Wisdom Teeth:
Third Molars
      
  
Many people require removal of their third molars also known as wisdom teeth. As with any surgical procedure, there are some possible risks and complications. The decision on third molar removal should be decided by a patient and their dentist

Is it necessary to remove wisdom teeth? Wisdom teeth are a valuable asset to the mouth when they are healthy and properly positioned. Often, however, problems develop that require their removal. When the jaw isn't large enough to accommodate wisdom teeth, they can become impacted (unable to come in or misaligned) Wisdom teeth may grow sideways, emerge only part way through the gum or remain trapped beneath the gum and bone. 
Extraction of third molars is generally recommended: 

• When wisdom teeth only partially erupt;
• When there is a chance that poorly aligned wisdom teeth will damage adjacent teeth;
• When a cyst (fluid-filled sac) forms, destroying surrounding structures such as bone tooth roots. 

The most common reason people choose to remove their wisdom teeth is that their mouth is too small for these teeth to normally erupt behind the second molar into a good position.

This can result in one of the following situations

1.  Complete Bony Impaction:
When the tooth is completely covered with bone it will remain completely covered with its "developmental sack" in which all teeth develop. Later in life, this sack may undergo changes and enlarge and develop into a cyst. This cyst will enlarge at the expense of the bone of the jaw. These cysts should be removed and examined by a pathologist.

2.  Partial Bony Impaction:
When the teeth begin to erupt but are not able to erupt completely. In this situation, the upper third molars usually are positioned towards the cheek while the lower third molars usually lean forward with only part of the crown sticking through the gum. This situation can lead to decay and gum disease around the second molar directly in front of it.  The most common complication of the partial bony impaction is that the flap of gum tissue which partially covers the erupting third molar creates a pocket where bacteria that are present in the mouth can grow and cause an infection known as pericoronitis. The swelling and infection can become very serious. The treatment for pericoronitis is extraction of the third molar tooth. 
Some dentists believe that wisdom teeth may push the other teeth in the mouth forward and cause crowding and misalignment of the lower front teeth. Not all dentists believe that this actually happens.

The risks and complications involved in the removal of third molars are:

PAIN
Surgical removal of the third molars can lead to some discomfort and pain. This is usually treated with pain medication. 

INFECTION
Because of the large number of bacteria present in the mouth post surgical infection is always possible. Patients are usually placed on prophylactic antibiotics to prevent infections from developing.

SWELLING
Following surgery patients may experience swelling and bruising. These symptoms vary between patients. 

BLEEDING
Some post surgical bleeding is considered normal. This is usually minimal and is easily controlled with the pressure of biting on gauze.  Most wisdom teeth can be removed with local anaesthesia alone but many people prefer I.V. sedation during surgery. 
Finally there are some risks/complications that are unique to the removal of third molars. 

The upper third molars have roots which often are separated from the maxillary sinuses by only a very thin layer of bone.  Occasionally, a small communication is established between the sinus and the oral cavity when one of the upper third molars is removed. If this is the case, the normal procedure is for the area to be suture closed, the patient to be informed of the finding, appropriate antibiotics and decongestants to be prescribed, the patient to be instructed to avoid Valsalva manoeuvres (tasks which build up pressure in the sinus like nose blowing and bearing down forcefully) and the patient reappointed for follow up. Most often this results in an uneventful healing period with no further treatment being required.  Occasionally, the area will heal open rather than closed in which case an additional small surgical procedure will be required to close the communication. 
The lower third molars often have roots that lie very near or even wrapped around the inferior alveolar nerve. This is the nerve that supplies feeling to the lip, teeth and on each side of the mouth. Occasionally, when a lower third molar is removed, that nerve will be bumped or bruised and if so a change in sensation may be noted on that side. It is important to understand that this is a sensory nerve and does not affect the ability to move the parts of the oral cavity to which it gives sensation (feeling). In most cases, the nerve heals by itself but, because nerves heal slowly, it may take six months to one year before return of normal sensation. Very rarely, the damage to the nerve is permanent. 

