oral surgery
What Happens If The Eyetooth Will Not Erupt When Proper Space Is Available?
TMJ (Jaw Therapy) / Night Guards
There are the most common surgical procedures performed in a dental office. Teeth extractions may be needed in a number of reasons:
Severe decay
Advanced periodontal disease
Broken in a way that cannot be repaired
Poorly positioned in the mouth (such as impacted teeth)
Preparation for orthodontic treatment
The removal of a single tooth can lead to problems related to your chewing ability, problems with your jaw joint, and shifting teeth, which can have a major impact on your dental health. To avoid these complications, we will discuss alternatives to extractions as well as replacement of the extracted tooth.
Surgical procedure
At the time of extraction we will numb your tooth, jawbone and gums that surround the area with a local anesthetic. During the extraction process you will feel a lot of pressure. This is from the process of firmly rocking the tooth in order to widen the socket for removal. You feel the pressure without pain as the anesthetic has numbed the nerves stopping the transference of pain, yet the nerves that transmit pressure are not profoundly affected. If you do feel pain at any time during the extraction, we will give you more anesthesia to make you comfortable.
Some teeth require sectioning. This is a very common procedure done when a tooth is so firmly anchored in its socket or the root is curved and the socket can't expand enough to remove it. The doctor simply cuts the tooth into sections then removes each section one at a time.
Replacing extracted teeth with: Dental Implants
Wisdom Teeth
By the age of 18, the average adult has 32 teeth; 16 teeth on the top and 16 teeth on the bottom. Each tooth in the mouth has a specific name and function. The teeth in the front of the mouth (incisors, canine, and bicuspid teeth) are ideal for grasping and biting food into smaller pieces. The back teeth (molar teeth) are used to grind food up into a consistency suitable for swallowing.
The average mouth is made to hold only 28 teeth. It can be painful when 32 teeth try to fit in a mouth that holds only 28 teeth. These four other teeth are your third molars, also known as "wisdom teeth."
Why Should I Remove My Wisdom Teeth?
Wisdom teeth are the last teeth to erupt within the mouth. When they align properly and gum tissue is healthy, wisdom teeth do not have to be removed. Unfortunately, this does not generally happen. The extraction of wisdom teeth is necessary when they are prevented from properly erupting within the mouth. They may grow sideways, partially emerge from the gum, and even remain trapped beneath the gum and bone. Impacted teeth can take many positions in the bone as they attempt to find a pathway that will allow them to successfully erupt.
These poorly positioned impacted teeth can cause many problems. When they are partially erupted, the opening around the teeth allows bacteria to grow and will eventually cause an infection. The result: swelling, stiffness, pain, and illness. The pressure from the erupting wisdom teeth may move other teeth and disrupt the orthodontic or natural alignment of teeth. The most serious problem occurs when tumors or cysts form around the impacted wisdom teeth, resulting in the destruction of the jawbone and healthy teeth. Removal of the offending impacted teeth usually resolves these problems. Early removal is recommended to avoid such future problems and to decrease the surgical risk involved with the procedure.
Oral Examination
With an oral examination and x-rays of the mouth, we can evaluate the position of the wisdom teeth and predict if there are present or may be future problems. Studies have shown that early evaluation and treatment result in a superior outcome for the patient. Patients are generally first evaluated in the mid-teenage years by their dentist, orthodontist or by an oral and maxillofacial surgeon.
All outpatient surgery is performed under appropriate anesthesia to maximize patient comfort. Our surgeon has the training, license and experience to provide various types of anesthesia for patients to select the best alternative.
Removal
In most cases, the removal of wisdom teeth is performed under a sedative. These options, as well as the surgical risks (i.e., sensory nerve damage, sinus complications), will be discussed with you before the procedure is performed. Once the teeth are removed, the gum is sutured. To help control bleeding, bite down on the gauze placed in your mouth, for one hour. You will rest under our supervision in the office until you are ready to be taken home. Upon discharge, your postoperative kit will include postoperative instructions, a prescription for pain medication, antibiotics, and a follow-up appointment in one week for suture removal.
Impacted Canines
An impacted tooth simply means that it is "stuck" and cannot erupt into function. Patients frequently develop problems with impacted third molar (wisdom) teeth. These teeth get "stuck" in the back of the jaw and can develop painful infections among a host of other problems (see wisdom teeth). Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary cuspid (upper eyetooth) is the second most common tooth to become impacted. The cuspid tooth is a critical tooth in the dental arch and plays an important role in your "bite". The cuspid teeth are very strong biting teeth and have the longest roots of any human teeth. They are designed to be the first teeth that touch when your jaws close together so they guide the rest of the teeth into the proper bite.
