFS’S are some of the most highly trained and may be the most highly trained group as it relates to providing the office-based team model for anesthesia and surgery delivery. Our American Society continues to stress, train, and monitor best practices for our membership.

The cited article studied self-care and practices for a two year period in one state, but it is representative of our national standards and care-desires as a specialty.

We are well aware that there are risks adherent in anesthesia and surgery and we train and stress preparedness. We also see the trends of more and more patients living longer and with more significant health problems and risks. We continue to provide care as comfortably and cost effectively as we can. I am sure that I do not speak for all OMFS’S, but I am sure that I speak for most. We care deeply about our patients and we wish to provide the best care in a safe, comfortable way and in a cost effective manner.

Having your impacted wisdom teeth removed is a serious surgical procedure, and post-operative care is extremely important! Read on for instructions on how to care for your sore mouth, and how to minimize unnecessary pain and complications.

Immediately Following Surgery:
Keep a firm, yet gentle, bite on the gauze packs that have been placed in your mouth to keep them in place. You can remove them after an hour if the bleeding is controlled. If the surgical area continues to bleed, place new gauze for another 30 to 45 minutes.

Do Not:
• Rinse vigorously
• Probe the area
• Smoke (hopefully you don’t!!)
• Participate in strenuous activities

You Can:
• Brush gently (but not the area)
• Begin saltwater rinses 24 hours after surgery (mix 1 tbs of salt with 1 cup of water).
• Make sure to swish gently. These rinses should be done 2-3 times a day, especially after eating.

Enjoy some down-time! Keep activity level to a minimum! Enjoy a day of couch or bed-rest, as being active could result in increased bleeding. Avoid exercise for 3-4 days, and when you do begin exercising again, keep in mind your caloric intake has been reduced so you may feel weaker. There are also some diet restrictions to keep in mind!

Avoid:
• Extremely hot foods
• Straws (for the first few days)
• Chewing (until tongue sensation has returned)
• Smaller foods that can become stuck in the socket area
• Skipping meals—while eating may seem like a lot of work, you need your nourishment to be able to heal and feel better!

Swelling is a completely normal occurrence. Keep in mind, swelling will usually be at it’s worst in the 2-3 days after surgery. You can minimize swelling by applying a cold compress (covered with a towel) firmly to the cheek next to the surgical area. Apply the pack with 20 minutes on, and 20 minutes off for the first 24-48 hours.

We have used Mini Dental Implants (implant diameter less than or equal to 2.9 mm) over the years for a variety of applications. The most common use has been to use them for orthodontic anchorage – that is where the implant is placed and used to secure braces in order to move teeth. The implant is essentially immovable and the orthodontist can anchor their braces to this and move the teeth relative to the implant. I have also used Mini Dental Implants (MDI’s) as temporary support for dental applications such as to attach a denture during a period of healing such as after grafting. I have found them to work consistently well in these types of applications. (Compendium of Dentistry April 2019, Vol. 40, #4, pg. 238-241)

Where we have seen problems – and this was apparent to us from the start – is when the expectation is that this would be a long-term or permanent functioning device. Mini Implants fail at this.

I see advertisements for them all over and they are being done for “low cost implant care”. We get to see many of these cases after several years when they are failing. What we end up with is discouraged, unhappy patients trying to find the “fly by night” practitioner who provided this care and it often costs much more to recover this situation than it would have to do it the correct way in the beginning. In spite of this, I see patients continually going to that well expecting that they are going to get pure water at a cheap price. There is no substitute for excellence. And excellence does cost something.

I have seen very few Mini Implant cases that I would expect to be long-term. If you are going to pursue that care, I would recommend that you find a doctor who has been around and who will be around to stand by his or her work. I would advise a minimum of 2.5 mm diameter and a roughened surface implant. Make sure you get several opinions.

My basic recommendation is to not get Mini Implants in the first place unless you are in a particularly unique situation where the implant will not be called on to carry much load.

Computerization has been present since the start of my practice life, about 30 years ago. We have always transcribed our notes and so we have always utilized computer based systems to organize our data including patient registration. The use of this information to file insurance came on the scene a number of years ago and has been useful and helpful in expediting a still cumbersome process as it relates to oral surgical-insurance ease. The true use of Electronic Medical Record – as it exists in the hospital setting may seem like it is up and running strong. But the truth is that these systems are not readily accessible to practitioners and especially when you cross boundaries from one corporate entity to another. (J Oral and Maxillofac Surg 77:896-897, 2019). When you get to the level of a clinical application such as an oral surgery group or a dental group it becomes even more narrow.