Finally, the normal precautions, risks and benefits of extraction of any tooth (which are beyond the scope of this discussion) also apply here and should be discussed with the dentist prior to beginning any procedure.

1.  Complete Bony Impaction:
when the wisdom teeth are completely covered in bone.  When the tooth is completly covered with bone it will remain completly covered with its "developmental sack" in which all teeth develop. Later in life, this sack may undergo changes and enlarge and develop ionto a cyst. This cyst will enlarge at the expense of the bone of the jaw. These cysts should be removed and and examined by a pathologist.
 
2.  Partial Bony Impaction:
whenThe teeth begin to erupt but are not able to erupt completely. In this situation, the upper third molars usually are poisitoned towards the cheek while the lower third molars usually lean forward with only part of the crown sticking through the gum. This situation can to decay and gum disease around the second molar directly in front of it.  The most common complication of the partial bony impaction, is that the flap of gum tissue which partially covers the erupting third molar, creates a pocket where bacteria that are present in the mouth can grow and and cause an infection known as pericoronitis. The swelling and infection can become very serious. The treatment for pericoronitis is extraction of the third molar tooth. 
Some dentists believe that wisdom teeth may push the other teeth in the mouth forward and cause crowding and misalignment of the lower front teeth. Not all dentists believe that this actually happens.
The risks and complications involved in the removal of third molars are:

PAIN
Surgical removal of the third molars can lead to some discomfort and pain. This is usually treated with pain medication. 

INFECTION
Because of the large number of bacteria present in the mouth post surgical infection is always possible. Patients are usually placed on prophylactic antibiotics to prevent infections from developing.

SWELLING
Following surgery patients may experience swelling and bruising. These symptome vary between patients. 

BLEEDING
Some post surgical bleeding is considered normal. This is usually minimal and is easily controlled with the pressure of biting on gauze.  Most wisdom teeth can be removed with local anesthesia alone but many people prefer I.V. sedation during surgery. 
  Finally there are some risks/complications that are unique to the removal of third molars. 
The upper third molars have roots which often are separated from the maxillary sinuses by only a very thin layer of bone.  Occasionally, a small communication is established between  the sinus and the oral cavity when one of the upper third molars is removed. If this is the  case, the normal procedure is for the area to be sutured closed, the patient to be informed  of the finding, appropriate antibiotics and decongestants to be prescribed, the patient to be  instructed to avoid Valsalva maneuvers (tasks which build up pressure in the sinus like nose  blowing and bearing down forcefully) and the patient reappointed for followup. Most often  this results in an uneventful healing period with no further treatment being required.  Occasionally, the area will heal open rather than closed in which case an additional small  surgical procedure will be required to close the communication. 
  The lower third molars often have roots that lie very near or even wrapped around the  inferior alveolar nerve. This is the nerve that supplies feeling to the lip, teeth and tongue on  each side of the mouth. Occasionaly, when a lower third molar is removed, that nerve will  be bumped or bruised and if so a change in sensation may be noted on that side. It is  important to understand that this is a sensory nerve and does not affect the ability to move  the parts of the oral cavity to which it gives sensation (feeling). In most cases, the nerve  heals itself but, because nerves heal slowly, it may take six months to one year  before return of normal sensation. Very rarely, the damage to the nerve is permanent. 
Finally, the normal precautions, risks and benefits of extraction of any tooth (which are  beyond the scope of this discussion) also apply here and should be discussed with the  dentist prior to beginning any procedure.

Orthognathic Surgery

Orthognathic surgery is the type surgery performed by Oral Surgeons to correct skeletal mismatches. The word Orthognathic is derived from "ortho" meaning correct or straight and "gnathos" meaning jaw. These situations involve a situation where one of the jaws is:

• Too large
• Too small
• Too far forward or 
• Too far back in relation to the rest of the skull.
  
  

Orthognathic Surgery is not intended to replace orthodontics for straightening the teeth when the relationship to the jaws is within the normal range, but cannot change the relationship of the jaw.
Orthognathic surgery is usually done in conjunction with orthodontics to provide the best possible end result.

