Oral Surgery Procedures

Patients are in need of dental extractions for a variety of reasons and this is one of the most common surgeries performed in this office. In general, extractions can be simple or routine, taking only one or two minutes to perform with extraction forceps, or they may be more complicated surgical extractions, involving soft tissue (gum) incisions and flaps, bone removal, sectioning the tooth with a drill, and sutures to reposition the soft tissue flap. 

Obviously, a surgical extraction takes longer to perform and can be expected to result in more post-operative discomfort and expense, and a prolonged period of healing. Some tooth extractions can be accomplished with only a local anesthetic (“Novocaine”) while others might better be performed with some added form of pain and anxiety control, ranging from nitrous oxide to IV sedation. Such surgical extractions might necessitate time off from school or work to allow for an adequate recovery period. Dr. Kuepper will discuss all of these considerations with you prior to your proposed surgery.

Most patients have four wisdom teeth or third molars. They are called “wisdom teeth” since they usually attempt to erupt or grow into the mouth around the age of 18 years, or what is thought to be the time when young adults reach the “age of wisdom.” Interestingly, some humans have more than the usual number of four wisdom teeth and others are congenitally missing one or more wisdom teeth.

In most patients, wisdom teeth do not have room to fully erupt into the mouth and become impacted or trapped in the jaw in positions where they are prone to result in one or more of the following problems: pain from decay and/ or infection, bone loss from the adjacent tooth surface, undesirable movement of adjacent teeth, and cysts and tumors. Recent research now supports the fact that wisdom teeth which have fully erupted and were previously believed to be properly left in the mouth, may increase the risk of adults developing coronary artery disease, diabetes, and other systemic problems.

In most instances, wisdom teeth should be removed and their removal is easiest in patients under the age of 20 years. In general, the older the patient, the more difficult wisdom tooth removal can be expected to be, due to teeth which have more well-developed and often crooked roots, which are more tightly positioned against the adjacent teeth, which have roots which are closer to sinuses and nerves, which are buried in less soft and forgiving bone, all of which requires more surgical effort and time.  The result is a higher risk of complications, greater post-operative swelling and pain for a longer period of time and greater cost to the patient.

It should come as no surprise that, after having been fully informed of what will be involved in the surgical removal of their wisdom teeth, most patients do not wish to “be awake” during their surgery. State of the art anesthetic agents and techniques are used to allow patients to undergo such surgery, experiencing no pain and having no awareness of the surgery. Typically, the removal of four wisdom teeth with IV sedation is a one-hour office procedure.

Wisdom teeth are the most common teeth to become impacted or which fail to erupt properly into the mouth. Cuspids (also know as canines or eye teeth) are the second most common teeth to become impacted. The permanent cuspids normally erupt around age 13 years. The cuspids are very important teeth as they have the longest roots of any teeth and play an important role in chewing food and in guiding the path of the jaw in opening and closing. They are the cornerstones of the dental arch.

Early recognition of their failure to properly erupt is best managed by creating adequate space for them with orthodontic therapy and may require surgical exposure (uncovering) and the attachment of orthodontic brackets for traction, in order to guide them into proper position. Impacted cuspids are best managed earlier rather than later in their development, as early recognition and treatment yield more predictable results.

Dental implants are changing peoples lives for the better. They improve the way they look, feel and function and allow patients to smile with confidence.  Dental implants are small metal screws placed into the jaws to replace missing teeth.  Dental implants replace the root portions of teeth and may then be used to support individual teeth, bridges or partial and complete dentures. Within a few months after surgical placement, dental implants become “osseointegrated” or securely held in jaw bones. Even though the dental implants themselves are fixed or “permanent”, they can be used to support or retain either fixed or removable dental prostheses (i.e. fixed, non-removable crowns and bridges or removable dentures).

Dental implants are now the standard of care to replace any missing tooth. Most are made of titanium and are guaranteed never to decay, never to die and never to need root canal therapy. Therefore, some of the most common problems contributing to the loss of a natural tooth are guaranteed never to occur with a dental implant. Dental implants also reduce or prevent ongoing bone loss, which would otherwise occur following tooth extraction, something which no other form of tooth replacement can claim. The cost of replacing a single tooth with a dental implant is similar to that of a traditional 3-unit bridge. And a dental implant is statistically two times more likely to survive for 12 years than a bridge.