It is only beneficial in that the members of our group are able to share and access information on shared patients. It is my opinion that the data we can access through hospital based systems to evaluate and treat our patients is extremely helpful. The problem for us – as private practitioners – is that our information is not easily shared on their (the hospital or medical group’s) system without either functioning in their system, or by spending a great amount of time inputting data into their system.

Frankly, as a small group practice, I have found it easiest and best to maintain our own records and in our case that includes a combination of electronic documentation and paper charts. I am actually hopeful that shared systems will not become mandated by the government. It seems that we do not have very much privacy as it is.

Yes, You Still Have to Floss. No, the dance move “flossing” does not count. The AP recently released an article making the claim that “there’s little proof that flossing works”. Their review cited a series of studies that found flossing does little or nothing to improve oral health. Here’s the problem: the studies were flawed. The AP concluded that floss does little for oral health, but it’s important to note that the evidence they cited was very weak at best. In fact, they said so themselves.

As acknowledged by the AP, many of these studies were extremely short. “Some lasted only two weeks, far too brief for a cavity or dental disease to develop” (Associated Press). They also say that “One tested 25 people after only a single use of floss” (Associated Press).

Of course, the evidence is unreliable. You don’t simply develop gum disease because you forgot to floss yesterday. Cavities and gum disease do not happen overnight. Gum disease is preventable by maintain great oral health habits for a long period of time. Lets put it this way: If a study claims drinking milk does nothing for bone health, but draws conclusions after only three glasses of milk, is it a reliable study?

The fact of the matter is floss removes gunk from teeth. You can see it. Gunk feeds bacteria which leads to plaque, cavities, poor gum health, and eventually gum disease. Floss has the ability to reach the food particles that your brush can’t get to. Using a sawing motion instead of moving up and around the teeth to clean the cracks. Positive results come from correct use and it’s critical that people learn to use a tool properly before discarding it as useless.

That’s just what floss is: a tool. Just like your toothbrush, it is designed to keep your mouth clean, and therefore keep your body safe from infection. Both your toothbrush and floss are designed to do what the other can’t, and both successfully remove bacteria from your mouth. Just like proper brushing technique, it is important that you know how to use floss properly, so that you can reap the long-term health benefits of good oral hygiene.

Oral hygiene is a long-term process and requires long term observations to make worthwhile conclusions. In the meantime, it’s obvious that you should continue to do everything you can to protect your well-being, and floss is one of many tools that can help you do that. If you would like a refresher on the best, most efficient techniques for floss use feel free to call our office today

If you or your child are getting your wisdom teeth removed, you must have questions! We are here to make you feel as comfortable as possible. As always, if you have other questions feel free to contact us. We are more than happy to help you understand more on your upcoming procedure. Read on for some frequently asked questions:

1. Why do we have Wisdom Teeth?
Centuries ago our human ancestors used wisdom teeth to help them grind up tough food, like leaves and roots. Their jaws were larger and had more room for extra molars. As we evolved, our diets changed to include softer foods. The third molars became unnecessary as our jaws became smaller.

2. Why do I need to have my wisdom teeth removed?
There are several reasons why you would need your wisdom teeth extracted, as they can cause a variety of complications.
• Impaction: If there is not enough room in your mouth, your wisdom teeth will become impacted and grow at an angle. This can cause problems such as pain and discomfort while eating.
• Damage to other teeth: Your impacted tooth can begin pushing against your second molars, causing potential tooth decay.
• Disease: Spaces between the impacted tooth and your molars allows room for bacteria to grow, putting you at risk for inflammation, cysts, and periodontal (gum) disease.

3. When should I get my wisdom teeth removed?
Wisdom teeth usually come out between the ages of 17- 25, and are typically removed during your high school years. The longer you wait, the more complications that may arise. The root will continue growing and can cause potential permanent nerve damage.

4. When are wisdom teeth okay to keep?
If there is enough room for them to erupt correctly without causing any damage, then they are safe to keep. It is also important to note that not everyone is born with all four wisdom teeth, as evolution has been removing them for generations.

We hope this article has helped you, and if you have any other questions please contact us. Everyone’s teeth are different, and we want to make sure we take the right course of action for your wisdom teeth.