Situations that lend themselves to Orthognathia are:

1. Apertognathia:
Is a situation when the back teeth meet but the front teeth do not touch. This space causes difficulty in biting with the front teeth.

2. Prognathia:
Is a situation where the lower jaw is too large and grows too far forward. Surgery can be used to slide the lower jaw back.

	PROGNATHIC LOWER JAW

3. Retrognatia:
Is a situation where there is a "severe" overbite. These situations are managed with surgery and orthodontics together.

	RETROGNATHIC LOWER JAW

4. Vertical Maxillary Excess:
Also known as the gummy smile. In this case the upper jaw has grown too far down. Surgery can move the jaw upward to create a much nicer looking smile. If you believe you have any of these situations discuss them with your dentist who will refer to specialists qualified to carry out these procedures.

The lower jaw is a frequent site for fractures because of:
Accidents assaults sometimes underlying disease

There are 2 types of fractures:
 
1-Open: The bone is exposed to air inside the mouth or outside the facial skin
2-Closed: The bone is completely covered by soft tissue. 

Fractures can further be characterized as:
Complete: The bone is broken completely into two or more pieces
Incomplete: The bone is fractured only part way through.
Comminuted:  The fracture is composed of many pieces 

Here are the three steps in the repair of most fractures.
1. Reduction of the fracture: Realigning the bony parts in their original anatomic relationship. 
2. Fixation of the fracture: Methods and materials are used to hold the bony parts in their correct relationship while healing occurs. 
 
Maxillomandibular fixation (IMF) is the wiring of the jaw shut.  Many fractures lend themselves to this treatment. When the upper dentition is good and the upper jaw is stable this allows the upper jaw to act as a cast for the lower jaw while it heals.

Internal fixation is the use of wires and or screws and plates to hold the bony segments in their correct relationship. This hardware may be applied inside the mouth or outside the mouth depending upon the situation.

External fixation is the use surgical pins that are placed in the bony fragments and an external frame is placed between the pins to fix the bony fragments in their proper orientation. 

3. Healing and Rehabilitation: This is the time that is allowed for healing and for physical therapy.  Adequate nutrition and rest, avoiding alcohol and, tobacco is very important.

Oral Pathology

The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and coral pink in colour. Any alteration in this appearance could be a warning sign for a pathological process. The most serious of these is oral cancer. The following can be signs at the beginning of a pathologic process or cancerous growth: 

• Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth a sore that fails to heal and bleeds easily
• A lump or thickening on the skin lining the inside of the mouth
• Chronic sore throat or hoarseness
• Difficulty in chewing or swallowing

These changes can be detected on the lips, cheeks, palate, gum tissue around the teeth, tongue, face, and/or neck. Pain is not always necessary to define pathology and, curiously, is not often associated with oral cancer. However, any patient with facial and/or oral pain without an obvious cause or reason may also be at risk for oral cancer.

We would recommend performing an oral cancer self examination monthly and remember that your mouth is one of your body's most important warning systems. Do not ignore suspicious lumps or sores, please contact us so we may help you.

If you feel that you or someone you know have any of the symptoms that have been discussed or if you have any questions and / or concerns, please do not hesitate to contact our office so we may be of some assistance to you

Extraction

One of the main goals of modern dentistry is the prevention of tooth loss. All possible measures should be taken to preserve and maintain your teeth because the loss of a single tooth can have a major impact upon your dental health and appearance. However, it is still sometimes necessary to remove a tooth.

Here are some of the reasons a tooth may need to be extracted:

• Severe Decay
• Advanced periodontal disease
• Infection or abscess
• Orthodontic correction
• Malpositioned teeth
• Fractured teeth or roots
• Impacted teeth

If you've just had a tooth extracted or your dentist has recommended that a tooth be extracted, the following information will help you get through the first few days after your extraction. Should anything occur that seems out of the normal, do not hesitate to call your dentist.