When you lose one or more permanent teeth, you also lose bone and the covering soft tissue (gum tissue) as the ridge resorbs or shrinks over time. This is a natural process and occurs in all humans following tooth loss to varying degrees, unless appropriate measures are taken at the time of extractions to minimize this process. If a patient intends to replace a tooth with a dental implant, this becomes an especially important consideration to optimize the amount of bone available for future implant placement.

A socket bone graft is the standard procedure used to maintain adequate bone following a tooth extraction. Particles of bone are immediately placed into the tooth extraction site. These bone particles are obtained from commercial bone banks who prepare human cadaver bone from organ donors. An extensive process is used to assure the bone is free of any form of transmittable disease. To stimulate the growth of these dead bone particles, they are mixed with PRGF (plasma rich in growth factors) prepared from the patientʼs own blood. Three to six months following the socket bone graft, there is adequate bone regeneration in the extraction site to allow for dental implant placement.

In cases where socket grafts were not placed for ridge preservation at the time of tooth extractions, patients often present with inadequate amount of bone for dental implant placement. In such situations, patients will require more complex forms of hard (bone) and soft tissue grafting to provide an adequate quantity and quality of bone for implant placement. These procedures might involve particles or blocks of bone, obtained from bone banks or from donor sites in the patientʼs jaws. Such bone grafts may actually double the volume of bone available in any potential implant site. The initial blood supply for such bone grafts comes from the overlying soft tissues. 

Soft tissue grafts are often required prior to bone grafting to develop an adequate soft tissue

drape and blood supply for the planned bone graft. As with bone grafts, soft tissue (connective tissue) grafts may be acquired from tissue banks or from donor sites within the patientʼs own mouth (e.g. from the palatal tissues).

The loss of any of the upper six front teeth is one of the more frequent challenges for the dental implant team. Since this is the esthetic zone, the loss of one or more of these teeth results in cosmetic, functional and often emotional issues. If teeth are lost due to injury or infection, there can be considerable bone loss associated with the tooth loss. These situations often require hard and soft tissue grafting prior to, or in combination with, dental implant placement to obtain the optimal cosmetic and functional results.

All hard and soft tissue grafting surgeries are performed in the office with the same methods of pain and anxiety control used to make other oral surgery procedures painless and as pleasant an experience as is possible.

Pre-prosthetic oral surgery procedures include all surgery performed to prepare the mouth for dentures. As explained in the Hard and Soft Tissue Grafting information in our web site, tooth loss is associated with bone loss due to resorption of the ridges of the jawbone. This bone loss makes it more difficult to wear dentures and leads to the common complaints from denture wearers that their dentures are loose, hurt, click when talking and do not allow them to eat a meal without applications of denture adhesives.

Many denture patients confess that they wear one or both dentures for show in public, but remove them at home to eat and for comfort.  Some of these denture problems can be managed by various surgical procedures to either remove loose, redundant, painful gum tissue under dentures or by remodeling and reshaping the ridges, with or without bone and soft tissue grafting. However, in many cases, the best solution to loose, uncomfortable dentures is the placement of dental implants in the jaw to provide support and stability for the

denture. This is one of the most satisfying surgeries we perform, because it produces such an immediate and drastic improvement in the quality of life for our denture patients.

When Tiger Woods had major reconstructive knee surgery, he returned to golf sooner than many expected. Some attributed it to his dedication to physical therapy and exercise following his surgery. Tiger attributed it to his orthopedic surgeonʼs use of PRGF. 

Growth factors are proteins that play a key role in wound healing and tissue formation. They are located both in plasma and within platelets, all of which are prepared from the patientʼs own blood. PRGF technology is a state of the art procedure used in orthopedics, arthroscopic sports medicine, oral surgery, ulcer repair, ophthalmology and in peripheral nerve repair. 

Using a preparation of growth factors from the patientʼs own blood eliminates the risk of transmission of HIV or hepatitis viruses from blood bank donors and reduces the cost of the surgery. These growth factors are used in oral surgery to promote healing of soft and hard tissue grafting.

Unfortunately, dental infections originating from decayed, dying and non-vital teeth are a common reason patients seek the help of an oral surgeon. These infections may range in severity from a simple, chronic dental abscess, which is causing no pain or swelling and is identifiable only by a dark shadow at the end of a tooth root on x-ray, to a life threatening infection, which has spread from the tooth to the soft tissue spaces around the throat and neck. While the former may require only a tooth extraction in the office, the later requires admission to a hospital for intravenous antibiotics and surgical drainage tubes placed into the infected areas from incisions inside the mouth and throat and from outside the neck.