Normally, the maxillary cuspid teeth are the last of the "front" teeth to erupt into place. They usually come into place around age 12 and cause any space left between the upper front teeth to close tighter together. If a cuspid tooth gets impacted, every effort is made to get it to erupt into its proper position in the dental arch. The techniques involved to aid eruption can be applied to any impacted tooth in the upper or lower jaw, but most commonly they are applied to the maxillary cuspid (upper eye) teeth. Sixty percent of these impacted eyeteeth are located on the palatal (roof of the mouth) side of the dental arch. The remaining impacted eye teeth are found in the middle of the supporting bone but stuck in an elevated position above the roots of the adjacent teeth or out to the facial side of the dental arch.
Early Recognition Of Impacted Eyeteeth Is The Key To Successful Treatment
The older the patient, the more likely an impacted eyetooth will not erupt by nature's forces alone even if the space is available for the tooth to fit in the dental arch. The American Association of Orthodontists recommends that a panorex screening x-ray, along with a dental examination, be performed on all dental patients at around the age of seven years to count the teeth and determine if there are problems with eruption of the adult teeth. It is important to determine whether all the adult teeth are present or are some adult teeth missing. Are there extra teeth present or unusual growths that are blocking the eruption of the eyetooth? Is there extreme crowding or too little space available causing an eruption problem with the eyetooth? This exam is usually performed by your general dentist or hygienist who will refer you to an orthodontist if a problem is identified. Treating such a problem may involve an orthodontist placing braces to open spaces to allow for proper eruption of the adult teeth. Treatment may also require referral to an oral surgeon for extraction of over-retained baby teeth and/or selected adult teeth that are blocking the eruption of the all-important eyeteeth. The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of any of the adult teeth. If the eruption path is cleared and the space is opened up by age 11-12, there is a good chance the impacted eyetooth will erupt with nature's help alone. If the eyetooth is allowed to develop too much (age 13-14), the impacted eyetooth will not erupt by itself even with the space cleared for its eruption. If the patient is too old (over 40), there is a much higher chance the tooth will be fused in position. In these cases the tooth will not budge despite all the efforts of the orthodontist and oral surgeon to erupt it into place. Sadly, the only option at this point is to extract the impacted tooth and consider an alternate treatment to replace it in the dental arch (crown on a dental implant or a fixed bridge).
What Happens If The Eyetooth Will Not Erupt When Proper Space Is Available?
In cases where the eyeteeth will not erupt spontaneously, the orthodontist and oral surgeon work together to get these unerupted eyeteeth to erupt. Each case must be evaluated on an individual basis but treatment will usually involve a combined effort between the orthodontist and the oral surgeon. The most common scenario will call for the orthodontist to place braces on the teeth (at least the upper arch). A space will be opened to provide room for the impacted tooth to be moved into its proper position in the dental arch. If the baby eyetooth has not fallen out already, it is usually left in place until the space for the adult eyetooth is ready. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted eyetooth exposed and bracketed. (orthodontic small plate bonded on tooth)
In a simple surgical procedure performed in the surgeon's office, the gum on top of the impacted tooth will be lifted up to expose the hidden tooth underneath. If there is a baby tooth present, it will be removed at the same time. Once the tooth is exposed, the oral surgeon will bond an orthodontic bracket to the exposed tooth. The bracket will have a miniature gold chain attached to it. The oral surgeon will guide the chain back to the orthodontic arch wire where it will be temporarily attached. Sometimes the surgeon will leave the exposed impacted tooth completely uncovered by suturing the gum up high above the tooth or making a window in the gum covering the tooth (on selected cases located on the roof of the mouth). Most of the time, the gum will be returned to its original location and sutured back with only the chain remaining visible as it exits a small hole in the gum.
Shortly after surgery (1-14 days) the patient will return to the orthodontist. A rubber band will be attached to the chain to put a light eruptive pulling force on the impacted tooth. This will begin the process of moving the tooth into its proper place in the dental arch. This is a carefully controlled, slow process that may take up to a full year to complete. Remember, the goal is to erupt the impacted tooth and not to extract it! Once the tooth is moved into the arch in its final position, the gum around it will be evaluated to make sure it is sufficiently strong and healthy to last for a lifetime of chewing and tooth brushing. In some circumstances, especially those where the tooth had to be moved a long distance, there may be some minor "gum surgery" required to add bulk to the gum tissue over the relocated tooth so it remains healthy during normal function. Your dentist or orthodontist will explain this situation to you if it applies to your specific situation.