Postoperative instructions:

DO NOT DISTURB THE WOUND: In doing so you may invite irritation, infection and/or bleeding. Be sure to chew on the opposite side for 24 hours and keep anything sharp from entering the wound (i.e. eating utensils etc.)

DO NOT SMOKE FOR 12 HOURS: Smoking will promote bleeding and interfere with healing. BRUSHING: Do not brush your teeth for the first 8 hours after surgery. After, you may brush your teeth gently, but avoid the area of surgery.

MOUTH WASH: Avoid all rinsing for 24 hours after extraction. This is to insure the formation of a healing blood clot which is essential to proper wound healing. Disturbance of this clot can lead to increased bleeding or the loss of the blood clot. If the clot is lost, a painful condition called dry socket may occur. You may use warm salt water or mild antiseptic rinses after 24 hours only if prescribed.

DO NOT SPIT OR SUCK THROUGH A STRAW: This will promote bleeding and may dislodge the blood clot causing a dry socket.

BLEEDING: When you leave the office, you will be given verbal instructions regarding the control of postoperative bleeding. A rolled up gauze pad will be placed on the extraction site and you will be asked to change this dressing every 20 minutes or so depending on the amount of bleeding that is occurring. It is normal for some blood to ooze from the area of surgery. We will also give you a package of gauze to take with you to use at home if the bleeding should continue. Should you need to use the gauze at home, remember to roll it into a ball large enough to cover the wound. Hold firmly in place, by biting or with finger pressure, for about 20-30 minutes. If bleeding still continues, you may fold a tea bag in half and bite down on it. Tea contains Tannic Acid, a styptic, which may help to reduce the bleeding. PAIN: Some discomfort is normal after surgery. Analgesic tablets (Tylenol etc.) may be taken under your dentist's direction. Prescription medication, which may have been given to you, should also be taken as directed. If pain continues, call your dentist.

SWELLING: To prevent swelling, apply an ice pack or a cold towel to the outside of your face in the area of the extraction during the first 12 hours. Apply alternately, 20 minutes on then 20 minutes off, for an hour or longer if necessary.

DIET: Eat normal regular meals as soon as you are able after surgery. Cold, soft food such as ice cream or yogurt may be the most comfortable for the first day. It is also important to drink plenty of fluids.

The Preparation of Your Mouth for Dentures:

After years of comfortably wearing dentures, you may find that your dentures don't fit the way they once did. Advances in surgical procedures and materials now allow oral and maxillofacial surgeons to help the patient without teeth to eat, speak and smile without worrying about slipping or uncomfortable dentures.
 
Over time, the shape and size of the jawbone changes, beginning at the time that a tooth is lost. These changes can result in dentures that slip and click, and even cause pain. The irritation caused by ill-fitting dentures can cause further changes in the bone or the gum tissues. After years of shrinkage, many patients are left without enough jawbones to support dentures at all.

Treatment Option Exists :

Oral and maxillofacial surgeons have developed many procedures for treating the patient without teeth who suffers with the social and physical problems caused by ill-fitting dentures. Your oral surgeon will explore these options with you before deciding on a treatment plan.
If shrinkage of the jawbone has taken place and some ridge height and width remains, the oral surgeon may use a bone substitute, hydroxyl apatite, to build up the jawbone. Depending on the degree of shrinkage, this treatment sometimes can be completed in the office. In cases of severe shrinkage, your oral surgeon may recommend a bone graft. This procedure uses bone from the hip or rib and requires general anaesthesia and hospitalization.
Another treatment option which your oral surgeon may consider is called a vestibuloplasty. If enough jawbone remains below the muscle attachments of the lip, cheeks and tongue, firm tissue can be grafted over the bone to provide a larger ridge. This usually requires taking tissue from the roof of the mouth or thigh.
After careful evaluation of your problem, the oral surgeon may decide that an implant is necessary to restore proper function

Maintenance is Important :

Many people stop going to their dentist after dentures are fitted. Regular checkups are still the best insurance that your mouth is healthy. Changes in the gums and jawbone can occur under a denture, especially as a result of chronic irritation.