The sooner patients seek proper surgical treatment for all dental infections, the better the odds of their requiring simpler surgical procedures, involving less time, expense and suffering. The vast majority of dental infections are abscesses, or localized infections at the end of, or around, the root(s) of a tooth. They typically do not spread far beyond the area of the tooth and respond well to early surgical intervention, such as tooth removal if root canal therapy is not deemed to be appropriate. 

In many such cases, patients are prescribed antibiotic therapy when symptoms of pain and/ or swelling first arise and improve temporarily. However, if the cause of the infection (i.e. the tooth is not treated or removed) the infection will return with more severe symptoms.  Any dental infection results in loss of the bone surrounding the tooth. That is never a good result. Again, early, proper treatment is the answer.

A cyst is a fluid filled soft tissue sack. A tumor (or neoplasm) is a new growth which is not normal tissue. Cysts and tumors may be benign or malignant and may grow in hard (bone) or soft tissues. In the jaw bones, most cysts and tumors of are odontogenic (tooth) origin, having grown from remnants of embryonic cells which originally grew tooth structures. Cyst and tumors in the oral and maxillofacial regions may also arise from non-dental sources, just as they may occur anywhere else in the human body.

Some cysts and tumors can be seen with a visual exam while others are only detected with imaging studies such as x-rays or CT scans. Some lesions or abnormal tissue growths cause symptoms (pain,swelling, etc.) while other do not and can only be detected with routine periodic clinical and x-ray examinations. The importance of regular dental exams (at least every six months) cannot be over-emphasized.

Most cysts and tumors in the oral and maxillofacial region can be removed in the office. Some larger growths and some located near vital structures in areas more difficult to approach by means of standard procedures from inside the mouth, are best performed in a hospital setting. As in the case of dental infection, early detection and early treatment usually result in simpler, less complex surgical intervention, with less post-operative suffering and expense and a faster recovery.

Office Anesthesia

Letʼs face it, no one looks forward to visiting an oral surgeon for SURGERY!

Fortunately we live in a time when we have methods of providing excellent pain and anxiety control, allowing us to perform surgical procedures safely in a comfortable, relaxed office setting, with patients experiencing no pain and being as unaware of the surgery as he or she wishes to be. This also allows patients to avoid the more stressful, complicated and expensive hospital setting and results in a shorter overall visit, a quicker recovery from anesthesia and a faster return to the comfort of their own homes.

The following are descriptions of the current state of the art methods of pain and anxiety control for oral surgery in the office.

Injections of local anesthesia remain the most common method of pain relief during any office oral surgery procedure. Most local anesthetic injections can be made without the patient experiencing any discomfort from the injection, given the availability of topical numbing gels applied to the soft tissue injection sites prior to the surgery, combined with small diameter disposable needles and good operator technique. Local anesthetic injections are also used in combination with oral premedications, nitrous oxide and IV sedation as the underlying means of pain control. The numbing effects of standard local anesthetic injections last for 1 1/2 to 2 hours, while long-lasting local anesthesia injections may last up to 8 hours. Such long-lasting pain relief is a welcome benefit appreciated by all patients having more complicated and extensive oral surgical procedures.

Many patients are apprehensive about local anesthesia injections, in addition to the anticipated surgery itself. Prescriptions for sedatives and tranquilizers to be taken the night before and just prior to office surgery can greatly reduce anxiety. The appropriateness of such pre-medications depends on the patientʼs medical history and other prescription drug usage, as well as the availability of someone to drive the patient to and from the office.

Nitrous oxide is a gas, which is administered by a nasal hood. It provides anxiety reduction and pain relief. When used prior to the injection of local anesthesia, nitrous oxide helps a patients to relax and to feel less of the discomfort from the injection.  Nitrous oxide is also used with IV sedation procedures, making the starting of an IV less worrisome and more comfortable.

IV sedation has become one of the most frequently used methods of providing control of apprehension, anxiety and awareness of out-patient surgery. Medications are administered intravenously, until the patient is relaxed and comfortable, and is no longer concerned or cares about surgery. IV sedation results in patients having little or no memory of their surgery and results in patients who are pleasantly surprised by their surgical experience.

© 2021 Robert C. Kuepper, DDS

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