These basic principals can be adapted to apply to any impacted tooth in the mouth. It is not that uncommon for both of the maxillary cuspids to be impacted. In these cases, the space in the dental arch form will be prepared on both sides at once. When the orthodontist is ready, the surgeon will expose and bracket both teeth in the same visit so the patient only has to heal from surgery once. Because the anterior teeth (incisors and cuspids) and the bicuspid teeth are small and have single roots, they are easier to erupt if they get impacted than the posterior molar teeth. The molar teeth are much bigger teeth and have multiple roots making them more difficult to move. The orthodontic maneuvers needed to manipulate an impacted molar tooth can be more complicated because of their location in the back of the dental arch.
Recent studies have revealed that with early identification of impacted eyeteeth (or any other impacted tooth other than wisdom teeth), treatment should be initiated at a younger age. Once the dentist identifies a potential eruption problem, the patient should be referred to the orthodontist for early evaluation. In some cases the patient will be sent to the oral surgeon before braces are even applied to the teeth. As mentioned earlier, the surgeon/dentist will be asked to remove over-retained baby teeth and/or selected adult teeth. He will also remove any extra teeth or growths that are blocking eruption of the developing adult teeth. Finally, he may be asked to simply expose an impacted eyetooth without attaching a bracket and chain to it. In reality, this is an easier surgical procedure to perform than having to expose and bracket the impacted tooth. This will encourage some eruption to occur before the tooth becomes totally impacted (stuck). By the time the patient is at the proper age for the orthodontist to apply braces to the dental arch, the eyetooth will have erupted enough that the orthodontist can bond a bracket to it and move it into place without needing to force its eruption. In the long run, this saves time for the patient and means less time in braces (always a plus for any patient!).
Extraction Site Preservation
There is a special type of bone surrounding your teeth. This bone is called alveolar "ridge" bone (jawbone), and exists solely to support your teeth. As soon as the tooth is removed, this bone begins to degenerate and "melt away." The overlying gum tissue melts away with the alveolar bone and thins out as the ridge flattens. This occurs in two dimensions. The first is loss of horizontal width caused by the collapse of the bone surrounding the socket. This makes the remaining ridge narrower than when the tooth was present. The second is a loss of vertical height. This makes the remaining bone less "tall." This process is faster in areas where you wear a partial or complete denture.
When multiple teeth are lost, this can lead to a shrunken facial profile and can make an individual look much older than he or she is.
You have many options to prevent this, and it is important that you consider them BEFORE any teeth are extracted. Some of these procedures are best performed at the time the tooth is removed.
When you need to have a tooth or teeth extracted, whether it be due to tooth decay, fracture, abscess, gum disease or traumatic injury, a socket site preservation is recommended to preserve as much of your underlying jawbone as possible for your future restorations.
With today's technology, the bone can be rebuilt at the time of extraction, which will preserve the vital structures.
You will have several choices for replacing the newly missing teeth. All of the options rely on bone support and bone contour for the best function and esthetics. Here is a list of the possible options:
Dental implants : These are root-shaped supports that hold your replacement teeth. The more bone support you have, the stronger the implant replacements will be. In some cases, the bone can degenerate to a point where implants can no longer be placed without having more complex bone grafting procedures to create the necessary support. Obviously, preventing bone loss is much easier than recreating the bone later.
Fixed bridge : This is a restoration that is supported by the teeth adjacent to the missing tooth space. The replacement tooth (or pontic) spans across the space. If the bone is deficient, there will be an unsightly space under the pontic that will trap food and affect your speech.
Other replacement alternatives include removable partial or full dentures. These often perform better with more supporting bone as there is added support against dislodgement.
Procedure
There are two important phases in retaining your alveolar ridge during and after the tooth extraction. Non-traumatic extraction techniques are designed to preserve as much bone as possible and reduce bleeding and discomfort. In addition to non-traumatic extractions, and key to preventing the collapse of the socket, is the addition of bone replacement material to the extraction socket.
There are several types of bone grafting materials and techniques. We will discuss the most appropriate one with you. After the tooth is extracted, the socket will be packed with bone or bone substitute and covered with a absorbable membrane then suture. Early on, the grafting material will support the tissue surrounding the socket, and in time will be replaced by new alveolar bone. This bone will be an excellent support should you choose later to have dental implant-supported replacement teeth.
Although the bone created by socket grafting supports and preserves the socket, it will not do so indefinitely. Placing dental implants three to twelve months after the extraction and socket grafting will provide the best long-lasting support for preserving your jawbone and allow you to function as before. Otherwise the graft may "melt away" or resorb over time.
In some selected cases it is possible to actually extract the tooth and place the dental implant at the same time. We will discuss this option with you if it is a viable alternative.
Ridge Expansion
In severe cases, the ridge has resorbed and the jaw ridge is too thin to receive implants. To correct this condition, a bone graft is placed to increase ridge height and/or width. In this procedure, the bony ridge of the jaw is literally expanded via the bone graft. After several months, the site is evaluated for bone quality and suitability for implant placement.