Overgrowth of tissues in some areas, or sores on the gum, is also common. In addition, your dentist or oral surgeon will sometimes see early warning signs of generalized disease. It is also important to be aware of changes in oral tissue due to cigarette smoking or alcohol consumption so that alterations in these habits can prevent future problems.

Exploring your options with your dentist and oral maxillofacial surgeon will allow you to function without worrying about your dentures and will preserve the health of your mouth.  

	TEMPEROMANDIBULAR JOINT DISEASE

Causes and treatments for temporomandibular disorders:

What is the Temporomandibular Joint?

The temporomandibular joint (TMJ) is a joint that slides and rotates just in front of your ear, consisting of the temporal bone (side and base of the skull) and the mandible (lower jaw). Mastication (chewing) muscles connect the lower jaw to the skull, allowing you to move your jaw forward, sideways, and open and close.

The joint works properly when the lower jaw (mandible) and its joint (both the right and left) are synchronized during movement. Temporomandibular Disorder (TMD) may occur when the jaw twists during opening, closing or side-motion movements. These movements affect the jaw joint and the muscles that control chewing.

What is Temporomandibular Disorder?

TMD describes a variety of conditions that affect jaw muscles, temporomandibular joints, and nerves associated with chronic facial pain. Symptoms may occur on one or both sides of the face, head or jaw, or develop after an injury. TMD affects more than twice as many women than men and is the most common non-dental related chronic orofacial pain.

What causes TMD?

Normal function for this muscle group includes chewing, swallowing, speech and communication. Most experts suggest that certain tasks, either mental or physical, cause or aggravate TMD, such as strenuous physical tasks or stressful situations. Most discomfort is caused from overuse of the muscles, specifically clenching or grinding teeth (bruxism).

These excessive habits tire the jaw muscles and lead to discomfort, such as headaches or neck pain. Additionally, abnormal function can lead to worn or sensitive teeth, traumatized soft tissues, muscle soreness, jaw discomfort when eating, and temporal (side) headaches.

What TMD symptoms can I experience?

An earache without an infection Jaw pain or soreness that is more prevalent in the morning or late afternoon Jaw pain when you chew, bite or yawn Clicking when opening and closing your jaw Difficulty opening and closing your mouth Locked or stiff jaw when you talk, yawn, or eat Sensitive teeth when no dental problems can be found

What can I do to treat TMD?

The majority of cases can be treated by unloading (resting) the joint, taking a non-aspirin pain reliever and practicing stress management and relaxation techniques. It's important to break bad habits to ease the symptoms. Most treatment for TMD is simple, often can be done at home, and does not need surgery. For example, control clenching or grinding during the day by sticking your tongue between your teeth. If you still experience pain, you may be grinding or clenching your teeth at night. So see your dentist for a nighttime mouthguard.

Most people will experience relief with minor treatment. More severe cases may be treated with physical therapy, ice and hot packs, posture training and orthopedic appliance therapy (splint). Eating soft foods and avoiding chewing gum also will help relax the muscles.

Is TMD permanent?

The condition is often cyclical and may reoccur during times of stress, good or bad. As the patient, you should be active in your treatment after seeing a dentist for a diagnosis regime by being aware of the causes of your jaw problems. Make routine dental appointments, so your doctor can check TMD on a regular basis

CHIN RECONSTRUCTION

Chin reconstruction in situations where a person appears to have little or no chin. In the absence of other skeletal abnormalities, surgical procedures are available to change the chin.

The chin point can be augmented with materials from the patient's own body (autografting) or with materials from outside the body (allografting) and each have its own advantages and disadvantages.

Autograft procedures involves sectioning the chin from the remainder of the lower jaw, and moving it forward and reattaching it to the lower jaw with plates, wires and/or screws. This surgery is done from an incision inside the mouth so that there are no visible scars.

Allograft procedures also involve an incision made inside the mouth. Prosthesis is placed in front of the bone of the chin, to give the appearance of a more normal chin.

There are many new biocompatible materials being developed all the time to create implants for the chin and for other facial defects.