Bone Grafting
Over a period of time, the jawbone associated with missing teeth atrophies or is reabsorbed. This often leaves a condition in which there is poor quality and quantity of bone suitable for placement of dental implants. In these situations, most patients are not candidates for placement of dental implants.
Today, we have the ability to grow bone where needed. This not only gives us the opportunity to place implants of proper length and width, it also gives us a chance to restore functionality and aesthetic appearance.
Guided Tissue Regeneration
Bone grafting can repair implant sites with inadequate bone structure due to previous extractions, gum disease or injuries. The bone is obtained from the jaw, it is your own bone. We generally use your own bone for better and stable results. Sinus bone grafts are also performed to replace bone in the posterior upper jaw. In addition, special membranes will be utilized that dissolve or not under the gum and protect the bone graft and encourage bone regeneration. This is called guided bone regeneration or guided tissue regeneration .
Sinus Lift Procedure
The maxillary sinuses are behind your cheeks and on top of the upper teeth. Sinuses are like empty rooms inside the bone, that have nothing in them. Some of the roots of the natural upper teeth extend up into the maxillary sinuses. When these upper teeth are removed, there is often just a thin wall of bone separating the maxillary sinus and the mouth. Dental implants need bone to hold them in place. When the sinus wall is very thin, it is impossible to place dental implants in this bone.
There is a solution and it's called a sinus graft or sinus lift graft. The dental implant surgeon enters the sinus from where the upper teeth used to be. The sinus membrane is then lifted upward and donor bone is inserted into the floor of the sinus. Keep in mind that the floor of the sinus is the roof of the upper jaw. After several months of healing, the bone becomes part of the patient's jaw and dental implants can be inserted and stabilized in this new sinus bone.
The sinus graft makes it possible for many patients to have dental implants when years ago there was no other option other than wearing loose dentures.
If enough bone between the upper jaw ridge and the bottom of the sinus is available to stabilize the implant well, sinus augmentations and implant placement can sometimes be performed as a single procedure. If not enough bone is available, the sinus augmentation will have to be performed first, then the graft will have to mature for several months, depending upon the type of graft material used. Once the graft has matured, the implants can be placed.
Nerve Repositioning
The inferior alveolar nerve, which gives feeling to the lower lip and chin, may need to be moved in order to make room for placement of dental implants in the lower jaw. This procedure is limited to the lower jaw and indicated when teeth are missing in the area of the two back molars and/or and second premolar, with the above-mentioned secondary condition. Since this procedure is considered a very aggressive approach (there is almost always some postoperative numbness of the lower lip and jaw area, which dissipates only very slowly, if ever), usually other, less aggressive options are considered first (placement of blade implants, etc.).
Typically, an outer section of the cheek side of the lower jawbone is removed in order to expose the nerve and vessel canal. Then we isolate the nerve and vessel bundle in that area and slightly pull it out to the side. At the same time, we will place the implants. Then the bundle is released and placed back over the implants. The surgical access is refilled with bone graft material of the surgeon's choice and the area is closed.
These procedures may be performed separately or together, depending upon the individual's condition. There are several areas of the body that are suitable for attaining bone grafts. In the maxillofacial region, bone grafts can be taken from inside the mouth, in the area of the chin or third molar region, or in the upper jaw behind the last tooth. In more extensive situations, a greater quantity of bone can be attained from the hip or the outer aspect of the tibia at the knee. When we use the patient's own bone for repairs, we generally get the best results.
TMJ (Jaw Therapy) / Night Guards
Many patients grind or clench their teeth, which is a condition know as bruxism. This grinding may also put unintended pressure on the muscles and tissues of your jaw resulting in tooth and other jaw disorders, headaches and ear pain. The symptoms of this disorder are often referred to as TMJ/TMD (Temporomandibular Joint Dysfunction).
Signs and symptoms that may be related to TMJ/TMD (Temporomandibular Joint Dysfunction)
Headaches
Sharp pain in the area under the earlobe
Waking up with sore jaw muscles
Clicking, popping of the jaw joint
Abnormal tooth wear (teeth getting shorter over the years)
Grinding or clenching your teeth
Tooth sensitivity unrelated to cavities or gum disease
At your initial examination, we perform a thorough examination of your occlusion (bite) and surrounding muscles. If the bite is not correct, we will perform an occlusal adjustment, a procedure whereby biting contacts that are higher than others are lightly shaped. The object is to provide a harmony of all of the teeth when in contact.
If a night guard is recommended for you, we will take an impression and send the molds to a professional dental laboratory. A custom fit, durable acrylic night guard will be fabricated and then custom fit to your mouth. With a good occlusion (bite) of your natural teeth, along with a well fitting and functioning night guard, you will most likely see a significant decrease in headaches or other TMJ symptoms.